What is Reflux in Children?

Reflux is a general medical term that means backflow or leakage. For example, the pathological leakage of food back into the esophagus after passing into our stomach.

What is Vesicoureteral Reflux (VUR)?

Under normal conditions, the blood coming to the kidney passes through a very advanced filter system here and the harmful wastes in it are separated. While clean blood and useful minerals return to the circulatory system, the wastes and harmful substances filtered as urine are transmitted from the kidney to the bladder (urinary bladder) through tubes (pelvis, ureters). Urine is stored in the bladder and excreted through a tube called the Urethra (urinary tract).

Urine produced in the kidneys comes to the bladder (urinary bladder) through the ureters (urine canal) and after being stored here for a certain period of time, it is excreted through the urethra at the appropriate time and location. Under normal conditions, this flow is always outward and there is no backflow unless there is a pathological condition. The backward flow of urine from the bladder to the ureters, the urine leaking into the kidney, is called vesicoureteral reflux (VUR). VUR is the most common urological pathology in children and the most common cause of urinary tract infection.

What are the Causes of Vesicoureteral Reflux?

VUR can be examined in two groups as primary and secondary.

Primary VUR; Anatomically, the ureters create a tunnel of a certain length in the bladder as they enter the bladder, partial or complete insufficiency in the length of this tunnel causes VUR, and this is called Primary VUR. This insufficiency is congenital.

Secondary VUR; VUR that occurs due to neurogenic (nerve) or obstruction (blockage) that causes increased intravesical pressure.

What is the Frequency of Vesicoureteral Reflux, Is It Familial?

Although the frequency of primary VUR in children is not known for sure, it is accepted as 1-2%. We cannot say that it is definitely familial, in other words, if it is present in the mother and father, it is not certain that it will also occur in children. However, if it is detected in the mother and father or in one of the siblings, the frequency of occurrence in children and other siblings is more frequent than in normal children.

In Which Situations Should VUR Be Considered in Children?

In children, VUR is first and foremost started with the history and a complete physical examination, during which VUR is considered. Therefore, the patient and family history should be evaluated well. Then, a complete physical examination should be performed.

Two things are very important in the history. The first is the findings of the prenatal (in the womb) ultrasound. In the ultrasound, hydronephrosis and/or hydroureteronephrosis, which we call enlargement in the urinary tract, are detected. It is very important in which month of pregnancy this enlargement is detected, in which anatomical regions, whether the enlargement is unilateral or bilateral, and whether there is a change in the fleshy part of the kidneys, which we call the parenchyma, which produces urine. Secondly, it is important whether the child has had a urinary tract infection after birth. However, the diagnosis of urinary tract infection should be made correctly. This issue is explained in our article titled Diagnosis of Urinary Tract Infection in Children.

In addition, especially in terms of distinguishing secondary VUR, the detection of pathological findings in the examination; neurological and especially walking disorders and deformities in the lower extremities are important. In the family (parents, siblings), VUR diagnosis, urination disorders and fecal incontinence disorders should be well evaluated

Among these, the clinical signs that most often lead the physician to the diagnosis of VUR (renal reflux) are urinary tract infection and dilatation of the urinary tract in prenatal ultrasonography.

How is Vesicoureteral Reflux Diagnosed in Children?

First of all, the disease must be considered. The basic tests that need to be done for diagnosis and follow-up are as follows; complete urine analysis, urine culture, blood test, urinary system ultrasonography, voiding cystourethrography - (VCUG) called voiding cystogram and scintigraphy.

Definitive diagnosis is made with VCUG. In this method, radiological direct cystography (Voiding cystourethrography - VCUG) is applied by administering standard contrast material to the bladder with urethral catheterization. Thus, it is displayed whether the contrast has leaked from the bladder to the ureters and kidneys.

