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Vesicoureteral reflux

Definition


Disease: Vesicoureteral reflux Vesicoureteral reflux
Category: Genito-urinary diseases

Disease Definition:

In normal cases, urine flows only down from the kidneys to the bladder. The abnormal flow of urine from the bladder back up the tubes to the kidneys is called vesicoureteral reflux. Vesicoureteral reflux increases the risk of urinary tract infections, leading to kidney damage when left untreated. This condition usually occurs in infancy and childhood. Vesicoureteral reflux could be either primary or secondary. 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, while an infection that blocks a urinary tract is the cause of secondary vesicoureteral reflux. Treatment that includes medication or surgery, aims at preventing kidney damage. Children might outgrow primary vesicoureteral reflux.
 

Work Group:


Symptoms, Causes

Symptoms:

The most common indication of vesicoureteral reflux is a urinary tract infection (UTI). Although most people have some, still not everyone with a UTI develops recognizable signs and symptoms. These signs and symptoms could include the following:

  • A burning sensation when urinating
  • A strong, persistent urge to urinate
  • Fever
  • Abdominal or flank pain
  • Blood in the urine (hematuria) or cloudy, strong-smelling urine
  • Passing frequent, small amounts of urine

 

In children who have nonspecific signs and symptoms, diagnosing a UTI may be difficult. Infants with a UTI may experience some of these signs and symptoms:

  • Lack of appetite
  • Lethargy
  • Lack of normal growth (failure to thrive)
  • Vomiting and diarrhea

 

As the child grows older, untreated vesicoureteral reflux could lead to other signs and symptoms, such as:

  • Kidney failure
  • Protein in urine
  • Bed-wetting
  • High blood pressure

 

Swelling of the urine-collecting structures of one or both kidneys (hydronephrosis) as a result of the backup of urine into the kidneys could be detected by sonogram of the fetus in the womb. This condition is another indication of vesicoureteral reflux. In case a child develops any of the signs or symptoms of a UTI, parents must consult a doctor, such as:

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

 

Parents should call a doctor about fever in case the child:

  • Is 3 months or older and has a fever of 38.9 C (102 F)
  • Is less than 3 months old and has a fever of 38 C (100.4 F)
  • Parents must also call the doctor immediately in case the infant has the following signs or symptoms:

 

Changes in mood: 

When the baby is unusually difficult to rouse or is lethargic, parents should contact the doctor immediately. Parents should also let the doctor know if the baby has inconsolable crying jags or is persistently irritable.

 

Vomiting:

Sometimes spitting up is normal. The doctor should be contacted in case the baby vomits forcefully after feedings or spits up large portions of multiple feedings.

 

Changes in appetite:

The doctor should be contacted in case the baby refuses several feedings in a row or eats poorly.

 

Diarrhea:

In case the baby’s stools are especially loose or watery, a doctor should be contacted.
 

Causes:

The urethra, bladder, ureters and kidneys make up the urinary system. To remove waste products from the body, each of these play an essential role. While the tubes named ureters carry urine from the kidneys down to the bladder where it is stored until it exits the body through the urethra throughout urination, the kidneys that are a pair of bean-shaped organs at the back of the upper abdomen filter waste, water and electrolytes, which are minerals like sodium, potassium and calcium that help keep the balance of fluids in the body from the blood. Primary and secondary are the two forms of vesicoureteral reflux:

 

Primary vesicoureteral reflux:

A congenital defect is the cause of this more common form. In the valve between the bladder and a ureter that normally closes to stop urine from flowing backward is where this defect occurs. The ureters lengthen and straighten as the child grows, improving valve function and eventually resolving the reflux. This form of the condition may be genetic because it tends to run in families, but still, no clear cause of the defect is determined.

 

Secondary vesicoureteral reflux:

A blockage in the urinary system is the cause of this form. Swelling of a ureter may result from the blockage caused by a UTI.

