incidence of vesicoureteral reflux in asymptomatic siblings inour study is significantly higher than that reported by mostin the literature.4–7 However, a comparable incidence of vesi-coureteral reflux has been demonstrated.8–10 The high inci-dence in our study seems to justify screening of asymptom-atic siblings of patients with vesicoureteral reflux.

We found it interesting that 77 of 78 patients evaluatedwere asymptomatic with only 1 presenting with a urinarytract infection. This finding separates our patient populationfrom those previously reported, as our patients had a muchlower percentage of symptomatic siblings.7, 11 Anecdotally,we do agree that a less favorable outcome can be expected insymptomatic siblings. In fact, our only patient with symp-toms required surgery for breakthrough infection.12

Patient age has been shown to be one of the factors pri-marily affecting the incidence of vesicoureteral reflux. In ourstudy 39 of a total 65 (60%) units with vesicoureteral refluxwere in children younger than 2 years. The 34% incidence ofgrades I to II vesicoureteral reflux in these children matchesthose older than 2 years, which is 35%. However, the inci-dence of grades III to IV vesicoureteral reflux in childrenyounger than 2 years is significantly higher (26%) than those(4.6%) older than 2 years. This relationship between patientage, and incidence and severity of vesicoureteral reflux hasalso been documented in previous sibling studies and mimicsthe pattern found in the index patients with vesicoureteralreflux.5 The aforementioned finding seems to support furtherthe evaluation of asymptomatic siblings, especially in theyounger population.

The incidence of vesicoureteral reflux was significantlyhigher in females (75%) compared to males (25%), which con-tradicts what has been reported earlier.9 The vast majority(69.2%) of our patients had low grade reflux (range I to II), withgrade III in 29.2%. Only 1 patient had grade IV reflux. Thesenumbers agree with earlier reports,6 although the incidence ofgrade IV vesicoureteral reflux is much lower in our presentstudy.

The most important parameter in long-term outcome re-gards scarring and irreversible renal damage. The incidenceof renal damage and scarring in this population has beenvariably reported from 4.7% to as high as 23%.3, 5, 6 However,in our study we did not encounter a single renal unit withevidence of parenchymal scarring or damage and/or hyper-tension. We do recognize that renal ultrasound is not the bestanalysis to investigate for scars. However, a gross significantabnormality would clearly have been documented.

The resolution rate of reflux and time to resolution in ourpresent study compares favorably to that reported for tradi-tional, including nonsibling, reflux as well as sibling.13, 14

One would like to think that these improved outcomes aredue to a decrease in urinary tract infection due to screeningand aggressive management. However, it also brings intoquestion whether the response to injury may be somewhatdifferent in this patient population.

CONCLUSIONS

The incidence of sibling vesicoureteral reflux is significant.It is asymptomatic in most cases, and a direct relationshipbetween patient age and the incidence and severity of vesi-coureteral reflux does exist. However, grade specific time toresolution is shorter and resolution rate is higher in ourpatient population, as compared to those patients with pri-mary reflux diagnosed for other reasons. The incidence ofrenal damage appears to be decreased compared to “tradi-tional” reflux. Although a decrease in urinary tract infectiondue to screening and aggressive management is the mostlikely cause, a different response to injury from vesi-coureteral reflux in this patient population cannot be ex-cluded. It is reasonable to recommend screening for siblingvesicoureteral reflux. However, we suggest that sibling vesi-coureteral reflux may follow a more benign course.

