Vesicoureteral reflux

Vesicoureteral (ves-ih-koe-yoo-REE-tur-ul) reflux is the abnormal flow of urine from your bladder back up the tubes (ureters) that connect your kidneys to your bladder. Normally, urine flows from your kidneys through the ureters down to your bladder. It's not supposed to flow back up.

Vesicoureteral reflux is usually diagnosed in infants and children. The disorder increases the risk of urinary tract infections, which, if left untreated, can lead to kidney damage.

Children may outgrow primary vesicoureteral reflux. Treatment, which includes medication or surgery, aims at preventing kidney damage.

Urinary tract infections commonly occur in people with vesicoureteral reflux. A urinary tract infection (UTI) doesn't always cause noticeable signs and symptoms, though most people have some.

These signs and symptoms can include:

• A strong, persistent urge to urinate
• A burning sensation when urinating
• The need to pass small amounts of urine frequently
• Cloudy urine
• Fever
• Pain in your side (flank) or abdomen

A UTI may be difficult to diagnose in children, who may have only nonspecific signs and symptoms. Signs and symptoms in infants with a UTI may also include:

• An unexplained fever
• Lack of appetite
• Irritability

As your child gets older, untreated vesicoureteral reflux can lead to:

• Bed-wetting
• Constipation or loss of control over bowel movements
• High blood pressure
• Protein in urine

Another indication of vesicoureteral reflux, which may be detected before birth by sonogram, is swelling of the kidneys or the urine-collecting structures of one or both kidneys (hydronephrosis) in the fetus, caused by the backup of urine into the kidneys.

When to see a doctor

Contact your doctor right away if your child develops any of the signs or symptoms of a UTI, such as:

• A strong, persistent urge to urinate
• A burning sensation when urinating
• Abdominal or flank pain

Call your doctor about fever if your child:

• Is younger than 3 months old and has a rectal temperature of 100.4 F (38 C) or higher
• Is 3 months or older and has a fever of 100.4 F (38 C) or higher and seems to be ill
• Is also eating poorly or has had significant changes in mood

Your urinary system includes your kidneys, ureters, bladder and urethra. All play a role in removing waste products from your body via urine.

Tubes called ureters carry urine from your kidneys down to your bladder, where it is stored until it exits the body through another tube (the urethra) during urination.

Vesicoureteral reflux can develop in two types, primary and secondary:

• Primary vesicoureteral reflux. Children with primary vesicoureteral reflux are born with a defect in the valve that normally prevents urine from flowing backward from the bladder into the ureters. Primary vesicoureteral reflux is the more common type.

  As your child grows, the ureters lengthen and straighten, which may improve valve function and eventually correct the reflux. This type of vesicoureteral reflux tends to run in families, which indicates that it may be genetic, but the exact cause of the defect is unknown.

• Secondary vesicoureteral reflux. The cause of this form of reflux is most often from failure of the bladder to empty properly, either due to a blockage or failure of the bladder muscle or damage to the nerves that control normal bladder emptying.

Risk factors for vesicoureteral reflux include:

• Bladder and bowel dysfunction (BBD). Children with BBD hold their urine and stool and experience recurrent urinary tract infections, which can contribute to vesicoureteral reflux.
• Race. White children appear to have a higher risk of vesicoureteral reflux.
• Sex. Generally, girls have a much higher risk of having this condition than boys do. The exception is for vesicoureteral reflux that's present at birth, which is more common in boys.
• Age. Infants and children up to age 2 are more likely to have vesicoureteral reflux than older children are.
• Family history. Primary vesicoureteral reflux tends to run in families. Children whose parents had the condition are at higher risk of developing it. Siblings of children who have the condition also are at higher risk, so your doctor may recommend screening for siblings of a child with primary vesicoureteral reflux.

Kidney damage is the primary concern with vesicoureteral reflux. The more severe the reflux, the more serious the complications are likely to be.

Complications may include:

• Kidney (renal) scarring. Untreated UTIs can lead to scarring, which is permanent damage to kidney tissue. Extensive scarring may lead to high blood pressure and kidney failure.
• High blood pressure. Because the kidneys remove waste from the bloodstream, damage to your kidneys and the resultant buildup of wastes can raise your blood pressure.
• Kidney failure. Scarring can cause a loss of function in the filtering part of the kidney. This may lead to kidney failure, which can occur quickly (acute kidney failure) or may develop over time (chronic kidney disease).

A urine test can reveal whether your child has a UTI. Other tests may be necessary, including:

• Kidney and bladder ultrasound. This imaging method uses high-frequency sound waves to produce images of the kidney and bladder. Ultrasound can detect structural abnormalities. This same technology, often used during pregnancy to monitor fetal development, may also reveal swollen kidneys in the baby, an indication of primary vesicoureteral reflux.

• Specialized X-ray of urinary tract system. This test uses X-rays of the bladder when it's full and when it's emptying to detect abnormalities. A thin, flexible tube (catheter) is inserted through the urethra and into the bladder while your child lies on his or her back on an X-ray table. After contrast dye is injected into the bladder through the catheter, your child's bladder is X-rayed in various positions.

  Then the catheter is removed so that your child can urinate, and more X-rays are taken of the bladder and urethra during urination to see whether the urinary tract is functioning correctly. Risks associated with this test include discomfort from the catheter or from having a full bladder and the possibility of a new urinary tract infection.

