Recurrent urinary tract infections (UTIs) in children with congenital abnormalities of the kidneys and urinary tract (CAKUT) with secondary vesicoureteric reflux are likely to result in renal scarring as well as multiple episodes of illness, often requiring admission for intravenous antibiotics. Increasing antibiotic resistance is also a major concern as the antibiotic options typically decrease with each infection. There are many management options including prophylactic antibiotics, non-medicinal products such as D-mannose, clean intermittent catheterisation (CIC), anticholinergics and bladder washouts/instillations. When such interventions fail, management options are limited. The aim of this abstract is to report successful use of overnight free drainage of the bladder to control recurrent UTIs.

A retrospective case note review was undertaken for 5 patients, aged 21 months, 2, 3, 6 & 10 years each of whom had recurrent febrile urinary tract infections with increasing antibiotic resistance. Underlying pathology included 3 with neuropathic bladder secondary to spinal dysraphism, 1 boy with bilateral grade 5 VUR and detrusor failure and 1 girl with bilateral ectopic insertion of ureters in association with a frozen abdomen from neonatal pathology and a refluxing reimplantation. Creation of a vesicostomy was considered in all of the patients as an alternative to overnight free drainage but kept in reserve as a ‘bail out’ option due to the potential for the patients to need major urinary tract reconstruction at a later date. Overnight drainage was established via a urethral catheter in 4 patients and via a suprapubic catheter in the boy with VUR & detrusor failure as he was sensate and did not tolerate urethral catheterisation. Daytime bladder management was by spontaneous voiding in the girl with ectopic insertion of ureters, intermittent SPC drainage or CIC.

UTIs resolved completely in the 3 patients with spinal dysraphism within 2 months of commencing overnight free drainage. Subsequent break-through infections have been rare, <1/year; one patient has had no further UTIs at all over a 5 year period. The girl with ectopic insertion of ureters had previously had multiple admissions, following commencement of overnight catheterisation the UTIs became infrequent and could be managed at home with regular bladder washouts and instillation of GAG-layer replacements. She has been infection free for 2 years. UTIs persisted in the boy with VUR & detrusor failure until he was established on 24 hour free drainage and fortnightly instillation of GAG-layer replacement, he has been infection free for 17 months.

The range of abnormalities included within CAKUT is broad and there is no ‘one-size-fits-all’ solution to managing recurrent UTIs. Paediatric urologists have a broad armamentarium of options which are often selected according to how each patient and their family will manage the therapies. Overnight catheterisation dramatically improved the need for antibiotic therapy for UTIs and reduced the number of hospital admissions. Whilst not formally assessed, quality of life was also improved through prevention of hospital admissions.

Patients with challenging recurrent urinary tract infections in the setting of secondary VUR and an abnormal bladder require individualised solutions. Overnight bladder drainage prevented more invasive management options in these patients. Providing a low pressure 'empty' urinary tract for 12 hours can minimise damaging UTIs.

Continence 2S2 (2022) 100442
DOI: 10.1016/j.cont.2022.100442