Vesicoureteral Reflux
- What Is Vesicoureteral Reflux?
- How Common Is Vesicoureteral Reflux?
- What Are the Possible Causes of Vesicoureteral Reflux?
- What Are the Symptoms of Vesicoureteral Reflux?
- How Is Vesicoureteral Reflux Diagnosed?
- How Is Vesicoureteral Reflux Treated?
- When Is Surgical Treatment Performed for Vesicoureteral Reflux?
- What Are the Surgical Treatments for Vesicoureteral Reflux?
- How Does Vesicoureteral Reflux Cause Damage?
What Is Vesicoureteral Reflux?
Normally, there are mechanisms that ensure urine flows in one direction—out of the bladder—during urination. When malfunctions in this mechanism occur for any reason, causing some of the urine to flow back toward the ureters and/or kidneys during urination, this condition is called vesicoureteral reflux.
How Common Is Vesicoureteral Reflux?
It occurs in roughly 1% of the general population. However, this rate is much higher in children with urinary tract infections. For example, in children under 1 year of age with a febrile urinary tract infection, this rate exceeds 70%. The prevalence decreases with age.
Another important point to note is that VUR may also be observed in the siblings of children diagnosed with VUR at a rate of 15–45%.
What Are the Possible Causes of Vesicoureteral Reflux?
Anatomical and functional abnormalities can cause vesicoureteral reflux. It can occur when the portion of the ureter that passes through the bladder is shorter than normal. Anatomical problems such as the presence of two separate ureters in a single kidney (ureteral duplications), pouches near the ureter (paraureteral diverticula), an open ureteral orifice, or trigone insufficiency may result in a deficiency in the mechanisms that prevent urine from flowing back into the upper urinary tract during urination.
In cases of voiding dysfunction or neurogenic bladder, however, intravesical pressures are higher than normal, which can lead to the breakdown of the mechanism that prevents reflux over time. Both anatomical and functional problems may be responsible for vesicoureteral reflux, either individually or in combination.
In cases of voiding dysfunction or neurogenic bladder, however, intravesical pressures are higher than normal, which can lead to the breakdown of the mechanism that prevents reflux over time. Anatomical and functional problems may be responsible for vesicoureteral reflux, either individually or in combination.
What Are the Symptoms of Vesicoureteral Reflux?
The most common presentation is frequent and recurrent urinary tract infections. The specific symptoms associated with this condition are described under the relevant heading.
How Is Vesicoureteral Reflux Diagnosed?
The diagnosis is made during an evaluation conducted due to a urinary tract infection.
Tests should be performed to identify any anatomical or functional abnormalities that could cause vesicoureteral reflux in children.
Since the presence of a urinary tract infection can lead to false results, any infection must be treated first, if present, and the tests should be performed afterward. The tests most commonly used in this evaluation are listed below:
⦁ Ultrasonography (USG): This is the initial diagnostic test performed on a child with a urinary tract infection.
⦁ Voiding cystourethrogram: This is the most important and informative test to perform in a child with suspected vesicoureteral reflux. This test allows for the assessment of whether vesicoureteral reflux is present and, if so, its severity, as well as any additional abnormalities in the ureter or bladder.
⦁ Scintigraphy: DMSA scintigraphy is often used to determine whether there is damage to the functional part of the kidney. During an acute infection, DMSA
Whether the damage visible on the scintigram is permanent is determined by a follow-up test performed 6 months later. This is an important test for planning treatment.
⦁ Indirect nuclear cystogram: This is a method that uses dynamic nuclear medicine studies, such as DTPA or MAG-3 scintigraphy. After these tracers are released from the kidneys, images are acquired during urination to assess for the presence of vesicoureteral reflux. Its most significant advantage is that the radiation risk is much lower than that of a conventional voiding cystourethrogram; however, it does not provide as clear information regarding anatomical details as a voiding cystourethrogram does. It is frequently recommended as a screening test for siblings of children with vesicoureteral reflux.
⦁ Urodynamic study (UD): This is a recommended test for children in whom vesicoureteral reflux is thought to be associated with voiding dysfunction or a neurogenic bladder. When performed under fluoroscopy using a contrast-enhanced fluid (videourodynamics), it can also provide information similar to that of a voiding cystourethrogram.
