Vesicoureteral reflux: Difference between revisions

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{{DiseaseDisorder infobox |
{{DiseaseDisorder infobox |
   Name          = Vesicoureteral Reflux |
   Name          = Vesicoureteral Reflux |
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   OMIM_mult      = |
   MedlinePlus    = 000459 |
   MedlinePlus    = 000459 |
  eMedicineSubj  = ped |
  eMedicineTopic = 2750 |
   DiseasesDB    = 13835 |
   DiseasesDB    = 13835 |
}}
}}
{{Search infobox}}
{{Search infobox}}
{{SCC}}
{{CMG}}, {{SCC}}
 


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==Overview==
==Overview==


'''Vesicoureteral reflux''' (VUR) is an abnormal movement of [[urine]] from the [[urinary bladder|bladder]] into [[ureter]]s or [[kidney]]s.  Urine normally travels from the kidneys via the ureters to the bladder. In vesicoureteral reflux the direction of urine [[flow]] is reversed (retrograde).
'''Vesicoureteral reflux''' (VUR) is an abnormal movement of [[urine]] from the [[urinary bladder|bladder]] into [[ureter]]s or [[kidney]]s.  Urine normally travels from the kidneys via the ureters to the bladder. In vesicoureteral reflux the direction of urine [[flow]] is reversed (retrograde). In the majority of cases, it occurs as a result of a primary maturation abnormality of the vesicoureteral junction or a short distal ureteric submucosal tunnel in the bladder that alters the function of the valve mechanism. VUR may be an isolated anomaly or associated with other congenital anomalies such as [[posterior urethral valves]] or complete [[Duplicated collecting system | duplication of the urinary tract]].
 
In the majority of cases, it occurs as a result of a primary maturation abnormality of the vesicoureteral junction or a short distal ureteric submucosal tunnel in the bladder that alters the function of the valve mechanism.  
 
VUR may be an isolated anomaly or associated with other congenital anomalies such as [[posterior urethral valves]] or complete [[Duplicated collecting system | duplication of the urinary tract]].


==Symptoms==
==Symptoms==
Vesicoureteral reflux may present before birth as prenatal hydronephrosis, an abnormal widening of the [[ureter]] or with a [[urinary tract infection]] or [[acute pyelonephritis]]. Symptoms such as painful urination or [[renal colic]] / [[flank pain]] are not symptoms associated with vesicoureteral reflux.  
* Prenatal hydronephrosis.<ref name="pmid9284209">{{cite journal |vauthors=Yeung CK, Godley ML, Dhillon HK, Gordon I, Duffy PG, Ransley PG |title=The characteristics of primary vesico-ureteric reflux in male and female infants with pre-natal hydronephrosis |journal=Br J Urol |volume=80 |issue=2 |pages=319–27 |date=August 1997 |pmid=9284209 |doi= |url=}}</ref>
 
* Abnormal widening of the [[ureter]] .
Newborns may be [[lethargy|lethargic]] with failure to thrive, while infants and young children typically present with [[pyrexia]], [[dysuria]], [[polyuria|frequent urination]], malodorous urine and [[Gastrointestinal tract|GIT]] symptoms, but only when urinary tract infection is present as the initial presentation of VUR.
* Urinary tract infection.
* Acute pyelonephritis .
* Symptoms such as painful urination or [[renal colic]] / [[flank pain]] are not symptoms associated with vesicoureteral reflux.
* Newborns may be [[lethargy|lethargic]] with failure to thrive, while infants and young children typically present with [[pyrexia]], [[dysuria]], [[polyuria|frequent urination]], malodorous urine and [[Gastrointestinal tract|GIT]] symptoms, but only when urinary tract infection is present as the initial presentation of VUR.


==Causes==
==Causes==
In healthy individuals the ureters enter the urinary bladder obliquely and run submucosally for some distance. This in addition to the ureter's muscular attachments help secure and support them posteriorly. Together these features produce a valve like 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.
Vesicoureteral reflux has two type ; primary and secondary


===Primary VUR===
===Primary VUR===
Insufficient 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.
* Is due to incompetent or inadequate closure of the ureterovesical junction (UVJ).
* Usually  reflux is prevented during bladder contraction by completely compressing the intravesical ureter and sealing it with surrounding bladder muscle.
* Failure of anti-reflux mechanism is due to shortening of the intravesical ureter.


===Secondary VUR===
===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 as follows:
* Is due to abnormally high pressure in the bladder which cause failure of the closure of the ureterovesical junction during bladder contraction.
 
* Secondary VUR is related with anatomic ( eg , posterior urethral valves)  or
'''Anatomical:''' Posterior urethral valves; urethral or meatal stenosis.
* Functional bladder obstruction (eg , dysfunctional voiding and neurogenic bladder)
 
These causes are treated surgically when possible.
 
