Vesicoureteral reflux

Vesicoureteral reflux refers to the retrograde flow of urine from the bladder to the ureter and kidney.

It is thought to result from a congenital incompetence of the ureterovesical junction

The ureteral attachment to the bladder normally is oblique, between the bladder mucosa and detrusor muscle,creating a flap-valve mechanism that prevents reflux Reflux occurs when the submucosal tunnel between the mucosa and detrusor muscle is short or absent

Primary Vesicoureteral Reflux

Reflux usually is congenital

Occurs in families Affects approximately 1% of children.

Reflux predisposes to infection of the kidney (pyelonephritis) by facilitating the transport of bacteria from the bladder to the upper urinary tract .

Reflux is potentially harmful because of the exposure of the kidney to increased hydrodynamic pressure during voiding. Incomplete emptying of the ureter and bladder predisposes the patient to UTIs Without complete emptying of the urinary tract, it is difficult for voiding to prevent bacterial colonization

Reflux nephropathy refers to development and progression of gross and histologic renal scarring, particularly if reflux is associated with infection or obstruction (bladder neck obstruction or posterior urethral valves). Reflux nephropathy once accounted for as much as 15-20% of end-stage renal disease in children andyoung adults. Reflux nephropathy remains one of the most common causes of hypertension in children
Reflux in the absence of infection or elevated bladder pressure (e.g., neuropathic bladder, posterior urethral valves) does not cause renal injury.

Primary

Congenital incompetence of the valvular mechanism of the vesicoureteral junction Primary associated with Ureteral duplication other malformations of Ureterocele with the ureterovesical junction duplication Ureteral ectopia Paraureteral diverticula

Secondary to increased intravesical pressure

Neuropathic bladder Non-neuropathic bladder dysfunction

Bladder outlet obstruction

Secondary to inflammatory processes

Severe bacterial cystitis Foreign bodies Vesical calculi Clinical cystitis

Secondary to surgical procedures involvingthe ureterovesical junction

Surgery

Grading

Reflux severity is graded using the International Reflux Study Classification of I to V and is based on the appearance of the urinary tract on a contrast voiding cystourethrogram (VCUG) Reflux severity is an indirect indication of the degree of abnormality of the ureterovesical junction.

International classification of vesicoureteral reflux. Grade I, ureter only. Grade II, ureter, pelvis, and calyces; no dilation, normal calyceal fornices. Grade III, mild to moderate dilation or tortuosity of the ureter and mild to moderate dilation of the renal pelvis; slight or no blunting of the fornices. Grade IV, moderate dilation or tortuosity of the ureter and moderate dilation of the renal pelvis and calyces; complete obliteration of sharp angle of fornices, but maintenance of the papillary impressions in most calyces. Grade V, gross dilation and tortuosity of the ureter; gross dilation of the renal pelvis and calyces. The papillary impressions are no longer visible in most of the calyces. Some authors consider grade IV or V with intrarenal reflux into the collecting ducts a high risk for scarring

Voiding cystourethrogram

Grade 4 right vesicouretral reflux

Clinical Manifestations

Reflux usually is discovered during evaluation for a UTI

The younger the patient with a UTI, the more likely reflux is present No other clinical signs are reliable in differentiating children with UTI with and without reflux.

Among these children, 80% are female, and the average age at diagnosis is 2-3 yr.

Clinical Manifestations

In other children, a VCUG is performed during evaluation of voiding dysfunction, renal insufficiency, hypertension, or other suspected pathologic process of the urinary tract

Clinical Manifestations

Primary reflux also may be discovered during evaluation for prenatal hydronephrosis. In this select population, 80% of affected children are male The reflux grade usually is higher than in girls whose reflux is diagnosed following a UTI.

Treatment

The presence of VUR is generally an indication for long-term prophylactic antibiotic therapy (trimetho-primsulfamethoxazole, sulfisoxazole, or nitrofurantoin).

Treatment

The goals of treatment are to prevent pyelonephritis, refluxrelated renal injury, and other complications of reflux. Medical therapy is based on the principle that reflux often resolves over time and that if UTI can be prevented, the morbidity or complications of reflux may beavoided without surgery. The basis for surgical therapy is that in selected children, ongoing reflux has caused or has significant potential for causing renal injury or other reflux-related complications and that elimination of reflux minimizes the likelihood of these problems.

PROPHYLAXIS

Drugs commonly used for prophylaxis include trimethoprim-sulfamethoxazole (TMP-SMX), trimethoprim,nitrofurantoin, or cephalexin, which are administered once daily at a dose of 25-30% of the dosage necessary to treat an acute infection .Prophylaxis was continued until reflux resolved or until the risk of reflux to the patient was considered to be low.