| Vesicoureteral Reflux |
| Classification and external resources |
|
| ICD-10 |
N13.7 |
| ICD-9 |
593.7 |
| DiseasesDB |
13835 |
| MedlinePlus |
000459 |
| eMedicine |
ped/2750 |
| MeSH |
D014718 |
Vesicoureteral reflux (VUR) is an abnormal movement of urine from the bladder into ureters or kidneys. Urine normally travels from the kidneys via the ureters to the bladder. In vesicoureteral reflux the direction of urine flow is reversed (retrograde).
Contents
- 1 Symptoms
- 2 Causes
- 2.1 Primary VUR
- 2.2 Secondary VUR
- 3 Prevalence
- 4 International Classification of Vesicoureteral Reflux
- 5 Diagnosis
- 6 Treatment
- 6.1 Endoscopic injection
- 6.2 Medical Treatment
- 6.3 Surgical Management
- 7 Follow-up
- 8 References
Symptoms[edit source | edit]
Vesicoureteral reflux may present before birth as prenatal hydronephrosis, an abnormal widening of the ureter or with a urinary tract infection or acute pyelonephritis. Symptoms such as painful urination or renal colic/flank pain are not symptoms associated with vesicoureteral reflux.
Newborns may be lethargic with faltering growth, while infants and young children typically present with pyrexia, dysuria, frequent urination, malodorous urine and GIT symptoms, but only when urinary tract infection is present as the initial presentation of VUR.
Causes[edit source | edit]
In healthy individuals the ureters enter the urinary bladder obliquely and run submucosally for some distance. This, in addition to the ureter's muscular attachments, helps secure and support them posteriorly. Together these features produce a valvelike effect that occludes the ureteric opening during storage and voiding of urine. In people with VUR, failure of this mechanism occurs, with resultant retrograde flow of urine.
Hardikar syndrome can include Vesicoureteral reflux, hydronephrosis, cleft lip and palate, intestinal obstruction and other symptoms.[1]
Primary VUR[edit source | edit]
Insufficient submucosal length of the ureter relative to its diameter causes inadequacy of the valvular mechanism. This is precipitated by a congenital defect/lack of longitudinal muscle of the intravesical ureter resulting in an ureterovesicular junction (UVJ) anomaly.
Secondary VUR[edit source | edit]
In this category the valvular mechanism is intact and healthy to start with but becomes overwhelmed by raised vesicular pressures associated with obstruction, which distorts the ureterovesical junction. The obstructions may be anatomical or functional. Secondary VUR can be further divided into anatomical and functional groups as follows:
Anatomical: Posterior urethral valves; urethral or meatal stenosis.
These causes are treated surgically when possible.
Functional: Bladder instability, neurogenic bladder and non-neurogenic neurogenic bladder Urinary tract infections may cause reflux due to the elevated pressures associated with inflammation.[2]
Resolution of functional VUR will usually occur if the precipitating cause is treated and resolved. Medical and/or surgical treatment may be indicated.
Prevalence[edit source | edit]
It has been estimated that VUR is present in more than 10% of the population. In children without urinary tract infections 17.2-18.5% have VUR, whereas in those with urinary tract infections the incidence may be as high as 70%.[citation needed]
Age[edit source | edit]
Younger children are more prone to VUR because of the relative shortness of the submucosal ureters. This susceptibility decreases with age as the length of the ureters increases as the children grow. In children under the age of 1 year with a urinary tract infection, 70% will have VUR. This number decreases to 15% by the age of 12.
Sex[edit source | edit]
Although VUR is more common in males antenatally, in later life there is a definite female preponderance with 85% of cases being female.
International Classification of Vesicoureteral Reflux[edit source | edit]
- Grade I – reflux into non-dilated ureter
- Grade II – reflux into the renal pelvis and calyces without dilatation
- Grade III – mild/moderate dilatation of the ureter, renal pelvis and calyces with minimal blunting of the fornices
- Grade IV – dilation of the renal pelvis and calyces with moderate ureteral tortuosity
- Grade V – gross dilatation of the ureter, pelvis and calyces; ureteral tortuosity; loss of papillary impressions
The younger the age of the patient and the lower the grade at presentation the higher the chance of spontaneous resolution. Most (approx. 85%) of grade I & II cases of VUR will resolve spontaneously. Approximately 50% of grade III cases and a lower percentage of higher grades will also resolve spontaneously.
