Vesicoureteric reflux (VUR) is a common condition in children where urine flows backward from the bladder into the ureters or kidneys. It can lead to urinary tract infections and renal scarring. The document discusses the anatomy, pathophysiology, diagnosis and management of VUR. Management involves continuous antibiotic prophylaxis, endoscopic injection, or open surgical correction depending on the grade of reflux and individual patient factors. Spontaneous resolution is more likely for lower grades of reflux and in younger children. Bowel and bladder dysfunction can complicate management and decrease resolution rates.
3. Retrograde flow of urine from bladder into the kidney or ureter during emptying or
filling phase of bladder
Dynamic phenomenon
First described by GALEN 150 A.D- autopsy specimens
Human VUR-1893 POZZI- noted efflux of urine into ureter during plevic surgery
VUR is physiological in young of many species, considered abnormal in human!!
INTRODUCTION
4. INCIDENCE
In General pediatric population 0.5-3%
In children presenting with UTI 30-40%
AGE INCIDENCE OF VUR IN UTI
<1yr 70%
4 25%
12 15%
Overall picture
1yrs of life---boys +++
>2yrs --- girls >>> boys
Girls predominate
5. The prevalence of reflux is higher in siblings -32%, as low as 7% in older, 100% in
identical twins
Risk increase to 69% if a parent is affected
VUR is a familial, polygenic disease, has a tendency for an autosomal dominant
pattern of inheritance
Genes involved
PAX2
GDNF
RET
UPK3
AGTR2
ACE
INHERITANCE & GENETICS
6. VUR & ASSOCIATED CONDITIONS
o Renal agenesis
o Horshoe kidneys with renal ectopia
o Multicystic dysplastic kidneys
o Prune Belly syndrome
o Megacystis megaureter syndrome
o Duplication , Ureterocele, ectopic ureter
o Complex syndrome with genitourinary and neurogenic manifestations
7. Anti-Reflux Mechanism
Active
Passive
• Functional integrity of the ureter: -
Antegrade peristalsis
• Anatomic composition of the UVJ: - 5:1
ratio of tunnel length to ureteral diameter
in nonrefluxing junctions ( Paquin, 1959 )
• Functional compliance of the bladder
VUJ ANATOMY
8. VUJ ANATOMY- ANTI REFLUX MECHANISM
FILLING- Allows the
intramural ureter to move
in within the hiatus during
bladder filling
FILLING-Progressive obliquity
of intravesical ureter–trigone
stretched-- increased
resistance– increased
pressure
VOIDING- Intravesival ureter-
-Pulled down– ureteral wall
compressed against bladder
wall– passive reinforcement
of valvular mechanism
Natural tone of ureteral muscle-
active closure of intravesical
ureter
10. VUJ ANATOMY- NEURAL INNERVATION
The mechanism requires a complex
of muscular
components that includes ureteral
and vesical muscle bundles
and an elaborate neural influence
Dual autonomic innervation by
cholinergic and noradrenergic
nerves, and there is evidence for
neuropeptides that
may act as neuromodulators
15. Gram negative coliform bacteria arising from faecal flora colonising the perineum
Escherichia coli (E. coli) most common uropathogen (80% of paediatric UTI)