How Is Vesicoureteral Reflux Treated?
When selecting a treatment, many factors are taken into account, such as the child’s age, the severity of vesicoureteral reflux, the extent of kidney involvement, urination habits, and the family’s sociocultural background.
Follow-up Protocol: This protocol is implemented in a significant proportion of patients following the treatment of their first episode of urinary tract infection and the diagnosis of vesicoureteral reflux. The follow-up protocol adheres to the following principles:
Antibiotic prophylaxis: This is used to prevent the urine from becoming infected. As long as the urine that enters the kidney does not contain bacteria, it will not cause scarring. For this reason, one-third of the therapeutic dose of the antibiotic is administered orally once daily. It is generally recommended to take the medication at bedtime.
Toilet Training: As mentioned in the section on urinary tract infections, if a child has a voiding dysfunction, appropriate recommendations are implemented. It is important to encourage regular toilet use and to teach children how to maintain proper toilet hygiene. Circumcision in boys is beneficial not only for preventing urinary tract infections but also for preventing contamination during urine sample collection.
Monitoring for Urinary Tract Infections: Patients undergo regular urinalysis and urine cultures to check for urinary tract infections.
Follow-up for vesicoureteral reflux: The status of vesicoureteral reflux is monitored by performing a voiding cystourethrogram as often as the physician deems necessary.
Monitoring of kidney involvement: The extent of involvement of the renal parenchyma is assessed throughout the follow-up period using ultrasound and scintigraphy at regular intervals.
The follow-up protocol is based on the fact that bladder function will improve with age, the anatomy will mature, and, as a result, spontaneous resolution of vesicoureteral reflux will occur. The table below shows the rates of spontaneous resolution of vesicoureteral reflux. The most significant advantage of this treatment method is that surgery is not required to correct vesicoureteral reflux. However, the disadvantages of this method include the risk of developing antibiotic resistance due to prolonged antibiotic use, the need for the family to be compliant with long-term follow-up, the necessity of having a urine culture performed at regular intervals, and the risk of developing pyelonephritis during follow-up.
When Is Surgical Treatment Performed for Vesicoureteral Reflux?
⦁ Presence of obvious anatomical abnormalities
⦁ Failure to achieve sterile urine despite adherence to the follow-up protocol, or development of pyelonephritic episodes
⦁ The presence of new damage in the renal parenchyma as determined by serial evaluations
⦁ Failure to comply with the family’s monitoring protocol
What Are the Surgical Treatments for Vesicoureteral Reflux?
If the severity of reflux does not decrease or actually increases despite treatment, surgical options include endoscopic (minimally invasive) and open surgical techniques.
The endoscopic method involves injecting a filler material just below the ureteral orifice using a cystoscope (a lighted metal instrument that visualizes the inside of the bladder). The advantages of this procedure include the absence of a surgical scar on the skin, a very short or no hospital stay, and the fact that it can be repeated. However, its main disadvantages are that its success rate is lower than that of open surgery, particularly in cases of high-grade vesicoureteral reflux, and the need for a follow-up voiding cystourethrogram.
In open surgery, the ureter is reattached to the bladder in its proper anatomical and functional position. Disadvantages include the patient having a surgical scar and a longer hospital stay. However, the most significant advantages are the high success rates and the fact that, as a result, there is often no need for postoperative urinary stenting. In addition, there are treatment options available that combine open surgical methods with laparoscopic techniques. In rare cases where kidney function is completely lost, removal of the affected kidney (nephrectomy) may also be considered.
How Does Vesicoureteral Reflux Cause Damage?
If left untreated, vesicoureteral reflux can lead to recurrent episodes of pyelonephritis, which may cause permanent damage to the functional part of the kidney. This damage can result in kidney failure. Therefore, vesicoureteral reflux is one of the top three causes of kidney failure in children. In particular, persistent vesicoureteral reflux in adolescent girls can lead to conditions that threaten the health of both the mother and the baby during pregnancy. For this reason, prevention is of great importance.
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