ANALYSIS OF UROLITHS (URINARY STONES)

VINODCHANDRAN
1
, PRASANNACHANDRA M
2
, UDAY NARAYAN
SINGH
3
,SREEKANTHA *
4
, YOGESH B
5
, REMYA
6
, VIVIAN D’SOUZA
7
AND BENEDICTA D’SOUZA
8
1,4,5,7,8
Department of Biochemistry and Pharmacology
5
, Manipal University, KMC, Mangalore. India.
2,6
Department of Biochemistry and Anatomy
6
, Nitte University, KSHEMA, Mangalore, India.
3
Department of Biochemistry, Narayan Medical College, Jamuhar-Sasaram, Bihar, India.
*Corresponding author
BIO CHEMISTRY
SREEKANTHA
Department of Biochemistry, Manipal University, KMC, Mangalore. India
ABSTRACT
Stone(s) or calculi in the urin
ary tract are referred as urolithiasis. Clinically they usually presents
with acute abdominal pain, urinary obstruction and hematuria. In present study we have
analyzed 50 patients with uroliths for the chemical composition to know their cause,
complicatio
ns and measures for the preventing the occurrence of urolithiasis. We found that
90% of uroliths found to be calcium related stones and 10% were uric acid stones.
Metabolic
dysregulation, diet and environmental factors have a causative role in the etiogene
sis of
urolithiasis.
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KEY WORDS
Urolithiasis, chemical analysis, complications, prevention.
INTRODUCTION
Urolithiasis means stone(s) or calculi in the
urinary tract; kidney, ureter, urinary bladder and
urethra. The term nephrolithiasis can be used to
denote the presence of calculi in the kidney(s).
Nephrolithiasis pain is radiated to the back and
lumbar region. Stone(s) in the ureter present
with acute abdominal pain which radiates to
groin and genitals. Vesicle calculus refers to
bladder stone, presents with vague pain and
discomfort in supra pubic region (1).
Calcium stones are most common type of stones
(75-85%), Uric acid stones (5-8%) occurs in
males and magnesium stones (10-15%) usually
occur in females. Calcium stones are most
common type of stones; the average age of
onset is in between 20 to 30 years. They may
have familial background. Calcium oxalate
stones exhibit the property of birefringence which
means, these crystals appear bright against a
dark background with an intensity that is
dependent on orientation. Uric acid stones are
radiolucent and they are more common in men.
Magnesium stones occur mainly in women and
potentially dangerous as they have sharp edges
which may damage the mucus membrane and
they can grow very large in size and may present
with obstruction. They usually occur because of
the infection in urinary tract due to proteus
bacteria. In majority of the cases small stones (2-
3 mm) are discovered during the course of
radiographic studies for unrelated reasons. They
are asymptomatic depending on the position of
stone location. Urolithiasis is mainly explained by
the imbalance of water and salt ions. The main
function of the kidney is to preserve the water
and excrete materials having low solubility.
These two factors are to be balanced and
adjusted with climate, diet and activity of the
individual. If any imbalance between the above
mentioned factors results in urolithiasis (2,3).
The other causes of urolithiasis include
idiopathic hypercalcemia, hyperuricemia,
primary hyperparathyroidism, renal tubular
acidosis, prolonged immobilization etc (4).
Complications of urolithiasis include infection,
hematuria, obstruction, hydronephrosis,
diverticulum, ulceration and chronic
undislodged stone may predispose for
malignancy of the site of urinary tract (1).
MATERIALS AND METHODS
50 patients diagnosed with urolithiasis were
selected for the study. All subjects were males
between 25 to 50 years. All of subjects were
fish eaters and staying in the coastal region.
The selected patients were diagnosed
urolithiasis by classical ultrasound (USG) by
Seimen’s company. After surgery of
nephroliths and flushing therapy for uroliths
present in ureter and bladder were selected
and analyzed chemically for their composition.
The stones from the operation theater or after
flushing (dropped out) were brought in formalin
for the medical biochemistry laboratory and
analyzed for calcium, phosphate, oxalate,
ammonia, uric acid and magnesium(5).All
routine blood and urine parameters observed
in these patients were within normal limits;
mainly the serum calcium and uric acid levels.
RESULTS
Out of 50 uroliths, 45 uroliths were positive for
calcium oxalate, calcium phasphate and
ammonium sulphate, 5 uroliths were positive
for uric acid. The results from above study
made that 90% of our study population were
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B - 302
positive for calcium, oxalate, phosphate and
ammonium sulphate and 10% were positive for
uric acid.
Picture showing calcium and uric acid stones.
DISCUSSION
Urolithiasis is the disease of urinary tract, where
there is stone formation; which presents with
acute abdominal pain, infection and related
complications. Urolithiasis might be easily
prevented with a little knowledge, knowing the
causes for which is our main purpose of study. In
our study we noted that 85-90% of patients had
Urolithiasis which composed of mainly calcium
oxalate, calcium phosphate and ammonium
sulfate and the remaining 10% of uric acid and
its salts.
In coastal region people sweat more, and hence
they are dehydrated easily. Food habits like
eating fish and sea foods which are rich in
calcium may precipitate calcium stone formation.
Consuming high content of purine rich foods like
meat, fish, poultry, tomatoes etc increases uric
acid content and dehydration precipitates the
formation of uric acid stone with its salts.
The management of stone(s) depends on the
position and size of stone. If the stone(s)
present in ureter with less than 7mm size, they
can be made forcefully descended by flushing
procedure by intravenous fluids. If the stone(s)
size are more than 8 mm, they are to be
removed by surgery depending on the position
of calculi by trained urologist and if they are in
ureter they are to be removed by basket
procedure (1,6).
To conclude, urolithiasis can be easily
prevented by maintaining adequate hydration
in the form of consuming about 5 liters of
water, keeping oneself active by playing or
regular walking and limiting the food items
which are rich in purine content like red meat,
tomatoes etc and avoid drinking excess of tea
and drinking cranberry juice often limits the
development of stone(s).

