Summary about Disease
Vesicoureteral reflux (VUR) is a condition in which urine flows backward from the bladder into one or both ureters and sometimes into the kidneys. Normally, urine flows from the kidneys, through the ureters, to the bladder, and then is expelled from the body. VUR occurs when the valve-like mechanism at the junction of the ureter and bladder is defective or absent, allowing urine to reflux back up the urinary tract. This reflux can increase the risk of urinary tract infections (UTIs) and, in severe cases, can lead to kidney damage (reflux nephropathy).
Symptoms
Many children with VUR have no noticeable symptoms. VUR is often discovered when a child develops a urinary tract infection (UTI). Symptoms of a UTI can include:
Fever
Frequent urination
Painful urination (dysuria)
Urgent need to urinate
Bedwetting (enuresis), especially in children who are already toilet trained
Abdominal pain or flank pain
Nausea and vomiting
Poor appetite
Blood in urine (hematuria)
In infants, signs can be non-specific, such as irritability, poor feeding, or unexplained fever
Causes
The primary cause of VUR is a defect in the vesicoureteral valve – the valve between the ureter and bladder. This defect can be:
Primary VUR: The most common type, it occurs when the ureter is abnormally short or misplaced in the bladder, resulting in an inadequate valve mechanism from birth. It is often hereditary.
Secondary VUR: Occurs due to a blockage or malfunction in the bladder or urethra. This obstruction increases pressure in the bladder, causing urine to reflux into the ureters. Causes of secondary VUR include:
Posterior urethral valves (PUV) in males
Bladder dysfunction (neurogenic bladder)
Infrequent voiding
Medicine Used
The main goal of medical treatment is to prevent UTIs, which can cause kidney damage. Commonly used medications include:
Prophylactic Antibiotics: Low-dose antibiotics are prescribed daily to prevent UTIs. Common antibiotics include trimethoprim-sulfamethoxazole (Bactrim, Septra), nitrofurantoin (Macrobid), or cephalexin (Keflex). The choice of antibiotic depends on the child's age, allergy history, and local antibiotic resistance patterns.
Antibiotics for Treatment of UTIs: When a UTI does occur, a full course of antibiotics is prescribed to treat the infection.
Medications for Bladder Dysfunction: If secondary VUR is due to bladder dysfunction, medications such as anticholinergics (oxybutynin) may be prescribed to improve bladder emptying and reduce pressure.
Is Communicable
Vesicoureteral reflux itself is not communicable. It is a structural or functional abnormality of the urinary tract. However, UTIs, which are a common complication of VUR, are caused by bacteria and can be contagious.
Precautions
To prevent UTIs and manage VUR, the following precautions are important:
Good Hygiene: Teach children proper hygiene habits, including wiping front to back after using the toilet.
Adequate Hydration: Encourage children to drink plenty of fluids to help flush bacteria from the urinary tract.
Frequent Voiding: Encourage regular and complete bladder emptying. Avoid "holding" urine for long periods.
Treat Constipation: Constipation can contribute to bladder dysfunction. Manage constipation with diet and, if necessary, medication.
Antibiotic Prophylaxis: Adhere to the prescribed antibiotic regimen to prevent UTIs.
Follow-Up Care: Regular follow-up with a pediatric urologist or nephrologist is essential to monitor VUR and kidney function.
Proper Diaper Changes: Change diapers frequently to prevent bacterial growth.
Cotton Underwear: Breathable cotton underwear can help reduce moisture and bacterial growth.
Avoid Bubble Baths: Bubble baths can irritate the urethra and increase the risk of UTIs in some children.
How long does an outbreak last?
An "outbreak" in the context of VUR refers to a UTI. A typical UTI outbreak, when treated promptly with antibiotics, usually lasts for 5-10 days. However, symptoms may start to improve within a few days of starting antibiotics. It's crucial to complete the entire course of antibiotics as prescribed to ensure the infection is fully eradicated. VUR itself is a chronic condition, not an outbreak.
How is it diagnosed?
VUR is diagnosed through a combination of methods:
Voiding Cystourethrogram (VCUG): This is the gold standard test for diagnosing VUR. A catheter is inserted into the bladder, and the bladder is filled with a contrast dye. X-rays are taken while the bladder is filled and while the child urinates. This allows the doctor to visualize the flow of urine and identify any reflux into the ureters.
Renal Ultrasound: This imaging test uses sound waves to create images of the kidneys and bladder. It can help identify kidney abnormalities or hydronephrosis (swelling of the kidney due to urine backup), which can be associated with VUR.
Radionuclide Cystogram (RNC): Similar to VCUG, but uses a radioactive tracer instead of contrast dye. RNC delivers less radiation than VCUG but may not provide as much detail.
Urine Culture: To confirm the presence of a UTI.
Dimercaptosuccinic Acid (DMSA) Scan: This nuclear medicine scan is used to assess kidney scarring. It can help determine if VUR has caused kidney damage.
Timeline of Symptoms
The timeline of symptoms depends on whether the child has a UTI associated with VUR:
VUR Diagnosis (without UTI): Often discovered incidentally during workup for other problems or family history. No specific symptoms are present initially.
UTI Onset:
First 1-2 days: Fever, irritability (in infants), abdominal pain, frequent or painful urination may begin.
Days 3-5: Symptoms may worsen if untreated. Nausea, vomiting, flank pain, or blood in urine may develop.
With Antibiotics (after starting treatment): Symptoms typically begin to improve within 1-2 days.
5-10 days: Symptoms should resolve completely with appropriate antibiotic treatment.
Long-term (if VUR is not managed and UTIs recur): Possible kidney damage (reflux nephropathy) may develop over time, leading to high blood pressure, proteinuria (protein in urine), and impaired kidney function.
Important Considerations
Family History: VUR can be hereditary. If there is a family history of VUR, siblings and offspring should be screened.
Grade of Reflux: VUR is graded on a scale of I to V, with I being the mildest and V being the most severe. The grade of reflux influences the risk of kidney damage and the need for intervention.
Spontaneous Resolution: Mild to moderate VUR (grades I-III) can sometimes resolve spontaneously, especially in younger children, as the ureterovesical junction matures.
Surgical Correction: In severe cases of VUR (grades IV-V) or when medical management fails to prevent recurrent UTIs, surgical correction may be necessary. Surgical options include ureteral reimplantation.
Long-term Monitoring: Children with VUR require long-term monitoring of kidney function, even if the reflux resolves.
Psychological Impact: Recurrent UTIs and enuresis can have a psychological impact on children and families. Support and counseling may be helpful.
Pregnancy: Women with a history of VUR should be monitored during pregnancy, as UTIs can be more common and potentially harmful.
Circumcision: Some studies suggest that circumcision in males may reduce the risk of UTIs in infancy, potentially decreasing the risk of VUR-related complications, but it is not a primary treatment for VUR.