'''Functional:''' Bladder instability, neurogenic bladder and non-neurogenic neurogenic bladder
Urinary tract infections may cause reflux due to the elevated pressures associated with inflammation.
 
Resolution of functional VUR will usually occur if the precipitating cause is treated and resolved. Medical and/or surgical treatment may be indicated.


==Prevalence==
==Prevalence==
It has been estimated that VUR is present in more than 10% of the population. In children without urinary tract infections 17.2-18.5% have VUR, whereas in those with urinary tract infections the incidence may be as high as 70%.
VUR is present in more than 10% of the population. In children without urinary tract infections 17.2-18.5% have VUR, whereas in those with urinary tract infections the incidence may be as high as 70%.


===Age===
===Age===
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==International Classification of Vesicoureteral Reflux==
==International Classification of Vesicoureteral Reflux==
*Grade I – reflux into non-dilated ureter
*Grade I – Reflux only fills the ureter without dilation.
*Grade II – reflux into the renal pelvis and calyces without dilatation
*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 III – Reflux fills and mildly dilates the ureter and the collecting system with mild blunting of the calyces.
*Grade IV – dilation of the renal pelvis and calyces with moderate ureteral tortuosity
*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; papillary impressions
*Grade V – Gross dilatation of the ureter, pelvis and calyces; ureteral tortuosity; papillary impressions


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.
Almost  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.<ref name="pmid21896376">{{cite journal |vauthors=Mattoo TK |title=Vesicoureteral reflux and reflux nephropathy |journal=Adv Chronic Kidney Dis |volume=18 |issue=5 |pages=348–54 |date=September 2011 |pmid=21896376 |pmc=3169795 |doi=10.1053/j.ackd.2011.07.006 |url=}}</ref>


==Diagnosis==
==Diagnosis==
The following procedures may be used to diagnose VUR:
The following procedures may be used to diagnose VUR:
*Nuclear cystogram (RNC)
*Nuclear cystogram (RNC)
*Flouroscopic voiding cystourethrogram (VCUG)
*Fluoroscopic voiding cystourethrogram (VCUG)
*Ultrasonic cystography
*Ultrasonic cystography
*Abdominal ultrasound
*Abdominal ultrasound  
 
*if ureteral dilation is seen during abdominal ultrasound it suggest VUR  
An abdominal ultrasound might 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 UTI.  VCUG is the method of choice for grading and initial workup, while RNC is preferred for subsequent evaluations as there is less exposure to radiation. A high index of suspicion should be attached to any case a where a child presents with a urinary tract infection, and anatomical causes should be excluded. A VCUG and abdominal ultrasound should be performed in these cases.
*In children suspected of having VUR presenting with prenatal hydronephrosis or UTI
 
(Images shown below are courtesy of RadsWiki)


<gallery>
<gallery mode="packed">
Image:Vesicoureteral-reflux-002.jpg|VCUG demonstrating bilateral Grade III vesicoureteral reflux
File:Vesicoureteral-reflux-002.jpg|VCUG demonstrating bilateral Grade III vesicoureteral reflux
Image:Vesicoureteral-reflux-003.jpg|VCUG demonstrating bilateral Grade III vesicoureteral reflux
File:Vesicoureteral-reflux-003.jpg|VCUG demonstrating bilateral Grade III vesicoureteral reflux
Image:Vesicoureteral-reflux-004.jpg|VCUG demonstrating bilateral Grade III vesicoureteral reflux
File:Vesicoureteral-reflux-004.jpg|VCUG demonstrating bilateral Grade III vesicoureteral reflux
</gallery>
</gallery>


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===Medical Treatment===
===Medical Treatment===
Medical treatment entails low dose antibiotic prophylaxis until resolution of VUR occurs. Antibiotics are administered nightly at half the normal therapeutic dose. The specific antibiotics used differ with the age of the patient and include:
start with low dose antibiotic prophylaxis until resolution of VUR occurs. Antibiotics are give nightly at half the normal dose.
*[[Amoxicillin]] or [[ampicillin]] - infants younger than 6 weeks
*[[Amoxicillin]] or [[ampicillin]] infants younger than 6 weeks. <ref name="pmid17875650">{{cite journal |vauthors=Doganis D, Siafas K, Mavrikou M, Issaris G, Martirosova A, Perperidis G, Konstantopoulos A, Sinaniotis K |title=Does early treatment of urinary tract infection prevent renal damage? |journal=Pediatrics |volume=120 |issue=4 |pages=e922–8 |date=October 2007 |pmid=17875650 |doi=10.1542/peds.2006-2417 |url=}}</ref>
*[[Trimethoprim-sulfamethoxazole]] (co-trimoxazole) - 6 weeks to 2 months
*[[Trimethoprim-sulfamethoxazole|Trimethoprim - Sulfamethoxazole]] (co-trimoxazole) - 6 weeks to 2 months
After 2 months the following antibiotics are suitable:
After 2 months the following antibiotics are suitable:
*[[Nitrofurantoin]]{5-7mg/kg/24hrs}
*[[Nitrofurantoin]] (5-7mg/kg/24hrs )
*[[Nalidixic acid]]
*[[Nalidixic acid]]
*[[Bactrim]]
*[[Bactrim]]
Line 99: Line 94:
*[[Cephalosporin]]s
*[[Cephalosporin]]s


