Vesicoureteral reflux (VUR) is a pediatric condition that allows urine to flow backwards – from the bladder to the kidneys – through one or both of the connecting tubes (ureters). It is a condition that often co-exists with urinary tract infections (UTIs), although VUR is not caused by UTIs.
- Some children are born with a faulty valve at the point where the ureter connects into the bladder. In a normal urinary tract, the ureter joins the outside of the bladder at an angle and then forms a long tunnel through the muscular tissue of the bladder. If this tunnel is long enough, it serves as an effective one-way valve. In children with VUR, this tunnel can be too short to work properly as a valve and thus urine may flow in both directions.
- In some children, the ureters enter near the bottom of the bladder. A ureter that enters the bladder too far down does not make an effective valve and this can cause VUR. A child with this type of ureter is less likely to outgrow VUR on their own.
- A third cause of VUR is some type of blockage in the urethra which prevents urine from leaving the bladder. This results in greater pressure on the ureter valve, which may force the urine back through the valve and into the ureter.
Different types of VUR
The most common system of grading reflux severity includes five grades, from Grade I (least severe) to Grade V (most severe):
- Grade I results in urine reflux into the ureter only.
- Grade II results in urine reflux into the ureter and the renal pelvis, without swelling of the top of the ureter (hydronephrosis).
- Grade III results in reflux into the ureter and the renal pelvis, causing mild hydronephrosis.
- Grade IV results in moderate hydronephrosis.
- Grade V results in severe hydronephrosis and twisting of the ureter
What are the symptoms of VUR?
There are no specific symptoms of VUR. However, frequent and recurrent febrile urinary tract infections (UTIs) in children might be a symptom of VUR. In fact, VUR is present in nearly one-third of children with a febrile UTI. It is important to understand, however, that reflux does not cause UTIs, and conversely UTIs do not cause reflux. Signs of UTIs may include:
- Foul smelling or cloudy urine
- Stomach ache
- Side pain
- Burning or pain while urinating
- Frequent and urgent urination
- Antibiotic Prophylaxis: The most common first-line treatment used for VUR is to put the child on antibiotics to prevent UTIs. Typically, this involves taking a low dose of antibiotics once or twice a day, every day. This is called antibiotic prophylaxis. With this treatment option, the urologist tries to protect the child from UTIs while waiting for the VUR to go away by itself.
- Endoscopic injection: It involves using an endoscope to facilitate the injection of material in or around the area where the ureter enters the bladder to repair the valve function and keep urine from refluxing back into the kidneys. The child is put under general anesthesia. An instrument called an endoscope is inserted into the urethra up into the bladder. The endoscope has a tiny camera on its tip as well as a channel to allow the passage of a needle to make the injection. The surgeon guides the tip of the endoscope to the right spot and injects the material. The procedure takes about 20 minutes.
- Open surgery (Ureteric reimplantation) for VUR: This involves placing the child under general anesthesia and surgically fixing the ureters to stop VUR. The procedure varies, but can take up to three hours and involves removing the ureter where it joins the bladder and reimplanting it at another spot on the bladder. In effect, the surgeon creates a new valve structure by reattaching the ureter and creating a new tunnel through the bladder wall. This corrects the anatomical abnormality causing the reflux.
What are the pros and cons of open surgery?
The main advantage to surgery is its high success rate (88-99%). This procedure has been performed for many years and pediatric urologists have had great success with it. As with any surgical procedure there is a risk of infection and bleeding, however that risk is low. Surgery also usually requires a short hospital inpatient stay, and it can be stressful and uncomfortable for the child.