Ep 210: Pediatric UTIs: Myths, Treatment, and Prevention, Insights with Dr. Andrew Kirsch

Episode 210 of Your Child is Normal is a conversation discussing everything you've ever wondered about UTIs! 

It’s common for kids to occasionally feel discomfort when they pee — but how do you know when it’s something that needs more attention, like a urinary tract infection?

In this episode, pediatrician Dr. Jessica Hochman talks with pediatric urologist Dr. Andrew Kirsch, author of The Ultimate Bedwetting Survival Guide, about everything parents should know about UTIs in children — from the most common symptoms to when to see a doctor.

They discuss:

• How UTIs present differently in babies vs. older kids
• Why constipation is one of the biggest risk factors
• When testing and antibiotics are necessary
• What really works for prevention — hydration, bathroom habits, and (maybe!) cranberry extract
• Common myths, like whether bubble baths cause infections

If your child has ever had burning with urination, frequent accidents, or unexplained fevers, this episode will help you feel more confident about what to do next.

Dr. Kirsch  completed both a residency in general surgery and urology at the Columbia University and he completed his fellowship in pediatric urology at the Children’s Hospital of Philadelphia.He has written extensively with an emphasis on vesicoureteral reflux diagnosis and management, publishing nearly 300 journal articles and book chapters. Currently, Dr. Kirsch is a professor and chief of pediatric urology at Emory University School of Medicine and a partner at Georgia Urology.   Dr. Kirsch has been named in Atlanta Magazine’s Best Doctors and The Best Doctors in America list, representing the top 5% of doctors in America.

Your Child is Normal is the trusted podcast for parents, pediatricians, and child health experts who want smart, nuanced conversations about raising healthy, resilient kids. Hosted by Dr. Jessica Hochman — a board-certified practicing pediatrician — the show combines evidence-based medicine, expert interviews, and real-world parenting advice to help listeners navigate everything from sleep struggles to mental health, nutrition, screen time, and more.

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Transcript

Unknown: 0:06

Hi everyone, and welcome back to your child is normal. I'm your host, Dr Jessica Hochman, so I often get questions from parents about what to do when their kids are feeling uncomfortable. When they pee. They want to know why it's happening, how to prevent it, and how to tell when it's actually something that needs more attention, like having a urinary tract infection or UTI so in this episode, pediatric urologist Dr Andrew Kirsch returns to your child as normal to explain what parents should look for when to see a doctor and how to help prevent UTIs from happening in the first place. We also review some common myths, like whether bubble baths actually cause UTIs, if cranberry juice can really be a treatment for UTIs, and how things like constipation and bathroom habits can make a big difference if your child has ever had painful urination, or you just want to understand this topic better, I think you'll really enjoy my conversation with Dr Andrew Kirsch. Dr Kirsch, welcome back. Thank you so much for taking the time to be here again. Yeah, thanks for having me. It's great to be back. So discussion. I'm looking forward to it too. So I have to tell you that a lot of people, there's a lot of parents that I talked to that have concerns that their child may have a urinary tract infection, and I find there's a lot of confusion around this topic. So I wanted to talk to you to bust the myths out there, explain what UTIs are exactly and how to properly treat them. Okay. Yeah, great question. You know, urinary tract infections or UTIs are very common. So first of all, UTIs are most commonly caused by bacteria called E coli, that's probably 90% of them. And children will present with UTIs in different ways. So a small baby, they can't really tell you what's going on. They may just have a very high fever. You know, usually when you have a kidney infection, they have temperatures greater than 102 or three, sometimes only up to 105 and older kids tend to have symptoms other than fever, like burning when they urinate. We call it dysuria, or blood in the urine, hematuria, or they have foul smelling urine, or have urinary frequency. So you know it's really important to evaluate these kids, because there are mimickers of urine tract infections, and probably the biggest one is constipation. 80% to kids that have chronic constipation will get urinary tract infections. I appreciate that, because I think learning clues like, okay, constipation may be a risk factor for urinary tract infections. I think that's really helpful for parents to be aware of possible risk factors. I also really appreciate that you distinguish between the clinical symptoms of an older kid as opposed to what we see with babies. I think many people know that when you have painful urination, when you're going often, that may be a sign of a UTI, but I think a lot of people aren't aware that a fever in a young baby may be a sign of a urinary tract infection. So I think that's helpful to know. Yeah, you know, I think in very young babies, less than two months, you know, if they have a high temperature, they are seeing the emergency room, and they do get catheterized specimens, which is really important if they use bag specimens, putting a bag over their child's perineal area and collect urine, those