(PDF) International Journal of Pharma and Bio Sciences ANALYSIS OF UROLITHS

(URINARY STONES). Available from:
https://www.researchgate.net/publication/298904050_International_Journal_of_Pharma
_and_Bio_Sciences_ANALYSIS_OF_UROLITHS_URINARY_STONES [accessed Oct
27 2018].
ANALISIS UROLITHS (BATU URINARY)
VINODCHANDRAN
1
, PRASANNACHANDRA M
2
, UDAY NARAYAN
SINGH
3
, SREEKANTHA *
4
, YOGESH B
5
, REMYA
6
, VIVIAN D’SOUZA
7
DAN BENEDICTA D’SOUZA
8
1,4,5,7,8
Departemen Biokimia dan Farmakologi
5
, Universitas Manipal, KMC, Mangalore. India.
2,6
Departemen Biokimia dan Anatomi
6
, Universitas Nitte, KSHEMA, Mangalore, India.
3
Departemen Biokimia, Narayan Medical College, Jamuhar-Sasaram, Bihar, India.
*Penulis yang sesuai
BIO CHEMISTRY
SREEKANTHA
Departemen Biokimia, Universitas Manipal, KMC, Mangalore. India
ABSTRAK
Batu (s) atau batu di urin
saluran ary disebut sebagai urolitiasis. Secara klinis mereka biasanya hadir
dengan nyeri perut akut, obstruksi kemih dan hematuria. Dalam penelitian ini kami
punya
menganalisis 50 pasien dengan urolith untuk komposisi kimia untuk mengetahui
penyebabnya,
complicatio
ns dan langkah-langkah untuk mencegah terjadinya urolitiasis. Kami menemukan itu
90% dari urolith ditemukan sebagai batu terkait kalsium dan 10% adalah batu asam
urat. Metabolik
faktor disregulasi, diet dan lingkungan memiliki peran kausatif dalam etiogen
sis dari
urolitiasis.
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KATA KUNCI
Urolithiasis, analisis kimia, komplikasi, pencegahan.
PENGANTAR
Urolithiasis berarti batu atau batu di dalam
saluran kemih; ginjal, ureter, kandung kemih dan
pekencingan. Istilah nefrolitiasis dapat digunakan untuk
menunjukkan keberadaan batu di ginjal (s).
Nyeri nefrolitiasis diradiasikan ke punggung dan
daerah lumbar. Batu (s) dalam ureter hadir
dengan nyeri perut akut yang memancar ke
selangkangan dan alat kelamin. Vesicle calculus mengacu pada
batu kandung kemih, hadir dengan rasa sakit yang samar-samar dan
ketidaknyamanan di wilayah supra pubis (1).
Batu kalsium adalah jenis batu yang paling umum
(75-85%), batu asam urat (5-8%) terjadi di
laki-laki dan batu magnesium (10-15%) biasanya
terjadi pada wanita. Batu kalsium paling banyak
jenis batu biasa; usia rata-rata
onset terjadi antara 20 hingga 30 tahun. Mereka mungkin
memiliki latar belakang keluarga. Kalsium oksalat
batu menunjukkan properti birefringence yang mana
berarti, kristal ini tampak cerah melawan
latar belakang gelap dengan intensitas itu
tergantung pada orientasi. Batu asam urat berada
radiolusen dan mereka lebih sering terjadi pada pria.
Batu magnesium terutama terjadi pada wanita dan
berpotensi berbahaya karena mereka memiliki ujung yang tajam
yang dapat merusak selaput lendir dan
