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Pediatric – Vesicoureteral Reflux (VUR)

Vesicoureteral reflux (or VUR) is the condition which reverses the flow of urine. This causes the urine to flow back from the bladder to the kidneys. This condition develops in around 1% of all children.

This condition is mostly a congenital (birth) defect which results from an abnormal connection between the bladder and the ureter with an ineffective and short flap valve. The known reasons for development of VUR in children are if a child is born with defective neural tubes, has genetic predisposition or has a type of urinary tract abnormality. Caucasian females (around 75%) are most affected by this disorder.


What are the symptoms of VUR?

Normally, UTI (urinary tract infection) is the initial symptom of VUR in infants and young children. VUR can cause infection due to bacterial growth in the urine which is accumulated in the bladder without relieving. This can also spread to the kidneys. If the child is considerably older, other symptoms seen include hypertension (high blood pressure) and bed wetting habit.

Other symptoms of VUR are:

  • Constant urge to urinate

  • Burning sensation while urinating

  • Frequent urinating in small amounts

  • Hematuria (blood in the urine/cloudy and strong smelling urine

  • Fever

  • Flank/abdominal pain

A urinary tract infection is mostly difficult to diagnose in children who exhibit general symptoms that are caused with other disorders as well. When infants are affected by UTI, these are the commonly seen symptoms:

  • Abnormally slow/less growth

  • Diarrhea and nausea

  • Lack of appetite

  • Lethargy

As the child grows, the VUR may show other signs and symptoms, such as:

  • Hyper tension (high blood pressure)

  • Protein mixed with urine

  • Bed wetting

  • Renal failure

Another sign of VUR, which is mostly detected with a fetal sonogram, is the swelling of the kidney’s parts that collect urine before passing it on to the bladder. This condition is known as hydronephrosis which causes the urine to become accumulated inside the kidney.


Causes

There are several causes for development of VUR in children. The most common causes are:

  • Genetic vulnerability

  • Congenital neural defects (such as spina bifida)

  • Male infants are likely to experience pressure in the urinary tract as compared to female children who have higher risk when in the younger age of childhood

  • Urinary tract disorders, such as Ureterocele, posterior urethral valves or ureter duplication

  • Caucasian ethnicity of the child

Vesicoureteral reflux (VUR) is seen in mainly two types:

Primary VUR – This is a common type of VUR which is mostly caused due to a congenital abnormality in the valve between the ureter and the bladder. Normally, this valve prevents the reversal of the flow of urine from the kidney to the bladder. With the growth of the child, the ureters are extend  which also results in improved valve function and resolve the condition to normal, naturally. This type of VUR is mostly caused due to a genetic predisposition.

Secondary VUR – This type of VUR is the result of a blockage in the urinary system. This blockage mostly develops because of urinary tract infection, which causes the ureter to swell.


How is it detected?

Imaging tests help to identify abnormalities in the urinary tract. These may include:

  • Ultrasound – Using sound waves to create an image of the bladder and kidney.

  • VCUG (Voiding Cystourethrogram) – Specialized x-ray test of bladder that helps check the flow of urine. A small tube is inserted into the bladder through the urethra. A contrast dye is injected before the x-ray to get clearer image of the urine flow.

These tests are essential for determining the severity of VUR, which is rated grade I (very mild) through grade V (very severe).


What happens if VUR is left untreated?

Various complications, including infection and scarring in the kidneys can develop in case VUR is left untreated. This can also cause permanent damage to the kidneys. However, today there are several diagnostic and treatment methods for VUR that can help avoid these complications.


Procedures

One of the main factors that decide the treatment for a case of VUR is its stage. VUR condition is graded as:

  • Grade I – Causes urine to flow back into the ureter only.

  • Grade II – Causes urine to flow back into the ureter and the renal pelvis (without distention).

  • Grade III – Causes urine to flow back into ureter and renal pelvis (mild hydronephrosis).

  • Grade IV – Results in moderate hydronephrosis.

  • Grade V – Results in severe hydronephrosis and twists the ureter.

As the lower grades of this condition are not severe these tend to correct on their own. With the growth of the child, the length of the ureter also increases, often relieving the condition effectively without the need for treatment. Mild antibiotics are normally prescribed to prevent risk of infection. Often, other medications and bladder therapy are also needed. Such cases require regular monitoring using x-ray tests of the bladder and/or kidney.

For the higher grades, surgical correction is often required in the form of ureteral re-implantation. This surgery requires administering general anesthesia and is performed through a small incision in the mower abdomen. Often times, if the situation permits this surgery is performed using minimally invasive surgical method, otherwise it is performed with conventional surgical methods. The surgery mainly aims to correct the flap valve of the ureter which prevents reflux of urine from bladder back into the kidney. Follow-up x-ray examination allows checking the success of the procedure in preventing urine back-flow.

Another method of treatment of VUR is Cystoscopy with DeFlux injection. This procedure is performed using endoscopic technique where the cystoscope, inserted through the ureter, allows the surgeon to view the bladder. DeFlux, a gel-based mixture of hyaluronic acid and dextranomer, is injected at the entry point of the ureter and bladder.


Treatment for Vesicoureteral Reflux (VUR)

There are several stage of VUR, and several other factors that help the doctor to determine the best-suited treatment methods for this condition. These factors include:

  • Child’s age

  • Overall health

  • Medical history

  • Potential allergies to medications, therapies, etc

  • Your opinion/preference

Mostly, children are seen to be affected by Grade I to Grade III of VUR, which are comparatively milder in nature and often do not require extensive treatment or therapy. These are often seen to resolve within 5 years of the child’s birth. Antibiotics and other medications may be advised in such cases to prevent infection and other complications.

Children with the severe forms of VUR (Grade IV and Grade V) require surgical treatment. This focuses on creating a flap-valve system for the ureter which prevents the reversal of flow of the urine into the kidney once it has been passed on to the bladder. In most severe cases, removal of kidney and the ureter may be advised.

There are numerous advanced VUR treatments available in India today. Consults your physician for more information.

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