Vesicoureteral Reflux

An abnormal flow of urine from your bladder back up to the tubes (ureters) is called Vesicoureteral (ves-ih-koe-yoo-REE-tur-ul) reflux.

Normally urine only flows one way which is from your kidneys down to your bladder through the ureters, which are the tubes that connect your kidneys to your bladder.

Vesicoureteral reflux is commonly manifested and diagnosed in infants and children. Due to the abnormal flow of the urine, this disorder puts the person at risk of developing urinary tract infection which can lead to kidney damage if left untreated.

There are two types of Vesicoureteral reflux condition which are primary and secondary.

With primary Vesicoureteral reflux, children are born with a defect in the valve that normally prevents urine from flowing backward from the bladders into the ureters.

While secondary Vesicoureteral reflux, may happen following a urinary tract malfunction commonly caused by infection.

As long as children are given ample medication or surgery that aims to prevent kidney damage, children are able to outgrow Vesicoureteral reflux.

A common cause of Urinary tract infection (UTI) is from vesicoureteral reflux hence signs and symptoms of vesicoureteral reflux are related to the signs and symptoms of UTI which can remain unnoticeable at times.

These are the common signs and symptoms to watch out for:

• a burning sensation when urinating
• a strong persistent urge to urinate
• pain in your side (flank) or abdomen, passing frequent
• small amounts of urine
• hesitancy to urinate or holding urine to avoid the burning sensation
• fever
• and blood in the urine (hematuria) or cloudy
• strong-smelling urine

Diagnosing UTI in children may prove problematic as they are normally unable to verbalize or describe the discomforts they are feeling hence it is necessary that the child’s primary care taker is observant of what the child is feeling especially abnormal changes in urine and frequency. Infants may also show signs and symptoms of UTI such as unexplained fever, lack of appetite, diarrhea, and irritability.

If vesicoureteral reflux remains untreated, as your child gets older, other signs and symptoms may arise including:

• constipation or loss of control over bowel movements
• bed-wetting
• High blood pressure
• and protein in urine

Kidney failure is another indication of vesicoureteral reflux before birth may be detected by sonogram, there will be swelling of the kidneys or the urine-collecting structures of one or both kidneys (hydronephrosis) in the fetus, caused by the backup of urine into the kidneys.

As the child’s primary care provider, once you have observed the following signs and symptoms of UTI, you must immediately bring the child to a health care provider, such as a strong, persistent urge to urinate, a burning sensation when urinating, abdominal or flank pain and hesitancy to urinate. Your child’s doctor would need to be notified, if younger than 3 months old, if your child has a rectal temperature of 100.4 F (38 C) or higher.

If the child is 3 months or older and has a fever of 102 F (38.9 C) or higher without any other explainable factors, such as a recent vaccination then call the doctor as well. Urgently contact your doctor, for infants experiencing the following signs and symptoms: changes in appetite, if your baby refuses several feedings in a row or eats poorly, and changes in mood.

If your baby is lethargic or unusually difficult to rouse, call your the doctor right away. Also let the doctor know if your baby is persistently irritable or has periods of inconsolable crying.

Also, contact the doctor if several of your baby's stools are especially loose or watery including spitting of large portions of multiple feedings or vomits forcefully after feeding.

You have to be mindful of this as infants do normally spit their feeding but should only be a small portion of it.

Causes of vesicoureteral reflux vary depending on its type.

The kidneys, a pair of bean-shaped organs at the back of your upper abdomen, filter waste, water and electrolytes — minerals, such as sodium, calcium and potassium, that help maintain the balance of fluids in your body — from your blood.

The kidneys form the urinary system together with ureters, bladder and urethra which all play an important role in removing the body’s waste products that be toxic to the internal organs if not excreted.

Tubes called ureters carry urine from your kidneys down to your bladder, where it is stored until it exits the body through another tube (the urethra) during urination.

Vesicoureteral reflux can develop in two forms, primary and secondary:

• The cause of the primary Vesicoureteral reflux, which is the more common form, is a congenital (presented before birth) defect. The defect is in the functional valve between the bladder and a ureter that normally closes to prevent urine from flowing backward. As your child grows, the ureters lengthen and straighten, which may improve valve function and eventually resolve the reflux. The exact cause of the primary vesicoureteral is still unknown but it has been studied that genetic plays a role as it can run in families.
• In the case of secondary vesicoureteral reflux, the cause is a blockage or malfunction in the urinary system which commonly results from a recurring UTI that causes swelling of the ureters.

