Vesicoureteral Reflux

Definition

Vesicoureteral (Vesico = bladder, ureteral = ureter) Reflux is the backward flow of urine from the bladder up the ureter to the kidney.  Reflux is caused by an abnormal attachment to the ureter to the bladder resulting in a small, nonfunctioning valve which allows the urine to flow back up tot he kidney.  The prevalence of reflux is higher in girls (about 3/4) and fair-skinned children and appears to be inherited from the parents in some children; approximately 1/3 of the child's brothers and sisters will also have reflux.

Reflux is a silent problem and alone does not cause pain or discomfort with urination.  Reflux associated with recurrent infections of the urinary tract (UTI)is the most common cause of kidney damage or scarring in children.  An international grading system is used to rate the severity of the disease, and is important in the decision to perform corrective surgery or manage medically.  Graded 1-5 with 5 being the greatest, mild forms of reflux (1-3) have a greater chance of resolving with time as the child grows.  The presence of high-grade reflux (4-5), renal scarring, or recurrent urinary tract infections are indicators that favor surgical correction.

Diagnostic Tests

The diagnosis of Vesicoureteral reflux is made with an x-ray study called a Voiding Cystourethrogram (VCUG).  Cysto = bladder and urethrogram = x-ray of the urethra.  In this study a clear liquid with contrast material is instilled into the bladder thro ugh a urethral catheter.  The bladder is filled and x-ray "pictures" are taken of the child's bladder.  If there is no reflux, you will not see the ureters as the contrast fluid cannot pass upwards from the bladder.  If reflux is present, the VCUG will tell us the severity of the reflux on each side and will outline the anatomy ofthe urinary tract.  A VCUG will also outline the bladder and will give much information about the shape, smoothness and capacity of the bladder.  The radiologist will read the x-ray and dictate a report of her findings, which will then be sent to the urologist to examine.

The second diagnostic test in the evaluation for Reflux is the Renal Ultrasound.  This non-invasive study is used to evaluate the size and shape of the kidneys as well as the bladder and may reveal areas of scar on the kidney.  The ultrasound is performed much like those received by women during prgnancy and involves spreading lubricating jelly on the child's lower back (to scan the kidneys) and lower abdomen (to scan the bladder).  A wand is moved over the skin and projects an ultrasound image which is transferrd to x-ray film.  The bladder isusually scanned and then the child is asked to use the bathroom to empty the bladder.  The bladder is then re-scanned.  This will give the urologist an idea of how well the child's bladder is able to empty.  The amount of urine left in the bladder is called the Post-void Residual or PVR.

Occasinoally the urologist will ask that a renal scan (DMSA) be performed.  This study will give the physician more specific information about the prescence of scarring.

Management

The decision for medical management or surgical correction is one that must be made on an individual basis in conjunction with the parents.

Medical Management

It is important to prevent urinary tract infection in children with known reflux to protect kidneys from potentially harmful bacteria.  The child must take a daily preventative dose of antibiotic medication (often Septra or Macrodantin) to keep the urine sterile.  The dosage usedis a low dose that is administered once nightly.  This must be continued until the reflux is gone:  either through surgical correction or spontaneously resolved with time.  There is no way to know if the reflux has resolved on its own or has worsened unless it is shown by the VCUG.  The child with uncorrcted reflux must be followed yearly with the VCUG and Renal Ultrasound.

Surgical Correction

The correction of Vesicoureteral reflux is an inpatient procedure.  The child is admitted to the hospital the same day and stays in the hospital from 1-2 days.  Parents are encouraged to visit and one parent may sleep in the room with the child at night on a folding chair/bed.  The refulix is corrected by a procedure called Vesicoureteral Reimplantation and is performed either laparoscopically or through a small incision in the lower abdomen at the "bikini" line.  In a procedure that takes 3-4 hours, the ureters are tunneled through the wall of the bladder to create a stronger valve. 

Following surgery, the child will have a uretheral catheter in place and may have one or two small tubes called ureteral stents from the incision.  These tubes will be connected to a drainage bag and are usually removed before the child is discharged from the hospital.  In experienced hands, the success rate for the correction of reflux is 98%.

UNC Children's Hospital performs more than 50 surgeries to correct reflux each year.  We work closely with the Pediatric Anesthesiologists to provide a coordinated and sensitive approach to meet the unique needs of children undergoing a surgical procedure.

For more information, contact the Division of Pediatric Urology at the University of North Carolina Children's Hospital at (919) 966-8054.