• Nuclear scan. This test uses a tracer called a radioisotope. The scanner detects the tracer and shows whether the urinary tract is functioning correctly. Risks include discomfort from the catheter and discomfort during urination.

Grading the condition

After testing, doctors grade the degree of reflux. In the mildest cases, urine backs up only to the ureter (grade I). The most severe cases involve severe kidney swelling (hydronephrosis) and twisting of the ureter (grade V).

Treatment options for vesicoureteral reflux depend on the severity of the condition. Children with mild cases of primary vesicoureteral reflux may eventually outgrow the disorder. In this case, your doctor may recommend a wait-and-see approach.

For more severe vesicoureteral reflux, treatment options include:

Medications

UTIs require prompt treatment with antibiotics to keep the infection from moving to the kidneys. To prevent UTIs, doctors may also prescribe antibiotics at a lower dose than for treating an infection.

A child being treated with medication needs to be monitored for as long as he or she is taking antibiotics. This includes periodic physical exams and urine tests to detect breakthrough infections — UTIs that occur despite the antibiotic treatment — and occasional radiographic scans of the bladder and kidneys to determine if your child has outgrown vesicoureteral reflux.

Surgery

Surgery for vesicoureteral reflux repairs the defect in the valve between the bladder and each affected ureter. A defect in the valve keeps it from closing and preventing urine from flowing backward.

Methods of surgical repair include:

• Open surgery. Performed using general anesthesia, this surgery requires an incision in the lower abdomen through which the surgeon repairs the problem. This type of surgery usually requires a few days' stay in the hospital, during which a catheter is kept in place to drain your child's bladder. Vesicoureteral reflux may persist in a small number of children, but it generally resolves on its own without need for further intervention.

• Robotic-assisted laparoscopic surgery. Similar to open surgery, this procedure involves repairing the valve between the ureter and the bladder, but it's performed using small incisions. Advantages include smaller incisions and possibly less bladder spasms than open surgery.

  But, preliminary findings suggest that robotic-assisted laparoscopic surgery may not have as high of a success rate as open surgery. The procedure was also associated with a longer operating time, but a shorter hospital stay.

• Endoscopic surgery. In this procedure, the doctor inserts a lighted tube (cystoscope) through the urethra to see inside your child's bladder, and then injects a bulking agent around the opening of the affected ureter to try to strengthen the valve's ability to close properly.

  This method is minimally invasive compared with open surgery and presents fewer risks, though it may not be as effective. This procedure also requires general anesthesia, but generally can be performed as outpatient surgery.

Urinary tract infections, which are so common to vesicoureteral reflux, can be painful. But you can take steps to ease your child's discomfort until antibiotics clear the infection. They include:

• Encourage your child to drink fluids, particularly water. Drinking water dilutes urine and may help flush out bacteria.
• Provide a heating pad or a warm blanket or towel. Warmth can help minimize feelings of pressure or pain. If you don't have a heating pad, place a towel or blanket in the dryer for a few minutes to warm it up. Be sure the towel or blanket is just warm, not hot, and then place it over your child's abdomen.

If bladder and bowel dysfunction (BBD) contributes to your child's vesicoureteral reflux, encourage healthy toileting habits. Avoiding constipation and emptying the bladder every two hours while awake may help.

Doctors usually discover vesicoureteral reflux as part of follow-up testing when an infant or young child is diagnosed with a urinary tract infection. If your child has signs and symptoms, such as pain or burning during urination or a persistent, unexplained fever, call your child's doctor.

After evaluation, your child may be referred to a doctor who specializes in urinary tract conditions (urologist) or a doctor who specializes in kidney conditions (nephrologist).

Here's some information to help you get ready, and what to expect from your child's doctor.

What you can do

Before your appointment, take time to write down key information, including:

• Signs and symptoms your child has been experiencing, and for how long
• Information about your child's medical history, including other recent health problems
• Details about your family's medical history, including whether any of your child's first-degree relatives — such as a parent or sibling — have been diagnosed with vesicoureteral reflux
• Names and dosages of any prescription and over-the-counter medications that your child is taking
• Questions to ask your doctor

For vesicoureteral reflux, some basic questions to ask your child's doctor include:

• What's the most likely cause of my child's signs and symptoms?
• Are there other possible causes, such as a bladder or kidney infection?
• What kinds of tests does my child need?
• How likely is it that my child's condition will get better without treatment?
• What are the benefits and risks of the recommended treatment in my child's case?
• Is my child at risk of complications from this condition?
• How will you monitor my child's health over time?
• What steps can I take to reduce my child's risk of future urinary tract infections?
• Are my other children at increased risk of this condition?
• Do you recommend that my child see a specialist?

Don't hesitate to ask additional questions that occur to you during your child's appointment. The best treatment option for vesicoureteral reflux — which can range from watchful waiting to surgery — often isn't clear-cut. To choose a treatment that feels right to you and your child, it's important that you understand your child's condition and the benefits and risks of each available therapy.

What to expect from your doctor

Your child's doctor will perform a physical examination of your child. He or she is likely to ask you a number of questions as well. Being ready to answer them may reserve time to go over points you want to spend more time on. Your doctor may ask:

• When did you first notice that your child was experiencing symptoms?
• Have these symptoms been continuous or do they come and go?
• How severe are your child's symptoms?
• Does anything seem to improve these symptoms?
• What, if anything, appears to worsen your child's symptoms?
• Does anyone in your family have a history of vesicoureteral reflux?
• Has your child had any growth problems?
• What types of antibiotics has your child received for other infections, such as ear infections?