Making a diagnosis of vesicoureteral reflux is done by performing several tests.

The primary care givers, normally the parents, play an important role in the early detection of vesicoureteral reflux since the infant and/or the child is unable to verbalize their discomfort.

Vesicoureteral reflux is normally detection when an infant or a child shows signs and symptoms of urinary tract infection, such signs and symptoms include pain or burning during urination or a persistent, unexplained fever.

The child maybe referred to a Urologist which is a doctor that specializes in urinary tract conditions. To maximize the time spent with your health care provider, you must come prepared prior to your scheduled appointment, here are some important things to take note of.

Making a diagnosis of vesicoureteral reflux is done by performing several tests.

First, make a list of all the signs and symptoms your child has been experiencing and for how long. You will be the primary source of information for your child hence you must be observant of changes in urination.

Details about your family medical history, including whether any of your child's first-degree relatives — such as a parent or sibling — have been diagnosed with vesicoureteral reflux, since this condition has been observed to be hereditary in nature.

Here are some basic questions related to vesicoureteral reflux that you might find helpful in understanding the condition which you should ask from your doctor:

• What is likely causing my child's signs and symptoms?
• Is it a bladder or kidney infection?
• Are there other possible causes for these symptoms?
• What kinds of tests does my child need?
• How likely is it that my child's condition will resolve without treatment?
• What are the benefits and risks of the recommended treatment in my child's case?
• Is my child at risk of complications from this condition?
• How will you monitor my child's health over time?
• What steps can I take to reduce my child's risk of future urinary tract infections?
• Are my other children at increased risk of this condition?
• Do you recommend that my child see a specialist?

Don’t hesitate to clarify topics related to your child’s condition as they will prove helpful in taking care of your child. Also, expect the doctor to ask some of these questions:

• When did you first notice that your child was experiencing symptoms?
• Have these symptoms been continuous or occasional?
• How severe are your child's symptoms?
• Does anything seem to improve these symptoms?
• What, if anything, appears to worsen your child's symptoms?
• Does anyone in your family have a history of vesicoureteral reflux?
• Has your child had any growth problems?
• What types of antibiotics has your child received for other infections, such as ear infections?

Before coming up with the best treatment option for your child expect for the doctor to person a battery of tests. Your child's doctor will perform a physical examination of your child. Some tests include:

• Urinalysis — lab analysis of a urine sample — can reveal whether your child has a UTI.

Other tests are necessary to determine the presence of vesicoureteral reflux, including:

• Kidney and bladder ultrasound. Also called sonography, this imaging method uses high-frequency sound waves to produce images of the kidney and bladder. Ultrasound can detect structural abnormalities. The same technology, often used during pregnancy to monitor fetal development, may also reveal swollen kidneys in the baby, an indication of primary vesicoureteral reflux.
• Voiding cystourethrogram (VCUG). This test uses X-rays of the bladder when it's full and when it's emptying to detect abnormalities. A thin, flexible tube (catheter) is inserted through the urethra and into the bladder while your child lies on his or her back on an X-ray table. After contrast dye is injected into the bladder through the catheter, your child's bladder is X-rayed in various positions. Then the catheter is removed so that your child can urinate, and more X-rays are taken of the bladder and urethra during urination to see whether the urinary tract is functioning correctly. Risks associated with this test include discomfort from the catheter or from having a full bladder and the possibility of a new urinary tract infection.

• Nuclear scan. This test, known as radionuclide cystogram, uses a procedure similar to that used for VCUG, except that instead of dye being injected into your child's bladder through the catheter, this test uses a radioactive tracer (radioisotope). The scanner detects the tracer and shows whether the urinary tract is functioning correctly. Risks include discomfort from the catheter and discomfort during urination. Your child's urine may be slightly pink for a day or two after the test. Based on the assessment done and the tests results, doctors grade the vesicoureteral reflux condition on how advance it is which will be the basis of the treatment option. In the mildest cases, urine backs up only to the ureter (grade I). The most severe cases involve severe kidney swelling (hydronephrosis) and twisting of the ureter (grade V).

Doctors employ a grading system after running a series of test which will help them determine the severity of vesicoureteral reflux and come up with the appropriate treatment.

Your doctor will likely recommend a wait-and-see approach for children with mild cases of primary vesicoureteral reflux since eventually they will outgrow the disorder.

For more severe cases of vesicoureteral reflux, medication is focused on the treatment of UTI as it may lead to kidney failure if left untreated.

