VESICOURETERAL REFLUX

R.A.S HEMAT, MB;BCh, FRCSI, DUL.

The incidence of VUR in children with a normal urinary tract and no prior UTI is 10.5%. Girls at a proportion of 4:1, but its severity is greater in boys. Severe reflux may be associated with congenital renal pathology. Reflux resolves spontaneously with time. The radiation exposure of voiding cystourethrogram is a 100 times the isotope cystogram. The isotope cystogram is a sensitive and safe test that minimises long-term patient risks.

The greater risk of UTI is in children with large postvoid residual urine (drainage of refluxed urine into the bladder after voiding). Surgical failure or complications increases markedly in the child with detrusor instability.
The elevation of urinary levels of cytokines, including IL-1b, IL-6 and IL-8 has been observed in patients with acute urinary tract infections. IL-8 is a protein induced by lipopolysaccharide stimulation from peripheral monocytes or macrophages, also secreted by histocytes and induced by many stimulants. IL-8 primed neutrophils for enhanced superoxide anion production.
Two distinct but no exclusive patterns of VUR were identified: 1- mild reflux associated with normal kidneys that affected most females and a proportion of males; 2- severe reflux combined with kidney damage, most likely fetal in origin, that is almost exclusively a male disorder.

Possible finding on Micturating cystourethrogram:
1- VUR.
2- Bladder diverticula.
3- Posterior urethral valve or urethral stricture.
4- Ureterocele.
5- Reduced bladder capacity.
6- Thickened bladder wall from muscular hypertrophy.
7- Residual volume after voiding.

The more susceptible papillae tend to exist at the renal poles, explaining the higher incidence of scarring in those locations than in the mid-zone.
Grade II reflux, resolution occurs within 1.5 years, but 1.9 years for grade III reflux to resolve. With grade IV reflux, it is 9%, with grade I-II reflux resolves in 90%.

Management of VUR is centred around management of UTI. There is no difference in the incidence of UTI or renal damage between patients treated surgically and those treated medically. Children older than 2-3 years with persisting severe reflux surgical intervention would seem more reasonable than long term prophylaxis and repeated studies..etc

Find more in Urotext, E. Book simplifying Urology.

Dr. R.A.S HEMAT declares no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, stock holdings, gifts, or honoraria.