Direct cystogram and VCUG tests for the diagnosis of VUR are performed by nuclear medicine and radiology specialists, respectively. The radiological method reveals the anatomy better and provides a better rating. These cannot be provided completely in nuclear medicine, but the child receives less radiation. As a result, while the initial diagnosis is made in radiology, nuclear medicine imaging is preferred for follow-up. Both imaging should not be repeated unless necessary due to radiation exposure.

What Should Be Considered When Performing VCUG?

First of all, the patient and family should be well informed considering that the procedure is a traumatic situation. Children should be lightly sedated during urination if necessary.

It should be ensured that the fluid that the bladder is filled with during urination is at body temperature. The fluid should be given without pressure, and the stage at which VUR occurs during filling or whether it is seen during urination and its degree should definitely be recorded. If there is an additional pathology, it should also be recorded.

Especially in boys and especially in young babies, images should definitely be taken during urination. Because VUR can sometimes occur during urination when bladder pressure increases. Sometimes, it diagnoses the disease we call posterior urethral valve.

Which Patients Should Have VCUG?

This issue is still controversial. However, the patient's clinic, especially the correctly diagnosed urinary tract infection, the patient's age and gender, the degree and anatomical location of the urinary tract dilatation detected on ultrasonography, whether it is bilateral or unilateral, and the status of the renal parenchyma play an important role.

The general approach is to recommend VCUG or radionuclide cystography in all infants who have a first febrile urinary infection between the ages of 2 months and 2 years. Currently, in many centers, girls under the age of 5 and boys of all ages are investigated for VUR after the first urinary infection proven by culture growth.

 

 

Are There Degrees of Vesicoureteral Reflux in Children?

VUR is divided into 5 degrees radiologically and 3 degrees scintigraphically. The most common radiological classification is as follows:

 

• Grade 0; Normal Kidney, Ureter, Bladder
• Grade I; Partial leakage to the ureter
• Grade II: Leakage to the entire ureter and calyces, no dilation
• Grade III; Leakage and dilation to the entire ureter and calyces
• Grade IV Leakage to the entire ureter and marked ureter and calyceal dilatation and blunting
• Grade V VUR Marked reflux tortuosity of the ureter and calyceal blunting

What Kind of Problems Are Encountered When Vesicoureteral Reflux Is Not Treated?

When Vesicoureteral Reflux is not treated, it causes urinary tract infection. VUR is detected in approximately 1/3 of children examined for urinary tract infection. Urinary tract infection causes damage called scarring in the parenchymal part of the kidney that produces urine. The scarred part of the kidney cannot fulfill its function of producing urine. Renal scarring is also detected in 1/3 of patients with VUR during examination. This shows that the disease is diagnosed late. If VUR is not treated and the scarring continues to progress, it ends with hypertension and renal failure. If both kidneys are in this condition, dialysis or even a kidney transplant may be required.

How is Kidney Damage Assessed in Vesicoureteral Reflux?

First of all, a good physical examination, hypertension may be present in patients with advanced kidney damage, and protein may be detected in the urine test. Urinary system ultrasonography shows advanced dilatation and parenchymal thinning. However, the definitive indicator of kidney damage is the demonstration of scarring on static renal scintigraphy (DMSA).

It is generally thought that sterile reflux does not cause scarring. Therefore, necessary precautions should be taken to prevent patients with VUR from developing urinary tract infections, and the patient and family should be informed accordingly.

Although the view that there will be no scarring without infection prevails, dysplasia detection, especially in male infants and infants with prenatal hydronephrosis, is also considered consistent with scarring. Therefore, the approach should be taken considering that especially advanced VUR can cause scarring without infection.

 

Scar images in DMSA renal scintigraphy

What are the Treatment Options for Vesicoureteral Reflux?

It is known that the frequency of VUR decreases with age and that reflux can disappear spontaneously or under antibiotic treatment and prophylaxis.

It has been shown that mild and moderate reflux (grades I-III) disappears in 80% of patients within 5 years after the initial diagnosis. It has been reported that severe VUR (grades III and IV) completely disappears in half of the cases after 10 years, decreases in degree in 25%, but continues with the severity at the time of diagnosis in 25%. It is generally accepted that vesicoureteral reflux improves with drug treatment at lower rates in patients with severe, bilateral VUR, patients with renal parenchymal lesions at the beginning, and in girls.