mereka dapat tumbuh sangat besar dalam ukuran dan dapat hadir
dengan obstruksi. Mereka biasanya terjadi karena
infeksi pada saluran kemih karena proteus
bakteri Dalam sebagian besar kasus batu-batu kecil (2-
3 mm) ditemukan selama proses
studi radiografi untuk alasan yang tidak berkaitan. Mereka
tidak menunjukkan gejala tergantung pada posisi
lokasi batu. Urolithiasis terutama dijelaskan oleh
ketidakseimbangan air dan ion garam. Utama
fungsi ginjal adalah menjaga air
dan material ekskresi memiliki kelarutan rendah.
Kedua faktor ini harus seimbang dan
disesuaikan dengan iklim, diet dan aktivitas
individu. Jika ada ketidakseimbangan antara hal di atas
faktor yang disebutkan menghasilkan urolitiasis (2,3).
Penyebab lain dari urolitiasis termasuk
hiperkalsemia idiopatik, hiperurisemia,
hiperparatiroidisme primer, tubulus ginjal
asidosis, imobilisasi berkepanjangan, dll (4).

Komplikasi urolitiasis termasuk infeksi, hematuria, obstruksi, hidronefrosis, diverticulum,

ulserasi dan kronis batu tidak beraturan dapat menjadi predisposisi keganasan situs
saluran kemih (1). MATERIAL DAN METODE 50 pasien yang didiagnosis dengan
urolitiasis dipilih untuk penelitian. Semua subjek adalah laki-laki antara 25 hingga 50
tahun. Semua mata pelajaran itu pemakan ikan dan tinggal di wilayah pesisir. Pasien
yang dipilih didiagnosis urolithiasis oleh ultrasound klasik (USG) oleh Perusahaan
Seimen. Setelah operasi nefrolith dan terapi pembilasan untuk urolith hadir di ureter dan
kandung kemih dipilih dan dianalisis secara kimia untuk komposisi mereka. Batu-batu
dari teater operasi atau sesudahnya flushing (drop out) dibawa dalam formalin untuk
laboratorium biokimia medis dan dianalisis untuk kalsium, fosfat, oksalat, amonia, asam
urat dan magnesium (5) .Semua parameter darah dan urin rutin diamati pada pasien-
pasien ini berada dalam batas normal; terutama kadar kalsium dan asam urat serum.
HASIL Dari 50 urolith, 45 urolith positif kalsium oksalat, kalsium phasphate dan
amonium sulfat, 5 urolith positif untuk asam urat. Hasil dari penelitian di atas membuat
90% dari populasi penelitian kami adalah Artikel ini dapat diunduh dari www.ijpbs.net B
- 302 positif untuk kalsium, oksalat, fosfat dan amonium sulfat dan 10% positif untuk
asam urat. Gambar menunjukkan batu kalsium dan asam urat. DISKUSI Urolithiasis
adalah penyakit saluran kemih, dimana ada formasi batu; yang hadir dengan sakit perut
akut, infeksi dan terkait komplikasi. Urolithiasis mungkin mudah dicegah dengan sedikit
pengetahuan, mengetahui penyebab yang merupakan tujuan utama kami belajar. Di
penelitian kami, kami mencatat bahwa 85-90% pasien memiliki Urolithiasis yang
tersusun terutama dari kalsium oksalat, kalsium fosfat dan ammonium

