More on imaging after urinary tract infection

Article Outline

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Few issues in ambulatory pediatric practice today are as contentious as the appropriate imaging for a child with a history of urinary tract infection. The issue has been addressed in a host of recent studies, many of which have been published in The Journal. A major point of contention has been the need for a voiding cystourethrogram (VCUG) in order to diagnose vesicoureteral reflux (VUR).

It will probably be awhile before the evidence-based practitioner will have sufficient data to make a truly informed decision on this issue. In the meantime, however, a study in this issue of The Journal provides very useful information. Preda et al report their experience with the use of DMSA scintigraphy in a consecutive series of 290 infants with UTI in the first year of life. A previous retrospective study by this same group had suggested that a normal DMSA scan made the likelihood of VUR very low, but this work was criticized because of its retrospective nature. In the current study, however, this conclusion was confirmed. Of the 27 children in whom dilating (grade III or above) VUR was present, all but one had an abnormal DMSA scan. In the total group of children, 149 had abnormalities in DMSA scintigraphy and went on to VCUG. Thus, if VCUG were only performed in the presence of an abnormal DMSA scan, 140 children would have been spared this invasive test and only a single child with dilating reflux would have been missed.

Of course, broader questions, such as the importance of detecting VUR in the first place and the correct approach after it is identified, are unaddressed by the current study. Nonetheless, data such as that reported by Preda et al can be added to the increasing accumulation of studies which, one day, may provide the framework for a comprehensive evidence-based approach to this common problem.