Introduction:
When there is a change in the path of urine, that is, it flows from the bladder to the ureters and the kidneys; the condition is known as vesicoureteral reflux. It is commonly seen in children and infants and increases the risk of urinary tract infections. Treatment is not required in mild cases, and the child survives the condition without any complications. However, surgery needs to be done if the child presents with fever and vesicoureteral reflux symptoms. In addition, the treatment must be carried out at the earliest to prevent kidney damage.
What Is Vesicoureteral Reflux?
The urinary system mainly consists of kidneys, ureters, bladder, and urethra. Each organ is designed to perform a specific function. The kidneys filter blood and form urine, which is then transported to the ureters. The ureters are tube-like structures that connect the kidneys to the urinary bladder. The urine then reaches the urinary bladder through the ureters. A tube-like structure known as the urethra attached to the bladder expels the urine outside the body. This is how the urine flows under normal conditions.
In the case of vesicoureteral reflux, the urine does not flow outside the body. Instead, it returns to the ureters. If the urine flows back to one of the ureters and the kidneys, the condition is known as unilateral reflux. Bilateral reflux occurs when the urine flows back to both the ureters and the kidneys. Vesicoureteral reflux can be broken into three parts to understand the terminology.
"Vesico" means bladder, "ureteral" denotes ureters, and "reflux" means the return or backflow. So the condition can be defined as the backflow of urine from the bladder to the ureters. It is commonly seen in newborns and young children and rarely in adults.
Is Vesicoureteral Reflux a Common Condition?
Vesicoureteral reflux has been reported to occur in one out of three children. If a child suffers from a urinary tract infection and fever, vesicoureteral reflux is most likely. The condition might also be hereditary; if a parent or a sibling had this condition, the child is expected to suffer from the same. The condition mainly affects children less than two years of age: infants, newborns, and girls. It is rarely seen in adults. If a child is born with some defect in the kidneys or other organs of the urinary system, the risk of vesicoureteral reflux increases.
What Are the Causes of Vesicoureteral Reflux?
There are mainly two types of vesicoureteral reflux, primary and secondary, each having a different cause. The causes of the condition are listed below:
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Primary Vesicoureteral Reflux: It is the most common type of reflux that occurs in infants and newborns. A flap valve is present at the junction of the bladder and the ureters. The function of the valve is to allow the unidirectional flow of urine. Sometimes, the valve does not function properly, or the child is born with a defect in the valve. As a result, the urine flows back to the ureters and the kidneys. As the child undergoes growth and development, the length of the ureters increases, the valves start to function better, and the condition improves with time.
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Secondary Vesicoureteral Reflux: It occurs due to a blockage in the urethra and urinary bladder. The presence of an abnormal fold of tissue in the urethra blocks the flow of urine outside the body. The urine returns to the bladder, ureters, and kidneys in such a situation. The condition also develops when the bladder muscles or nerves are damaged. As a result, the bladder fails to function, causing the backflow of urine to the ureters and the kidneys.
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Bladder and Bowel Dysfunction: Children suffering from bladder and bowel dysfunction find it difficult to pass urine and stools. As a result, the risk of urinary tract infection and vesicoureteral reflux increases.
What Are the Different Grades of Vesicoureteral Reflux?
There are five grades of vesicoureteral reflux based on how far the urine refluxes to the ureters and the kidneys. The grades are described in the table below:
What Are the Signs and Symptoms of Vesicoureteral Reflux?
Sometimes, the child does not present with any symptoms in case of vesicoureteral reflux. However, urinary tract infection is the most common if the symptoms are present. In the case of vesicoureteral reflux, the urine remains within the body and does not get drained out. As a result, it provides a medium for bacteria to grow, resulting in infection. So, a child suffering from a urinary tract infection is likely to develop vesicoureteral reflux and presents with common symptoms. The symptoms of vesicoureteral reflux are listed below:
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The infection is usually accompanied by fever in infants and young children.
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The urine flow is restricted so the patient can pass a few drops of urine each time.
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Pain and burning sensation while urinating are commonly seen.
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Urinary incontinence or leakage of urine can occur in some children.
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The urine appears cloudy and smells bad.
What Methods Are Used to Diagnose Vesicoureteral Reflux?
The diagnosis of vesicoureteral reflux is made based on imaging and laboratory tests, and they have been described below:
1) Imaging Tests: The following imaging tests are done to diagnose vesicoureteral reflux:
- Ultrasound: It is an imaging technique in which images of the urinary system are obtained, including the bladder and the kidneys. The advantage of this procedure is that the child is not exposed to X-ray radiation. Instead, the child is laid down on a table, and sound waves are sent to the body to produce images of the organs. Next, the doctor moves the ultrasound probe over the abdomen and gets the images on the computer screen. The doctor then checks for blockage in the kidneys and ureters with the help of the images.