sulfat dan sisa 10% asam urat dan garamnya. Di wilayah pesisir, orang lebih banyak
berkeringat, dan karenanya mereka dehidrasi dengan mudah. Kebiasaan makanan
seperti makan ikan dan makanan laut yang kaya kalsium dapat mempercepat
pembentukan batu kalsium. Mengkonsumsi makanan purin kaya kandungan tinggi
seperti daging, ikan, unggas, tomat, dll meningkatkan uric kandungan asam dan
dehidrasi mengendapkan pembentukan batu asam urat dengan garamnya. Pengelolaan
batu (s) tergantung pada posisi dan ukuran batu. Jika batu (s) hadir di ureter dengan
ukuran kurang dari 7mm, mereka dapat dibuat dengan paksa diturunkan dengan
pembilasan prosedur dengan cairan intravena. Jika batu (s) ukurannya lebih dari 8 mm,
seharusnya dihilangkan dengan operasi tergantung pada posisinya dari batu oleh ahli
urologi terlatih dan jika mereka berada di ureter mereka harus dihapus oleh keranjang
prosedur (1,6). Untuk menyimpulkan, urolitiasis dapat dengan mudah dicegah dengan
mempertahankan hidrasi yang adekuat dalam bentuk mengkonsumsi sekitar 5 liter air,
menjaga diri sendiri aktif dengan bermain atau berjalan teratur dan membatasi
makanan yang kaya kandungan purin seperti daging merah, tomat dll dan hindari terlalu
banyak minum teh dan minum jus cranberry sering membatasi pengembangan batu (s).
(PDF) Jurnal Internasional Pharma dan Bio Sciences ANALISIS UROLITHS (BATU
URINARY). Tersedia dari:
https://www.researchgate.net/publication/298904050_International_Journal_of_Pharma
_and_Bio_Sciences_ANALYSIS_OF_UROLITHS_URINARY_STONES [diakses 27
Oktober 2018].
Urinary Infection Recurrence and Its Related Factors in Urinary Tract Infection
Simin Sadeghi Bojd , Gholamreza Soleimani , Alireza
1 1

Teimouri and Negar Aflakian

1,* 2

Authors Information
1
Children and Adolescents Health Research Center, Resistant Tuberculosis Institute,
Zahedan University of Medical Sciences, Zahedan, Iran
2
Medical School, Zahedan University of Medical Sciences, Zahedan, Iran
* Corresponding author: Alireza Teimouri, M.Phil, PhD in Demography
Children and Adolescents Health Research Center, Resistant
Tuberculosis Institute, Zahedan University of Medical Sciences,
Zahedan, Iran. E-mail:alirezateimouri260@gmail.com
Article information

 International Journal of Infection: April 2018, 5 (2); e64903

 Published Online: April 24, 2018
 Article Type: Research Article
 Received: January 24, 2018
 Revised: March 28, 2018
 Accepted: April 9, 2018
 DOI: 10.5812/iji.64903

To Cite: Sadeghi Bojd S, Soleimani G, Teimouri A, Aflakian N. Urinary Infection

Recurrence and Its Related Factors in Urinary Tract Infection, Int J Infect. 2018
;5(2):e64903. doi: 10.5812/iji.64903.

