Vesicoureteral Reflux

Dr. Iqra Khalid

Dr. Hafsa Ilyas
 Vesicoureteral Reflux (VUR)
Learning Objectives are:
• Definition
• Pathophysiology
• Etiology
• Epidemiology
• Classification
• Investigations
• Management
 Definition
Retrograde passage of urine from bladder into
the ureter.
 Pathophysiology
The normal UVJ is
characterized by
• Oblique entry of ureter into
the bladder
• High ratio = Length of
submucosal ureter/ 5:1
ureteral diameter (Paquin law)
• 5:1
 Etiology
Primary VUR Secondary VUR
Any intrinsic defect of VUJ Organic Causes:
Such as bladder outlet obstruction (BOO)
•Ureters with marginal Tunnels
• PUV (posterior urethral valves)
• Ectopic ureter
• Meatal Stenosis
• UVJ distortion
Dysfunction Disorders:
• UTI/ Cystitis (Most common cause)

• Neurovesical dysfunction (NVD)

Can be associated with imperforate anus,
ureteroceles, bladder exstrophy.

• Uninhibited Detruser muscle

contractions (UDCs) – Hinman Bladder
Etiology
 Hinman Bladder
(Nonneurogenic neurogenic bladder)
• An end stage bladder from nonneurogenic &
nonobstructive voiding dysfuntion is termed as Hinman
bladder.
• These patients develop
Uninhibited Detrusor
muscle contractions
(UDCs) which lead to ↑
intravesical pressure i.e
Detrusor-sphincter
dyssynergia (DSD)
• Recurrent UTI
 Classification
VUR is graded from I to V according to the
International Grading System

Into Into pelvis Mild to moderate moderate Severe

nondilated and calyces dilatation of ureter & dilatation &/or Dilatation &
ureter without renal pelvis tortuosity of tortuosity of
dilatation (fornices are sharp) ureter (Blunt ureter, pelvis &
fornices) calyces.
Kidney Anatomy
 Other Classifications
A B

Primary reflux Simple reflux

• Deficient UVJ

Secondary reflux Complex reflux

• Refluxingmegaureter
• BOO • Refluxing duplicated ureter
• NVD • Refluxing ureter with
Diverticulum or Ureterocele
• Ureter associated with ipsilateral
UPJ or UVJ
 Epidemiology
• 30-40% in patients with UTI
• More common in females
• Male account for approx. 14%
• Boys with VUR present at relatively young age
25% in <3 months of age
• Reported risk of siblings reflux range from 27-34%
• Offsprings of women with reflux has risk of VUR
66%.
• Screening later sslide
 Investigations
• Voiding cystourethrogram (VCUG)
• Ultrasound
• Isotope renography
• Urodynamic studies – Uroflow, perineal
electromyogram & filling cystometrogram.
 Voiding cystourethrogram
(VCUG)
• With either radiopaque contrast medium or a
nuclear radioisotope
• To assess for reflux that only occurs at the end
of filling and/or with voiding
 Renal Ultrasound (US)
• Detects scarring.
• Serial US imaging is helpful in quantitating
renal growth and following dilatation of the
renal pelvis and/or ureters.
• Bladder views are important to check for
bladder wall thickening, diverticula, distal
ureteral dilatation, ureteroceles, and bladder
emptying (PVRU).
 Isotope Renography
• Detect scarring
• Sensitive and defines the split differential
function in the case of a small or dysplastic
appearing kidney.
• Split renal function (SRF), or differential renal
function, is a determination of the relative
contribution of each of the two kidneys to
total renal function.
 Urodynamic Studies
• Patients with frequency, urgency &
incontinence should also be considered for
noninvasive urodynamic studies including a
uroflow and perineal electromyogram with a
postvoid residual.
• A filling cystometrogram (formal urodynamics)
is indicated to evaluate for NVD
 Screening tests
Siblings, especially those <2 years of age should
have a screening investigation.

• Ultrasound KUB in younger siblings

• VCUG if there is documented UTI

 Treatment
Medical Management:
Non operative management is successful in
most patients categorized into 4 stages
1- Diagnostic evaluation
2- Voiding dysfunction treatment.
3- Avoidance of infection
4- Active surveillance
 Voiding dysfunction treatment
Pt with UDC is managed with
• Behavioural therapy i.e toilet training
• Low dose anticholinergics e.g oxybutynin HCL
(oxycystin 5mg OD)
Side effects:
> Constipation
> Facial flushing
>Dry mouth
 Voiding dysfunction treatment
• Voiding dysfunction with retentive
characteristics requires
• Alpha blockers e.g tamsulosin (flowmax 0.4mg
OD)
• Rarely require Intermittent catherterization
• Pt with NVD requires
• CIC
• High dose anticholinergics
 General guidelines for non operative
management of VUR
• Hydration hygiene
• Perineal hygiene (Avoid: harsh soaps during
tub baths ,Bubble baths and shampoos )
• bowel management (Avoid: constipation)
• suppressive antibiotics
• observation without antibiotics
• Anticholinergics, spasmolytics
 Avoidance of infection
• Low dose continuous antibiotic prophylaxis
(CAP)
• Prophylactic dose is ¼ of the dose used for UTI
 AUA guidelines regarding VUR 2010
• CAP recommended In following.
1-VUR in infant diagnosed after febrile UTI.
2- child older than 1 year with
>recurrent febrile UTI.
>Bowel and bladder dysfunction.
> Renal cortical anomalies
3- Asymptomatic older child with normal
kidneys
 Surveillance
• Urine Culture: Monthly for 3 months after last UTI then every
2-3 months
• Renal Imaging: every 6-12 months. > Renal
size (ultrasound, IVU). > Focal scarring
(renal scan, IVU)
• Voiding Cystourethrography (yearly) >
Radiographic VCUG >
Initial (male, female suspected NVD). >
Follow-up (NVD). >
Isotope VCUG. >
Routine surveillance
• Record growth yearly (height, weight)
 Surveillance
• Blood pressure
>Routine (yearly)
>Renal scarring (quarterly).
• Renal Function Tests.
>BUN, creatinine (yearly if bilateral RN)
• GFR estimated (yearly if azotemic).
• Maximum urine osmolality (yearly if bilateral RN)
• Cystoscopy done at time of antireflux surgery;
otherwise rarely necessary
• Urodynamic Evaluation
>history of voiding dysfunction
THANK YOU