Click here to view next page of this article

Vesicoureteral Reflux

Vesicoureteral reflux is defined as the retrograde flow of urine from the bladder into the ureter and collecting system. Children who have a urinary tract infection (UTI) have a 45% incidence of vesicoureteral reflux. The incidence increases with decreasing age, and 65% of patients are females. However, in a male who has a UTI, the risk of reflux is vesicoureteral reflux.

Diagnosis

Radiologic evaluation for vesicoureteral reflux should be undertaken when a urinary tract infection occurs in one of the following patients:

Radiologic evaluation of the child with a urinary tract infection consists of a renal ultrasound and a voiding cystourethrogram (VCUG). If the child is not toxic, the VCUG and renal ultrasound should be done three weeks after initiation of antibiotics for UTI.

Grading of Vesicoureteral Reflux

Grade I reflux is defined as retrograde urine flow into a non-dilated ureter.

Grade II reflux refers to the filling of a non-dilated ureter and a non-dilated renal pelvis.

Grade III reflux consists of dilatation of the collecting system, but the fornices remain sharp.

Grade IV reflux consists of blunted fornices.

Grade V reflux is defined as massive dilatation and tortuosity of the collecting system.

Medical Management

Most cases of vesicoureteral reflux are managed nonoperatively with attention to perineal hygiene, normalization of bowel and voiding habits, and prophylactic antibiotics.

Diaper rashes and chemical irritants such as bubble bath should be discouraged because they predispose to UTIs. Children should avoid harsh soaps, shampoos, and tub baths. If constipation is a problem, stool softeners and scheduled defecation programs.

Prophylactic Antibiotics

Trimethoprim/sulfamethoxazole is the most commonly used drug, given in a dose of 2mg/kg of trimethoprim plus 10mg/kg of sulfamethoxazole orally once a day before.

For the newborn, penicillin or ampicillin are preferred for prophylaxis.

Suppression continues until the reflux resolves spontaneously or until surgery is performed.

Patient Monitoring

Urine cultures are obtained for 3 months after any UTI. Thereafter, a urine culture is obtained every other month for 6 months.

Repeat imaging is obtained every 6-12 months. Follow-up can be done.

Surgical Management

Absolute indications for ureteral reimplantation include progressive renal injury or breakthrough infections, despite urinary suppression.

Patients who have grade V vesicoureteral reflux should be managed by ureteral reimplantation.