About Vesicoureteral Reflux

Overview
Vesicoureteral reflux (VUR) is a condition in which urine flows backward from the bladder to one or both ureters and sometimes to the kidneys. Normally, urine flows down the urinary tract, from the kidneys, through the ureters, to the bladder. But with VUR, some urine will flow back up, or reflux, through one or both ureters and may reach the kidneys. VUR is most common in infants and young children and can cause urinary tract infections (UTIs) and, less commonly, kidney damage. There are different grades of VUR, ranging from mild (grade 1) to more serious (grade 5). Most children with VUR do not have long-term problems.
Causes and Risk Factors

The cause of Vesicoureteral reflux (VUR) can be:

  • Primary, where children are born with a defect of a valve that normally prevents urine from flowing backward from the bladder into the ureters. With the defective valve, urine can flow backward into the ureter.
  • Secondary, where there is a defect or condition that prevents the bladder from emptying properly. When the bladder cannot empty normally, the urine may flow backward into the ureter.

Risk factors for VUR include:

  • Female sex: VUR is more common in females compared to males
  • Race: The risk of having VUR is higher in children who are white
  • Age: VUR is more common in younger children (2 years old or younger). VUR is not common in adults
  • Family history: Primary VUR is more common in children whose parents or siblings had VUR
  • Birth conditions: Children born with kidney or urinary tract abnormalities have a higher risk of VUR
  • Bladder conditions: Children who have problems with urination (hold their urine) have a higher risk of VUR
  • Bowel conditions: Children who have problems with bowel movements (hold their stool) have a higher risk of VUR
Symptoms

The symptoms of VUR can vary depending on the age of the person and the severity of the condition. The most common symptom is frequent uterine tract infections (UTIs). This is when urine flows backwards and promotes the growth of bacteria.

Signs and symptoms of UTIs include:

  • Fever
  • Pain or burning when urinating
  • Frequent need to urinate, often with only small amounts of urine passed
  • Unpleasant-smelling urine
  • Blood in urine
  • Cloudy urine
  • Pain in the abdomen or sides (flank)
  • In infants who cannot communicate about symptoms of UTI, signs of a UTI may include lack of appetite, irritability and fever.

Additional symptoms of VUR, especially with children beyond the toddler stage include:

  • Constipation
  • Bedwetting

If you or your child experiences high fevers, symptoms of UTI, or recurrent UTIs, it's essential to consult with a doctor for diagnosis and appropriate treatment.

Diagnosis

To diagnose VUR, doctors often perform a combination of examinations, tests, and procedures. The tests and procedures may include:

  • Medical history and physical exam: The healthcare provider will want to know about symptoms, bladder and bowel habits, other medical conditions or issues, medications, and family medical history. The physical exam will include check the abdomen for swelling.
  • Blood tests: Blood tests may help look for signs of infection or kidney damage.
  • Urine tests: Urine tests may help look for signs of infection or kidney damage.
  • Ultrasound examination (USG): This uses sound waves to create images of the urinary tract, including the kidneys and bladder. It can show if there are any abnormalities or blockages.
  • Cystourethrography or voiding cystourethrogram (VCUG): This test involves taking x-rays of the bladder and urethra while a special dye is injected into the bladder. It helps determine if urine flows backward into the ureters, indicating VUR.
  • Radionuclide cystogram (RNC): This is a nuclear medicine test that involves injecting a small amount of radioactive material into the bladder. The flow of urine can then be traced.

As part of diagnosis, the healthcare provider may determine the severity of VUR. The severity grading of VUR reflects how far urine flows backward in the urinary tract. Grade 1 is mild, with urine flowing backward to part of the ureters. Grade 5 is severe with urine backflowing up the ureters and reaching the kidneys.

Other examinations, tests, and procedures may be used to diagnose or determine the severity of VUR based upon individual factors.

Treatment Options

The goals of treatment for VUR are to prevent recurring urinary tract infections (UTIs), prevent kidney damage, and minimize the overall impact of treatment and follow-up. Treatment options may depend on the type and severity of VUR and individualized factors, such as age and symptoms.

For primary VUR (VUR caused by an abnormality of the valve between the ureter and bladder), treatment options may include:

  • Antibiotics to help prevent and treat bacterial infections. For prevention, antibiotics may be used long-term at a low dose while waiting to see if the child outgrows VUR.
  • Surgery to fix the valve between the ureter and bladder to prevent backward flow of urine. Surgery treatments may include:
    • Ureteral reimplantation: This surgery involves adjusting the way the ureter enters the bladder so urine doesn’t flow backwards. This surgery can be done as an “open procedure” or a laparoscopic (“minimally invasive: procedure.
    • Bulking injections: During this procedure, a small amount of gel-like liquid is injected into the bladder wall near the opening of the ureter. This creates a bulge in the bladder wall that acts like a valve to prevent urine from flowing back into the ureter.

For secondary VUR (VUR caused by the bladder not emptying properly), treatment options aim to remove blockages or improve bladder emptying. Treatment options may include:

  • Antibiotics to prevent or treat UTI
  • Catheterization, where a thin tube is inserted through the urethra into the bladder to allow the bladder to drain through the tube
  • Medication that helps relax the bladder muscle so it can empty
  • Surgery to remove blockages or correct other bladder abnormalities

Alongside medical treatments, certain health behavior changes can also help manage VUR. These may include:

  • Encouraging children to drink plenty of fluids to promote regular urination and flushing out bacteria from the urinary tract.
  • Maintaining good hygiene practices, such as wiping front to back after using the toilet

It's important to note that treatment approaches for VUR can vary depending on factors such as age, renal function, severity of reflux, parental acceptance, and frequency of febrile UTIs. The healthcare provider will assess each individual case and recommend the most appropriate treatment plan based on these factors.

Progression or Complications

Most children with VUR recover without complications. Some children may not experience any symptoms of VUR. If symptoms do occur, the most common one is a urinary tract infection (UTI). When urine flows backward, bacteria can grow more easily in the urinary tract, leading to UTIs. In some cases, UTIs can result in kidney scarring or permanent scars on the kidneys. Kidney scarring is more likely if VUR is not treated or if treatment is delayed.

Over time, VUR can have different outcomes and complications. Complications of VUR may include:

  • Development of UTIs
  • UTIs that spread to the kidneys
  • Kidney scarring
  • Permanent kidney damage
  • High blood pressure
  • Kidney failure

It's important to note that while these treatments have shown effectiveness in reducing complications, it's always best to consult a healthcare professional for personalized advice. They can evaluate your specific situation and provide guidance on the most appropriate treatment options for you or your child.

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