A 4-year-old girl is brought to the office due to painful urination. For the past 2 days, the patient has cried during urination; only a small amount comes out each time. She has no vomiting, nausea, or fever. Medical history is unremarkable except for functional constipation since starting day care at age 2 and 3 episodes of cystitis in the past year. The patient completed a 3-day course of trimethoprim-sulfamethoxazole 6 weeks ago for the prior episode of cystitis. Temperature is 37.2 C (99 F), blood pressure is 98/56 mm Hg, and pulse is 110/min. On examination, the patient is not in acute distress. The suprapubic region is moderately tender to palpation. There is no back pain. Genitalia are normal. Anal fissures are present at the 12 o'clock and 2 o'clock positions. Rectal examination shows normal tone and hard stool in the rectal vault. Urinalysis results are as follows: Urine culture shows 100,000 colonies of Escherichia coli. Which of the following most likely contributed to this patient's current illness?

Question

A 4-year-old girl is brought to the office due to painful urination.  For the past 2 days, the patient has cried during urination; only a small amount comes out each time.  She has no vomiting, nausea, or fever.  Medical history is unremarkable except for functional constipation since starting day care at age 2 and 3 episodes of cystitis in the past year.  The patient completed a 3-day course of trimethoprim-sulfamethoxazole 6 weeks ago for the prior episode of cystitis.  Temperature is 37.2 C (99 F), blood pressure is 98/56 mm Hg, and pulse is 110/min.  On examination, the patient is not in acute distress.  The suprapubic region is moderately tender to palpation.  There is no back pain.  Genitalia are normal.  Anal fissures are present at the 12 o'clock and 2 o'clock positions.  Rectal examination shows normal tone and hard stool in the rectal vault.  Urinalysis results are as follows:  Urine culture shows 100,000 colonies of Escherichia coli.  Which of the following most likely contributed to this patient's current illness?

Quizplus · Accepted Answer

11ec25c8_d728_6bd1_bc81_fd80c1a6dae3_MD0003_00 This child with multiple episodes of simple cystitis (ie, no fever, flank pain) over the past year has recurrent cystitis. There are a variety of risk factors for recurrent cystitis in children; in this patient, this is most likely secondary to her functional constipation. Young children are at risk for functional constipation during times of dietary changes that alter stool consistency (eg, introduction of cow's milk and solid foods) or during the onset of stressors that cause withholding behavior (eg, toilet training, starting school/day care). In patients who develop chronic constipation, the retained feces cause the rectum to progressively dilate. The hard stool in the dilated rectum distorts and compresses the bladder and urethra, which prevents complete voiding and leads to urinary retention and stasis in the bladder. As a result, the residual urine becomes a potential breeding ground for bacteria that ascend through the urethra from the perineum, causing cystitis. Therefore, in addition to treating the recurrent cystitis, additional management includes treatment of the underlying risk factor. In patients with functional constipation, this involves long-term laxative therapy to soften stools, prevent stool withholding, and allow the rectum to return to normal size, thereby relieving the pressure on the bladder. (Choice A) Inadequate treatment of a prior infection is unlikely due to the 6-week gap between the current and prior infections. A short course of trimethoprim-sulfamethoxazole is adequate treatment for lower tract infection in children. (Choice B) Recurrent urinary tract infection can rarely be a sign of primary immunodeficiency; however, these patients have severe infections (ie, pyelonephritis rather than cystitis) and multiple types of infections; this patient's medical history is otherwise unremarkable. (Choice C) Sexual activity is associated with recurrent cystitis in women, but it is rarely the cause in children. The lack of genitalia injury to this patient makes sexual abuse less likely; anal fissures are a common feature of chronic constipation. (Choice E) An underlying anatomical condition (eg, vesicoureteral reflux) is a common cause of recurrent urinary tract infections in infants; however, vesicoureteral reflux leads to recurrent upper (rather than lower) tract disease (ie, pyelonephritis). Educational objective: Chronic constipation is a risk factor for recurrent cystitis in young children. The impacted stool can cause rectal distension, which compresses the bladder and urethra, prevents complete voiding, and leads to urinary stasis and bladder infection. References: Urinary tract infections in children: an overview of diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/31646191) Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. (http://www.ncbi.nlm.nih.gov/pubmed/9240804) Chronic constipation: a cause of recurrent urinary tract infections. (http://www.ncbi.nlm.nih.gov/pubmed/8165751)

A 4-Year-Old Girl Is Brought to the Office Due to Painful