Vesicoureteral reflux in children: symptoms and treatment

What is vesicoureteral reflux?

Vesicoureteral reflux (VUR, urinary reflux, vesicourethral reflux) Is a childhood disorder in which urine flows from the bladder back to the kidneys. The return flow (reflux) of urine increases pressure in the kidneys and may harbor bacteria that can lead to kidney infections.

Prolonged high blood pressure and repeated infections can damage and scar the kidneys (for example called kidney dysplasia), which can interfere with proper kidney function later in life child.

Vesicoureteral reflux occurs in approximately one in 100 children. Most children with this disease do not need treatment; the disease goes away with age on its own.

However, a small number of children may need surgery to correct this condition, as complications may occur (infections, chronic tubulointerstitial nephritis and etc.).

Prevalence rates are 70% in patients younger than 1 year old, 25% in patients aged 4 years, 15% in patients aged 12 years, and 5.2% in adult patients.

Pathogenesis of urinary reflux

The urinary tract is made up of the kidneys, ureters, bladder, and urethra. Urine produced by the kidneys enters the bladder through the ureters.

The bladder serves as a reservoir for urine until it is passed out of the body through the urethra. There is a valve mechanism at the junction where each ureter enters the bladder (ureteral junction). When the bladder empties, these valves close, preventing urine from flowing back (reflux) to the kidneys.

In vesicoureteral reflux, urine flows from the bladder, through the valves in the ureteral node, lifts the ureters back and returns to the kidneys. This is usually a congenital condition (present at birth) that occurs when one or both of the valve mechanisms are not working properly. The condition is more common in girls than in boys.

PMR classification

Vesicoureteral reflux is classified from grade 1 to grade 5, with grade 1 being the mildest grade and 5 being the most severe:

1. 1st degree - reflux of urine partially rises up the ureter to the kidney;
2. 2nd degree - urinary reflux rises up to the ureter itself and enters the kidney;
3. Grade 3 - urinary reflux rises to the ureter itself and enters the kidney. There is some dilation of the ureter and the part of the kidney where urine is collected
4. 4 degree - reflux of urine into the kidneys, there is an expansion of the ureter and the part of the kidney where urine is collected;
5. 5 degree - a large amount of reflux of urine in the kidneys, there is a twisting and expansion of the ureter and the part of the kidney where urine is collected.

The valves in the ureteral joints mature as the baby ages, and most babies with vesicoureteral reflux grow out of this condition within a few years after birth.

Spontaneous resolution is more common in children with mild to moderate reflux. 4-5 degree, severe urinary reflux is less likely to go away on its own.

Causes

The cause of the primary reflux defect is unknown.

The presence of a hereditary predisposition is indicated by a high level of reflux in relatives of patients with reflux, but the mechanism of transmission is unclear. Some researchers suggest polygenic inheritance, while others suggest autosomal or sex-related transmission with variable permeability.

Reflux rates are likely to increase in congenital bladder obstruction and neurogenic bladder conditions. More than 50% boys with posterior urethral valves have VUR. Similar results were seen when a series of children underwent neurogenic bladder urodynamic studies.

Dysfunctional urination, with an inherent increase in intravesical pressure, probably also leads to reflux, even in healthy children.

The incidence of reflux is clearly influenced by genetic factors, although specific modes of inheritance have not yet been determined.

Signs and symptoms of vesicoureteral reflux

With vesicoureteral reflux symptoms do not appear. Signs appear when there is urinary tract infections (IMP). The infection causes symptoms such as fever, pain, unpleasant urine smell and burning when urinating. Other common symptoms include:

• night urinary incontinence (nocturnal enuresis);
• pain in the lower abdomen;
• blood in the urine (hematuria) and / or pus in the urine (pyuria);
• high blood pressure;
• renal failure.

Diagnostics

Vesicoureteral reflux may be suspected before the baby is born. If a prenatal ultrasound scan shows an enlarged kidney (s) and / or dilated ureters, this may indicate reflux.

