Vesicoureteric reflux , a common condition in children which could be misdiagnosed . Early diagnosis can help prevent renal scarring and other complications

1. Vesicoureteral reflux
presented
by
Dr Emmanuel Godwin
Nephrology unit
Department of Pediartics ,ABUTH Shika

2. TABLE OF CONTENT
• Introduction
• Epidemiology
• Etiology
• International Classification of Vesicoureteral Reflux
• Pathophysiology
• Clinical features
• Complications of Reflux
• Investigation
• Treatment
• Follow-up
• Prognosis
• References

3. Introduction
Vesicoureteral reflux (VUR) is a condition in which urine flows retrograde, or
backward, from the bladder into the ureters/kidneys.
Urine normally travels in one direction (forward, or antegrade) from the
kidneys to the bladder via the ureters, with a 1-way valve at the
ureterovesical (ureteral-bladder) junction preventing backflow
The valve is formed by oblique tunneling of the distal ureter through the wall
of the bladder, creating a short length of ureter (1–2 cm) that can be
compressed as the bladder fills.
Reflux occurs if the ureter enters the bladder without sufficient tunneling

4. Epidemiology
• It has been estimated that VUR is present in more than 10% of the
population.
• 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.
• VUR is more common in males antenatally,
• in later life there is a definite female preponderance with 85% of cases
being female.
• 30 to 60% of children with VUR have renal scarring
• Female: Male ratio= 5:1

5. Etiology
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, helps secure and support them
posteriorly. Together these features produce a valvelike 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.
It could be primary or secondary

6. Etiology Con’t

7. VESICO URETERAL REFLUX
Primary
Congenital inadequacy of
valvular mechanism at
the U-V Junction
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8. Primary Reflux
Normal mechanism has –
• oblique entry of the ureter
• submucosal –intramural length of ureter
• Ratio of tunnel length : diameter of ureter-3:1
• Ureterotrigonal longitudinal muscles
• Active ureteral peristalsis
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9. Primary Reflux
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.

10. 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.

11. Secondary VU Reflux
Anatomical
• Posterior urethral valves
• Urethral or meatal stenosis
• Prune belly Syndrome
• Anorectal Malformations
Functional
• Dysfunctional voiding
(neurogenic bladder)

12. International Classification of Vesicoureteral Reflux
• Grade I – reflux into non-dilated ureter
• 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 IV – dilation of the renal pelvis and calyces with moderate
ureteral tortuosity
• Grade V – gross dilatation of the ureter, pelvis and calyces; ureteral
tortuosity; loss of papillary impressions
• Note:

13. International Classification of Vesicoureteral Reflux
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.

14. Vesico- ureteral reflux
Normal kidney, ureter, and bladder

15. Vesico- ureteral reflux
Grade I Vesicoureteral Reflux:
urine (shown in blue) refluxes part-way up the ureter

16. Vesico- ureteral reflux
• Grade II
Vesicoureteral
Reflux:
urine refluxes all
the way up the
ureter

17. Vesico- ureteral reflux
• Grade III
Vesicoureteral Reflux:
urine refluxes all the
way up the ureter with
dilatation of the ureter
and calyces (part of
the kidney where urine
collects)

18. Vesico- ureteral reflux
• Grade IV
Vesicoureteral
Reflux:
urine refluxes all
the way up the
ureter with
marked
dilatation of the
ureter and
calyces

19. Vesico- ureteral reflux
• Grade V Vesicoureteral
Reflux:
massive reflux of urine
up the ureter with
marked tortuosity and
dilatation of the ureter
and calyces

20. ..

21. Pathophysiology
• VUR > High pressure urine into ureters & Kidneys
• Stasis of urine because of post-voidal residual urine
• Stasis of urine good nidus for superadded infection
• Refluxed infected urine >Pyelonehritis >Renal scarring >Reflux
Uropathy >ESRD
• Reflux,UTI & Pyelonephritis scarring >Well known Triad in Pediatric
urology

22. Clinical Features
• Neonates : usually asymptomatic, non specific symptoms
• Infants : the signs and symptoms of a urinary tract infection may
include only fever and lethargy, with poor appetite and sometimes
foul-smelling urine, Young infant not thriving
• older children : dysuria and frequent urination, urine retention,
Cloudy or blood tinged urine

23. Complications of Reflux
• Recurrent Urinary tract infections
• Renal scar formation
• Renal growth arrest
• Renal function drops – Electrolytes inbalance
• Hypertension
• Somatic growth drops- Failure to thrive

24. Investigations
• Prenatal screening : hydronephrosis or hydroureter on Ultrasound
• Fluoroscopic Voiding cystourethrogram (VCUG) : VCUG is the method of
choice for grading and initial workup
• Abdominal ultrasound :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 urinary tract infection (UTI).

