Vesicoureteric reflux

Vesicoureteric reflux (VUR) is the result of an abnormality in the valve between the tube from the kidney (ureter) and bladder (vesico). A normal vesico-ureteric valve allows urine to travel only in one way from the kidney to the bladder. The valve does not work then reflux occurs, allowing urine to go back out of the bladder and up the ureter and up to the kidney.

VUR can be present from birth or can occur later in childhood. Although it is very common to have VUR it is usually only problematic when the child has had a urine tract infection as there is a risk of renal damage. Occasionally dilated ureters are seen on antenatal scans and further tests are needed after the baby’s birth. At London Children’s Surgery we recognise that most children with VUR do not require surgery and with careful monitoring children can be kept infection free. We provide a comprehensive management plan for vesicoureteric reflux from initial diagnosis, treatment and follow up.

Symptoms

Vesicoureteric reflux is at times diagnosed on antennal scan. If on this scan there is evidence of the ureter being dilated or the ureter changing size and shape this can lead to a diagnosis of VUR. In the postnatal period, it’s important for the child to have further investigations to prove this diagnosis.

Most children are diagnosed after a urinary tract infection. UTI in children can be quite variable. Some children present a high temperature and vomiting with a reduced appetite and foul smelling urine. In an older child it can be associated with abdominal pain when voiding, frequent visits to the toilet and rushing to the toilet.

present. If the x-ray is able to determine if there is reflux present, then there is a grade to be given.

Causes

VUR occurs in 1 in 100 to 1 in 150 boys. It is much more common in girls than in boys and can run in the family. If an older sibling has VUR, it’s important that their siblings are screened.

The exact cause of VUR is still debated. Simplistically the ureter is the tube which drains the urine from the kidney and empties into the bladder. As the ureter enters the muscle of the bladder there is a small valve like structure. If the tunnel to the bladder wall is not long enough, the valve which stops urine going from the bladder back up into the ureter does not work properly. If this valve is incompetent or fails to work, the urine will easily reflux from the bladder back up into the ureter. Reflux of urine can occur when the child is voiding or when the bladder is filling.

Treatment

In the vast majority of children, the management is really focused on improving bladder function, emptying their bladder well and stop the infections. Therefore the use of antibiotics is used in first line treatment in order to prevent urinary tract infections and maintain kidney function. If the child continues to get ongoing urinary tract infections despite being treated unsuccessfully, there can be then need for surgery. However, most children do not require surgical intervention.

Surgery

The vast majority of children can be treated with a keyhole operation. This consists of a procedure where a small camera is inserted into the bladder through the urethra. This enables us to see where the urethral opening is. A small amount of material is injected into the valve to improve the valve mechanism. This is a very successful day case procedure and has very low complications.

In the past, a very common operation called ureteric re-implantation was performed. This is a basic procedure where the bladder is opened, the ureters are disconnected from the bladder and then re-implanted and reattached in a new fashion to make a longer tunnel which recreates a newly functioning valve. The child will require staying in hospital for a few days following the surgery. In general, this operation is required less frequently and the vast majority can be treated with endoscopic method.

FAQ’s

VUR occurs in 1 in 100 to 1 in 150 boys. It is much more common in girls than in boys and can run in the family. If an older sibling has VUR, it’s important that their siblings are screened.
The exact cause of VUR is still debated. Simplistically the ureter is the tube which drains the urine from the kidney and empties into the bladder. As the ureter enters the muscle of the bladder there is a small valve like structure. If the tunnel to the bladder wall is not long enough, the valve which stops urine going from the bladder back up into the ureter does not work properly. If this valve is incompetent or fails to work, the urine will easily reflux from the bladder back up into the ureter. Reflux of urine can occur when the child is voiding or when the bladder is filling.
Vesicoureteric reflux is at times diagnosed on antennal scan. If on this scan there is evidence of the ureter being dilated or the ureter changing size and shape this can lead to a diagnosis of VUR. In the postnatal period, it’s important for the child to have further investigations to prove this diagnosis.
Most children are diagnosed after a urinary tract infection. UTI in children can be quite variable. Some children present a high temperature and vomiting with a reduced appetite and fowl smelling urine. In an older child it can be associated with abdominal pain when voiding, frequent visits to the toilet and rushing to the toilet.
Ultrasound scan is useful for detecting any abnormality or dilation within the ureter or dilation within the bladder or kidney. However, in a younger child, the gold standard test for investigating VUR is called micturating cystourethrogram (MCUG). In this situation the child who is under the age of 1 year old, a catheter is inserted into bladder. The bladder is then filled a contrast material and x-ray, which is able to show whether there is any reflux present. If the x-ray is able to determine if there is reflux present, then there is a grade to be given.
In the vast majority of children, the management is really focused on improving bladder function, emptying their bladder well and stop the infections. Therefore the use of antibiotics is used in first line treatment in order to prevent urinary tract infections and maintain kidney function. If the child continues to get ongoing urinary tract infections despite being treated unsuccessfully, there can be then need for surgery. However, most children do not require surgical intervention.
The vast majority of children can be treated with a keyhole operation. This consists of a procedure where a small camera is inserted into the bladder through the urethra. This enables us to see where the urethral opening is. A small amount of material is injected into the valve to improve the valve mechanism. This is a very successful day case procedure and has very low complications.
In the past, a very common operation called ureteric re-implantation was performed. This is a basic procedure where the bladder is opened, the ureters are disconnected from the bladder and then re-implanted and reattached in a new fashion to make a longer tunnel which recreates a functioning valve. The child will require staying in hospital for a few days following the surgery. In general, this operation is required less frequently than it was historically in the past and the vast majority can be treated with endoscopic method.

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Mr. Feilim Murphy

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