tend to only be useful if they're negative, if they don't show bacteria, because they do, it's usually a contaminant. Now, I'm glad you brought that up, because we do recommend to families to get a catheterized specimen, and that's hard, because you have to put a catheter in the urethra of a young child, but it really is the best way to accurately know if there's a urinary tract infection with an older kid, you can have them urinate in the cup where they can clean ahead of time, and you can get a pretty good sample. But with a baby, it's too risky to not get a catheterized specimen. Like you said, it's too easy to get a contaminated specimen, absolutely. To point out, I think, is that in small babies that have urine tract infections associated with fever, we define that as a kidney infection, the chance of them having some type of anatomic or structural problem really goes up in incidents. For example, one of the problems that we see with babies with urine tract infections is vesicular reflux or VuR, and that could be seen up to 50% babies and infants that are less than two, and so we're very careful about screening for that problem, because it is easy to diagnose and easy to treat. And can you explain what that is? Exactly what is VuR, yeah. So vor is when the urine either during bladder filling or during emptying, or both the urine shoots up to the kidneys, so instead of coming down to the bladder, it does that, plus it also goes back up. And if you have a bladder infection, then that bladder infection could become a kidney infection by the backward flow of urine. And that's something that, again, is very common. So in babies, less than. Two, maybe 50% in kids over age three, four or five, it goes to about 30 or 50% so it's still very common, and probably 1% of the population has urinary reflux. So if a parent hears that their child has urinary reflux, we can reassure them that we'll keep an eye on it, but likely it will improve over time. It depends we do a catheter study of the bladder to make the diagnosis. That's called avoiding cysto uregram or vcug. That's the only way you could really diagnose reflux. So once we have that information, there are a couple of factors that will increase a child's likelihood of not resolving the reflux. So a couple of factors that are important are gender, so girls tend to have a much higher risk of infections than boys due to having a short urethra. And then the other factor would be the timing of reflux on that actual study. So if you think the bladder filling up slowly with contrast, or die. If the reflux is seen to happen very early in that filling phase, that's the type of reflux that really does not go away very quickly. And then the final risk factor is whether or not there are other problems in the bladder. One of those problems is maybe a child has two ureters on one side, that's called the duplication anomaly, or they have a little pouching next to the uterus called the diverticulum. So if you put all those risk factors together, the child that has the highest risk is a girl with early filling reflux, with high grade reflux that has an anomaly. In that case, there's about an 8% chance that over the next several years, the reflux will go away. But now what we're seeing is that there are more and more children that are at risk if you don't diagnose reflux. So for example, after a first kidney infection, again, that's a urinary tract infection with fever, the chance of a child having a scar in their kidney is about 3% the chance of having a scar in the kidney after your second infection is about 25% and you say a kidney scarring. How bad is that? Exactly? Yeah, so it's a great question, and a complex one, because scarring could be either congenital, which means you're born with it, and that's really a developmental problem, that kidney never developed normally. So if you do a study to look for scarring, you're going to find it that has to be distinguished from acquired scarring. Acquired scarring means your kidneys are normal. You've had multiple infections, and now those infections have led to inflammation, and the inflammation causes some of that tissue to die off. So there's a difference. And the main difference is, if you don't have a UTI and you have scarring, that's congenital renal dysplasia, as opposed to acquired scarring, which typically is in girls with recurrent urinary tract infections. So what is the significance of scarring? If you have one small scar in your kidney, it probably doesn't mean much at all if you have scarring in both of your kidneys that's significant that may lead to high blood pressure you're typically around puberty. It can also lead to problems during pregnancy, and so another reason to be more aggressive, especially in children that are high risk for UTI children that have abnormal kidneys, or even one kidney, or some type of abnormality structurally with their kidneys, we will spend a little bit more time trying to do what we can to prevent scarring, but most kids that have low grade reflux, that have not had multiple UTIs, will not have scarring that's of any clinical significance. Thank you for explaining that. That's that's very helpful. Okay, so just to summarize the risk factors that you mentioned that may increase the risk of urinary tract infections, being a girl because you have a shorter urethra, constipation, certain anatomic issues, reflux, is there anything else that may cause an increased risk of urinary tract infections. So there's a whole lot of risk factors, you know, some we call host factors. That's