Urologic practice patterns of pediatricians: a survey from a large multisite pediatric care center

“An anonymous 15-question survey was created and distributed to all pediatricians at our institution, a large multisite care center. This study was deemed exempt by the institutional review board.”

• “55 of the 122 (45%) providers queried responded. 93% of the participants were female, and 7.3% were male. 55% recommended testicular self-examination at adolescence, while 39% did not recommend at any age. 78% stated that they were “Fairly confident” in the exam for undescended testicle (UTD). One-third referred patients with UDT to a subspecialist upon recognition at birth, 13% at 3 months of age, and 28% at 6 months of age. 10% reported obtaining a VCUG after the first febrile urinary tract infection (UTI), 26% after the second, and 36% only if there were abnormal findings on renal ultrasound. 28% of providers reported that they refer to pediatric urology after the initial febrile UTI. 19% provided antibiotics for UTI symptoms alone with negative urinalysis and urine culture.”

• “Despite established guidelines, practice patterns varied among pediatricians. Pediatricians typically followed the AAP's guidelines regarding VCUGs (62%), with only a few adhering to urologic recommendations (9%). Despite the consistency between AAP and AUA guidelines regarding the age at which to refer a patient for cryptorchidism, about 70% of practitioners referred patients too early or too late.”

• “Harmonized, consolidated guidelines between pediatricians and pediatric urologists would improve patient care and efficiency of the healthcare system.”

• “After initial febrile UTI, 10% of respondents reported ordering a VCUG while 28% report that they would directly refer to pediatric urology for all further work up. The largest group of providers (36%) ordered a VCUG only if there were abnormal findings on renal ultrasound. 26.4% preferred to order a VCUG after a second febrile UTI.

• “75% of pediatricians adhered to AUA standards regarding the performance of GU exam. 40% of pediatricians adhered to AUA standards regarding performance of female GU exam. 28% of pediatricians adhered to AUA guidelines regarding the timing of referral for UDT. 62% of pediatricians adhered to the AAP guidelines regarding VCUG timing. 81% of pediatricians adhered to AAP guidelines regarding treating UTls with a negative urine culture.”

• “The timing of obtaining a VCUG has historically been controversial and our study suggests that this continues to be an area of ongoing debate. 62% of pediatricians (36% obtained if abnormality seen in ultrasound and 26% obtained after second febrile UTI) followed the most recent guidelines put forth by the AAP, which recommends against a routine VCUG after the first febrile UTI unless abnormalities are present on the renal bladder ultrasound or there are other clinical reasons to suspect high-grade vesicoureteral reflux or obstructive uropathy.”

• “Although the majority of pediatricians are following AAP guidelines in terms of timing of obtaining a VCUG, there is growing evidence that renal scarring may be missed by not obtaining VCUGs after the first UTI: Narchi et al. showed that following AAP guidelines would have missed 56% of children with VUR ≥ grade II, and all children with renal scarring would not have been imaged.”

• “While VCUGs are an invasive imaging modality and can cause morbidity such as patient and parent distress, although perhaps less with pretest preparation and child life specialist involvement (22), future studies will be necessary to delineate risk factors for developing renal scarring in order to not improperly delay the diagnosis of symptomatic vesicoureteral reflux.”

• “A small number (9%) of pediatricians did prefer to order a VCUG after the first febrile UTI, which is supported by the Section of Urology" (but not updated AAP recommendations, 2011).