WHAT IS VESICOURETERAL REFLUX?
To understand vesicoureteral (ves i ko' yur ee ter al) reflux, it
is necessary to first understand the normal structure and function
of the urinary tract. Below is a diagram of the urinary tract.
The kidneys filter the blood to form urine, which is the body's
waste product. Urine then travels from the kidneys down the ureters
into the bladder where it is stored until urination occurs. With
children who have vesicoureteral reflux (VUR), the urine backflows
or refluxes from the bladder up the ureters towards the kidneys
Reflux is caused by a faulty valve mechanism between the ureter
and bladder. It is a condition with which people are born. It does
tend to run in families. If your child has reflux, your doctor may
recommend testing for the condition in your other children
Reflux becomes a problem when urine becomes infected. Infected
urine usually stays within the bladder. When reflux exists, however,
bacteria can get into the kidneys and cause a kidney infection. This
can lead to kidney damage
GRADING REFLUX
Reflux is classified according to its severity. It ranges from
very mild backflow of urine up the ureter to very severe backflow
with ureter and kidney dilation (swelling). Below are diagrams of
each level of reflux
DIAGNOSIS
We screen for urinary tract infections at several well check ups,
but also may do a urinalysis with a culture if your child has
concerning symptoms such as pain with urination, frequency, change
in the color of the urine, or any concerns that there may be blood
or discharge mixed in with the urine. If your child does have
growth of bacteria on the culture, they will need to be treated with
antibiotics. We ask that after 48 hours of the antibiotic you
return to the office to repeat the urine culture. This is to
assure that the antibiotic is working, and is necessary for proper
treatment. If your child is under 5 years old, they will
usually require a renal ultrasound and VCUG (voiding
cystourethrogram) to find out if they have reflux. These tests
are generally done 3 weeks after treatment of the infection.
The diagnosis of reflux is made by a bladder x-ray called a
voiding cystourethrogram (sis' toe yur ee' throw gram), also called
VCUG test. During the test, a small plastic or rubber tube
(catheter) is placed into the urethra, and the bladder is filled
with liquid contrast material. X-ray pictures are then taken to
check for the presence of reflux. Another similar test called a
nuclear cystogram may be used instead. This test provides the same
results, but requires less radiation. Your child will feel some
discomfort when the catheter is passed, but in general, the test is
not painful. Pain medication or sedation are not needed
A kidney (renal) and bladder ultrasound test will also be done.
This test uses sound waves to measure kidney size and to look for
kidney scarring. Ultrasound tests will be done periodically to check
for normal kidney growth and to test for possible damage due to
infections
A renal (nuclear medicine) scan may also be done to test for how
well the kidneys work
TREATMENT
In certain instances, a cystoscopy may be needed. This consists
of the urologist looking into the bladder through the urethra with a
long thin tube with a light. The shape of the opening of the ureter
into the bladder can help the urologist decide how your child should
be treated. This test involves giving the child a short general
anesthetic. It is done in the operating room
The plan of treatment will vary according to your child's age,
number of urinary tract infections, and test results. All children
with reflux will need to take low dose "suppressive"
antibiotics. This is done to prevent urinary tract infections so
that kidney damage does not occur. The benefit to the body of taking
low dose antibiotics for a period of time and preventing kidney
infections greatly outweighs the risks of the medication
Your child will need periodic urine cultures to monitor for
breakthrough infections
Periodic x-ray and ultrasound tests will be done to monitor for
kidney growth, kidney damage, and changes in the reflux
Periodic blood tests may be needed, depending on the medications
your child takes
Children with mild to moderate reflux (grades 1 and 2) will be
managed medically. (As outlined just previously). Those with grades
3 or 4 reflux may need surgery to repair the valve. Those with grade
5 reflux will need surgery. If a child with a lesser grade of reflux
develops breakthrough infections while on antibiotic suppression, or
continues with the reflux without improvement in its severity for
several years, then surgery may also need to be done in these cases
as well. Each child will be treated as an individual and his family
circumstances will be considered in the plan of treatment. The goals
of treatment are to prevent kidney damage and to preserve kidney
function, utilizing the safest method possible for your child
VOCABULARY
- antibiotic suppression - a low dose of antibiotic given in
order to prevent urinary tract infections
- breakthrough infections - urinary infections occurring while a
child is taking suppression medication
- general anesthesia - medication given to someone so that they
are asleep during a procedure; the person will feel no pain
- urologist - a doctor who specializes in the care of the
kidney, ureters, bladder, urethra, and genitals