the patient. So a really young child, maybe doesn't have a good immune system, has more trouble fighting bacteria, or somebody with chronic illness, they may have more difficulty fighting infection, but reflux itself is probably one of nine risk factors, and within that category of reflux, there are factors that increase the chance of infection, and some make you very low risk, even if you get diagnosed with reflux, we look at gender, but we also look at boys that are uncircumcised, they have a risk factor. Typically, that risk is for the first year of life, and after that, if they have relatively normal foreskin, that's easy to clean, that goes back partially, at least, they are at no increased risk compared to girls you mentioned constipation. Yes, we have an additional category that encompasses constipation called bowel and bladder dysfunction, or. BBD. And these are kids that have holding maneuvers. They basically hold the urine. They hold their stool. So these are the kids that all of a sudden develop severe urgency. They got to run to the bathroom. They have five seconds. So that's urgency frequency. Some of these kids will have incontinence because they get bladder instability. And the reason why bowel and bladder problems go together is because they're all related to the pelvic floor musculature. For example, think of the pelvic floor muscles as a hammock, and it's holding the rectum through the back and the urethra through the front. So if a child is holding they're holding both at the same time, and that's where they get bladder instability and constipation. And the way we treat those children is, besides just treating their constipation is sometimes with biofeedback, we have to try to teach them how to relax when they go so they don't get bladder instability and urinary tract infections and the whole host of other issues that we see with bowel bladder dysfunction. I really like the hammock analogy. Someone once explained to me that they share similar real estate. The bladder sits so closely to the colon, and if the colon is filled, it will sort of tug on the nerves of the bladder and give the sensation like one has to urinate frequently. We like to say the rectum is pushing on the bladder, and that's where you feel like an urge to go. But the other thing is, this may be more theoretical, is that the bacteria responsible for infections are sitting right behind the bladder, and girls have a short urethra, closer contact to the anus and rectum. But there may also be what's called translocation. Bacteria get directly through the wall of the rectum and then into the bladder and cause a urinary tract infection. I think everything else probably makes more sense than that, but that's what's in the textbooks. It's interesting because, as you pointed out, E coli is responsible for most of the urinary tract infections that we see, and E coli comes from the bowel, but there's so many babies that I see that are sitting in dirty diapers all the time and they never get a urinary tract infection. I think the body also has amazing defenses. It's just that you would identify the ones that don't have those defenses and protect them the most. Okay, so now let's say a parent thinks that their child may have a urinary tract infection. What would you tell a parent should be the next step to diagnose a UTI, so they would need to get a urine culture, and so they would either see their pediatrician, or if it's after hours or weekends, pediatrician may not be available. They need to go to an urgent care. But I always tell the parents that they're the best judge of how their children are doing, but you can't diagnose a urine Tract Infection without a culture. And so it's really important that you take that step. You also have to avoid treating the presumed infection with antibiotics, because once you do that, you miss the opportunity to know what that bacteria was, and it makes treatment more difficult. I think that's a really important point that you want to get the culture first, because there's a lot of parents who want to start treatment before we know what the diagnosis is. But it does help to have that culture just to confirm the diagnosis, to make sure we're prescribing the best antibiotic that's going to work for that particular infection. So that's very helpful to remind everybody that you want to get a culture first. Yeah, and another reason to at least be more concerned about, especially a kidney infection with fever, is that if that infection goes untreated for more than 48 hours, that's been shown to increase the risk of developing a collection of bacteria in your kidney called an abscess. And those kids do need to be admitted, they may need to be treated, even surgically, to drain it if they don't get proper treatment, not to scare people going more than 48 hours when you are concerned about your child, you should definitely have them evaluated. Now, the treatment for UTIs is antibiotics, and I have to tell you that this is a situation in medicine where I'm so grateful to live in an era where we have antibiotics readily available. Because in my experience, when I see kids with UTIs and we treat them properly, they get better really quickly. They do and getting harping back on the 48 hour rule. If they're not getting better quickly, they're not responding to your antibiotic, and you might assume that they have either a very unusual bacteria or a resistant bacteria. Those kids especially need to be seen when they potentially would need IV antibiotics to treat them. That's a helpful point. So if