In light of this basic information, when planning VUR treatment, the patient's clinic, especially the correctly diagnosed urinary tract infection, the patient's age and gender, the degree of urinary tract dilatation detected on ultrasonography (VUR degree) and anatomical localization, whether it is bilateral or unilateral, the condition of the renal parenchyma, and the compliance of the family and the patient with the treatment to be given play an important role.

There are basically two approaches in treatment. 1- Monitoring. 2- Surgical treatment

How is Vesicoureteral Reflux Monitoring Treatment Performed, What Should Be Considered?

Especially in newborns, VUR improves or decreases with the growth of the baby. Therefore, especially patients in this age group should be monitored.

The basic principle in monitoring treatment is that the patient does not have a urinary tract infection, and if he does, it is timely and effective treatment. For this reason, the patient is given prophylactic antibiotics to prevent infection. In cases of infection findings such as urine odor, fever, pain, crying while urinating, not feeding, the patient should definitely consult a pediatrician, and if urine analysis is necessary, urine culture should be performed. If a urinary tract infection is detected, the specialist (Pediatric Surgery or Pediatric Nephrology) should be consulted.

For prophylaxis (preventing infection), antibiotics are administered in half doses and once at night before going to bed. The patient is allowed to take a bath while standing. Necessary precautions are taken to prevent constipation of the child. Because a full bowel puts pressure on the bladder and causes VUR.

Although it has not been proven definitively by randomized, controlled studies involving large patient series, it is thought that low-dose, long-term antibiotic use in children prevents urinary infection. There is only one randomized study comparing the effect of antibiotic prophylaxis with no treatment in children with VUR. In this study involving a small patient series, no difference was found between the two groups in terms of urinary infection risk and renal parenchymal damage. However, the general opinion accepted all over the world today is that antibiotic prophylaxis should be administered to children with VUR. The antibiotics commonly used for this purpose are trimethoprim and sulfamethoxazole (2 mg/kg/day/single dose) and nitrofurantoin (1-2 mg/kg/day/single dose). Amoxicillin and cefaclor can also be recommended in infants. It has been reported that cefixime, which has been used in the treatment of urinary infections in recent years, can also be used for prophylaxis.

There is no definite scheme regarding the duration of antibiotic treatment. However, preventive antibiotics are definitely recommended within the first year of life, regardless of the degree of VUR. In the following years, prophylaxis may be considered to be continued or discontinued, considering the patient's age, degree of VUR, frequency of urinary infections, and compliance with treatment by the patient and the family. In the article of the international working group examining 10-year results in severe VUR, it was stated that prophylaxis was discontinued after the age of 8.

In asymptomatic patients, when they have urinary tract infections 4 times a year, and also when urinary symptoms occur and in the presence of unexplained fever, a urine sample should be taken for culture immediately. In order to reveal renal scars, dimercaptosuccinic acid (DMSA) scintigraphy should be performed following urinary infections at the time of initial diagnosis and later during follow-up. Unless there is a clinical complication, it is appropriate to repeat the VCUG examination at 2-3 year intervals.

Which Patients Should Have Vesicoureteral Reflux Surgery?

As a general approach;

• Girls who still have VUR after the age of 5,
• Children who have recurrent urinary tract infections under preventive antibiotic treatment,
• Children who have scars in the kidney or whose scars increase during follow-up,
• Children with a single kidney,
• Children who have recurrent urinary tract infections after kidney transplantation,
• Patients and families who are not compliant with follow-up and preventive antibiotic treatment.

How is Vesicoureteral Reflux Surgery Performed?

