Vesicoureteral reflux

Vesicoureteral reflux

Definition:

Vesicoureteral (ves-ih-koe-yoo-REE-ter-ul) reflux is the abnormal flow of urine from your bladder back up the tubes (ureters) that connect your kidneys to your bladder. Normally, urine flows only down from your kidneys to your bladder.

Vesicoureteral reflux is usually diagnosed in infants and children. The disorder increases the risk of urinary tract infections, which, if left untreated, can lead to kidney damage.

Vesicoureteral reflux can be primary or secondary. Children with primary vesicoureteral reflux are born with a defect in the valve that normally prevents urine from flowing backward from the bladder into the ureters. Secondary vesicoureteral reflux is due to a urinary tract malfunction, often caused by infection.

Children may outgrow primary vesicoureteral reflux. Treatment, which includes medication or surgery, aims at preventing kidney damage.

Symptoms:

A urinary tract infection (UTI) is the most common indication of vesicoureteral reflux. A UTI doesn't always cause noticeable signs and symptoms, though most people have some. These signs and symptoms can include:

• A strong, persistent urge to urinate
• A burning sensation when urinating
• Passing frequent, small amounts of urine
• Blood in the urine (hematuria) or cloudy, strong-smelling urine
• Fever
• Abdominal or flank pain
• Hesitancy to urinate or holding urine to avoid the burning sensation

A UTI may be difficult to diagnose in children, who may have only nonspecific signs and symptoms. Signs and symptoms in infants with a UTI may also include:

• Diarrhea
• Lack of appetite
• An unexplained fever
• Irritability

As your child gets older, untreated vesicoureteral reflux can lead to other signs and symptoms, including:

• Bed-wetting
• High blood pressure
• Protein in urine
• Kidney failure

Another indication of vesicoureteral reflux, which may be detected before birth by sonogram, is swelling of the kidneys or the urine-collecting structures of one or both kidneys (hydronephrosis) in the fetus, caused by the backup of urine into the kidneys.
When to see a doctor
Contact your doctor right away if your child develops any of the signs or symptoms of a UTI, such as:

• A strong, persistent urge to urinate
• A burning sensation when urinating
• Abdominal or flank pain
• A hesitancy to urinate

Call your doctor about fever if your child:

• Is less than 3 months old and has a rectal temperature of 100.4 F (38 C) or higher
• Is 3 months or older and has a fever of 104 F (40 C)

In addition, call your doctor immediately if your infant has the following signs or symptoms:

• Changes in appetite. If your baby refuses several feedings in a row or eats poorly, contact the doctor.
• Changes in mood. If your baby is lethargic or unusually difficult to rouse, tell the doctor right away. Also let the doctor know if your baby is persistently irritable or has periods of inconsolable crying.
• Diarrhea. Contact the doctor if your baby's stools are especially loose or watery.
• Vomiting. Occasional spitting up is normal. Contact the doctor if your baby spits up large portions of multiple feedings or vomits forcefully after feedings.

Causes:

Your urinary system includes your kidneys, ureters, bladder and urethra. All play a role in removing waste products from your body.
The kidneys, a pair of bean-shaped organs at the back of your upper abdomen, filter waste, water and electrolytes — minerals, such as sodium, calcium and potassium, that help maintain the balance of fluids in your body — from your blood. Tubes called ureters carry urine from your kidneys down to your bladder, where it is stored until it exits the body through another tube (the urethra) during urination.

Vesicoureteral reflux can develop in two forms, primary and secondary:

• Primary vesicoureteral reflux. The cause of this more common form is a defect that's present before birth (congenital). The defect is in the functional valve between the bladder and a ureter that normally closes to prevent urine from flowing backward. As the child grows, the ureters lengthen and straighten, which may improve valve function and eventually resolve the reflux. This type of vesicoureteral reflux tends to run in families, which indicates that it may be genetic, but the exact cause of the defect is unknown.
• Secondary vesicoureteral reflux. The cause of this form is a blockage or malfunction in the urinary system. The blockage most commonly results from recurrent UTIs, which may cause swelling of a ureter

Complications:

Kidney damage is the primary concern with vesicoureteral reflux. The more severe the reflux, the more serious the complications are likely to be. Complications may include:

• Kidney (renal) scarring. Untreated UTIs can lead to scarring, also known as reflux nephropathy, which is permanent damage to kidney tissue. A backup of urine exposes the kidneys to higher than normal pressure, which can lead to scarring over time. Extensive scarring may lead to high blood pressure and kidney failure.
• High blood pressure (hypertension). Because the kidneys remove waste from the bloodstream, damage to your kidneys and the resultant buildup of wastes can raise your blood pressure.
• Kidney failure. Scarring can cause a loss of function in the filtering part of the kidney. This may lead to kidney failure, which can occur quickly (acute) or it may develop over time (chronic). In either case, dialysis or a kidney transplant may be necessary. Dialysis is an artificial means of removing extra fluids and waste from your blood.

Treatments and drugs:

Treatment options for vesicoureteral reflux depend on the severity of the condition. Children with mild cases of primary vesicoureteral reflux may eventually outgrow the disorder. In this case, your doctor will likely recommend a wait-and-see approach. During this time, it will be important for you to be watchful for potential UTIs and to seek prompt treatment.

Children with moderate to severe primary vesicoureteral reflux have two treatment options: medication and surgery. Using medication is more common, with surgery usually reserved for those children for whom antibiotics aren't successful.
However, surgery may be a first line therapy for grades IV and V or for families who prefer a quicker, more definitive treatment than medication.

Medications
UTIs require prompt treatment with antibiotics to keep the infection from moving to the kidneys. Doctors may also use antibiotics to prevent UTIs, usually at about half the dose for treating an infection.

Commonly used antibiotics for prevention include the combination drug trimethoprim-sulfamethoxazole (Bactrim, Septra), trimethoprim (Primsol) and nitrofurantoin (Furadantin, Macrobid, Macrodantin). Some people may be allergic to one or more of these medications, preventing their use. Possible side effects of long-term use of these drugs include:

• Nausea and vomiting
• Abdominal pain
• Increased antibiotic resistance, in which the infection no longer responds to antibiotics and becomes more difficult to treat

A child being treated with medication needs to be monitored for as long as he or she is taking antibiotics. This includes periodic physical exams and urine tests to detect breakthrough infections — UTIs that occur despite the antibiotic treatment — and occasional radiographic scans of the bladder and kidneys to determine if your child has outgrown vesicoureteral reflux.

Surgery
Surgery for vesicoureteral reflux repairs the defect in the functional valve between the bladder and each affected ureter that keeps it from closing and preventing urine from flowing backward. There are two methods of surgical repair:

• Open surgery. Performed using general anesthesia, this surgery requires an incision in the lower abdomen through which the surgeon repairs the malformation that's causing the problem. This type of surgery usually requires a few days' stay in the hospital, during which a catheter is kept in place to drain your child's bladder. Risks include infection, blood clots and bleeding.
• Endoscopic surgery. In this procedure, the doctor inserts a lighted tube (cystoscope) through the urethra to see inside your child's bladder, then injects a bulking agent around the opening of the affected ureter to try to strengthen the valve's ability to close properly. This method is minimally invasive compared with open surgery and presents fewer risks, though it may not be as effective. This procedure also requires general anesthesia, but generally can be performed as outpatient surgery.