What is Kidney Reflux (Vesicoureteral reflux)?
Normally, urine flows one way, down from the kidneys, through tubes called ureters, to the bladder. But what happens when urine flows from the bladder back into the ureters? This is called vesicoureteral reflux.
Vesicoureteral reflux (VUR) is the result of abnormal formation of the normal valve between the kidney and bladder. This valve ensures that urine travels one way from the kidney to the bladder. If your child has VUR, the urine does move backward into the ureters and kidney which may lead to the bacteria from the bladder enter the kidney. This may cause a kidney infection that can cause kidney damage.. Some children only have mild VUR, while others have large amounts of urine moving backward into their kidneys.
When the flow of urine back up the ureters is more severe, the ureters and kidneys become large and twisted. More severe reflux is tied to a greater risk of kidney damage and UTI if there is an infection present.
Symptoms:
Many children with VUR don’t have symptoms. But when they do, the most common one is a urinary tract infection (UTI) caused by bacteria. UTIs might not always come with symptoms, but when they do, they could include:
Strong urge to pee
Pain or burning while urinating
Blood in urine or cloudy, stinky urine
Peeing small amounts
Fever
Sudden, frequent urination or wetting
Abdominal pain
As your child gets older, untreated vesicoureteral reflux can lead to:
Bed-wetting
Constipation or loss of control over bowel movements
High blood pressure
Protein in urine
Another indication of vesicoureteral reflux, which may be detected before birth by sonogram, is swelling of the kidneys or the urine-collecting structures of one or both kidneys (hydro nephrosis) in the fetus, caused by the backup of urine into the kidneys.
When to see a doctor?
Contact your doctor right away if your child develops any of the signs or symptoms of a UTI, such as:
A strong, persistent urge to urinate
A burning sensation when urinating
Abdominal or flank pain
Call your doctor about fever if your child:
Is younger than 3 months old and has a rectal temperature of 100.4 F (38 C) or higher
Is 3 months or older and has a fever of 100.4 F (38 C) or higher and seems to be ill
Is also eating poorly or has had significant changes in mood
Causes:
The cause of VUR is unknown, however there is a strong genetic component. Although no specific genes have been identified, VUR is common among children and siblings of parents with VUR. During infancy, VUR is more frequently in boys. In older children, VUR is more frequently diagnosed in girls.
VUR may also occur as a result of these less common issues:
abnormal bladder function, due to nerve or spinal cord problems, such as spina bifida
urinary-tract abnormalities, such as posterior urethral valves, bladder exstrophy, ureterocele, or ureter duplication
dysfunctional voiding (bladder and bowel problems, including accidents, frequent urination, or constipation)
Diagnosis:
VUR can be detected before birth by an ultrasound, which uses sound waves to provide an image of the inside of your body.
One or more of these tests can also be used:
Voiding cystourethogram (VCUG): During this exam, a doctor uses a thin, plastic tube to inject a fluid with an X-ray dye into your bladder. Then an X-ray machine takes a video while you pee to see whether the fluid goes backward from the bladder to reach one or both kidneys. Children may become upset during this test, so it can be done with medicines that help keep them calm.
Radionuclide cystogram (RNC): This process is similar to the voiding cystourethogram, except the contrasting dye is a radioactive material that is detected by a nuclear scan.
Abdominal ultrasound: Safe, painless sound waves bounce off organs to create an image of the entire urinary tract. This could be used to find out how your kidneys are doing, including whether there are scars or other problems.
Urodynamics: This tests the bladder to see how well it’s collecting, holding, and releasing urine. It’s used to see whether problems in the bladder are part of your VUR problem.
Blood test: This exam looks for waste products that are usually removed from the blood by your kidneys. The blood test gives an idea of how your kidneys are doing.
Urine test: This tests for proteins or blood in your pee, which could indicate whether you have a UTI.
How is VUR Measured?
The doctor looks at an X-ray of the urinary tract to find out the reflux grade. This shows how much urine is flowing back into the ureters and kidneys, and helps the doctor decide what type of care is best.
In children with reflux and UTI, kidney damage may occur. Higher grades of reflux are linked to a greater risk of kidney damage.
The most common system of grading reflux (the International Study Classification) includes 5 grades:
Grade I: urine reflux into the ureter only
Grade II: urine reflux into the ureter and the renal pelvis (where the ureter meets the kidney), without distention (swelling with fluid, or hydronephrosis)
Grade III: reflux into the ureter and the renal pelvis, causing mild swelling
Grade IV: results in moderate swelling
Grade V: results in severe swelling and twisting of the ureter
Treatment:
Medical or Non-Surgical Treatment:
Often reflux will go away with time. The lower the grade of reflux, the more likely it is to go away. The average age for this to happen is 5 to 6 years. The goal of medical or non-surgical treatment is to prevent UTI and kidney damage while the child grows. Reflux improves in many children because the junction between the bladder and the ureter gets longer with age.
UTIs require prompt treatment with antibiotics to keep the infection from moving to the kidneys. To prevent UTIs, doctors may also prescribe antibiotics at a lower dose than for treating an infection.
A child being treated with medication needs to be monitored for as long as he or she is taking antibiotics. This includes periodic physical exams and urine tests to detect breakthrough infections — UTIs that occur despite the antibiotic treatment — and occasional radiographic scans of the bladder and kidneys to determine if your child has outgrown vesicoureteral reflux.
Surgery:
Surgery for vesicoureteral reflux repairs the defect in the valve between the bladder and each affected ureter. A defect in the valve keeps it from closing and preventing urine from flowing backward.
Methods of surgical repair include:
Open surgery: Performed using general anesthesia, this surgery requires an incision in the lower abdomen through which the surgeon repairs the problem. This type of surgery usually requires a few days' stay in the hospital, during which a catheter is kept in place to drain your child's bladder. Vesicoureteral reflux may persist in a small number of children, but it generally resolves on its own without need for further intervention.
Endoscopic surgery: In this procedure, the doctor inserts a lighted tube (cystoscope) through the urethra to see inside your child's bladder, and then injects a bulking agent around the opening of the affected ureter to try to strengthen the valve's ability to close properly. This method is minimally invasive compared with open surgery and presents fewer risks, though it may not be as effective. This procedure also requires general anesthesia, but generally can be performed as outpatient surgery.
If surgery is necessary, the urologist will discuss the different options with the family.
At-Home Care
If you’re a parent of a child with VUR, try to get them to use the bathroom regularly. Other tips include:
Make sure your child takes the prescribed antibiotics, even if they’re used to prevent UTIs.
Get your child to drink more water, as it helps flush out bacteria from the UTI. Avoid juices and soft drinks as they can irritate the bladder.
Place a warm blanket or towel over your child’s abdomen to ease pain or pressure.
If bladder and bowel dysfunction (BBD) contributes to your child's vesicoureteral reflux, encourage healthy toileting habits. Avoiding constipation and emptying the bladder every two hours while awake may help.
Risk Factors:
Risk factors for vesicoureteral reflux include:
Bladder and bowel dysfunction (BBD): Children with BBD hold their urine and stool and experience recurrent urinary tract infections, which can contribute to vesicoureteral reflux.
Sex: Generally, girls have a much higher risk of having this condition than boys do. The exception is for vesicoureteral reflux that's present at birth, which is more common in boys.
Age: Infants and children up to age 2 are more likely to have vesicoureteral reflux than older children are.
Family history: Primary vesicoureteral reflux tends to run in families. Children whose parents had the condition are at higher risk of developing it. Siblings of children who have the condition also are at higher risk, so your doctor may recommend screening for siblings of a child with primary vesicoureteral reflux.
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