Vesicoureteral reflux is most often first suspected in infancy with recurrent urinary tract infections. Most children who experience UTIs have normal urinary tract flow. but up to 30% of these have some degree of urinary reflux.

Children who have recurrent UTIs should be evaluated for vesicoureteral reflux. Because it occurs in families, there is a possibility that vesicoureteral reflux may also be affected by a family history.

Common tests used to diagnose vesicoureteral reflux and assess kidney damage include:

• Ultrasound scanning: the bladder and kidneys are scanned for anatomy and any abnormalities.
• Microstructural cystourethrography: A small tube (catheter) is inserted into the baby's bladder, and a radiopaque (visible on X-rays) fluid is inserted into the bladder. X-rays are taken after the baby's bladder fills while urinating.
• Renal scan using DMSA: pictures of the kidneys are taken using a special scanner after a weak radioactive solution (radioisotope) is injected into the bloodstream through an IV. Scanner images can help assess the size, position, and function of your kidneys, and check for kidney scarring from repeated UTIs.

Urinary reflux treatment

The goal of any treatment for vesicoureteral reflux is to prevent kidney damage. Treatment will depend on the severity of the reflux and whether there are ongoing problems with the infection.

In most cases, no treatment is required and the child's doctor will monitor the growth and health of the child's kidneys with an ultrasound scan.

The child may be encouraged to have regular urine tests to make sure there is no infection. If treatment for vesicoureteral reflux is required, there are two main treatment options.

Drug treatment

UTIs require immediate antibiotic treatment to prevent kidney infections from developing. Children with recurrent UTIs may be recommended prophylactic antibiotic therapy (taking antibiotics) to prevent the development of a urinary tract infection, and therefore, prevent kidney damage. Again, kidney health and growth will be regularly assessed using ultrasound scans.

Surgery

Although surgery for vesicoureteral reflux is no longer routinely performed, a small number of children surgery will be required to fix the problem. It is especially necessary for children with severe (stage 4-5) vesicoureteral reflux who have the following problems:

• they continue to develop UTIs while taking prophylactic antibiotics;
• the child is allergic to antibiotics;
• reflux does not resolve or gets worse over time;
• the kidneys show signs of damage.

The operation to restore the valve mechanism in the urethrovesical junction is called "Ureteral reimplantation". The operation is performed under general anesthesia and may require a 2 or 3 day hospital stay. During surgery, the ureters are released and then "reimplanted" into the bladder wall so that an effective valve mechanism is created.

Prophylactic antibiotic treatment may be continued after surgery until subsequent evaluation shows that the reflux is cured. Ureteral reimplantation has a very high success rate in the treatment of vesicoureteral reflux.

Following therapy for vesicoureteral reflux, follow-up evaluation may be recommended. This may include urine tests, blood tests, and ultrasound scans. Blood pressure, height and weight can also be measured. These tests are done to evaluate kidney function and to make sure reflux is cured.

Food

Children with frequent UTIs have problems with constipation and poor bowel habits. High fiber diets combined with an emollient such as Dokuzat sodium, can improve bowel function and reduce enlargement of the colon and rectum. In severe cases, it is often used daily Polyethylene glycol.

To summarize

Vesicoureteral reflux (VUR), or the process of retrograde reflux of urine from the bladder into the ureter, is anatomical and functional a disorder that, in severe stages, can lead to significant complications such as acute infections, chronic tubulo-interstitial nephritis.

Basically, with a mild stage and timely treatment of the disease, the prognosis is favorable, in most cases 1-2 degree of pathology can be resolved on its own. It is important to get a consultation and conduct examinations.

Ongoing research efforts are aimed at better understanding the genetics of VUR, refining diagnostic criteria in order to better identify patients who appear to be at increased risk of kidney damage, and determining who will benefit the most from the final therapy. Finding molecular markers associated with kidney damage will also help treat VUR patients.