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 [[anticholinergic]]s.
===Surgical Management===
surgical treatment is needed in case of
* Antibiotic treatment is not effective.
* if VUR is severe ( Grade IV and V ).
* In case of pyelonephritic changes and congenital abnormalities
* Failure of renal growth or formation of new renal scars.<ref name="pmid21059720">{{cite journal |vauthors=Shaikh N, Ewing AL, Bhatnagar S, Hoberman A |title=Risk of renal scarring in children with a first urinary tract infection: a systematic review |journal=Pediatrics |volume=126 |issue=6 |pages=1084–91 |date=December 2010 |pmid=21059720 |doi=10.1542/peds.2010-0685 |url=}}</ref>
 
== open surgical reimplantation ==
Is surgical correction and highly successful procedure with correction rate of 95 to 99 %.


===Surgical Management===
In this procedure bladder is opened ( intravesical approach ) and the ureters are reimplanted by tunneling a ureteral segment through the detrusor muscle which is creating submucosal tunnel.
A surgical approach is necessary in cases where a breakthrough infection results despite prophylaxis, or there is non-compliance with the prophylaxis. Similarly if the VUR is severe (Grade IV & V), there are pyelonephritic changes or congenital abnormalities. Other reasons necessitating surgical intervention are failure of renal growth, formation of new scars, renal deterioration and VUR in girls approaching puberty.
 
== Endoscopic correction  ==
Also called STING procedure is surgical correction.


There are three types of surgical procedure available for the treatment of VUR: endoscopic (STING procedure); laparoscopic; and open procedures (Cohen procedure, Leadbetter-Politano procedure).
In procedure injecting a copolymer ( dextranomer / hyaluronic acid ) under the mucosa of the UVJ through a cystoscope as result of this injection change the angle and fixation of the intravesical ureter.


==References==
==References==
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*Walker et al: Screening schoolchildren for urologic disease. Pediatrics 1977;60:239
*Walker et al: Screening schoolchildren for urologic disease. Pediatrics 1977;60:239


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Latest revision as of 15:15, 27 August 2018

https://https://www.youtube.com/watch?v=7OqqtSlW9sA&t=75s |350}}

Template:DiseaseDisorder infobox Template:Search infobox Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Steven C. Campbell, M.D., Ph.D.


Overview

Vesicoureteral reflux (VUR) is an abnormal movement of urine from the bladder into ureters or kidneys. Urine normally travels from the kidneys via the ureters to the bladder. In vesicoureteral reflux the direction of urine flow is reversed (retrograde). In the majority of cases, it occurs as a result of a primary maturation abnormality of the vesicoureteral junction or a short distal ureteric submucosal tunnel in the bladder that alters the function of the valve mechanism. VUR may be an isolated anomaly or associated with other congenital anomalies such as posterior urethral valves or complete duplication of the urinary tract.

Symptoms

  • Prenatal hydronephrosis.[1]
  • Abnormal widening of the ureter .
  • Urinary tract infection.
  • Acute pyelonephritis .
  • Symptoms such as painful urination or renal colic / flank pain are not symptoms associated with vesicoureteral reflux.
  • Newborns may be lethargic with failure to thrive, while infants and young children typically present with pyrexia, dysuria, frequent urination, malodorous urine and GIT symptoms, but only when urinary tract infection is present as the initial presentation of VUR.

Causes

Vesicoureteral reflux has two type ; primary and secondary

Primary VUR

  • Is due to incompetent or inadequate closure of the ureterovesical junction (UVJ).
  • Usually reflux is prevented during bladder contraction by completely compressing the intravesical ureter and sealing it with surrounding bladder muscle.
  • Failure of anti-reflux mechanism is due to shortening of the intravesical ureter.

Secondary VUR

  • Is due to abnormally high pressure in the bladder which cause failure of the closure of the ureterovesical junction during bladder contraction.
  • Secondary VUR is related with anatomic ( eg , posterior urethral valves) or
  • Functional bladder obstruction (eg , dysfunctional voiding and neurogenic bladder)

Prevalence

VUR is present in more than 10% of the population. In children without urinary tract infections 17.2-18.5% have VUR, whereas in those with urinary tract infections the incidence may be as high as 70%.