anybody out there is taking antibiotics for urinary tract infection, you should feel better within 48 hours. Otherwise, make sure and talk to your doctor. That's correct. Is that what I'm hearing? You heard it, right? All right, yeah. And now there are a lot of families that are concerned about antibiotic overuse, and they ask, Does my child need to take antibiotics? Is there another treatment that could possibly help treat the UTI what would your response to that question be? I'm thinking, as you just mentioned, bacteria are killed by antibiotics. Is so you know, over the counter, types of remedies may treat symptoms, but not necessarily knock out the bacteria. So only antibiotics could treat a bacterial infection. A lot of parents, if their child's uncomfortable and they can't get in to see their doctor right away, they'll take azo. Do you think that's an okay treatment? So azo is again, it's not an antibiotic. It doesn't treat the urinary tract infection. It could treat the symptoms. So if your child is feeling better, it might be that they don't have burning when they urinate. They may have bladder pain goes away, but it's not going to make their fever go away. You shouldn't use azo for kidney infections. You might get symptomatic relief, but again, you shouldn't let these go for too many hours or days if there's significant symptoms. I wanted to bring that up, because the azo can give temporary relief, but I think it's important to remind people that you still want to go to the doctor, even if your child's feeling better. Yeah. Another one, besides azo, is cranberry extract. People need to know that you can't drink enough cranberry juice to get the active ingredient of cranberry and it's called Pax pro anthocyanidine. It's a big word, but it is effective. So there are studies every five to 10 years that come out in favor of this type of treat with cranberry extract, and then they come back and say, it's not effective. But the way that cranberry extract works is that it makes the bacteria E coli, it prevents it from binding to the colon wall, so you're really passing the bacteria. It doesn't get absorbed as well. So that's why you'll find articles that say it's effective. So you will see patients, yeah, and you know this when your practice that they don't want to be on antibiotics, and they've already tried all these things, and they probably will come to you when it's late in the disease development. But I don't think there's a whole lot wrong with patients who try some of these things for symptom relief, but I think the use of azo is probably less of a good treatment than using something like cranberry extract, at least there's some data to support it in treating bacterial infections and how I've thought about cranberry extract, It's not a treatment, but it may help with prevention. So along with good hydration, frequent urination, you could consider using cranberry extract. If you're someone who tends to get a lot of urinary tract infections, absolutely. So kids that are like bowel and bladder dysfunction, kids and they don't want to go on antibiotic prophylaxis every day, you could use it. It's probably not what you would say is the best treatment. But I think if some families are not going to give antibiotics, it's probably better to use something than nothing. It's true what you say, though, every five to 10 years, I would agree, something comes out about cranberry extract, and I think we want it to work. We want it to work well, because it sounds so nice. It's got a nice explanation for how it may be beneficial. It's natural, it's cranberry. And then how I understand it is you'd have to have so much sugar from all the cranberry juice that would actually provide a potential benefit that it's just not worth it. It's also bad for your teeth. Bad for your teeth. Okay, so if we are going to consider trying cranberry as a means to help with urinary tract infections, it sounds like the best thing is to take in the form of extract and to take it as a preventative measure. Absolutely Okay. All right, yeah. Again, this is a situation where I'm so grateful to have antibiotics. Yeah, I will say too. Another thing that I noticed in my practice is that teenagers, particularly teenage girls, when they have urinary tract infections with frequency, I find that there's a very high correlation between sexual activity and urinary tract infection. Yeah, it's not uncommon for in the adult world or late teenage years that antibiotics are used preventively after sexual intercourse or before. It's all just mechanically the bacteria being translocated. That's the explanation. Correct? That's the explanation. Yeah. Okay, so now I'd love to talk with you about prevention, because I know we touched on some aspects of prevention. What are some everyday habits that we can tell parents, or we can encourage parents that may help lower their child's risk of UTIs? There's so getting back to the risk category, we talked about anomalies, they can't really change that unless there's one that is clearly associated with it, like reflux, or if their urine tracks are obstructed, that's more of the surgical realm of UTI, which is clearly not the most common. But there are other factors like, besides just gender, there are factors like genetics. Some people just have, we say, stick your bladder linings, the bacteria like to harbor there. A lot of people, if you just randomly did a urine culture on the population, you'll find that 15% carry bacteria in their bladders. And that's by a standard urine culture. So genetics is important