REFERENCES

1. Noe, H. N.: The current status of screening for vesicoureteralreflux. Pediatr Nephrol, 9: 638, 1995

2. Ferrer, F. A., Mckenna, P. H., Hochman, H. I. et al: Results of avesicoureteral reflux practice pattern survey among AmericanAcademy of Pediatrics, Section on Pediatric Urology members.J Urol, part 2, 160: 1031, 1998

3. Kenda, R. B. and Fettich, J. J.: Vesicoureteric reflux and renalscars in asymptomatic siblings of children with reflux. ArchDis Child, 67: 506, 1992

4. Sahin, A., Ergen, A., Balbay, D. et al: Screening of asymptomaticsiblings of patients with vesicoureteral reflux. Int Urol Neph-rol, 23: 437, 1991

5. Connolly, L. P., Treves, S. T., Connolly, S. A. et al: Vesicoureteralreflux in children: incidence and severity in siblings. J Urol,157: 2287, 1997

6. Wan, J., Greenfield, S. P., Ng, M. et al: Sibling reflux: a dualcenter retrospective study. J Urol, part 2, 156: 677, 1996

7. Jerkins, G. R. and Noe, H. N.: Familial vesicoureteral reflux: aprospective study. J Urol, 128: 774, 1982

8. Van den Abbeele, A. D., Treves, S. T., Lebowitz, R. I. et al: Vesi-coureteral reflux in asymptomatic siblings of patients withknown reflux: radionuclide cystography. Pediatrics, 79: 147, 1987

9. Kenda, R. B., Kenig, T. and Budhina, N.: Detecting vesicoureteralreflux in asymptomatic siblings of children with reflux by directradionuclide cystography. Eur J Pediatr, 150: 735, 1991

10. Yoshioka, T., Utsunomiya, M., Itoh, H. et al: Familial vesi-coureteral reflux. Hinyokika Kiyo, 29: 1307, 1983

11. Sirota, L., Hertz, M., Laufer, J. et al: Familial vesicoureteralreflux: a study of 16 families. Urol Radiol, 8: 22, 1986

12. Puri, P., Cascio, S., Lakshmandass, G. et al: Urinary tract infec-tion and renal damage in sibling vesicoureteral reflux. J Urol,part 2, 160: 1028, 1998

13. Shimada, K., Taguchi, K., Koike, H. et al: Spontaneous resolu-tion of reflux in children with primary VUR. Nippon Hin-yokika Gakkai Zasshi, 81: 982, 1990

14. Connolly, L. P., Treves, S. T., Zurakowski, D. et al: Natural historyof vesicoureteral reflux in siblings. J Urol, 156: 1805, 1996

EDITORIAL COMMENT

The topic of sibling reflux reminds urologists that we are notnecessarily in a reactive field. Typically, patients present to us onlyafter a complaint has developed. We see patients because of blood inthe urine, flank pain, foul urine and incontinence. We then takeaction to determine the cause of symptoms and plan treatment. Werarely seek out otherwise healthy appearing asymptomatic patientsand search for the presence of a condition.

The findings of Parekh et al help to remind us that in the case ofsibling reflux a proactive course is warranted. Although their siblingreflux rate (51%) is higher than some other studies (references 5 to 7in article), the distribution of the affected age, sex and grade ofvesicoureteral reflux is similar to that found among all patients withvesicoureteral reflux. Many patients in whom symptoms, signs, andpossibly the sequelae of vesicoureteral reflux would otherwise laterdevelop were instead treated early and spared these afflictions.

Thanks to developments in the field of molecular genetics, it is nowclear that many clinical conditions are a result of a genetic basis orpredisposition. For this reason when a condition develops in 1 child,the question is naturally raised whether the full-blooded sibling isalso affected. When that condition can be asymptomatic and notpresent itself until the child is many years older, the possibility ofearly detection and treatment should be appealing.

Rather than waiting until a urinary tract infection develops and thepotential for renal scarring, a preemptive regimen of detection andtreatment is now possible. Instead of waiting for a condition to developand then react to it, we can prevent it. Despite the published data, thereare many families and some physicians who seem squeamish aboutrecommending testing for vesicoureteral reflux in siblings. They preferto “wait and see if anything develops” and, thereby, miss a chance atprevention.

Julian WanDepartment of Pediatric UrologyChildren’s Hospital of BuffaloBuffalo, New York

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