Vesicoureteral refluxpresented

by Dr Emmanuel Godwin

Nephrology unit Department of Pediartics ,ABUTH Shika

TABLE OF CONTENT• Introduction• Epidemiology• Etiology• International Classification of Vesicoureteral Reflux• Pathophysiology• Clinical features• Complications of Reflux• Investigation• Treatment• Follow-up• Prognosis• References

IntroductionVesicoureteral reflux (VUR) is a condition in which urine flows retrograde, or backward, from the bladder into the ureters/kidneys.

Urine normally travels in one direction (forward, or antegrade) from the kidneys to the bladder via the ureters, with a 1-way valve at the ureterovesical (ureteral-bladder) junction preventing backflow

The valve is formed by oblique tunneling of the distal ureter through the wall of the bladder, creating a short length of ureter (1–2 cm) that can be compressed as the bladder fills.

Reflux occurs if the ureter enters the bladder without sufficient tunneling

Epidemiology

• It has been estimated that VUR is present in more than 10% of the population. • Younger children are more prone to VUR because of the relative shortness of the

submucosal ureters. This susceptibility decreases with age as the length of the ureters increases as the children grow.

• In children under the age of 1 year with a urinary tract infection, 70% will have VUR. This number decreases to 15% by the age of 12.

• VUR is more common in males antenatally,• in later life there is a definite female preponderance with 85% of cases being

female.• 30 to 60% of children with VUR have renal scarring• Female: Male ratio= 5:1

EtiologyIn healthy individuals the ureters enter the urinary bladder obliquely and run submucosally for some distance. This, in addition to the ureter's muscular attachments, helps secure and support them posteriorly. Together these features produce a valvelike effect that occludes the ureteric opening during storage and voiding of urine. In people with VUR, failure of this mechanism occurs, with resultant retrograde flow of urine.

It could be primary or secondary

Etiology Con’t

VESICO URETERAL REFLUX

Primary

Congenital inadequacy of valvular mechanism at

the U-V Junctionwww.drvivekrege.com

Primary Reflux

Normal mechanism has – • oblique entry of the ureter• submucosal –intramural length of ureter• Ratio of tunnel length : diameter of ureter-3:1• Ureterotrigonal longitudinal muscles• Active ureteral peristalsis

www.drvivekrege.com

Primary RefluxInsufficient submucosal length of the ureter relative to its diameter causes inadequacy of the valvular mechanism. This is precipitated by a congenital defect/lack of longitudinal muscle of the intravesical ureter resulting in an ureterovesicular junction (UVJ) anomaly.

Secondary VUR

• In this category the valvular mechanism is intact and healthy to start with but becomes overwhelmed by raised vesicular pressures associated with obstruction, which distorts the ureterovesical junction. The obstructions may be anatomical or functional.

• Secondary VUR can be further divided into anatomical and functional groups.

Secondary VU Reflux

Anatomical• Posterior urethral valves• Urethral or meatal stenosis• Prune belly Syndrome• Anorectal Malformations

Functional• Dysfunctional voiding (

neurogenic bladder)

International Classification of Vesicoureteral Reflux• Grade I – reflux into non-dilated ureter• Grade II – reflux into the renal pelvis and calyces without dilatation• Grade III – mild/moderate dilatation of the ureter, renal pelvis and calyces

with minimal blunting of the fornices• Grade IV – dilation of the renal pelvis and calyces with moderate ureteral

tortuosity• Grade V – gross dilatation of the ureter, pelvis and calyces; ureteral

tortuosity; loss of papillary impressions

• Note:

International Classification of Vesicoureteral Reflux

The younger the age of the patient and the lower the grade at presentation the higher the chance of spontaneous resolution. Most (approx. 85%) of grade I & II cases of VUR will resolve spontaneously. Approximately 50% of grade III cases and a lower percentage of higher grades will also resolve spontaneously.

Vesico- ureteral reflux

Normal kidney, ureter, and bladder

                                         

                                           

Vesico- ureteral reflux

Grade I Vesicoureteral Reflux:urine (shown in blue) refluxes part-way up the ureter

Vesico- ureteral reflux

• Grade II Vesicoureteral Reflux:urine refluxes all the way up the ureter

Vesico- ureteral reflux

• Grade III Vesicoureteral Reflux:urine refluxes all the way up the ureter with dilatation of the ureter and calyces (part of the kidney where urine collects)

Vesico- ureteral reflux

• Grade IV Vesicoureteral Reflux:urine refluxes all the way up the ureter with marked dilatation of the ureter and calyces

Vesico- ureteral reflux

• Grade V Vesicoureteral Reflux:massive reflux of urine up the ureter with marked tortuosity and dilatation of the ureter and calyces

..