for the family, but it's also the genetics of the bacteria, and that's why some bacteria will mutate, so they may be effectively treated by one antibiotic, and maybe next time you get an infection, it's not effective. So genetics plays a role. And then there's simple things that we talked about, bowel bladder dysfunction, that is something that you could control. You try to divide things and things that you can control and things you can't. Bowel habits is really important. Keeping the bladder empty as much as possible is important, staying hydrated, and that's just flushing bacteria out. It's important to be hydrated, not constipated. And so those are the basics to preventing a urinary tract infection. Now, just to talk about this a little bit more, when you talk about bathroom habits and going to the bathroom regularly, can you explain why that is? Why does that help prevent UTIs? If you realize that 15% of the population has bacteria, the bladders are not having a clinically urinary tract infection, then the population that are getting infections, there's something different. We talked about the genetics and things like that, but bacteria in your bladder is not necessarily a bladder infection. Bacteria that colonize in your bladder, they form multiple colonies of bacteria, and you are clinically affected by that. The symptoms that you see, blood burning, frequency, urgency, that's a clinical urinary tract infection. So we do see kids that get misdiagnosed with urine tract infections because they had a low bacterial count, perhaps, or a dipstick that showed white blood cells and bacteria, but really they may not have a true urinary tract infection. Again, it's important to distinguish between what is just asymptomatic bacteria, which is bacteria in your bladder versus a clinical urinary tract infection, because the treatments are totally different. Totally different. You don't really want to treat asymptomatic bacteria for the most part. Interesting. That's really good to know, because as someone who prescribes antibiotics, and I'm really careful and hesitant to not prescribe when it's not necessary, I think that's an important point to understand that you want to treat those who are symptomatic, who have clinical symptoms, those that are experiencing the burning dysuria, the frequency, as opposed to not having any symptoms at all, and treating right? That's helpful, exactly right. And also, the way I understand it is for children, you want to encourage them to go to the bathroom frequently, because if they hold their bladder, that gives the bacteria a chance to be stagnant, and those small colonies can multiply into larger colonies, and then you can have an increased risk for urinary tract infection. We call that urinary stasis. So the same thing, it happens in your bladder, it could also happen in your kidney, and that's something you want to avoid. So drinking and clearing out your kidneys is always a good thing. And what I tell families where I'm really concerned about their intake of fluid, I said, aim for clear urine. If your child is peeing clear, they're hydrated. If their mucous membranes are wet, they're hydrated. And so it's hard to tell somebody drink two liters of fluid a day, and especially constipated kids, they don't want to eat or drink. So those are the ones that you really have to be a little more concerned about and be a little more aggressive. That's a great point. I also think it's helpful for parents to know that you want to encourage your kids to pee when they have to pee, because I remember when I was a kid, we got praised for holding our urine if we were on a long car trip or we could wait it out through a movie or whatever the occasion was, it was a good thing if you were good at holding your urine, but you don't want to do that. That's actually not healthy for kids, it's not healthy. And there's actually a condition, it's very rare, called a human bladder. And these are kids that hold their urine for so long that their bladders just expand. The same concept is with truck drivers, they may drink coffee and try to drive 910 hours without stopping. Their bladders get stretched out so they no longer empty. They get stasis. They get infections, they get incontinence. So any child that's holding their urine all day, it should be a red flag that something needs to be done differently. And somebody that's holding their urine, if they're not also holding their stool, may have this type of bladder dysfunction. So very rare, but very important to know. So just to summarize, when we're considering urinary tract infection prevention, we want to think about going to the bathroom regularly. We want to think about drinking enough so that our urine looks clear. We want to make sure that we're treating constipation, and it sounds like also, for bonus, you could take a cranberry extract supplement. Yeah, there's definitely no harm in that. It might be helpful. Now I'd love to talk to you now with the survey that you did at schools. I find this really interesting. Can you tell everybody about the survey that you did for school? Rules and bathroom breaks. Yeah. So we were very interested in determining what bathroom policies were at schools, because we see a lot of kids that have bowel and bladder dysfunction, and one of our treatments is that you need to go to the bathroom every two to three hours. And what we're finding is that these schools, first of all, they require a note, okay, so we have these print out in our office. Anybody could get a note that says free access to the