 

Risk factors for vesicoureteral reflux include the followings:

 

Age:

Older children are less likely to have vesicoureteral reflux than infants and children up to the age of 2.

 

Race:

White children are three times as likely to have vesicoureteral reflux as black children are.

 

Sex:

Girls are at least twice as likely as boys are to have the condition.

 

Family history:

Children whose parents had this condition are at an increased risk of developing it, for primary vesicoureteral reflux tends to run in families. The siblings of a child with primary vesicoureteral reflux may be recommended screening because they also have a high risk of developing the condition.
 

Complications

Complications:

The main concern with vesicoureteral reflux is kidney damage. The more severe the reflux, the more serious the complications are likely to be. Complications might include the following:

 

Kidney (renal) scarring:

Also known as reflux nephropathy, untreated UTIs could lead to scarring permanently damaging the tissue of the kidney. A backup of urine exposes the kidneys to higher than normal pressure that leads to scarring over time. Kidney failure and high blood pressure may be caused by extensive scarring.

 

Hypertension:

Damage to the kidneys and the resulting buildup of wastes could raise the blood pressure, because the kidneys remove waste from the bloodstream.

 

Acute kidney failure:

Waste products may accumulate rapidly in the body due to loss of function in the filtering part of the kidney. The extra fluids and waste should be removed by artificial means, usually with the use of a dialyzer, which is an artificial kidney machine; this method is called dialysis.

 

Chronic kidney failure:

The kidneys gradually lose function in this extremely serious complication. End-stage kidney disease that often needs dialysis or a kidney transplant to sustain life occurs when kidney function is less than 15 % of normal capacity.
 

Treatments:

The severity of the condition will determine the type of treatment. Children with mild cases of primary vesicoureteral reflux might finally outgrow the disorder. The child in this case will be recommended a wait-and-see approach. Noticing potential UTIs and seeking prompt treatment is very important during this time. Medication and surgery are the two treatment options for children suffering from moderate to severe primary vesicoureteral reflux. Medication usage is more common, while children who don’t benefit from antibiotics undergo surgery. For families preferring a faster, more definitive treatment than medication, and for grades IV and V, surgery may be the first line treatment option. 

 

MEDICATIONS:

To keep the infection from moving to the kidneys, prompt treatment with antibiotics is required for UTIs. UTIs could also be prevented with antibiotics, but only half the dose needed for treating an infection is needed in this case. Trimethoprim, trimethoprim-sulfamethoxazole and nitrofurantoin are commonly used antibiotics for prevention. Possible side effects of long-term use of these medications include the following:

  • Abdominal pain
  • Nausea and vomiting
  • Increased antibiotic resistance, in which the condition no longer responds to antibiotics and treating it becomes more difficult.

 

For as long as the child is taking antibiotics he/she should be monitored; this includes periodic physical exams and urine tests that detect breakthrough infections, UTIs that occur despite the antibiotic treatment, and sometimes radiographic studies of the bladder and kidneys determining if and when the child outgrows vesicoureteral reflux.

 

SURGERY:

The defect that has occurred in the valve between the bladder is repaired in surgery for vesicoureteral reflux, as well as each affected ureter that keeps it from closing and preventing urine from flowing backward. The two techniques of surgical repair are:

 

Open surgery:

An incision is made in the lower abdomen in this surgery, through which the malformation that is causing the problem is repaired. General anesthesia is used during this surgery, and the patient should stay in the hospital for a few days, during which time a catheter will be kept in place to drain the child’s bladder. Bleeding, infection and blood clots are some of the risks of open surgery.

 

Endoscopic surgery:

To see inside the child’s bladder, a lighted tube (cystoscope) is inserted through the urethra to, then, to try to strengthen the valve’s ability to close properly, a bulking agent is injected around the opening of the affected ureter. Compared with open surgery, this technique is minimally invasive and presents fewer risks. This procedure can usually be performed on an outpatient basis, despite the fact that it also requires general anesthesia.
 

Prognosis:

Not available

Expert's opinion

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