1. Cystoscopic Injection
2. Open Surgery; can be performed directly with open or laparoscopic methods.

1. Cystoscopic Injection Treatment

The surgery is performed under general anesthesia and the procedure takes approximately 1 hour. Children can go home on the same day and there is no need for a catheter. Patients can travel by plane or car on the same day. No microbes should grow in the urine culture before the surgery. The success rate of this method is 45-80% depending on the degree of VUR and the experience of the person performing it. Its advantage is that it is repeatable, there is no incision in the patient, the surgery is shorter, and the patient comfort is better after the procedure. The success rate increases even more in the 2nd and 3rd repetitions of the procedure.

The procedure can be repeated especially in patients whose degree of VUR decreases in the first injection and who do not have an infection.

After the surgery, follow-up treatment is applied, if there is no infection, a urinary system ultrasound is taken after 6 weeks. After 6 months, the catheter film is taken again and reflux is checked. If reflux has stopped, antibiotic protection is stopped. If the patient has a urinary tract infection during this period, the follow-up and treatment protocol can be changed.

Cystoscopic injection

Disadvantages of Injection Treatment and Is There a Risk of Reflux Recurrence?

Sometimes a severe reaction to the injected substance and complete closure of the ureter with reflux may develop. Sometimes the injected substance can be seen as a stone on films. There may be a risk of reflux recurrence.

2. Open Surgery Treatment in Vesicoureteral Reflux

In open surgery treatment, a 6-7 cm cesarean section incision is made under general anesthesia and the urinary tract is stitched back into the bladder. After this procedure, the catheter is left in the child for approximately 1-7 days and the hospital stay varies between 2-7 days. The basic principle here is to extend the length of the subureteric tunnel of the ureter in the bladder, which we mentioned earlier. The success of this treatment is around 98%. Follow-up treatment is applied after surgery. Prophylaxis is stopped after 3 months. In follow-up, urine analysis and urinary system ultrasonography are performed, if these are normal, no additional tests are performed. Follow-ups are done at 1, 3 and 6 months. Subsequent follow-ups are done annually. These surgeries can be performed with or without opening the bladder.

Above is the open surgery performed by opening the bladder, below is the open surgery performed without opening the bladder.

What is Done Before Vesicourethral Reflux Surgery?

First of all, a good history should be taken and a general physical examination should be performed. Then, the family (mother and father) should be well informed about the process, that is, before the surgery, during the surgery and after. If the child is older, the child is also included in this. A number of tests are performed, these tests are not general and are determined according to the patient. The patient is also seen by the anesthesiologist, the family and the child are informed about the anesthesia process that will be experienced. The patient is left hungry for 4 hours before the surgery.

What is the Recovery Process After Vesicourethral Reflux Surgery?

If the procedure was performed by injection, the patient is fed 2 hours after the surgery in accordance with the doctor and / or nurse's directions. Babies over the age of 2 can be sent home after 4-6 hours. Newborns may need to stay in the hospital for 1 day. After the surgery, the patient only takes painkillers in accordance with the doctor's recommendations and the monitoring protocol is continued. The patient is seen by the doctor after 48-72 hours.

If the procedure was performed as open surgery, the patient is fed after 24 hours. There may be several catheters, these are removed in order on the 4th-5th days depending on the patient's condition. The patient is then discharged. There is no need for dressing at this time, the stitches dissolve on their own and do not need to be removed. The patient continues his normal active life in accordance with the doctor's recommendations after the surgery. Then, the follow-up treatment described above is applied.

What are the Risks of Vesicourethral Reflux Surgery?

Since the patient will receive general anesthesia during the surgery, there may be anesthesia risks, and the patient's relatives are informed about this by the anesthesiologist physician before the surgery.

In addition, there may be some surgical complications (wound site infection, bleeding, urinary tract infection, temporary or permanent blockages in the urinary tract, etc.)

*** The information provided here and the content of the website are arranged for the purpose of informing the visitors, especially the families. No information should be considered as advice by the visitors and should not lead to any decision or action. Families should definitely have their patients examined by a pediatric surgeon and make a decision based on their personal knowledge and experience.