bathroom. Most schools in this survey, most parents, they would the respondents, and what they would say is, yes, our school has free access probably 75% of the time. But when we supply a note to them, they do say that about 10% of these kids felt comfortable even letting their teachers know that they need to use the bathroom every two hours, so they're hesitant to share that note with their teachers. So it may be that parents have to be a little more aggressive, knowing that their child still may feel very awkward about showing their teachers these notes that allow them free access to use it. In the worst case scenario, there are schools out there that give you passes, and I understand why teachers and schools do that, because especially when you get into the junior high years, people may be using the bathroom as an excuse not to be in the classroom. I get that, but what we found is that about 5% of schools or teachers will give extra credit if you don't use your bathroom passes. That's concerning to me, that they're tying in a medical health problem to inflating grades if you don't follow medical advice. So as part of the American Academy of Pediatrics in Georgia, this is one of the studies that we're doing, leading this study trying to figure out what bathroom policies at school are, because there may be a bathroom policy at the school, but teachers override any bathroom policy, and I'm not sure what the communication is yet between school policy and teacher policy, we found that it's a common problem, and I think we now have identified, at least from the parents perspective and a child's perspective, some of the areas of improvement that we can affect. I actually do find, when I talk to families, that school bathrooms are a big issue, and I think for a couple of reasons. One, as you pointed out, I understand that it's difficult for teachers to teach a class of young children, and if they're going to the bathroom all the time, it can be very disruptive, and I'm sure it's really hard to get the lessons taught that they want to get taught. Also, a lot of kids don't want to use their school bathrooms. They're afraid of them. They think they smell funny, they stay away, and they don't use the bathroom for the entire day. And so that's also something that I try exploring with children. Is there something that we could do to get you to use that bathroom at school? Yeah, that's been reported that children sometimes it depends on schools, but that they don't feel safe, or the bathrooms are really dirty and they really smell bad, and they just are not going to have it. So they've learned to hold their urine for multiple hours during a day. I think the only thing that a parent really could do is make sure your child goes to the bathroom before school, because if they miss that morning void then they are going to have big problems during the day, and you don't want them to have an accident in school, because that will lead to other social issues. So they could be proactive in that respect. And if they really do have recommendations made to them by their doctor about timed voiding, then I think it probably is a visit to the teacher or school to at least find out what the situation is, so that they can be the best advocate they could be for their children. I'm curious what led you to start this parent survey? It's something we started probably three or four years ago where we just got curious because to treat patients that have bowel bladder dysfunction, it's not something you treat overnight, but if you think about how long a kid spends of their lifetime in school, it's most of it. If we could tell them everything to do at home, if it's not happening all day at school, then it's not helping at all. That realization came to us, and then we started to just ask parents, and then we started to learn about bathroom policy. And I said, Wouldn't it be nice to have every patient that comes through my door scan this QR code and answer these questions so we could get a better idea of how we could affect policy in our state? So if you could give a message to all schools about a healthy bathroom habit. What would you recommend to them? Yeah, I'd say there probably needs to be a time with select children where you can identify as a time where they could use the restroom. And I understand it's disruptive, but if you think about how schools treat children and. Use the bathroom, they start off by lining them all up at the same time, and not every bladder is filling at the same rate. So it's not like everybody needs to use the restroom. You could probably trip train kids, and I think that's what they're doing, but it's not going to be effective in everybody. And I know those kids are going in and not using the restroom, so there needs to be some type of fallback for the kids that really need to go. So I think schools need to figure this one out, and we're around to help with this process. Yeah, maybe I'm thinking out loud that if a child really needs to go regularly and they're embarrassed to talk to the teacher, I think as the parent, I would also want to have a conversation with the teacher on the side and let them know, maybe they can remind the child to use the restroom Exactly. Yeah, because the teachers are the daytime parents, and they have a huge responsibility, because their family is pretty big within that classroom, and they I totally get why they're doing everything they're doing, but again, we have to identify that at risk population. I have to tell you, before I became a pediatrician, I had no idea how important good