Pediatric Urinary Tract Infection Clinical Presentation

Updated: Apr 25, 2022
  • Author: Donna J Fisher, MD; Chief Editor: Russell W Steele, MD  more...
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The history and clinical course of a urinary tract infection (UTI) vary with the patient's age and the specific diagnosis. No one specific sign or symptom can be used to identify UTI in infants and children.

Combinations of findings, including a prior history of UTI, circumcision in boys, and, in older children, typical symptoms such as frequency, abdominal or suprapubic discomfort, and dysuria, should be taken into account when making a decision to evaluate for UTI. [10, 11] Guidelines from the American Academy of Pediatrics recommend considering the diagnosis of UTI in patients aged 2 months to 2 years with unexplained fever. [12]

When UTI is diagnosed in a child, an attempt should be made to identify any risk factors for the UTI. These include recent broad-spectrum antibiotic therapy, an anatomic anomaly, voiding dysfunction, and constipation.

Children aged 0-2 months

Neonates and infants up to age 2 months who have pyelonephritis usually do not have symptoms localized to the urinary tract. UTI is discovered as part of an evaluation for neonatal sepsis.

Neonates with UTI may display the following symptoms:

Infants and children aged 2 months to 2 years

Infants with UTI may display the following symptoms:

  • Poor feeding

  • Fever

  • Vomiting

  • Strong-smelling urine

  • Abdominal pain

  • Irritability

As with young infants, the majority of infants and young children in this age range who have pyelonephritis also lack symptoms localized to the urinary tract. However, some children aged 1-2 years may present with voiding symptoms suggestive of cystitis, with crying on urination or only a foul odor to the urine in the absence of clinically significant fever (temperature < 38°C).

Infants and young children of this age may also have only a history of unexplained fever (ie, rectal or tympanic membrane temperature of >38°C). Some infants with pyelonephritis in this age range have fever and few other symptoms, whereas others are acutely ill and have a history of irritability, decreased oral intake, abdominal pain, vomiting, and loose bowel movements. Patients in this age group are at higher risk for renal injury than are older children, possibly because the lack of localizing signs of infection delays the start of antibiotic therapy.

Children aged 2-6 years

Preschoolers with UTI can display the following symptoms:

  • Vomiting

  • Abdominal pain

  • Fever

  • Strong-smelling urine

  • Enuresis

  • Urinary symptoms (dysuria, urgency, frequency)

Children in this age group with febrile UTI (pyelonephritis) usually have systemic symptoms with loss of appetite, irritability, and abdominal, flank, or back pain. Voiding symptoms may be present or absent.

Children with acute cystitis have voiding symptoms with little or no temperature elevation. Voiding dysfunction may include urgency, frequency, hesitancy, dysuria, or urinary incontinence. Suprapubic or abdominal pain may be present, and the urine sometimes has a strong or foul odor.

Children older than 6 years and adolescents

School-aged children with UTI can display the following symptoms:

  • Fever

  • Vomiting, abdominal pain

  • Flank/back pain

  • Strong-smelling urine

  • Urinary symptoms (dysuria, urgency, frequency)

  • Enuresis

  • Incontinence

Adolescents are more likely to present with typical urinary symptoms (eg, dysuria, urgency, frequency). Adolescent girls with vaginitis or a sexually transmitted infection (STI) may present with similar symptoms. In addition, adolescent girls who are diagnosed with cystitis may have a concurrent vaginitis or STI. [13]

UTI among children in this age range usually affects the lower tract, but pyelonephritis also occurs. Symptoms are similar to those in children aged 2-6 years.

Girls who have pyelonephritis in infancy or early childhood, including those with persistence of vesicoureteral reflux (VUR), usually have cystitis with UTI when they are older. They are also prone to have a recurrence during pregnancy.


Physical Examination

Infants and younger children with pyelonephritis usually have no localizing findings, but they are febrile and often irritable. Older children with pyelonephritis often have tenderness of the flank or costovertebral angle, and those with cystitis may have suprapubic tenderness. Hypertension should raise suspicion of hydronephrosis or renal parenchyma disease.

Physical examination findings in pediatric patients with UTI can be summarized as follows:

  • Costovertebral angle tenderness

  • Abdominal tenderness to palpation

  • Suprapubic tenderness to palpation

  • Palpable bladder

  • Dribbling, poor stream, or straining to void

Examine the external genitalia for signs of irritation, pinworms, vaginitis, trauma, or sexual abuse.