Urinary tract infections (UTIs) are among the most common urological problems in childhood. In girls under three years presenting with fever, the incidence is about 7.5%; in circumcised boys about 2.4%; and in uncircumcised boys about 20.1%. In male children, the rate is highest during the first six months of life and declines to around 2% thereafter, whereas in girls it is lowest in the first six months and increases to approximately 11% with age.

Normally, urine is sterile and contains no bacteria. The presence of bacteria on urinalysis indicates a UTI and requires treatment. Risk factors for recurrent childhood UTIs include constipation, vesicoureteral reflux (VUR), anatomical abnormalities of the urinary tract, urinary tract stones, and obesity. Escherichia coli (E. coli) is the most common pathogen, though other bacteria are increasingly implicated.

In constipation, the fecal mass in the rectum can press against the bladder, impairing its emptying and leaving residual urine that promotes bacterial growth. Therefore, any coexisting constipation must be identified and treated to prevent chronic or recurrent UTIs.

Poor toilet hygiene, prolonged urine-holding habits, leaving the toilet before complete bladder emptying, inadequate personal hygiene, failure to relax pelvic floor muscles during voiding, errors in clean intermittent catheterization, poor diet, and insufficient fluid intake can also contribute to UTIs.

The pelvic floor muscles support the bladder and bowel and normally relax during voiding to allow complete emptying. If these muscles contract instead of relaxing during urination, residual urine remains in the bladder, creating an environment for bacterial proliferation. Studies have shown that children with UTIs often exhibit increased pelvic floor muscle tension and dysfunctional voiding patterns. Without retraining these muscles, UTIs tend to recur even after antibiotic treatment.

UTI symptoms vary by age. In infants, common signs include poor feeding, vomiting, lethargy, fever, and changes in urine color or odor. Newborns may also present with poor growth, jaundice, or irritability, with or without fever. In children over two, look for frequent urination, urgency, daytime and/or nighttime wetting, pain or burning on urination, and pain in the abdomen or flank. Any of these signs should prompt evaluation by a pediatric urologist.

Assessment of UTIs by a pediatric urologist begins with a detailed history and physical examination, including past medical history (medications, surgeries, related health issues, family history), urinary tract anomalies, constipation, and other bladder or voiding problems. Physical exam should include inspection of the throat, lymph nodes, abdomen, and flank, as well as measurement of weight and temperature.

• Urinalysis and Culture: to confirm infection—proper clean-catch technique is essential.
• Blood Tests: to evaluate kidney function, metabolic disorders, and inflammatory markers.
• Renal and Bladder Ultrasound: to detect hydronephrosis, structural anomalies, and post-void residual urine.
• DMSA Scan: a nuclear medicine study to assess renal structure and function and detect scarring.
• Voiding Cystourethrography (VCUG): the gold standard for diagnosing vesicoureteral reflux and evaluating bladder and urethral anatomy.
• Uroflowmetry (Voiding Test): to assess flow rate and voiding pattern using a sensor-equipped toilet.
• Bladder Diary (2-day voiding diary): logs frequency, volume, and incontinence episodes.
• Bowel Diary (7-day stool diary): records stool frequency and consistency when constipation is suspected.

Test selection is individualized to guide optimal treatment planning.

Once a UTI is diagnosed, prompt antibiotic therapy is administered based on culture results. After infection clearance, underlying factors must be addressed.

• Urotherapy Education (Healthy Bladder & Bowel Training): behavioral modification taught by specialized physiotherapists, covering toileting posture, diet, fluid intake, scheduled voiding, and pelvic floor relaxation techniques.
• Medication: targeted antibiotics, prescribed for the appropriate duration; exercise caution to avoid unnecessary use and antibiotic resistance.
• Pelvic Floor Muscle Rehabilitation: retraining of hyperactive pelvic floor muscles through biofeedback, breathing exercises, and muscle relaxation techniques to ensure complete bladder emptying and prevent recurrence.

Delayed or untreated UTIs can lead to serious complications, including kidney scarring, hypertension, and, in severe cases, renal failure. Early diagnosis and treatment are essential to protect kidney health and minimize long-term risks.