Abstract
Background: Recurrent urinary tract infection (UTI) is one of the major health problems in children
because of its high rate of occurrence. This study aimed at evaluating the frequency of recurrent urinary
tract infection and related factors in children aged two months to 15 years old, refereed to the pediatric
nephrology clinic of Zahedan city.
Methods: In this descriptive study, 270 children with urinary tract infection were studied. The sampling
method was convenient. Information was gathered from patients and their files. Data was analyzed by the
SPSS version 18 software, using Chi Square and T-test.
Results: The mean age of the children was 4.3 ± 3.7 years old. Thirty-four children (12.6%) were male
and 236 (87.4%) female (P > 0.05). Overall, 109 children (73.6%) with recurrent UTI and 53 children
(44.2%) without recurrent UTI had abnormal ultrasonography (P = 0.001). Furthermore, 115 children
(76.7%) with recurrent UTI and 100 children (83.3%) with first UTI had positive results for E. coli culture
(P = 0.177). Seventy-nine children (54.5%) with recurrent UTI and 61 children (39%) with first UTI were
diagnosed to have elimination syndrome (P = 0.067). Abnormal VCUG was found in 39 children (47.6%)
of 82 children with recurrent UTI yet children with first UTI had normal VCUG (P = 0.001).
Conclusions: There was no difference regarding age, gender, dysfunctional elimination syndrome, and
urine culture in children with recurrent UTI compared to those with first UTI, yet abnormal VCUG, kidney,
and urinary tract ultrasonography were much more common in children with recurrent UTI.
Keywords: Urinary Tract Infection; Recurrent; Children
Copyright © 2018, International Journal of Infection. This is an open-access article distributed under the terms of the
Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-
nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is
properly cited

1. Background
The most prevalent disease of the urinary system is Urinary Tract Infection (UTI), specially in children,
with a prevalence of 9% in more than 38 C febrile infants below 60 days old ( 1, 2). Urinary Tract Infection
is diagnosed when 105 colonies are cultured in urine sampling with the clean catch method, more than
104 in catheter sampling, and any colony count from suprapubic urine sampling ( 2-5). Escherichia coli is
the most common infecting organism in uncomplicated UTI. It causes about 85% of community-acquired
infections and approximately 50% of nosocomial infections. Other gram-negative microorganisms causing
UTI include Proteus, Klebsiella, Citrobacter, Enterobacter, and Pseudomonas spp. Gram-positive
pathogens, such as Enterococcus faecalis, Staphylococcuss aprophyticus, and group B streptococci, can
also infect the urinary tract. Anaerobic microorganisms are frequently encountered in suppurative
infections of the genitourinary tract (6-10). Different types of UTIs are cystitis, pyelonephritis, and renal
abscess in the kidney or its surrounding. Urinary tract system and urine itself should be sterile, naturally.
At least one episode of UTI is experienced in children by the age of 11 years old and this happens in 8%
and 10% of females and males, respectively, and during life time is 30% in females and about 1% in
males. About 75% of infants below three months old with bacteriuria are male; this value reaches 10%
between three to eight months, and after 12 months of age it is seen in girls only ( 11). Urinary Tract
Infection in children does not have clear signs and symptoms compared to adults and it changes with
growing up due to the unusual symptoms presentation like losing weight, Failure to Thrive (FTT),
anorexia, icterus or fever of unknown origin (12, 13), yet in infants it is usually presented with FTT,
nutritional disorders, diarrhea, fever of unknown origin and increased bilirubin gastrointestinal symptoms
like colic, irritability, and agitation (7-12). Children of two to six years of age may have gastrointestinal
symptoms as well; however, classic signs and symptoms of UTI, including urgency, dysuria, frequency,
and lower abdominal pain, also appear.

Urinary Tract Infection accrues in males more than females in the first month of life ( 13-15)
and is more common in females from the second month to adulthood. Furthermore, UTI relapse is two or
more episodes of infection in a six-month period (16). Recurrence occurs with two types of relapse and
reinfection. Infection repetition with the previous infection pathogen is called relapse. However, reinfection
is considered when infection reoccurs with another pathogen different from the previous infection
episode. Relapse usually occurs two weeks after the end of treatment and reinfection occurs months after
the first episode of infection (17). Children below six years of age have are at greater risk of reinfection
(6% to 18%). The risk of reinfection within a year in a patient with one episode of infection is nearly 25%
and it reaches 50% in those with two previous episodes of infection and 80% in children with three
previous episodes. Diagnosis is based on history taking and physical examination. Early complications of
UTI are septicemia or bacteremia and delayed, such as hypertension, chronic renal failure, and reflux
nephropathy. Therefore, prompt diagnosis and treatment is of great importance. Scar is the most
common kidney parenchymal disease due to pyelonephritis and is one of the most important causes of
hypertension in children and young adults (16, 18-21). Prevention from repetitive infection and its
complication is the most important goal of treatment, yet achieving this target needs a close consideration
of different factors, such as age, gender, and underlying diseases. Behavioral disorders, such as delaying
urination or defecation, should be assessed in children with UTI to prevent further episodes of infection.
On the other hand, urinary tract anomalies, such as vesicoureteral reflux (VUR) are considered as an
important predisposing factor for UTI, which increase the risk of infection up to 37% ( 19, 22, 23). The
importance of performing such study is apparent considering the high prevalence and important
complications of UTI. Therefore, the present study aimed at assessing UTI prevalence and its underlying
factors in children aged two months to 15 years admitted to pediatric clinics of Zahedan City, Iran.

