Urine formation occurs in kidneys and from there urine flows into the bladder through ureters. However, in some children, urine from the bladder flows back through the ureters into the kidneys. This condition is known as Vesicoureteral reflux (VUR) and is common in infants and children. It can be unilateral or bilateral. This could cause infections and damage your kidneys. VUR affects about 10% of children. Although most can grow out of this condition, people who have severe cases may need surgery to protect their kidneys.
This condition should not be ignored as it damages the function of kidneys and can lead to high blood pressure later in life. The risk of kidney damage is greatest during the first 6 years of life.
There are two types of VUR, Primary or Secondary VUR.
In Primary VUR- A flap valve is located where the ureter joins with the bladder. Usually, the valve allows only a one-way flow of urine from the ureters to the bladder. Sometimes, a defective flap valve allows urine to flow backward. This can affect one or both ureters. This is called “primary vesicoureteral reflux.”
Secondary VUR occurs because of blockage at the bladder outlet(Posterior urethral valve or abnormality of the bladder functions (Neurogenic bladder) that can causes urine to push back into the ureters.
This back flow of urine is responsible for recurrent urinary tract infections and damage of kidney (Renal scarring).
Urinary tract infection is one of the commonest presentations seen in children younger than the age of 5.
Common symptoms are:
Infants may have following symptoms.
VUR can often be suspected by ultrasound before a child is born or if child has urinary tract infection. Ultrasound may show dilatation of drainage system of kidney (Pelvi-calyceal system and ureter) called as Hydroureteronephrosis, but this does not prove that reflux is present.
VUR is diagnosed using an X-ray of the bladder known as voiding cystourethrogram (VCUG). In this procedure, a thin, soft tube (catheter) is placed in the bladder through the urethra. Dye is then introduced into the bladder through the tube. X-ray pictures are taken to see if the dye flows back into the ureters.
Grades of VUR - Based upon the severity on VCUG, VUR is categorized into five grades. Milder grade of VUR does not require any treatment. All infants with urinary tract infection and other older children with frequent urinary tract infections with or without hydronephrosis should a be considered for VCUG test.
There are 3 main options for managing or treating VUR. One should understand the risks, benefits, and follow-up of each treatment.
Antibiotic: It is used to prevent infections until VUR goes away by itself. This treatment may take several years, and children must take medication every day. These children need to be reassessed for VUR and renal damage on regular basis. However, long term treatment with antibiotics may cause the bacteria to become resistant, increasing the risks of recurrent infections.
Surgery: This type of treatment cures most children. Surgery is good option for high grade reflux. This can be performed by open,laparoscopic, or Robotic technique.
Endoscopic treatment: This is a day care procedure, in which a medication (A gel made from two tissue-friendly polysaccharides (types of sugars) – hyaluronic acid (HA) and dextranomer (Dx) – Brand name Deflux/ Dexell) is used as a tissue bulking agent that is injected around the ureteral opening (see fig) to prevent urine from flowing back up from the bladder through the ureters. It is a safe and effective treatment for VUR. The gel is placed at the spot where the ureters connect to the bladder with the help of a small camera called a cystoscope (a type of endoscope used to view the bladder). Eventually, new tissue grows around the gel, preventing the reflux of urine. Usually, there will be no pain after the procedure. Deflux is used for the treatment of all grades of VUR in children. Many children have success after one injection, while some may need more injection procedures. However, lower the grade of VUR, the better it works. Also, the procedure works better for children who have reflux in only one ureter.
Fig: - Endoscopic management of VUR