Vesico-ureteral Reflux

Background

Patients that have fever associated with a urinary tract infection by definition have a kidney infection or pyelonephritis. 1/3 of children with a urinary tract infections associated with a fever have vesio-ureteral reflux. 

Causes

Vesico-ureteral reflux (VUR) is a condition where urine moves up from bladder towards the kidneys. Urine usually travels in a forward fashion; it is produced by the kidneys and travels down to the bladder where it dwells prior to being peed or voided out. With VUR the urine can travel in a backward or retrograde fashion back of the ureter toward the kidney. Vesicorueteral reflux is graded 1-5.

Historically, it was thought the refluxing urine caused damage to the kidneys. We know now that the damage is created if infected urine in the bladder is refluxed up to the kidneys potentially causing a kidney infection or pyelonpehritis. 

When a kidney becomes infected there is a 30% chance that the kidney can form a scar after the infection. Scarring can result in potential kidney dysfunction and over the long term hypertension (high blood pressure).

Diagnosis and Evaluation

The diagnosis and work up for reflux includes:

  • history and physical exam
  • urinalysis and culture and review of prior urine culture findings
  • renal bladder ultrasound
  • +/- renogram
  • +/- VCUG

Most children with a urinary tract infection associated with a fever will get a renal ultrasound then will have a renogram 6 months following the infection. The renogram looks for renal scarring. If there are findings suspicious for scarring then a VCUG will be considered to look for reflux.

Vesicoureteral reflux is diagnosed with a VCUG (voiding cystourethrogram). A VCUG is where contrast is put into the bladder via a catheter or tube. X-Rays are then taken to see if the urine travels back up the ureter. It is graded from I to IV based on the 

Grade I - reflux into a non-dilated ureter (but not into the kidney)

Grade II - reflux into renal pelvis and calyces of the kidney with no dilation

Grade III - reflux into ureter, renal pelvis and calyces with minimal dilation

Grade IV - reflux into ureter, renal pelvis and caylces with dilation and mild tortuosity of the ureter

Grade V - refux in the ureter, renal pelvis and calyces with gross dilation of calyces and tortuosity of the ureter

Treatment

Possible treatment options include:

  • daily low dose antibiotic prophylaxis for infection prevention and observation
  • surgery with DEFLUX sub-ureteric injection for reflux prevetion
  • surgery with ureteral re-implantation

 

 

 

 

Author : Dr J Mickelson - Last edited Oct 2015

 

Web Site Links

Antibiotic Prophylaxis for Children with Vesicoureteral Reflux (The RIVUR Trial). NEJM, vol 370, No 25, June 2014.