Diagnosis[edit source | edit]
VCUG demonstrating bilateral Grade III vesicoureteral reflux.
The following procedures may be used to diagnose VUR:
- Nuclear cystogram (RNC)
- Fluoroscopic voiding cystourethrogram (VCUG)
- Ultrasonic cystography
- Abdominal ultrasound
An abdominal ultrasound might suggest the presence of VUR if ureteral dilatation is present; however, in many circumstances of VUR of low to moderate severity, the sonogram may be completely normal, thus providing insufficient utility as a single diagnostic test in the evaluation of children suspected of having VUR, such as those presenting with prenatal hydronephrosis or urinary tract infection (UTI). VCUG is the method of choice for grading and initial workup, while RNC is preferred for subsequent evaluations as there is less exposure to radiation. A high index of suspicion should be attached to any case a where a child presents with a urinary tract infection, and anatomical causes should be excluded. A VCUG and abdominal ultrasound should be performed in these cases
Early diagnosis in children is crucial as studies have shown that the children with VUR who present with a UTI and associated acute pyelonephritis are more likely to develop permanent renal cortical scarring than those children without VUR, with an odds ratio of 2.8.[3] Thus VUR not only increases the frequency of UTI's, but also the risk of damage to upper urinary structures.
Treatment[edit source | edit]
The goal of treatment is to minimize infections, as it is infections that cause renal scarring and not the vesicoureteral reflux.[4] Minimizing infections is primarily done by prophylactic antibiotics in newborns and infants who are not potty trained. However in children who are older, physicians and parents should focus on bowel and bladder management. Children who hold their bladder or who are constipated having a greater number of infections then children who void on a regular schedule. When medical management fails to prevent recurrent urinary tract infections, or if the kidneys show progressive renal scaring then surgical interventions may be necessary. Medical management is recommended in children with Grade I-III VUR as most cases will resolve spontaneously. A trial of medical treatment is indicated in patients with Grade IV VUR especially in younger patients or those with unilateral disease. Of the patients with Grade V VUR only infants are trialled on a medical approach before surgery is indicated, in older patients surgery is the only option.
Endoscopic injection[edit source | edit]
Deflux is a gel that is used in endoscopic injections to treat Vesicoureteral Reflux. It is the material that the surgeon injects around the ureteral opening to create a valve function and stop urine from flowing back up the ureter. Deflux consists of two types of sugar-based molecules called dextranomer and hyaluronic acid. Both substances are well-known from previous uses in medicine. Both materials are also biocompatible, which means that they do not cause significant reactions within the body. In fact, hyaluronic acid is produced and found naturally within the body.
Medical Treatment[edit source | edit]
Medical treatment entails low dose antibiotic prophylaxis until resolution of VUR occurs. Antibiotics are administered nightly at half the normal therapeutic dose. The specific antibiotics used differ with the age of the patient and include:
- Amoxicillin or ampicillin - infants younger than 6 weeks
- Trimethoprim-sulfamethoxazole (co-trimoxazole) - 6 weeks to 2 months
After 2 months the following antibiotics are suitable:
- Nitrofurantoin{5–7 mg/kg/24hrs}
- Nalidixic acid
- Bactrim
- Trimethoprim
- Cephalosporins
Urine cultures are performed 3 monthly to exclude breakthrough infection. Annual radiological investigations are likewise indicated. Good perineal hygiene, and timed and double voiding are also important aspects of medical treatment. Bladder dysfunction is treated with the administration of anticholinergics.
Surgical Management[edit source | edit]
A surgical approach is necessary in cases where a breakthrough infection results despite prophylaxis, or there is non-compliance with the prophylaxis. Similarly if the VUR is severe (Grade IV & V), there are pyelonephritic changes or congenital abnormalities. Other reasons necessitating surgical intervention are failure of renal growth, formation of new scars, renal deterioration and VUR in girls approaching puberty.
There are three types of surgical procedure available for the treatment of VUR: endoscopic (STING/HIT procedures); laparoscopic; and open procedures (Cohen procedure, Leadbetter-Politano procedure).