Age

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.

Sex

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

International Classification of Vesicoureteral Reflux

  • Grade I – Reflux only fills the ureter without dilation.
  • Grade II – Reflux into the renal pelvis and calyces without dilatation
  • Grade III – Reflux fills and mildly dilates the ureter and the collecting system with mild blunting of the calyces.
  • 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; papillary impressions

Almost 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.[2]

Diagnosis

The following procedures may be used to diagnose VUR:

  • Nuclear cystogram (RNC)
  • Fluoroscopic voiding cystourethrogram (VCUG)
  • Ultrasonic cystography
  • Abdominal ultrasound
  • if ureteral dilation is seen during abdominal ultrasound it suggest VUR
  • In children suspected of having VUR presenting with prenatal hydronephrosis or UTI
  • VCUG demonstrating bilateral Grade III vesicoureteral reflux

    VCUG demonstrating bilateral Grade III vesicoureteral reflux

  • VCUG demonstrating bilateral Grade III vesicoureteral reflux

    VCUG demonstrating bilateral Grade III vesicoureteral reflux

  • VCUG demonstrating bilateral Grade III vesicoureteral reflux

    VCUG demonstrating bilateral Grade III vesicoureteral reflux

Treatment

Medical treatment is the preferred mode of management but 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 trialed on a medical approach before surgery is indicated, in older patients surgery is the only option.

Medical Treatment

start with low dose antibiotic prophylaxis until resolution of VUR occurs. Antibiotics are give nightly at half the normal dose.

After 2 months the following antibiotics are suitable:

Surgical Management

surgical treatment is needed in case of

  • Antibiotic treatment is not effective.
  • if VUR is severe ( Grade IV and V ).
  • In case of pyelonephritic changes and congenital abnormalities
  • Failure of renal growth or formation of new renal scars.[4]

open surgical reimplantation

Is surgical correction and highly successful procedure with correction rate of 95 to 99 %.

In this procedure bladder is opened ( intravesical approach ) and the ureters are reimplanted by tunneling a ureteral segment through the detrusor muscle which is creating submucosal tunnel.

Endoscopic correction

Also called STING procedure is surgical correction.

In procedure injecting a copolymer ( dextranomer / hyaluronic acid ) under the mucosa of the UVJ through a cystoscope as result of this injection change the angle and fixation of the intravesical ureter.

References

  • Atala. A, Keating. M, in Campbells Urology 8th ed. Pgs 2053-2094
  • Bailey RR: The relationship of VUR to UTI and chronic pyelonephritis-reflux nephropathy. Clin Nephrol 1973;1:132
  • Baker et al, Relation of age, sex and infection to reflux: Data indicating high spontaneous cure rate in paediatric patients. J Urol 1966;95:27
  • Duckett JW: VUR a "conservative analysis." Am J Kidney Dis 1983;3:139
  • Hodson CJ, Edwards D: Chronic Pyelonephritis and VUR. Clin Radiol 1960;11:219
  • King et al: Natural history of VUR: Outcome of a trial of non-operative therapy. Urol Clin North Am 1974;1:144
  • Ring E et al: Primary VUR in infants with a dilated fetal urinary tract. Eur J Pediatr 1993;152:523
  • Sargent MA: what is the normal prevalence of VUR? Pediatr Radiol 2000;9;587
  • Smellie JM, Normand ICS: The clinical features and significance of UTIs in children. Proc R Soc London 1966;59:415
  • Walker et al: Screening schoolchildren for urologic disease. Pediatrics 1977;60:239


Template:WikiDoc Sources

  1. ↑ Yeung CK, Godley ML, Dhillon HK, Gordon I, Duffy PG, Ransley PG (August 1997). "The characteristics of primary vesico-ureteric reflux in male and female infants with pre-natal hydronephrosis". Br J Urol. 80 (2): 319–27. PMID 9284209.
  2. ↑ Mattoo TK (September 2011). "Vesicoureteral reflux and reflux nephropathy". Adv Chronic Kidney Dis. 18 (5): 348–54. doi:10.1053/j.ackd.2011.07.006. PMC 3169795. PMID 21896376.
  3. ↑ Doganis D, Siafas K, Mavrikou M, Issaris G, Martirosova A, Perperidis G, Konstantopoulos A, Sinaniotis K (October 2007). "Does early treatment of urinary tract infection prevent renal damage?". Pediatrics. 120 (4): e922–8. doi:10.1542/peds.2006-2417. PMID 17875650.
  4. ↑ Shaikh N, Ewing AL, Bhatnagar S, Hoberman A (December 2010). "Risk of renal scarring in children with a first urinary tract infection: a systematic review". Pediatrics. 126 (6): 1084–91. doi:10.1542/peds.2010-0685. PMID 21059720.
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