2. Methods
This study was a retrospective analytic cross-sectional study with the aim of assessing UTI prevalence
and its underlying factors in children. The patients were selected for the study from 2016 for one and a
half years. They were followed for at least 6 months for responding to treatment. Medical records of all
patients aged two months to 15 years were assessed and from them, those with two or more episodes of
UTI in the last six-month were selected. The sampling was hospital-based. The sampling was performed
amongst those, who referred to pediatric clinics of Zahedan City, Iran.
Exclusion criteria were one episode of infection and lack of attendance to follow-up to
assess reinfection. Using sample size formula for cross sectional study “N = (Zα / E ) 2 P(1-P)” with
considering Zα = 1.96, α = 0.05, E = Marginal error = 0.25, and the interest proportion of P = 0.69, 270
samples were required for the study. Convenient sampling was used until the sample size was achieved.
Several variables were recorded in designed forms, including age, gender, recurrent UTI, urinary tract
anomaly, cultured bacteria, and elimination syndromes. After obtaining an approval from the ethics
committee, patients’ documents were assessed and required information was recorded in special forms.
In case of any reported anomaly, it was verified using ultrasonography. All data were recorded in special
forms regarding the above-mentioned variables and bacteria grown on culture. Data was analyzed using
SPSS 18 (SPSS Inc., IMB Corporation, Chicago, Illinois, USA) with application of Chi-square and Fisher’s
exact tests. The significance level was considered at P ≤ 0.05.

3. Results
In this study, 270 children with UTI were assessed. The mean age of the patients was 4.3 ± 3.7 years.
Thirty-four (12.6%) were male. Patients were assigned in two groups of recurrent and non-recurrent
infection. There was no meaningful difference regarding age and gender between the two groups (P ≥
0.05). From 150 children with recurrent UTI, 29 (19.3%) were aged below one year, 69 (46%) were aged
one to five years, and 52 (34.7%) were aged over five years. In this study, 109 (73.6%) children with
recurrent UTI and 53 (44.2%) children with first UTI had urogenital anomaly; the difference was
statistically significant (P = 0.001). Escherichia coli was detected in 115 (76.7%) children with recurrent
UTI and 100 (83.3%) children with non-recurrent infection; the difference was not statistically significant
(P = 0.177). In children with recurrent UTI, 38 (26.2%) had urine incontinency, 27 (18.6%) defecation
incontinency, and 14 (9.7%) both urine and feces incontinency. In children with first UTI, 24 (20.3%) had
urine incontinency, 12 (10.2%) defecation incontinency, and 10 (8.5%) both urine and feces incontinency;
the difference was not statistically significant (P = 0.067). In this investigation, 82 children with recurrent
UTI underwent voiding cystourethrography, which had abnormal results in 39 (47.6%). In those with non-
recurrent UTI, 23 underwent VCUG and none of them had abnormal results; the difference was
statistically meaningful (P = 0.001).