Antibiotics will be prescribed to the child to treat UTI in which the child will be regularly monitored while on antibiotics. Periodic physical exams will be performed as well as urine tests to detect breakthrough infection, which is UTIs that continuous to progress despite antibiotic treatment.

Occasional radiographic scans of the bladder and kidneys will also be done to determine if your child has outgrown vesicoureteral reflux.

Another treatment option is to have the child undergo surgery which would repair the defect in the functional valve between the bladder and each affected ureter that keeps it from closing and preventing urine from flowing backward.

There are different methods of surgical treatment that your doctor will explain to you to be able to come up with what is best to treat the child.

• First is Open surgery, this is performed under general anesthesia. This surgery requires an incision in the lower abdomen through which the surgeon repairs the malformation that's causing the problem. This type of surgery usually requires a few days' stay in the hospital, during which a catheter is kept in place to drain your child's bladder. Vesicoureteral reflux may persist in a small number of children, but it generally resolves on its own without need for further intervention.
• Second is the Robotic-assisted laparoscopic surgery. Similar to open surgery, this procedure involves repairing the valve between the ureter and the bladder, but it's performed using small incisions. Preliminary findings suggest that robotic-assisted laparoscopic surgery has similar success rates to open surgery. It was also associated with a longer operating time, but a shorter hospital stay.
• Lastly is the Endoscopic surgery which also requires general anesthesia but can be performed as outpatient surgery. In this procedure, the doctor inserts a lighted tube (cystoscope) through the urethra to see inside your child's bladder, then injects a bulking agent around the opening of the affected ureter to try to strengthen the valve's ability to close properly. This method is minimally invasive compared with open surgery and presents fewer risks, though it may not be as effective.

There is no known specific prevention of vesicoureteral reflux other than urinary tract infection must remain untreated to prevent further complications.

An alternative to surgery treatment is deflux which is a gel-like liquid containing complex sugars that will be injected into the bladder wall. This creates a bulge in the tissue that makes it harder for urine to flow back up the uterer.

The primary difficulty that a child with vesicoureteral reflux is coping with is the pain brought by the urinary tract infections. Although the child is already undergoing antibiotic treatment, pain and discomfort would still be felt hence you as a parent or the primary care giver would need to take steps to ease the child’s discomforts.

You can provide the child with a warm blanket or towel as warmth can help minimize feelings of bladder pressure or pain. Place a towel or blanket in the dryer for a few minutes to warm it up. Be sure the towel or blanket is just warm, not hot, and then place it over your child's abdomen.

Increasing the fluid intake, especially water, will prove to be helpful for the child since drinking water dilutes urine and may help flush out bacteria.

Avoid juices and sodas containing citrus and caffeine until your child's infection has cleared. They can irritate the bladder and tend to aggravate the frequent or urgent need to urinate which is painful and causes further discomfort to the child.

Studies show that specific demographic factors put a group at greater risk of developing vesicoureteral reflux. Risk factors include:

• Sex. Generally, girls have about double the risk of having this condition as boys do. The exception is for vesicoureteral reflux that's present at birth, which is more common in boys.
• Race. White children appear to have a higher risk of vesicoureteral reflux.
• Family history. Primary vesicoureteral reflux tends to run in families. Children whose parents had the condition are at higher risk of developing it. Siblings of children who have the condition also are at higher risk, so your doctor may recommend screening for the siblings of a child with primary vesicoureteral reflux.
• Age. Infants and children up to age 1 are more likely to have vesicoureteral reflux than older children are. The primary complication that may arise from vesicoureteral reflux is Kidney failure hence treatment is focused on stopping urinary tract infection to prevent further damage.

Additional complications may include:

• Kidney (renal) scarring. Untreated UTIs can lead to scarring, also known as reflux nephropathy, which is permanent damage to kidney tissue. A backup of urine exposes the kidneys to higher than normal pressure. If your kidneys are infected, this can lead to scarring over time.

Extensive scarring may lead to high blood pressure and kidney failure:

• High blood pressure (hypertension). Because the kidneys remove waste from the bloodstream, damage to your kidneys and the resultant buildup of wastes can raise your blood pressure.
• Kidney failure. Scarring can cause a loss of function in the filtering part of the kidney. This may lead to kidney failure, which can occur quickly (acute) or may develop over time (chronic).

Early detection and proper treatment of vesicoureteral reflux is key to not allow progression of the condition leading to severe complications.