Vesicoureteral Reflux

Retrograde flow of urine from the bladder to the ureter and renal pelvis
Ureter is normally attached to the bladder in an oblique direction, perforating the bladder
(detrusor) muscle runs between the bladder mucosa and detrusor muscle, creating a valve
mechanism that prevents reflux
Reflux occurs when the sub-mucosal tunnel between the mucosa and detrusor muscle is
short or weak detrusor muscle, or both.
Reflux is a birth defect
Reflux predisposes to renal infection (pyelonephritis) by facilitating the transport of
bacteria from the bladder to the upper urinary tract.
inflammatory reaction caused by a pyelonephritic infection result in renal injury
scarring impairs renal function
results in
renin-mediated hypertension
reflux nephropathy
renal insufficiency
end-stage renal disease
reduced somatic growth,
morbidity during pregnancy.
CLASSIFICATION.
Reflux severity
International Study Classification - I to V
based on the appearance of contrast voiding cystourethrogram (VCUG)
more severe the reflux, higher the rates of renal injury
Reflux severity is an indication of the degree of abnormality of the ureterovesical
junction.
Reflux may be primary or secondary
Primary vesicoureteral reflux results from an anatomic deformity of the ureterovesical
junction
bladder becomes overdistended. - megacystic-megaureter syndrome ,
In this condition, re-implantation of the ureters into the bladder to correct reflux resolves
the condition.
duplication of the upper urinary tract - two ureters drain the kidney.
lower pole ureter drains higher and more lateral in the bladder,
the upper pole ureter is typically infero-medial.

Reflux occurs into the lower ureter, which has a less competent valve
ectopic ureter, upper pole ureter drains outside the bladder.
ureterocele, is a cystic swelling of the intramural portion of the distal ureter.
reflux is present in neuropathic bladder, occurs in myelomeningocele and sacral agenesis,
Reflux is seen in boys with posterior urethral valves.
congenital urinary tract abnormalities.
multicystic dysplastic kidney
renal agenesis
hydronephrotic kidney
siblings of children with reflux should be screened
Screening with a radionuclide scan
renal ultrasonography,
cystography
CLINICAL MANIFESTATIONS.
discovered during evaluation for a urinary tract infection, prenatal hydro-nephrosis
voiding cysto-urethrography
DIAGNOSIS.
VCUG or radionuclide cystogram
Give midazolam before the study
catheterization of the bladder
instil a solution containing iodinated contrast or a radiopharmaceutical,
radiologic imaging of the lower and upper urinary tract
bladder and upper urinary tracts are imaged during bladder filling and voiding.
Reflux occurring during bladder filling is termed low-pressure or passive reflux
reflux occurring during voiding is termed high-pressure or active reflux .
contrast study provides more information, such as demonstration of a duplex collecting
system, ectopic ureter, paraurethral diverticulum, bladder outlet obstruction in boys,
upper urinary tract stasis, and signs of voiding dysfunction.
reflux grading system is based on the appearance on VCUG.
radionuclide cystogram has lower radiation exposure
indirect cystography
injecting an intravenous dye
It is excreted by the kidneys
wait for it to be excreted into the bladder,

imaging the lower urinary tract while the patient voids.

detects only 50% of reflux cases.

assess the upper urinary tract

to assess whether renal scarring and associated urinary tract anomalies are present.
by Ultrasonography
excretory urography (intravenous pyelogram),
renal scintigraphy.
can demonstrate
hydronephrosis,
renal duplication with an obstructed upper pole system,
gross renal scars
Intravenous pyelography injection of an iodinated contrast agent
provides good anatomic detail of the kidneys.
Renal scintigraphy
dimercaptosuccinic acid, demonstrates renal cortical detail
shows all renal scarring.
less reliable in demonstrating hydronephrosis.
voiding dysfunction, = urgency, frequency, diurnal incontinence, infrequent voiding, or a
combination
bowel habits should be assessed.
anticholinergic therapy
antibiotic prophylaxis.
child's height, weight, and blood pressure be measured.
serum creatinine
urine for infection and proteinuria.
Cystoscopy is of no value
NATURAL HISTORY.
Bilateral grade IV reflux is less likely to resolve
posterior urethral valves, neuropathic bladder, and non-neurogenic neurogenic bladder
( Hinman syndrome ), sterile reflux can cause significant renal damage.
Children with high-grade reflux who acquire a UTI are at risk for pyelonephritis and
renal scarring.
TREATMENT.

prevent pyelonephritis, renal injury, and complications of reflux.

Continuous antibiotic prophylaxis
sulfamethoxazole-trimethoprim
nitrofurantoin,
once daily at a dose of one quarter to one third of the dose necessary to treat an acute
infection.
till reflux resolves
considered successful if the child remains free of infection,
no new renal scarring,
the reflux resolves spontaneously.
Breakthrough UTI, development of new renal scars, or failure of reflux to resolve are
considered failure
Noncompliance, allergic reaction, or side effects to the medication lead to failure.
follow-up evaluation performed annually
child's height, weight, and blood pressure are recorded.
child's voiding pattern is assessed
urine culture
Cystography (radionuclide) every 1218 mo.
Surgical therapy
suprapubic incision or by endoscopic
modify the ureterovesical attachment