Vesicoureteral reflux refers to the back-up flow of urine from the bladder. Although gastroesophageal reflux is known more in life, pediatric urology reflux is VUR, in which urine returns to the kidneys through the ureter through the bladder. Sometimes reflux is seen in one ureter, and sometimes there is reflux in both ureters.
What is the incidence of VUR?
The incidence of vesicoureteral reflux in the community is approximately 1%. Its incidence increases with age. While it is more common in boys due to underlying reasons in infants, it is more common in girls in the play age group. The rate of VUR in children diagnosed with urinary tract infection is between 30-50%. Therefore, children with urinary tract infections should definitely be investigated.
Does VUR damage the kidneys?
There is also a very strong relationship between VUR and urinary tract infection. Recurrent urinary tract infections due to delayed diagnosis or inadequate treatment; It can cause hypertension, growth retardation, kidney damage, and even kidney failure in children. Early recognition of VUR is very important to prevent damage to the kidneys.
Is there a familial predisposition?
The incidence in siblings of children with vesicoureteral reflux is 30%. Reflux has been detected in 70% of children whose parents have reflux. Therefore, children with reflux in family members should definitely be investigated.
What causes VUR?
Vesicoureteral reflux is mostly due to the opening of the ureter, which we call the primary cause, by creating less tunnels in the bladder. However, it can also be due to an underlying cause, which we call secondary reflux. Conditions that may cause secondary reflux;
- Voiding disorders (daytime urinary incontinence)
- Posterior urethral valve
- neurogenic bladder
- anal atresia
- Dual system in kidneys
- ureterocele
- Epispadias – exstrophy association
- Prune belly syndrome
What are the symptoms of VUR?
1. Kidney enlargement on ultrasound in unborn babies
2. Urinary tract infection
- burning while urinating
- Fire
- bad odor in urine
- Inability to gain weight in infants, restlessness, vomiting
3. Urinary incontinence, frequent urination and voiding disorders
4. Constipation
5. High blood pressure
6. The presence of protein in the urine and kidney failure
How is the diagnosis made and what tests are required?
Generally, enlargement of the kidneys (hydronephrosis) is detected in the ultrasounds taken while the babies are in the womb, and VUR can be seen in the examinations performed after the baby is born. In children, it is detected in a study after a urinary tract infection. The first thing to do is ultrasound. This examination does not show reflux, but warns us by showing enlargement in the kidneys and ureters.
The main diagnosis is made by a procedure called voiding cystourethrography. With the help of a thin catheter inserted into the bladder, a radio-opaque substance is injected into the bladder and images are taken while this liquid fills the bladder, and then when the child pees. By seeing the extent of the opaque material, both the diagnosis of reflux is made and the degree of reflux is determined.
After detecting reflux, a scintigraphic study called DMSA is requested. This is a study showing damage to the kidneys.
If there is voiding disorder and urinary incontinence in older children, in addition to the above, voiding schedule and uroflow (voiding testis) are performed. If neurogenic bladder is suspected, urodynamics and lumbosacral MRI will also be ordered.
What are VUR ratings?
It has 5 degrees according to the international classification. Especially in primary reflux, it is very related to how the treatment will be and how it will progress. Its degree is determined by images obtained during diagnosis. We know very well that high-grade reflux is less likely to go away on its own and has a high probability of damaging the kidneys.
What is the treatment for VUR?
In the treatment of vesicoureteral reflux, many factors such as the patient's age, the degree of VUR, whether there is kidney damage, whether there is a voiding disorder, and the sociocultural status of the family are taken into consideration. We know that especially low-grade reflux passes spontaneously in the first years of life.
In the treatment of mild vesicoureteral reflux that has not caused kidney damage in infants and young children, antibiotic therapy is given to prevent infection. The aim of this treatment is to prevent urinary tract infection. The preventive antibiotic given for this is used as a single dose at night before going to bed. This antibiotic, which is given in very low doses, does no harm. If there is voiding disorder, bladder rehabilitation (especially pelvic floor muscle rehabilitation in our clinic) is applied.
If there is secondary reflux, treatment is first applied to the underlying cause. At the same time, prophylactic antibiotics are given to prevent urinary tract infection in this group.
If reflux continues despite protective antibiotics or correction of the underlying cause, and if it causes urinary tract infection, surgical intervention should be performed instead of waiting for this condition. There are two types of intervention;
- Cystoscopic correction (Sting method): It is a daily procedure. It is aimed to prevent leakage by entering the bladder with thin cystoscopes and filling just below the leaky ureter opening with a special filling material (as little as 0.1-0.6 cc). The success rate varies according to the degree of reflux. It is 80-85% in low grades and 50% in large grade reflux. It can be repeated several times.
- Open surgical method: The aim is to lengthen the ureteral tunnel within the bladder wall. Although there are different methods, the success rate is 95%. Generally, the hospital stay of children is 4-5 days.