Pathophysiology• VUR > High pressure urine into ureters & Kidneys• Stasis of urine because of post-voidal residual urine• Stasis of urine good nidus for superadded infection• Refluxed infected urine >Pyelonehritis >Renal scarring >Reflux Uropathy >ESRD• Reflux,UTI & Pyelonephritis scarring >Well known Triad in Pediatric

urology

Clinical Features• Neonates : usually asymptomatic, non specific symptoms

• Infants : the signs and symptoms of a urinary tract infection may include only fever and lethargy, with poor appetite and sometimes foul-smelling urine, Young infant not thriving

• older children : dysuria and frequent urination, urine retention, Cloudy or blood tinged urine

Complications of Reflux• Recurrent Urinary tract infections• Renal scar formation• Renal growth arrest• Renal function drops – Electrolytes inbalance • Hypertension • Somatic growth drops- Failure to thrive

Investigations• Prenatal screening : hydronephrosis or hydroureter on Ultrasound

• Fluoroscopic Voiding cystourethrogram (VCUG) : VCUG is the method of choice for grading and initial workup

• Abdominal ultrasound :suggest the presence of VUR if ureteral dilatation is present; however, in many circumstances of VUR of low to moderate severity, the sonogram may be completely normal, thus providing insufficient utility as a single diagnostic test in the evaluation of children suspected of having VUR, such as those presenting with prenatal hydronephrosis or urinary tract infection (UTI).

Investigations• U/E/Cr• FBC + Diff• Blood culture• Urine M/C/S

USG AbdomenGrd 5 VURHydronephrosis+Hydroureter+

MCU or VCUG

Gd 1 VURLt VUR Gd 1

MCU or VCUG

Gd 2 VURBilateral VUR Gd 2

MCU or VCUG

Gd 3 VURBilateral VUR Gd 3

MCU or VCUG

Gd 4 VURBilateral VUR Gd 4

Gd 5 VUR

Gd 5 VURBilateral VUR Gd 5

Neurogenic Bladder with VUR

Neurogenic Bladder with VURGd 3 VURNeurogenic Bladder+VP shunt+

DMSA Scan

Tch99 DMSA Scan(Dimercaptosuccinic Acid)Renal ScarringDifferential Function

Treatment•Medical •Surgical

Treatment• The goal of treatment is to minimize infections, as it is infections that

cause renal scarring and not the vesicoureteral reflux.• Minimizing infections is primarily done by prophylactic antibiotics in

newborns and infants who are not potty trained.• When medical management fails to prevent recurrent urinary tract

infections, or if the kidneys show progressive renal scarring then surgical interventions may be necessary.

• Medical management is recommended in children with Grade I-III VUR as most cases will resolve spontaneously.

….• A trial of medical treatment is indicated in patients with Grade IV VUR

especially in younger patients or those with unilateral disease.• Of the patients with Grade V VUR only infants are trialled on a

medical approach before surgery is indicated.• In older patients surgery is the only option.

Medical Treatment

• Medical treatment entails low dose antibiotic prophylaxis until resolution of VUR occurs• The specific antibiotics used differ with the age of the patient and include:• Amoxicillin or ampicillin - infants younger than 6 weeks• Trimethoprim-sulfamethoxazole (co-trimoxazole) - 6 weeks to 2 months• After 2 months the following antibiotics are suitable:• Nitrofurantoin {5–7 mg/kg/24hrs}• Nalidixic acid(10 mg/kg in bid doses)• Bactrim(2 mg/kg of TMP as a single dose at bedtime)

• Trimethoprim• Cephalosporins

Medical Treatment• Urine cultures are performed 3 monthly to exclude breakthrough

infection• Annual radiological investigations are likewise indicated. Good

perineal hygiene, and timed and double voiding are also important aspects of medical treatment.

• Bladder dysfunction is treated with the administration of anticholinergics.

Surgical Treatment

• A surgical approach is necessary in cases where a breakthrough infection results despite prophylaxis, or there is non-compliance with the prophylaxis.

• if the VUR is severe (Grade IV & V), • pyelonephritic changes or• congenital abnormalities.• failure of renal growth,• formation of new scars,• renal deterioration and • VUR in girls approaching puberty.

Surgical Treatment

• There are three types of surgical procedure available for the treatment of VUR:

• Endoscopic (STING/HIT procedures);• Laparoscopic; and • Open procedures (Cohen procedure, Leadbetter-Politano procedure).

Prognosis• The younger the age of the patient and the lower the grade at

presentation the higher the chance of spontaneous resolution.• Most (approx. 85%) of grade I & II cases of VUR will resolve

spontaneously. • Approximately 50% of grade III cases and a lower percentage of

higher grades will also resolve spontaneously.• Prognosis is good when diagnosis is made early

Follow-up

• The American Urological Association recommends ongoing monitoring of children with VUR until the abnormality resolves or is no longer clinically significant.

• The recommendations are for annual evaluation of blood pressure, height, weight, analysis of the urine, and kidney ultrasound.

References • Institute of Urology & Nephrology, London, UK,

The cellular basis of bladder instability UJUS 2009, Retrieved 4-20-2010• Peters CA, Skoog SJ, Arant BS, Copp HL, Elder JS, Hudson RG, Khoury AE,

Lorenzo AJ, Pohl HG, Shapiro E, Snodgrass WT, Diaz M (September 2010). "Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children.". The Journal of Urology. 184 (3): 1134–44. doi:10.1016/j.juro.2010.05.065. PMID 20650499

• Tekgül, S; Riedmiller, H; Hoebeke, P; Kočvara, R; Nijman, RJ; Radmayr, C; Stein, R; Dogan, HS; European Association of, Urology (September 2012). "EAU guidelines on vesicoureteral reflux in children.". European Urology. 62 (3): 534–42. doi:10.1016/j.eururo.2012.05.059. PMID 22698573.

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