25. Investigations
• U/E/Cr
• FBC + Diff
• Blood culture
• Urine M/C/S

26. USG
Abdomen
Grd 5 VUR
Hydronephrosis+
Hydroureter+

27. MCU or VCUG
Gd 1 VUR
Lt VUR Gd 1

28. MCU or VCUG
Gd 2 VUR
Bilateral VUR Gd 2

29. MCU or VCUG
Gd 3 VUR
Bilateral VUR Gd 3

30. MCU or VCUG
Gd 4 VUR
Bilateral VUR Gd 4

31. Gd 5 VUR
Gd 5 VUR
Bilateral VUR Gd 5

32. Neurogenic
Bladder with VUR
Neurogenic Bladder with
VUR
Gd 3 VUR
Neurogenic Bladder+
VP shunt+

33. DMSA Scan
Tch99 DMSA Scan
(Dimercaptosuccinic
Acid)
Renal Scarring
Differential Function

34. Treatment
•Medical
•Surgical

35. Treatment
• The goal of treatment is to minimize infections, as it is infections that
cause renal scarring and not the vesicoureteral reflux.
• Minimizing infections is primarily done by prophylactic antibiotics in
newborns and infants who are not potty trained.
• When medical management fails to prevent recurrent urinary tract
infections, or if the kidneys show progressive renal scarring then
surgical interventions may be necessary.
• Medical management is recommended in children with Grade I-III
VUR as most cases will resolve spontaneously.

36. ….
• 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 trialled on a
medical approach before surgery is indicated.
• In older patients surgery is the only option.

37. Medical Treatment
• Medical treatment entails low dose antibiotic prophylaxis until resolution
of VUR occurs
• The specific antibiotics used differ with the age of the patient and include:
• Amoxicillin or ampicillin - infants younger than 6 weeks
• Trimethoprim-sulfamethoxazole (co-trimoxazole) - 6 weeks to 2 months
• After 2 months the following antibiotics are suitable:
• Nitrofurantoin {5–7 mg/kg/24hrs}
• Nalidixic acid(10 mg/kg in bid doses)
• Bactrim(2 mg/kg of TMP as a single dose at bedtime)
• Trimethoprim
• Cephalosporins

38. Medical Treatment
• 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
anticholinergics.

39. Surgical Treatment
• A surgical approach is necessary in cases where a breakthrough infection
results despite prophylaxis, or there is non-compliance with the
prophylaxis.
• if the VUR is severe (Grade IV & V),
• pyelonephritic changes or
• congenital abnormalities.
• failure of renal growth,
• formation of new scars,
• renal deterioration and
• VUR in girls approaching puberty.

40. Surgical Treatment
• There are three types of surgical procedure available for the
treatment of VUR:
• Endoscopic (STING/HIT procedures);
• Laparoscopic; and
• Open procedures (Cohen procedure, Leadbetter-Politano procedure).

41. Prognosis
• 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.
• Prognosis is good when diagnosis is made early

42. Follow-up
• The American Urological Association recommends ongoing
monitoring of children with VUR until the abnormality resolves or is
no longer clinically significant.
• The recommendations are for annual evaluation of blood pressure,
height, weight, analysis of the urine, and kidney ultrasound.

43. References
• Institute of Urology & Nephrology, London, UK, The cellular basis of
bladder instability UJUS 2009, Retrieved 4-20-2010
• Peters CA, Skoog SJ, Arant BS, Copp HL, Elder JS, Hudson RG, Khoury AE,
Lorenzo AJ, Pohl HG, Shapiro E, Snodgrass WT, Diaz M (September 2010).
"Summary of the AUA Guideline on Management of Primary Vesicoureteral
Reflux in Children.". The Journal of Urology. 184 (3): 1134–44.
doi:10.1016/j.juro.2010.05.065. PMID 20650499
• Tekgül, S; Riedmiller, H; Hoebeke, P; Kočvara, R; Nijman, RJ; Radmayr, C;
Stein, R; Dogan, HS; European Association of, Urology (September 2012).
"EAU guidelines on vesicoureteral reflux in children.". European Urology. 62
(3): 534–42. doi:10.1016/j.eururo.2012.05.059. PMID 22698573.

44. Thank You for your time