health relied upon regular bathroom use like I had no idea how important it was to poop regularly, and that using the bathroom urinating frequently, how much of a difference it made in children's health, I agree, comes up all the time, every day comes up every Day. Okay, so I thought before we close, I thought it'd be fun to ask you a few lightning round questions just to hear what you have to say. Absolutely. Let's do it all. Right, what would you say is the single most important daily habit to reduce UTI risk? I think regular bathroom habits, using the restroom every four hours, I would say is a reasonable time. Some kids need to go every two to three hours, but I think every four hours. Using the restroom works well. Wiping front to back is that truly helpful in preventing UTIs, true or false? I think it could be helpful the hygiene, the way that you move bacteria from back to front is probably not a good idea, and going front to back is the way to go. Bubble baths. Do they cause UTIs? So that's a great one, because that's the biggest one. I think over the years, that is a myth. I believe that bubbles and detergents in general, cause irritation of the urethra. They look like a UTI, but bubbles don't cause urine tract infections, because the bubbles. Aren't bacteria. Any myths that you'd like to bust with regards to UTIs? I think when parents are concerned about UTIs, they go to the drugstore and get a dipstick. There are lots of parents that like to dip their kids urine, and if they're concerned, they dip it often. I think you got to be really careful with those that they're doing them properly and that not just one of the indicators is positive, but if you have leukocyte esterase positive, and you have bacteria positive, and you have nitrates positive, then those will increase the sensitivity to about 90% but again, you still need a urine culture if you want to treat it properly, most common symptom of a UTI, it depends on age. Small kids that can't tell you will have high fever, and older kids might complain of dysuria or burning when they pay all right, vanilla or chocolate. Vanilla sounds a fun one to wrap up with, all right. And last thing I'd like to ask you, you were on the podcast before and you talked about your brilliant new pending invention to help kids that are urinating overnight, that can't hold their bladder overnight. Can you tell us? Are there any updates about this product? The Salou, yeah. So I'll start by saying we have a book. So you know, this is the ultimate bed wedding Survival Guide. So if your listeners want to go to their favorite bookstore online, they could look up the ultimate bed wedding Survival Guide, and it gives them all tips about bed wetting, all the different treatments, but for interventional therapies, which means that you're going to do something beyond having your child empty their bladders before they go to bed, and your Child has bed wetting, then we have a new device that we're about to study, called Salu. And so Salu is a wearable. It means that it has electrodes that stick to the bottom, and as soon as one drop of urine hits the sensor, then we have a little device, which is a nerve stimulator, which will actually make their sphincter muscle close, which is your control muscle. It'll make the bladder relax. It'll actually stop them from urinating. It's not commercially available yet, but it's the only device that actually stops bed wetting by using neuromodulation or nerve stimulation. And part of the device is an app that will send a message to the parent that it went off. That way, they can wake their child up, who may not wake up to an alarm, most of them don't, and they can wake them up with a full bladder, take them to the bathroom. So if people are interested in hearing more about this, please go to my website. They can just google s, o, l, u, u, and they'll take them to globe. Continents.com we have a place that they can sign up, put in their email that's all private, and they'll be the first to know about this device. And hopefully within the next year or so, we'll be able to get people dried up using this device. So we're very excited about it. I appreciate your asking about it. Of course, after our previous podcast together, I've had a number of patients inquire about it, and so this is helpful to know that they can't get it quite yet, but they can give their email, and then they'll be the first to be notified what it is available, yeah, and I can show them that this will be safe and effective treatment, because we're going through the FDA, and it is a requirement to show that it's safe and effective. So if this does go through this year or next year, then it will be the only FDA approved treatment for bed wetting. Amazing. Well, I look forward to hearing about the product. I can't wait for it to be released. I know it's going to help a lot of people. And thank you so much for being here. I really appreciated talking about urinary tract infections. I know there's a lot of confusion and myths out there that I'm so happy we got a chance to clear those up. And I also think it's just really helpful for people to know what symptoms to expect, what to look out for, how to treat them and how to prevent them. So thank you very much. Thank you very much for having me. Thank you for listening, and I hope you enjoyed this week's episode of your child is normal. Also, if you could take a moment and leave a five star review, wherever it is you listen to podcasts, I would greatly appreciate it. It really makes a difference to help this podcast grow.