Follow-up[edit source | edit]
2010 guidelines from the American Urological Association recommend ongoing monitoring of children with VUR until the abnormality resolves or is no longer clinically significant. The recommendations are for annual evaluation of blood pressure, height, weight, urinalysis, and renal ultrasonography.[5]
References[edit source | edit]
- ^ Hardikar syndrome symptoms
- ^ Institute of Urology & Nephrology, London, UK, The cellular basis of bladder instability UJUS 2009, Retrieved 4-20-2010
- ^ Peters, CA; Skoog, SJ, Arant BS, Jr, Copp, HL, Elder, JS, Hudson, RG, Khoury, AE, Lorenzo, AJ, Pohl, HG, Shapiro, E, Snodgrass, WT, Diaz, M (2010 Sep). "Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children.". The Journal of Urology 184 (3): 1134–44. doi:10.1016/j.juro.2010.05.065. PMID 20650499.
- ^ Tekgül, S; Riedmiller, H; Hoebeke, P; Kočvara, R; Nijman, RJ; Radmayr, C; Stein, R; Dogan, HS; European Association of, Urology (2012 Sep). "EAU guidelines on vesicoureteral reflux in children.". European urology 62 (3): 534–42. PMID 22698573.
- ^ Peters, CA; Skoog, SJ, Arant BS, Jr, Copp, HL, Elder, JS, Hudson, RG, Khoury, AE, Lorenzo, AJ, Pohl, HG, Shapiro, E, Snodgrass, WT, Diaz, M (2010 Sep). "Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children.". The Journal of urology 184 (3): 1134–44. PMID 20650499.
|
Urinary system · Pathology · Urologic disease / Uropathy (N00–N39, 580–599)
|
|
| Abdominal |
Nephropathy/
(nephritis+
nephrosis) |
Glomerulopathy/
glomerulitis/
(glomerulonephritis+
glomerulonephrosis) |
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Primarily
nephrotic
|
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Non-proliferative
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Minimal change · Focal segmental · Membranous
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Proliferative
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Mesangial proliferative · Endocapillary proliferative · Membranoproliferative/mesangiocapillary
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By condition
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Diabetic · Amyloidosis
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Type I RPG/Type II hypersensitivity
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Goodpasture's syndrome
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Type II RPG/Type III hypersensitivity
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Post-streptococcal · Lupus (DPN) · IgA/Berger's
|
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Type III RPG/Pauci-immune
|
Granulomatosis with polyangiitis (Wegener's) · Microscopic polyangiitis · Churg-Strauss Syndrome
|
|
|
|
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Tubulopathy/
tubulitis
|
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Proximal
|
RTA (RTA 2) · Fanconi syndrome
|
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Thick ascending
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Bartter syndrome
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Distal convoluted
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Gitelman syndrome
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Collecting duct
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Liddle's syndrome · RTA (RTA 1) · Diabetes insipidus (Nephrogenic)
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Renal papilla
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Renal papillary necrosis
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Major calyx/pelvis
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Hydronephrosis · Pyonephrosis · Reflux nephropathy
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Any/all
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Acute tubular necrosis
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Interstitium
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Interstitial nephritis (Pyelonephritis, Danubian endemic familial nephropathy)
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Any/all
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General syndromes
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Renal failure (Acute renal failure, Chronic renal failure) · Uremic pericarditis · Uremia
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Vascular
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Renal artery stenosis · Renal Ischemia · Hypertensive nephropathy · Renovascular hypertension · Renal Cortical Necrosis
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Other
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Analgesic nephropathy · Renal osteodystrophy · Nephroptosis · Abderhalden-Kaufmann-Lignac syndrome
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Ureter
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Ureteritis · Ureterocele · Megaureter
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| Pelvic |
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Bladder
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Cystitis (Interstitial cystitis, Hunner's ulcer, Trigonitis, Hemorrhagic cystitis) · Neurogenic bladder · Bladder sphincter dyssynergia · Vesicointestinal fistula · Vesicoureteral reflux
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Urethra
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Urethritis (Non-gonococcal urethritis) · Urethral syndrome · Urethral stricture/Meatal stenosis · Urethral caruncle
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| Any/all |
Obstructive uropathy · Urinary tract infection · Retroperitoneal fibrosis · Urolithiasis (Bladder stone, Kidney stone, Renal colic) · Malacoplakia · Urinary incontinence (Stress, Urge, Overflow)
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noco/acba/cong/tumr, sysi/epon, urte
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proc/itvp, drug (G4B), blte, urte
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