Vesicoureteral Reflux
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Introduction
Vesicoureteral reflux (VUR) is a common condition in which urine passes backwards from the bladder up the ureter. It commonly causes urinary tract infections.
The Case of...
a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.
Causes and Risk Factors
VUR is very common, affecting 1-18.5% of children and in 70% of children with a UTI. Almost 85% of VUR occurs in females. Primary reflux is caused by anatomical variations (described under pathophysiology). Secondary causes include:
- cystitis
- subvesical obstruction
- iatrogenic
- ureteric abnormalities: ureterocele, ectopic ureter, duplication
Pathophysiology
Primary reflux can be caused by various anatomical variations, including trigonal weakness, lateral insertion of the ureters, and a short submucosal segment.
Signs and Symptoms
- history
- physical exam
History
UTIs and urosepsis are a common indicator of VUG, and can present with:
- pain on voiding
- fever
Physical Exam
Renal failure can lead to hypertension
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Renal function tests should be carried out to assess for uremia.
Diagnostic Imaging
VCUG and/or ultrasound is used to diagnose and stage VUR:
- I: ureters only
- II ureters and renal pelvis
- III: ureters and pelvis, shows some dilatation
- IV: ureters, pelvis and calyces, shows significant dilatation
- IV: ureters, pelvis and calyces, shows significant dilatation and tortuosity
Differential Diagnosis
Treatments
Annual renal ultrasound and VCUG can be done to monitor condition, with renal scans if new renal scars are suspected.
The treatment of choice depends on the grade of VUR
- I-III: keep urine free of infection in the hopes that VUR will spontaneously resolve; use prophylactic antibiotics at half dose (TMP/SMX, amoxicillin, nitrofurantoin)
- IV, V: surgery (ureteroneocystostomy/ureteroplasty) or subureteral injection
Consequences and Course
Over 60% of cases of primary reflux resolve with no treatment.
However, complications can include:
- renal scarring
- pyelonephritis
- hydroureteronephrosis
Resources and References
Topic Development
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