Table 1. Comparison of Recurrence of Urinary Tract Infection in Children by Age and Gender
Variables Recurrent Infection Non-Recurrent Infection P Value
Age, mean ± SD 3.8 ± 4.5 3.6 ± 4.1 0.366
Gender, frequency (%) 0.682
Males 20 (13.3) 14 (11.7)
Females 130 (86.7) 106 (88.3)
Total 150 (55.6) 120(44.4)
Table 2. Frequency of Recurrence of Urinary Tract Infection in Children by Age and Gender
Variables No. %
Variables No. %
Age, y
Less than 1 29 19.3
Between 1 - 5 69 46
More than 5 52 34.7
Total 150 100
Gender
Females 130 86.7
Males 20 13.3
Total 150 100
Table 3. Recurrent and Non-Recurrent Infection of Patients in Different Variable Groups a

Recurrent Non-Recurrent P
Variables Total
Infection Infection Value
Urinary tract abnormalities 0.001
162
Yes 109 (6.73) 53 (2.44)
(4.60)
106
No 39 (4.26) 67 (8.55)
(6.39)
268
Total 148 (2.55) 120 (8.44)
(100)
Bacteria’s type 0.177
215
E. coli 115 (7.76) 100 (3.83)
(6.79)
55
Non E. coli 35 (3.23) 20 (7.16)
(4.20)
270
Total 150 (6.55) 120 (4.44)
(100)
Defective syndrome 0.067
62
Urinary incontinence 38 (2.26) 24 (3.20)
(6.23)
39
Fecal incontinence 27 (6.18) 12 (2.10)
(8.14)
Urinary incontinence and
14 (7.9) 10 (5.8) 24 (1.9)
stool
138
Normal 66 (5.45) 72 (61)
(5.52)
 Recurrent Non-Recurrent P
Variables Total
Infection Infection Value
263
Total 145 (1.55) 118 (9.44)
(100)
<
Voiding cystourethrography
0.001
66
Normal 43 (4.52) 23 (100)
(9.62)
39
Abnormal 39 (6.47) 0 (0)
(6.47)
105
Total 82 (1.78) 23 (9.21)
(100)
a
Values are expressed as No. (%).

4. Discussion
This study showed no meaningful difference regarding age and gender between the two groups of
recurrent and no recurrent UTI. Abnormal results of VCUG and ultra-sonography were significantly more
in children with recurrent UTI. However, E. coliand dysfunctional elimination syndromes had no
meaningful difference between the two groups.

Jantunen et al. (24) showed that UTI occurred in most neonates due to reversion. In
another study by Snodgrass et al. (20), the prevalence and risk factors of renal scar were assessed in
patients with febrile UTI compared to healthy children; from the study it was found that 4% had congenital
renal dysplasia and 15.5% had focal defect.
The factors associated with more risks of scar formation were reflux, especially grades 4
and 5, recurrent UTI with fever and older age. Urine analysis and culture easily detects UTI and unwanted
complication can be avoided by prompt diagnosis and appropriate management. Recurrent UTI should be
treated more aggressively than a simple episode of infection (21, 25-27).

Vachvanichsanong et al. ( 15) conducted a follow up study for one year to evaluate the
prevalence and to determine the risk factors of recurrent UTI in children. In their study, which included all
UTI children aged less than 15 years old, over a ten-year period at hospitals, they found that recurrent
UTI in normal children was low; while in children with a genitourinary (GU) anomaly or other underlying
disease indicating an immune compromised host, the recurrence rates were significantly higher. The
major significant risk factor of recurrent UTI was genitourinary anomaly (GA) and children with GA or VUR
had recurrence rates of 43% or 37%, respectively. The results of Vachvanichsanong et al.’s study were in
the same line as the current results in relation to the risk factors of recurrent UTI. Although different
results concerning recurrence have been found in different studies, such differences can largely be
explained by different methodologies, ages of children, and durations of follow-up. Panaretto et al. (28)
reported a recurrence rate of 10% for UTI in normal preschool children and 30% in children with VUR. In
accordance with the present study results, Panaretto et al. ( 28) reported that urinary tract abnormality,
such as VUR, were more common in patients with recurrent UTI.

