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Vesicoureteral Reflux (VUR) correction in children

What is vesicoureteral reflux or urinary reflux in children?

Vesicoureteral reflux (VUR) is a medical disorder of the urinary system. The urinary system is composed of the kidneys, ureters, bladder, and urethra that together excrete waste products from the body via urine. Thin tubes called the ureters  carry urine from the kidneys down to the bladder.

In the normal state, urine flow is unidirectional and the urine stored in bladder is expelled out through the urethra. However, in VUR the direction of this flow gets reversed and some urine in the bladder flows back into the ureters and kidneys.

 Vesicoureteral reflux is diagnosed more often in infants and children up to 5 years of age. Girls have a much higher risk of having this condition than boys.

The risk of developing recurrent kidney infections increases in children with VUR. Over some time, recurrent infections can lead to damage and scarring of the kidneys. Children with VUR are managed by urologists.

What are the causes of vesicoureteral reflux?

Vesicoureteral reflux can take two forms namely, primary and secondary:

  • Primary vesicoureteral reflux: A defect in the muscular backing of the ureter where it enters into the bladder may be present since birth in the primary vesicoureteral reflux. It is the more common type.

With the lengthening and straightening of the ureters, as the child grows, the function of the valve may improve. Consequently, the reflux gets corrected.

The exact cause of the defect remains unknown. However, it is suspected to be genetic, as it tends to run in families.

  • Secondary vesicoureteral reflux: Any obstruction at or distal to the bladder outlet can lead to high pressures in the bladder which weaken the vesicoureteric valve mechanism and predispose to reflux of urine into the ureter. Posterior urethral valves, urethral stricture, dysfunctional voiding and neurogenic bladder are some of the causes of secondary reflux. 

What are the symptoms of vesicoureteral reflux?

Though each child may have some variability in the symptoms, some of the common signs and symptoms of vesicoureteral reflux may include:

  • Urinary tract infection: Children, especially boys below 5 years of age are unlikely to get urinary tract infections (UTI). If a child shows symptoms of UTI, he/she is highly likely to have VUR as the underlying cause of UTI. The signs and symptoms of UTI can include:
    • Frequent, urgency to pass urine
    • Burning sensation while passing urine
    • Cloudy urine
    • Fever
    • Pain in the flank or abdomen

In the case of infants with vesicoureteral reflux UTI may have the following symptoms:

  • Unexplained fever
    • Lack of appetite
    • Irritability
  • Children with high grade VUR into both the kidneys may have chronic kidney disease presenting as weakness,lack of appetite, stunted growth, poor weight gain.
  • Long-standing damage to the kidneys and the resultant buildup of wastes can lead to high blood pressure.

As the symptoms of VUR can resemble other conditions or medical problems, it is always recommended that a paediatrician or urologist  be consulted for an accurate diagnosis and further management of the condition.

What is the grading of vesicoureteral reflux?

The vesicoureteric reflux can occur in varying severity and is graded accordingly. In milder grades (1and 2) urine refluxes into ureter or into the kidney without any swelling of the kidney. In severe grades (3,4 and 5) there can be gross dilatation of ureter and kidney due to severe reflux. Hence the higher the grade the severe is the reflux.

How do doctors diagnose vesicoureteral reflux?

VUR may sometimes be initially suspected before a child is born. If the ultrasound during a check-up of the pregnant women shows hydronephrosis (dilatation of the kidney) it may indicate that reflux may be present.

The paediatrician or urologists usually diagnose VUR based on a detailed medical history, physical examination, and investigations. The diagnostic tests for VUR include:

Voiding cystourethrogram (VCUG): It is an X-ray test to evaluate the urinary tract. A small  catheter is passed through the urinary opening into the baldder. Once the catheter is in place, the bladder is filled with a liquid dye. As the bladder fills and empties, a series of X-ray images are taken. Any reverse flow of urine into the ureters and kidneys can be observed in the X-rays as the dye appears white in these images.

Renal ultrasound: The size and shape of the kidney can be assessed with a renal ultrasound. Dilatation of the kidney called as hydronephrosis is well visualised on ultrasound. Small kidneys with irregular contour on ultrasound indicate renal damage. The presence of any abnormality like a mass, cyst or a stone, or presence of any obstruction can be also be identified using a renal ultrasound.

Blood and urine tests: Kidney function tests- serum creatinine and urine tests like- complete urine examination and urine culture test are done.

A urine culture may be needed to confirm a UTI.

What is the treatment of vesicoureteral reflux?

Treatment for VUR depends on many factors like:

  • Age of the child, health status, and medical history
  • Grade and laterality of VUR

VUR Grade 1-3: In most cases of grade 1-3 VUR, antibiotic prophylaxis is given to prevent urinary tract infection. Surgery is usually not needed in low grade reflux.  Generally, over some time, the reflux may resolve on its own. This usually happens within five years.

 Preventive antibiotics are generally prescribed at a lower dose than that for treating an infection. Such children should undergo periodic physical exams and urine tests

VUR Grade 4-5: Children with grade 4 and 5 VUR may require antireflux surgery.

The common methods of surgical repair include:

  • Open surgery: It is performed using general anesthesia, a lower abdominal incision known as bikini incision, is made to repair the condition. The most common type of surgery is ureteral reimplantation. Open surgery has a high success rate of 95 – 97 percent.

The VUR may persist in a few children even after the surgery. However, it generally resolves on its own without much intervention.

A few days of stay may be required in the hospital after the surgery. A catheter is kept in place to drain the child’s bladder during recovery in the hospital.

  • Robotic-assisted laparoscopic surgery: With the same objective as open surgery this technically advanced surgery is performed using very small incisions.

The main advantage of this procedure is the smaller incisions, less pain, early recovery and shorter hospitalisation.

Endoscopic surgery: This is a minimally invasive procedure performed as outpatient surgery. A bulking agent is injected around the opening of the affected ureter to prevent the reflux.

What lifestyle and home remedies can parents of children with VUR follow?

The parents need to be educated about the condition. Abnormal voiding habits and constipation contribute to the persistence of the reflux in many children. Parents should encourage the child to void at regular intervals. Constipation is treated by high fibre diet and laxatives.

How should one choose a facility for the treatment of vesicoureteral reflux?

All cases of VUR aren’t the same. Consequently, the treatment of vesicoureteral reflux should follow an individualized approach to medical care.  Care is sought from a urologist experienced in treating the disorder.

 VUR due to conditions like bowel and bladder dysfunction with recurrent UTI can cause a significant impact on the body’s physiology, a center with multidisciplinary services and state-of-the-art services like pelvic floor rehabilitation and biofeedback program for holistic care is ideal for the treatment of VUR.

Conclusion:

Even though many children overcome the VUR by age 5, it is imperative that VUR if present should be diagnosed early and closely monitored with the urologist. Getting treatment if the need is, will help prevent any lasting damage to the child’s kidneys and bladder.

Dr Surya Prakash V and his team is highly experienced in treating VUR. The team works closely in collaboration with paediatrician, nephrologist to give the best results with the least invasive method.

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