Urinary tract infection in under 16s: diagnosis and management

Reason for the exceptional review

An enquiry was received from the Child Safeguarding Practice Review Panel, which raised the issue of urinary tract infection (UTI) symptoms as a possible indicator of child sexual abuse. The enquiry noted that NICE's guideline on UTI in under 16s does not provide details of the potential for sexual abuse as a possible cause of or contributor to UTI or symptoms of UTI. It was suggested that this should be updated to be consistent with NICE's guideline on when to suspect child maltreatment, which recommends considering sexual abuse for a girl or boy with dysuria or ano-genital discomfort that is persistent or recurrent and does not have a medical explanation (such as UTI).

Methods

The exceptional surveillance process consisted of:

For further details about the process and the possible update decisions that are available, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.

Information considered in this exceptional surveillance review

The enquiry from the Child Safeguarding Practice Review Panel described a case involving a 6 year old girl who presented to a GP 3 times over 3 years with a possible UTI but a negative urine sample on each occasion. Sexual abuse was later confirmed upon presentation with vaginal bleeding. It is possible that with a recommendation to consider sexual abuse in NICE's guideline on UTI in under 16s this may have been identified sooner. NICE's guideline on when to suspect child maltreatment has recommendation 1.1.21 on the need to consider sexual abuse where a girl or boy has persistent or recurrent dysuria or ano-genital discomfort with no medical explanation, such as UTI. The enquiry highlighted the need for the 2 guidelines to be consistent in the consideration of sexual abuse, specifically that the guidelines on UTI in under 16s acknowledges the circumstances in which sexual abuse should be considered or suspected. It was also highlighted that a clinician presented with a child with urinary symptoms is likely to refer primarily to NICE's guideline on UTI in under 16s. Therefore it is important that the consideration of sexual abuse is referred to in this guideline.

No ongoing or published events were identified from the NICE event tracker.

Information considered when developing the guidelines

NICE's guideline on UTI in under 16s was published in July 2022. The committee discussed the implications of non-consensual sexual activity and the implications for safeguarding in babies, children and young people under 16 years. It was considered that clinicians are already aware of safeguarding requirements and noted that the reasons to consider safeguarding actions would be wider than a single or recurrent UTI and that to make a specific recommendation here might lead to unnecessary referrals and trauma for these children or young people and their families.

NICE's guideline on child maltreatment was developed in 2009. The recommendation to consider sexual abuse was based on a small amount of relevant literature, which included the Royal College of Paediatrics and Child Health's: The Physical Signs of Child Sexual Abuse. Two additional case series (n=161 and n=428) were identified that looked at genital symptoms of abuse and highlighted genital pain or soreness, dysuria, genital bleeding, increased urinary frequency and recent onset of daytime or night-time enuresis. The committee thus considered there to be sufficient evidence to establish recommendation 1.1.21.

Equalities

No equalities issues were identified during the surveillance process.

An equalities and health inequalities assessment was completed during this surveillance review. See appendix A for details.

Overall decision

After considering the details of the enquiry and reviewing the evidence presented in NICE's guidelines on UTI in under 16s and when to suspect child maltreatment it was decided that a cross-reference should be added to NICE's guideline on UTI in under 16s. This will link to the recommendation to consider sexual abuse (recommendation 1.1.21). This is primarily to ensure that clinicians consider sexual abuse if presented with a girl or boy with UTI symptoms that are persistent or recurrent and not explained by a UTI diagnostic test. This remains consistent with the committee's thinking during the development of NICE's guideline on UTI in under 16s because a recommendation is not being added but the issue is cross-referenced in line with the enquiry from the Child Safeguarding Practice Review Panel.

ISBN: 978-1-4731-5217-5