VESICOURETERAL REFLUX

The normal urinary tract is made up of the two kidneys, two ureters, a bladder and a urethra. Each of the kidneys produces urine which flows down through the ureters and into the bladder. Normally, each ureter enters the bladder at an angle that creates a tunnel through the bladder wall muscle. As the bladder fills and during emptying, this tunnel prevents any urine from backing up from the bladder into the ureter. By the end of urination, nearly all the urine has passed from the bladder and out of the body through the urethra.

Vesicourteral reflux (VUR) is the congenital condition (children are born with it) in which urine backs up from the bladder and into the ureter toward the kidney. Reflux occurs in varying degrees of severity ranging from Grade I to Grade V, with Grade I being the least severe and Grade V being the most severe. Reflux may be present in one or both ureters. It is more prevalent in girls than boys (2:1).

The diagnosis of reflux is made based on radiologic studies of the bladder and kidney and may be discovered in the fetus secondary to hydronephrosis, a swelling of the kidney, on prenatal ultrasound. Nuclear medicine and radiology testing is usually recommended following a urinary tract infection (UTI) or if reflux is discovered in other family members. It is essential that all children with urinary tract infection, diagnosed by a properly done urine specimen, be evaluated since infection may be the only symptom that suggests a potential problem. Reflux itself cannot be felt and rarely causes symptoms. Approximately one out of three children who have urinary tract infections are found to have reflux. If reflux is diagnosed in one child, the physician may recommend that siblings be checked for reflux.

Treatment will vary depending on the degree of reflux and frequency of urinary tract infection. Usually a child with Grade I, Grade II, and sometimes Grade III reflux will be treated nonoperatively after the diagnosis is made. Low dose antibiotics or prophylactic antibiotics are usually prescribed until follow up radiology studies are completed a year after diagnosis. This antibiotic will not cure the reflux, but will help to prevent a urinary tract infection. Many children will have spontaneous disappearance of the reflux with time (about 20%).

Urine cultures will be obtained routinely (every 2 to 3 months) to check for infection in the child. Symptoms of infection include, but are not limited to, burning during urination, frequent urination, abdominal pain, fever, vomiting, or foul smelling urine. If an infection is suspected at any time, a physician should be consulted. If one urine culture is positive for bacteria, a second culture is often recommended to verify the infection. A single culture has an accuracy rate of only 80%. Two urine cultures in a row increases the accuracy to 95%.

It is generally recommend that children return for evaluation on a yearly basis. At the time of the evaluation, radiologic studies (x-ray of the bladder, ureters, and kidneys) are usually performed to compare the grade of reflux to the previous year's evaluation. These radiologic studies will also show whether the kidneys are growing and if they have undergone any damage or scarring from recurrent infections. If periodic studies of the bladder do not show lessening of the reflux, if there is a severe degree of reflux, or if the child has a break through infection (infection while on an antibiotic) surgery may be indicated.

The surgery to correct reflux is called ureteral reimplant and is done in the bladder through an incision just above the pubic bone (a bikini cut). The ureter is reconnected to the bladder at an angle that creates an anti-reflux tunnel in the bladder wall. This tunnel will prevent urine from backing up towards the kidney. No artificial materials are used. The operation usually takes between 2 and 3 hours to complete and the child is hospitalized for approximately 5 days.

The information provided in this section should in no way serve as medical advice. Readers are encouraged to confirm the information contained here with other sources and seek medical advice from a physician. Neither the authors nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete and they are not responsible for any errors or omissions or for the results obtained for the use of such information.

Information provided by the Division of Urology, Children's Hospital, Boston, MA.

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