Contributed by Sherril Sego, FNP-C, DNP, a staff clinician at the VA Hospital in Kansas City, Mo., where she practices adult medicine and women’s health. She also teaches at the nursing schools of the University of Missouri and the University of Kansas. 



A 3-year-old girl presented with recurrent urinary tract infection (UTI)/pyelonephritis (three occurrences within the last year). She is potty-trained but wears a diaper at night. Each time, she responds well to antibiotic therapy and has a positive culture for E. coli. Urologic workup was ordered, and a VCUG was done, which showed a grade-3 VUR on the left side with mild hydronephrosis. Interestingly, a “spinning top” formation was noted in the distal urethra. This is a widening of the distal urethra, creating a “pseudo-bladder.” When voiding, this area empties, and the patient feels she is done. The chronic, large, postvoid residual eventually leads to the presenting problems. 


The patient was started on daily prophylactic antibiotic therapy with a timed voiding schedule. A repeat VCUG six months later showed a decrease in the VUR. No more episodes of UTI followed. (201-7)



These are letters from practitioners around the country who want to share their clinical problems and successes, observations and pearls with their colleagues. We invite you to participate. If you have a clinical pearl, submit it here.