Much like adult urology, a focused history and examination should be taken from the child and parents/caregiver to aid diagnosis and management in paediatric urology. In this section, we will aim to discuss clinical investigations and management of paediatric urological conditions commonly seen in the clinic setting.

Recurrent Urinary Tract Infections

Urinary tract infections (UTIs) are the most common bacterial infection in the paediatric population. The incidence is initially higher in boys, affecting up to 20.3% of uncircumcised boys and 5% of girls at the age of 1. There is a gradual shift, with UTIs affecting 3% of prepubertal girls and 1% of prepubertal boys. The National Institute for Health and Care Excellence (NICE) have defined a recurrent UTI as two or more episodes of pyelonephritis, or one episode of pyelonephritis plus one or more episodes of cystitis, or three or more episodes of cystitis.

Diagnostic investigations include urinalysis, which may require suprapubic bladder aspiration or bladder catheterisation in infants. A urine culture and microscopy should be carried out if there is evidence of infection. The role of further imaging is to differentiate between an uncomplicated and complicated UTI, but should also be considered in those with haematuria. A UTI is complicated in the presence of an abnormal urinary tract including upper tract dilatation, atrophic or duplex kidneys, ureterocoele, posterior urethral valves, intestinal connections, and vesico‐ureteric reflux (VUR). NICE guidelines recommend an urgent ultrasound of the urinary tract for all those with recurrent UTI under six months. For children six months and older, NICE in the UK recommends an ultrasound within six weeks of the latest infective episode. All children with recurrent UTIs should be referred to a paediatric specialist and have a dimercapto‐succinic acid (DMSA) scan within four to six months of an acute infection to evaluate for renal scarring. European Association of Urology (EAU) guidelines recommend a renal tract ultrasound in febrile UTIs if there is no clinical improvement, as an abnormal result is seen in 15% of these patients.

Antimicrobial treatment for each episode should be guided by the local antimicrobial guidelines to avoid contributing to resistance. In principle, antibiotic prophylaxis should not be prescribed following a first episode of UTI. In those with recurrent UTIs, trimethoprim and nitrofurantoin are the recommended first line antibiotics by NICE. If unsuitable or second line treatment is needed, cephalexin and amoxicillin should be considered. This should be reviewed on a regular basis and behavioural, personal hygiene measures and self‐care treatments should always be discussed prior to antibiotic prophylaxis.

Reflux

Vesico‐ureteric reflux is a common cause of complicated UTIs and is seen in up to 50% of children presenting with UTIs. The incidence is higher in boys (29%) compared to girls (14%) and they also tend to have higher grades of VUR. Although it can be asymptomatic, VUR is seen in 16.2% of those found to have hydronephrosis in‐utero. There is a hereditary risk, in those with parents with VUR having an incidence of 35.7%, and a 22% sibling risk.