6 month old presented with high fever. 

No respiratory symptoms.
Good stream of urine, doesn't cry while passing urine.
H/o Similar episode of fever one month back, subsided with antibiotics, no urine analysis was done.
O/E: Phimosis+
Urine analysis showed 15-20 pus cells/HPF. 
Urine culture showed Ecoli >1,00,000, sensitive to most antibiotics.
Blood Tests not done.
Ultrasound Abdomen: Both kidneys normal, No dilatation of Ureter, Bladder wall thickness 5mm, Cystitis+, Posterior urethra normal.

1. Should we circumcise only after culture negative?
2. Should we do a VCUG at the time of circumcision?
3. Role of antibiotic prophylaxis?
4. Should we get a DMSA done?
5. Should we get renal function tests done?


  • Dr. Anil Takvani
    Dr. Anil Takvani
    27 May 2020 08:25:10 PM

    1> I have reason to believe child has suffered more than one febrile UTI----I will do VCUG first with reasonable control of UTI.

    2> Till that time I will continue with AB prophylaxis.
    3> No circumcision before or with VCUG
    4> DMSA not now, may consider later based on VCUG and repeat USG scans
    5> Yes, will do renal biochemistry...

  • Altaf Khan
    Altaf Khan
    28 May 2020 11:17:29 AM

    Dear Dr Anil Takwani,

    What is the reason for not doing Circumcision before or during VCUG, since the child has a reason for his UTI in form of Phimosis?

    Thanks and Warm Regards

  • Dr. Anil Takvani
    Dr. Anil Takvani
    28 May 2020 11:52:35 AM

    Only reason is first confirm underlying anatomical condition/conditions responsible for recurrent febrile UTI.

    The evidences of effectiveness of circumcision in absence of underlying anatomical conditions are on either sides. Better not to presume by parents, circumcision only is likely to solve the problem of recurrent febrile UTI.
    We are doing VCUG without any anesthesia without admitting patient in that case there is no logic in combining circumcision with VCUG!

  • Dr. Aadil Farooq
    Dr. Aadil Farooq
    28 May 2020 02:40:05 PM


    CBC,  RFT, USG (KUB)

    Antibiotic tt. & prophylaxis based on Culture sensitivity. 
    Prepucial hygiene and perineal hygiene. 

    When sterile and afebrile, do VCUG  (filling and voiding)
    Assess VUR and grade.
    DMSA if high grade vur,scars on usg, and proteinuria in urine exam.

    Sincere Regards. 

  • Ramesh Babu
    Ramesh Babu
    28 May 2020 03:51:34 PM

    One can do a top down approach. DMSA first and if + MCU. 

    In infants I prefer MCU first. (If no VUR, no need for DMSA, CAP, Circ)

    All infants of this age have physiological phimosis. Circ is not the solution (unless VUR+)

  • Altaf Khan
    Altaf Khan
    29 May 2020 11:53:56 AM

    Thanks for your responses.

    Repeat culture: No Growth
    Did VCUG followed with circumcision today.
    Grade II bilateral VUR.
    S. Creat: 0.2mg/dl

    What next?

  • Dr. Anil Takvani
    Dr. Anil Takvani
    29 May 2020 09:38:29 PM

    As there is history of febrile UTI,put patient on AB prophylaxis despite non dilating low grade reflux.

    3 monthly follow up with symptoms, physical examination, urine analysis. USG 3 to 6 month till age of 18 months.
    As USG is normal will not advice DMSA at present.
    Focus on hydration, nutrition and constipation issues in follow up
    I will stop AB once patient is of 18 to 24 months if no breakthrough infections.
    If no breakthrough infections or new infection after termination of AB prophylaxis...No second VCUG.
    VCUG only if patient develop UTI...

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