- Voiding Cystourethrogram: This test is mainly done to check if the child is urinating correctly or any backflow of urine from the bladder to the kidneys. In this procedure, a tube is passed into the bladder of the child, and a solution is injected through this tube into the bladder. X-rays are then taken from different angulations to monitor the functioning of the bladder. The doctor will check if any amount of solution is flowing backward to the kidney or if any blockage is present in the passage of urine.
- Dimercaptosuccinic Acid Scintigraphy (DMSA Scan): It is the "gold standard" for diagnosing kidney infections. In this procedure, a special material is injected into the body through veins. The images of the kidneys are obtained through the special camera known as the gamma camera. It is used in the detection of infection and scars in the kidneys.
- Radionuclide Cystogram: It is a diagnostic test that determines whether the child is suffering from vesicoureteral reflux or not. In this procedure, radioactive material is inserted through a tube into the urethra of the child. The images are then obtained with the help of a gamma camera as the liquid flows into the urinary tract.
2) Laboratory Tests: The following laboratory tests are usually recommended by the doctor if a child is suffering from vesicoureteral reflux:
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Blood Tests: The doctor usually recommends a blood test to check creatinine and urea levels. Creatinine is formed by the muscles, and urea is formed due to protein breakdown. In the case of kidney disease, the levels of both these substances are elevated in the blood.
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Urinalysis: The patient collects urine in a container in this test. It is sent to the labs for examination under a microscope. If the white blood cells and bacteria are present in the urine, it is a sign of urinary tract infection.
What Is the Treatment of Vesicoureteral Reflux?
The treatment of vesicoureteral reflux depends upon the age of the child, symptoms, types, and grades of vesicoureteral reflux. In the case of primary vesicoureteral reflux, no treatment is required because the condition subsides as the child grows and matures. However, treatment is usually necessary in severe cases where a child presents with urinary tract infection, fever, and blockage in the urinary system. The treatment options are listed below:
- Antibiotics: Urinary tract infection is commonly seen in vesicoureteral reflux and needs to be treated on priority. Antibiotics remain the first choice to prevent urinary tract infections from spreading to other organs. After the child has completed the course of antibiotics, urine tests are usually done to check if the infection has subsided or recurred. The doctor usually prescribes the following antibiotics in low doses:
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Amoxicillin and Clavulanic acid.
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Cefixime.
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Cefprozil.
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Cefalexin.
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Trimethoprim.
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- Surgical Options: Surgery aims to repair the defect in the flap valve present between the ureters and urinary bladder to prevent the backflow of urine. The surgical options are listed below:
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Ureteral Reimplant: The ureteral reimplantation surgery is the "gold standard" procedure that aims to change the position of the ureters when they enter the urinary bladder. It is carried out under general anesthesia, and the surgery gets completed in two to three hours. First, the doctor reaches the bladder by making an incision near the stomach. Next, a tunnel is created between the bladder wall and muscles, and the ureters are placed in this tunnel. Next, the surgeon stitches the ureters in this position and closes the incision made in the abdomen with the help of stitches. The patient is required to stay in the hospital for one to two days.
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Cystoscopy: In this procedure, a tube known as a cystoscope is inserted into the urethra to inject a bulking agent (Dextranomer or Hyaluronic acid). The agent created a tissue bulge that did not allow the urine to flow back. The treatment is usually carried out under general anesthesia, and the patient can go home the same day.
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Home Remedies: There are no home remedies available to prevent the condition. The parents need to make sure that the child drinks a sufficient quantity of water to flush out the bacteria from the body. In addition, it is important to maintain healthy bowel and bladder habits to prevent constipation and urinary retention.
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What Are the Complications of Vesicoureteral Reflux?
The complications of vesicoureteral reflux are listed below:
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Kidney Damage: If the urinary tract infection is left untreated, scarring of the kidneys occurs, which can cause permanent damage to the kidneys.
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Hypertension: If the kidneys get damaged, the waste products and toxins accumulate in the body resulting in a rise in blood pressure or hypertension.
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Bladder Problems: The urinary bladder stores the urine temporarily. In the case of a bladder defect, the urine might leak out of the bladder (urinary incontinence). Children often urinate on the bed (bed-wetting) due to urinary incontinence.
Conclusion:
Vesicoureteral reflux occurs when the urine flows back to the ureters and does not flow out of the body. One thing that the patient needs to keep in mind is that it is not a life-threatening condition. If the child presents with symptoms of urinary tract infection, the parents need to consult the doctor immediately. The condition can be managed easily with antibiotics, and no surgical intervention is required. Only when the condition becomes severe does the doctor recommend surgery. Home remedies cannot cure the disease, but the child needs to drink plenty of water to maintain adequate fluid levels. Once the condition subsides, the patient lives a healthy life ahead.
