Vesicoureteral reflux
Vesicoureteral reflux: Excerpt from Professional Guide to Diseases (Eighth Edition)
In vesicoureteral reflux, urine flows from the bladder back into the ureters and eventually into the renal pelvis or the parenchyma. Because the bladder empties poorly, urinary tract infection (UTI) may result, possibly leading to acute or chronic pyelonephritis with renal damage.
Vesicoureteral reflux is most common during infancy in males and during early childhood (ages 3 to 7) in females. Primary vesicoureteral reflux that results from congenital anomalies is most prevalent in females and is rare in blacks. Up to 25% of asymptomatic siblings of children with diagnosed primary vesicoureteral reflux also show reflux.
Causes and incidence
In patients with vesicoureteral reflux, incompetence of the ureterovesical junction and shortening of intravesical ureteral musculature allow backflow of urine into the ureter when the bladder contracts during voiding. Incompetence may result from congenital anomalies of the ureters or bladder, including short or absent intravesical ureter, ureteral ectopia lateralis (greater-than-normal lateral placement of ureters), and gaping ureteral orifice; inadequate detrusor muscle buttress in the bladder, stemming from congenital paraureteral bladder diverticulum; acquired diverticulum (from outlet obstruction); flaccid neurogenic bladder; and high intravesical pressure from outlet obstruction or an unknown cause. Vesicoureteral reflux may also result from cystitis, with inflammation of the intravesical ureter, which causes edema and fixation of the intramural ureter and usually leads to reflux in persons with congenital ureteral or bladder anomalies or other predisposing conditions.
Reflux nephropathy occurs in about 4 out of 1,000 asymptomatic people. However, in infants and children who experience UTIs, its prevalence approaches 40% to 50%. Reflux nephropathy may lead to chronic renal failure and end-stage renal disease.
Signs and symptoms
Vesicoureteral reflux typically manifests itself as the signs and symptoms of UTI: frequency, urgency, burning on urination, hematuria, foul-smelling urine and, in infants, dark, concentrated urine. With upper urinary tract involvement, signs and symptoms usually include high fever, chills, flank pain, vomiting, and malaise.
PEDIATRIC TIP In children, fever, nonspecific abdominal pain, and diarrhea may be the only clinical effects. Rarely, children with minimal symptoms remain undiagnosed until puberty or later, when they begin to exhibit clear signs of renal impairment (anemia, hypertension, and lethargy).
Diagnosis
Symptoms of UTI provide the first clues to diagnosis of vesicoureteral reflux. In infants, hematuria or strong-smelling urine may be the first indication; palpation may reveal a hard, thickened bladder (hard mass deep in the pelvis) if posterior urethral valves are causing an obstruction in male infants.
Cystoscopy, with instillation of a solution containing methylene blue or indigo carmine dye, may confirm the diagnosis. After the bladder is emptied and refilled with clear sterile water, color-tinged efflux from either ureter positively confirms reflux.
Other pertinent laboratory studies include the following:
❑ Clean-catch urinalysis shows a bacterial count greater than 100,000/µl. Microscopic examination may reveal white blood cells, red blood cells, and an increased urine pH in the presence of infection. Specific gravity less than 1.010 demonstrates inability to concentrate urine.
❑ Laboratory studies reveal elevated creatinine levels (more than 1.2 mg/dl) and elevated blood urea nitrogen levels (more than 18 mg/dl), indicating advanced renal dysfunction.
❑ Excretory urography may show dilated lower ureter, ureter visible for its entire length, hydronephrosis, calyceal distortion, and renal scarring.
❑ Voiding cystourethrography (either fluoroscopic or radionuclide) identifies and determines the degree of reflux and shows when reflux occurs. It may also pinpoint the causative anomaly. In this procedure, contrast material is instilled into the bladder, and X-rays are taken before, during, and after voiding. Nuclear cystography and renal ultrasound may also be used to detect reflux.
❑ Abdominal computed tomography scan or ultrasound of the kidneys or abdomen shows hydronephrosis, reflux, a small kidney, or scarring.
❑ Catheterization of the bladder after the patient voids determines the amount of residual urine.
Treatment
The goal of treatment in a patient with vesicoureteral reflux is to prevent pyelonephritis and renal dysfunction with antibiotic therapy and, when necessary, vesicoureteral reimplantation. Appropriate surgical procedures create a normal valve effect at the junction by reimplanting the ureter into the bladder wall at a more oblique angle.
Antimicrobial therapy is usually effective for reflux that’s secondary to infection, reflux related to neurogenic bladder and, in children, reflux related to a short intravesical ureter (which abates spontaneously with growth). Reflux related to infection generally subsides after the infection is cured. However, 80% of females with vesicoureteral reflux will have recurrent UTIs within a year. Recurrent infection requires long-term prophylactic antibiotic therapy and careful patient follow-up (cystoscopy and excretory urography every 4 to 6 months) to track the degree of reflux.
UTI that recurs despite adequate prophylactic antibiotic therapy necessitates vesicoureteral reimplantation or reconstructive repair. Bladder outlet obstruction in neurogenic bladder requires surgery only if renal dysfunction is present. After surgery, as after antibiotic therapy, close medical follow-up is necessary (excretory urography every 2 to 3 years and urinalysis once per month for 1 year), even if symptoms haven’t recurred.
Special considerations
Patient care includes education and postoperative support.
❑ To ensure complete emptying of the bladder, teach the patient with vesicoureteral reflux to double void (void once and then try to void again in a few minutes). Because his natural urge to urinate may be impaired, advise him to void every 2 to 3 hours whether or not he feels the urge.
PEDIATRIC TIP Because the diagnostic tests may frighten the child, encourage one of his parents to stay with him during all procedures. Explain the procedures to the parents and to the child, if he’s old enough to understand.
❑ If surgery is necessary, explain postoperative care: suprapubic catheter in the male, indwelling catheter in the female; and, in both, one or two ureteral catheters or splints brought out of the bladder through a small abdominal incision. The suprapubic or indwelling catheter keeps the bladder empty and prevents pressure from stressing the surgical wound; ureteral catheters drain urine directly from the renal pelvis. After complicated reimplantations, all catheters remain in place for 7 to 10 days. Explain that the child will be able to move and walk with the catheters but must be very careful not to dislodge them.
❑ Postoperatively, closely monitor fluid intake and output. Give analgesics and antibiotics, as ordered. Make sure the catheters are patent and draining well. Maintain sterile technique during catheter care. Watch for fever, chills, and flank pain, which suggest a blocked catheter.
❑ Before discharging the patient, stress the importance of close follow-up care and adequate fluid intake throughout childhood.
❑ Instruct parents to watch for and report recurring signs of UTI (painful, frequent, burning urination; foul-smelling urine).
❑ If the child is taking antimicrobial drugs, make sure his parents understand the importance of completing the prescribed therapy or maintaining low-dose prophylaxis.
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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