Vesicoureteral reflux (urinary reflux) is a condition in which urine flows from the bladder, back into the kidneys. The refluxing urine increases the pressure within the kidneys and may contain bacteria that can lead to kidney infection. Long term increased pressure and repeated infections can lead to damage and scarring of the kidneys, potentially interfering with kidney function later in life.

 

 

 

 

The urinary tract is made up  of the kidneys, the ureters, the bladder and the urethra. Urine produced by the kidneys flows to the bladder via the ureters. The bladder acts as a reservoir for the urine until it is excreted from the body via the urethra. At the junction where each ureter enters the bladder, there is a valve mechanism. As the bladder is being emptied these valves close, preventing urine from flowing backwards towards the kidneys.

 

 

With vesicoureteral reflux, urine flows from the bladder, through the valves at the junction of the bladder and the ureter, back up the ureters and back into the kidneys. It is usually a congenital condition (present at birth) and occurs when one or both of the valve mechanisms are not working correctly .

Vesicoureteral reflux is graded 1 – 5, with 1 being the mildest and 5 being the most severe. It appears to be more common in girls than in boys.

The valve mechanisms at the junction of the ureters and the bladder mature as the child ages and approximately 70% of children with vesicoureteral reflux will grow out of the condition within a few years of birth. This is more likely to occur in children who have mild to moderate grade reflux. High-grade, severe reflux is less likely to spontaneously resolve.

 

 

 

Signs and Symptoms 

 

Vesicoureteral reflux in itself does not produce any symptoms. These occur when infection of the urinary tract (UTI) is present. Infection causes fever, pain, unpleasant smelling urine and a burning sensation when urinating.
Other symptoms commonly experienced include:

 

 

 

Vesicoureteral reflux may be suspected before a baby is born. If prenatal ultrasound scanning shows enlargement of the kidney(s) and/or dilation (widening) of the ureter(s), it may indicate that reflux is occurring.

Vesicoureteral reflux is most commonly first suspected in infancy with the occurrence of repeated urinary tract infections. Most children who experience urinary tract infections have a normal urinary tract. However up to 30% of them have some degree of urinary reflux. Children who experience repeated urinary tract infections should be investigated for vesicoureteral reflux.

There is up to a 1 in 3 chance that the child’s siblings may also be affected by vesicoureteral reflux. It may be suggested that they are screened to rule this out.

Common investigations used to diagnose vesicoureteral reflux and assess for kidney damage include:

Ultrasound Scanning:
The bladder and kidneys are scanned to survey the anatomy and assess for any irregularities.

Micturating Cystourethrogram (MCU):
A small tube (catheter) is put into the child’s bladder and a radio-opaque (visible on x-ray) liquid is passed into the bladder. X-rays are taken as the bladder fills and as the child urinates.

Intravenous Pyelogram (IVP):
A radio-opaque (visible on x-ray) liquid is injected through a small needle (a drip) in the child’s arm. X-rays are taken as the liquid is being filtered by the kidneys and excreted in the urine. This test can detect scarring in the kidneys.

 

 

 

 

The goal of any treatment for vesicoureteral reflux is to prevent damage to the kidneys. Treatment will depend on the severity of the reflux and the medical history of the patient. There are two main treatment options:

Medications:
Prophylactic (preventative) antibiotics may be recommended to prevent UTIs from developing, therefore preventing damage to the kidneys. During treatment with prophylactic antibiotics the child will be periodically assessed to check for resolution of the reflux.

Surgery:
It is often recommended that children with severe (grade 4 – 5) vesicoureteral reflux should have surgery to correct the problem. Surgery may also be recommended for children with lower grade vesicoureteral reflux if:

 

Surgery to correct the valve mechanism at the junction of the ureter and bladder is referred to as “ureteric reimplantation”. The surgery is performed under a general anaesthetic and may require a 2 – 3 day stay in hospital.

During surgery the ureters are released and are then “reimplanted” into the bladder wall in such a way that an efficient valve mechanism is created. Prophylactic antibiotic treatment may be continued after surgery until follow up assessment shows that the reflux has resolved. Ureteric reimplantation has a very high (approximately 95%) rate of success for the treatment of vesicoureteral reflux.

 

 

 

Follow Up 

 

After treatment for vesicoureteral reflux, follow up assessment may be recommended. This may involve urine tests, blood tests, ultrasound scanning, or MCU. Blood pressure and height and weight may also be measured. These tests aim to assess kidney function and to ensure that the reflux has resolved.

 

 

 

Anderson, K.N., Anderson, L.E. & Glanze, W.D. (eds.) (2006) Mosby’s medical, nursing, & allied health dictionary (6th ed.) St. Louis: Mosby-Year Book, Inc.

Davison, A.M., Cumming, A.D., Swainson, C.P. & Turner, N. (1999) Diseases of the kidney and urinary system. In C.Haslett, E.R. Chilvers, J.A.A. Hunter & N.A. Boon (eds.) Davidson’s principles and practice of Medicine (18th ed.) (pp417- 470) Edinburgh: Churchill Livingstone

Mercy Radiology Group (2000) IVP – Intravenous Pyelogram (pamphlet) Auckland: Mercy Radiology Group

 

Last Reviewed -  5/09/07