Vesicoureteral reflux

What is vesicoureteral reflux?
Reflux in the urinary tract means that urine is able to get back up into the kidney after it has drained down into the bladder. The problem is seen more frequently in girls and is usually present from the time of birth. It may occur in one or both sides, and is more likely to be present in children with an abnormal or obstructed bladder.

How is reflux discovered?
Reflux is usually discovered because a child has a urinary tract infection (UTI). Also, it may be suspected because there is an enlargement of the kidney drainage system on an ultrasound test done either before or after birth. The test that detects reflux is called the voiding cystourethrogram (VCUG). This test is an X-ray of the bladder that is performed in either the radiology or nuclear medicine department. A catheter (tube) is passed into the bladder and the bladder is filled with a substance that allows us to see the bladder. Pictures are then taken until the bladder is full and the child urinates. If the x-ray material is seen in the ureters or kidneys then we know that reflux is present. Urination is an important part of the test since sometimes reflux does not appear until the bladder starts to empty. That's why we do not usually give sedation or anesthesia to do this test.

What is the significance of reflux?
Reflux alone does not usually cause a problem unless there is a blockage of urine flow in the urinary tract. The problem with reflux is that if an infection (UTI) starts in the bladder, it may easily ascend to the kidney, leading to a kidney infection. If not treated soon or completely, kidney infections can cause permanent scarring of the kidneys. When this scarring is severe, the result may be high blood pressure and/or kidney failure. Therefore, in cases of severe reflux, we recommend that a scan of the kidneys be done to see if scarring is present. This scan is performed in the nuclear medicine department. Your child is injected with a tracer and pictures of the kidneys are taken.

What causes reflux?
Normally, urine is made in the kidney and travels down a tube, the ureter, into the bladder. As the bladder fills, the normal ureter becomes compressed, not permitting urine to pass up into the kidney. If this ³valve² does not work properly, reflux will occur. Reflux tends to run in families, therefore, your doctor may recommend that siblings of children with reflux should be checked for the condition as well.

How is reflux treated?
Once reflux is identified, treatment depends on how severe the reflux is and the age of your child. Reflux is graded on a scale of 1 (mildest) to 5 (most severe). Since the milder forms may go away with time, the goal of treatment is to prevent urinary tract infection until the reflux has a chance to subside, which may take at least several years. To prevent infection, your child will be placed on a low dose of an antibiotic at bedtime to prevent urinary tract infection. The 2 drugs used most often are: cotrimoxizole (Bactrim, Septra) or macrodantin (Furadantin, Macrobid). These drugs appear to have the fewest effects on other parts of the body. If your child is less than 2 months old, amoxicillin is used most often. You will be asked to take urine specimens to your pediatrician or family doctor every 2-3 months or if your child has symptoms of a urinary tract infection. A cystogram (VCUG) and an ultrasound are usually repeated every year as long as the reflux persists. Surgery may be recommended by your urologist for the following reasons:

• the reflux is high grade (grade 4 or 5)
• your child continues to have urinary infections even on antibiotic treatment
• your child is unable to take antibiotics as prescribed
• the reflux has persisted after several years or your child is reaching adolescence

How does surgery prevent reflux?
Surgery, called ureteral reimplantation, is performed by making an incision in the lower abdomen, opening the bladder and sewing the ureter(s) into the bladder to fix the one-way valve. This is done by tunneling the ureter along the wall of the bladder. Your child will need to stay in the hospital after surgery for 3 or more days. An IV, or catheter (tube) in a vein will be placed at the time of surgery and will remain until your child is tolerating liquids. Pain medication will be available as needed. A catheter will drain urine from the bladder for at least 24 hours and a small drainage tube may come through the skin at or near the incision. Also, tubes may drain one or both kidneys directly. The tubes may be removed before your child goes home or may remain in place for a week or longer in some cases. Your child may go to the bathroom frequently or complain of burning with urination. Even after the tubes are removed, you may continue to notice blood in the urine for 1 or 2 weeks. The stitches will dissolve on their own. Your child will be checked in the office 1-2 weeks after going home and the doctor may order an ultrasound 4 to 6 weeks after surgery.

What are the possible complications of surgery?
General anesthesia is used for the surgery, and is low-risk in healthy children. The most common problems, which may occur in 1-2% of patients, include blockage (obstruction) of the ureter(s) or persistent reflux. Obstruction may be temporary, but the kidney may need to be drained temporarily with a tube in the side or through the bladder. Rarely, surgery needs to be performed again to treat the blockage or correct persistent reflux. Other rarer problems after surgery include infection of the incision or elsewhere and bleeding. Your child will be encouraged to take deep breaths and cough after surgery to prevent infection of the lungs.

What happens after surgery?
Your child will remain on the nightly dose of antibiotics until your doctor confirms that the reflux has gone away. He/she will need to get yearly ultrasounds of the kidneys to make sure blockage is not present. Urinary tract infections may occur after surgery, but they are usually limited to the bladder. When there is kidney scarring, it will not improve and may even worsen over time even if your child has no further kidney infections. For that reason a blood pressure should be checked by us or by your primary doctor at least yearly if your child has kidney scarring.