Mingin et al. (29) reported that 32.1% of children with febrile UTI developed its recurrence.
Pennesi et al. (30) found that only 4.4% of children with UTI aged less than three years had recurrent UTI
after their first UTI. The results of Mingin et al. (29) and Pennesi et al. (30) were comparable with the
current study in age group of < 3 years and febrile status was the main cause of recurrent UTI. Therefore,
the results of the present study varied because of the goals and methodology.
 Nuutinen and Uhari (31) reported that infants with VUR in grades I and II were similar in UTI
recurrence rate with normal children, and infants with grades III to V VUR had recurrent UTI more
frequently than infants with low-grade VUR. However, in contrast, Smellie et al., (32) reported that the
rates of recurrent UTI were the same between high- and low-grade VUR.
In these two studies, VUR grading was considered as a risk factor of recurrent UTI with
dissimilar results. In the current study, VUR without regarding its grade, was considered and revealed as
a risk factor of recurrent UTI. Dias et al. (33) in their study reported that recurrent UTIs occurred in 16.2%
of patients. After adjustment UTI as clinical presentation, age < 6 months, female gender, dysfunctional
elimination syndrome, and severe grade of reflux it was demonstrated as an independent predictor of
recurrent UTI.
More recent studies concluded the prediction model of recurrent UTI and allowed for early
recognition of patients at risk for long-term morbidity.

Bakker et al. (34) analyzed different risk factors with the factors in the present study for
recurrent UTI. They focused on the influence of potty-training and found a strong correlation between
daytime and/or night-time wetting, voiding frequency of more than 10 times a day, and nocturia and
recurrent UTI. Similar reports with that of Bakker et al. indicated that fecal soiling was more frequent in
recurrent UTI. Bakker et al. also found a significant correlations between recurrent UTI and single UTI.

Conway et al. (35) conducted a study to identify recurrent UTI risk factors in a pediatric
sample and to determine the association of antimicrobial prophylaxis with recurrent UTI. Among a curded
group of children, < 1% had a first UTI and race, age, and grade 4 to 5 vesicoureteral reflux were
associated with increased risk of recurrent UTI, and the factors of gender and grade one to three
vesicoureteral reflux were not associated with risk of recurrence. They also concluded that antimicrobial
prophylaxis was not associated with decreased risk of recurrent UTI, yet was associated with increased
risk of resistant infections. Similar to Nuutinen and Uhari (31) and Smellie’s (32) studies, Conway et al.
(35) considered the grade of vesicoureteral reflux and reported similar results.

Sutton et al. (36) investigated recent literatures on first febrile UTI addressed to a broad
range of areas regarding the care of hospitalized patients. Overall, studies supported deep attention to
the potential risks, expenses, and invasiveness of various approaches for evaluation. Proposed updates
to practice included utilization of urinalysis for screening and diagnosis, transitioning to oral antimicrobials
based on clinical improvement, and limiting the routine use of voiding cystourethrogram and antimicrobial
prophylaxis. Swerkersson et al. (37) observed similarity between groups of patients regarding gender or
age and progression, regression, and unchanged status. In progression, amongst children with
vesicoureteral reflux (VUR) grade III to V, 65% had recurrent UTI. Both VUR grade III to V and recurrent
UTI were associated with progression. In the regression group, high percentage had no VUR or grade I to
II, and 10% had recurrent UTI. They concluded that young children with febrile UTI do not develop renal
damage and if they do, the majority remain unchanged or regress over time. However, up to one-fifth of
children with renal damage diagnosed after UTI are at risk of renal deterioration. These children are
characterized by the presence of VUR grades III to V and recurrent febrile UTI and may benefit from
follow-up.

4.1. Study Limitation

The limitation of this study was the lack of antimicrobial prophylaxis consideration. A randomized
trial involving children in the community setting after first UTI comparing daily prophylaxis versus close
follow-up would significantly improve understanding of the efficacy of antimicrobial prophylaxis.

4.2. Conclusion

From the study, it was concluded that recurrence was a serious problem in UTI. Furthermore, it was
demonstrated that age, gender, dysfunctional elimination syndromes, and urine culture were similar in
 patients with and without recurrent urinary infection; however, VCUG and ultrasonography abnormal
results were more prevalent in patients with recurrent UTI. It is suggested to perform further investigations
to assess urinary infection recurrence and administer antibiotics in patients at risk of recurrent episodes of
UTI. The long-term health of UTI children needs to be monitored in both normal children and children,
who have a GU anomaly, even when antibiotic prophylaxis has been prescribed for indicated cases.

Acknowledgements
The authors would like to gratefully acknowledge the medical students for providing information from
the patients’ medical records.

Footnote
Conflict of Interests: The authors declare no conflicts of interest.

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