What assessment and treatment should be done for a 20-month-old girl with dysuria?

Assessment and Management of Dysuria in a 20-Month-Old Girl

For a 20-month-old girl presenting with urinary pain, obtain a catheterized urine specimen for urinalysis and culture, perform a focused physical examination, and initiate empiric antibiotic therapy if urinary tract infection (UTI) is confirmed, followed by renal/bladder ultrasound imaging. 1, 2

Initial Clinical Assessment

History Taking

• Urinary symptoms: Specifically assess for frequency, urgency, fever, and any changes in urine appearance or odor 1, 3
• Fever evaluation: All febrile children 2 to 24 months of age with no obvious source of infection should be evaluated for UTI 3, 4
• Voiding pattern: Document any dribbling, changes in stream, or continuous wetting that might suggest anatomic abnormalities 1
• Recent illness: Assess for concurrent upper respiratory symptoms or other potential fever sources, though maintain high suspicion for UTI even with other symptoms present 1
• Bowel habits: Evaluate for constipation, which increases UTI risk and should be addressed 3

Physical Examination

• Abdominal examination: Palpate for bladder distention, masses, or suprapubic tenderness 1
• Genital examination: Inspect for abnormalities, signs of trauma, irritation, or labial adhesions 1
• Back examination: Look for sacral dimples or other signs suggesting spinal abnormalities 1
• General assessment: Evaluate hydration status and overall appearance to determine severity 2

Diagnostic Testing

Urine Collection and Analysis

• Collection method: Obtain urine via catheterization (preferred) or suprapubic aspiration—never use bag collection for culture 4, 2
• Urinalysis: Perform immediately to assess for leukocyte esterase, nitrites, pyuria (≥10 WBC/hpf), and bacteriuria 3, 4
• Urine culture: Send simultaneously with urinalysis; UTI diagnosis requires ≥50,000 CFU/mL of a uropathogen from catheterized specimen 4, 2
• Important caveat: Clear urine on inspection with negative dipstick has 95-98% negative predictive value for UTI, but culture should still be sent 1

Imaging Studies

• Renal and bladder ultrasound: This is the only imaging usually appropriate for a first febrile UTI in this age group (2-24 months) 1
• Timing: Can be performed during acute illness or shortly after treatment initiation 2
• Purpose: Identifies significant renal abnormalities, hydronephrosis, stones, or complications like abscess 1
• Voiding cystourethrography (VCUG): NOT routinely indicated after first UTI unless ultrasound shows abnormalities suggestive of vesicoureteral reflux (VUR), obstructive uropathy, or selected renal anomalies 1, 2

Treatment Orders

Antibiotic Therapy

• Empiric treatment: Initiate antibiotics promptly once urine specimens are obtained 4, 2
• Route: Oral antibiotics are appropriate if the child is not seriously ill and can tolerate oral intake 2
• First-line options:
  • Trimethoprim-sulfamethoxazole (higher cure rates than amoxicillin due to E. coli resistance) 3
  • Amoxicillin-clavulanate 3
  • Cephalosporins 3
• Duration: 7-10 days for febrile UTI 2
• Adjust based on culture: Modify antibiotic choice according to sensitivity results 4

Supportive Care

• Hydration: Ensure adequate fluid intake 3
• Constipation management: Address if present to prevent recurrent UTIs 3
• Pain management: Provide appropriate analgesia for dysuria symptoms

Follow-Up Planning

Short-Term Follow-Up

• Clinical response: Reassess within 48 hours to ensure improvement on antibiotics 4
• Culture results: Review and adjust antibiotics if needed based on sensitivities 4
• Parent education: Instruct caregivers to seek rapid medical assessment (within 48 hours) for any future febrile illness to detect recurrent infections early 4

Imaging Follow-Up

• Ultrasound results: Review for any abnormalities that would prompt further evaluation 2
• VCUG consideration: Only if ultrasound reveals concerning findings 1, 2
• Prophylactic antibiotics: Generally not recommended after first UTI, even with mild-moderate VUR, as they do not reduce recurrence risk 3

Common Pitfalls to Avoid

• Bag urine specimens: Never use for culture—high contamination rates lead to overdiagnosis and unnecessary treatment 4, 2
• Overimaging: VCUG is not indicated routinely after first UTI; reserve for specific ultrasound findings 1, 2
• Delayed treatment: Prompt antibiotic initiation after specimen collection improves outcomes 4
• Ignoring constipation: This modifiable risk factor should be addressed to prevent recurrence 3
• Routine prophylaxis: Avoid prophylactic antibiotics after first UTI unless specific high-risk features present 3