Colonisation and ascends into upper tract due to underlying reflux
URINARY TRACT INFECTION
DEFENCE AGAINST UTI
Urothelium
Low virulence strain of local bacteria
Wash out effect of urine
Acidic pH
Mucosal IgA
Anti reflux mechanism
16. PATHOGENS
GRAM STAINS ORGANISMS INCIDENCE
GRAM NEGATIVE E COLI 75-80%
Non E COLI
Klebsiella
3-5%
Pseudomonas
Proteus
GRAM POSITIVE Enterococcus
Staphylococcus
23. HYPERTENSION ?
Renal scarring
Arterial damage in scarred areas
Segmental ischaemia
Hypertension
Renin mediated
Elevated renin release
Incidence- 17-30%
34-38% of adults
Risk of HTN increases
with age
24. PRESENTATION
‡ Antenatal hydronephrosis -15% of ANH is due to VUR
‡ Urinary tract infection
‡ Pyelonephritis- in infants
‡ Incidental detected VUR - Hydro/ hydroureteronephrosis, small sized kidney
‡ Cystitis- in older children
‡ Bowel bladder dysfunction
‡ Hypertension
27. EAU, ESPU- USG in initial assessment of UTI followed by MCU
AAP- USG in first episode of UTI, MCU in recurrent episodes, renal anomaly,
presence of uretral dilatation in USG
The EAU, ESPU and AUA (American urological association) guidelines – recommended DMSA
in patients who have high grade of VUR, high creatinine levels and intercurrent UTI
ESPR- Top down approach USG folllowed by DMSA
Recommned MCU only in case of renal involvement
Targeted to reduce urethral cathterisation, detetcing clinically insignificant VUR,
ionising radiation to gonads
RECOMMENDATIONS & PRACTICES
29. MCU
Diagnostic of reflux
Invasive procedure
Delineates the anatomical
details of bladder, urethra,
ureter
Preferred for initial tests in
diagnosis of VUR, not
routinely done for follow up
of children
with VUR
30. DMSA
• Tracer Uptake
• Function
o Inflammation- acute phase
o Cold areas/ scars- late phase
o Contour
o “Biscuit bite deformity”
DMSA provides info of
32. Radionuclide Classification(DRCG)
grade 1 = grade I of the international grading system
grade 2 = grade II-III
grade 3 = grade IV-V
DRC- DIRECT RADIONUCLEOTIDE CYSTOGRAM
33. AIM OF THE TREATMENT
To Prevent Recurrent Febrile UTIs
New Renal Parenchymal Damage
Minimize The morbidity of therapy and follow-up procedures.
Consider these factors prior to decision making of VUR management
Age
Gender,
Reflux grade,
History of recurrent UTI
Renal dysfunction
Associated BBD
34. Principles of management:
1. Spontaneous resolution of reflux is very common
2. High-grade reflux is less likely to resolve spontaneously
3. Extended use of prophylactic antibiotics & “ Watchful waiting”
4. The success rate with surgical correction is very high
Management of VUR cannot be based simply on VUR grade or broad statements of the
utility of CAP, but must be individualized
It is prudent to consider UTIs not only as acute episodes of illness but also as a first
step to possible renal damage
STRATEGY IN VUR
35. CAP- CONTINUOUS ANTIBIOTIC PROPHYLAXIS
International reflux trial
Birmingham reflux trial
Swedish trial
RIVUR trial
GROSS RECOMMENDATION
Antibiotic upto 1 yr of age
Until circumcision in boys
CAP is widely accepted as a revolutionary conservative therapy for VUR, because it
prevents recurrent episodes of UTI and consequent new renal scarring
36. Antibiotic prophylaxis has been shown to be effective in preventing UTI in some
children with VUR but is not required for all
Although strict criteria for the identification of those who are best managed with
CAP have yet to be defined, there is evidence to guide us today
Children with a clear history of recurrent UTI
The child with documented renal abnormalities on US or DMSA scanning
The child with abnormal voiding patterns or BBD should be offered CAP while an
attempt is made to correct his or her voiding patterns.
Parental understanding of the risks of renal injury from infection must be clear
If CAP is to be used, the obligation of education is equally strong in that failure to
follow the medication program may lead to a false sense of security among both
parents and caregivers
CAP- CONTINUOUS ANTIBIOTIC PROPHYLAXIS
37. AUA- AMERICAN UROLOGICAL ASSOCIATION
An option of not using CAP in selected children-
children less than 1 year and with grade I or II VUR, no history of febrile UTI, and no
renal cortical abnormalities.
For children over 1 year, those without history of febrile UTI, no history of BBD, and no
renal cortical abnormalities
CAP- CONTINUOUS ANTIBIOTIC PROPHYLAXIS
41. ENDOSCOPIC MANAGEMENT
Injection of a bio- compatible bulking agent
beneath intravesical portion of ureter in sub-
mucosal tunnel
• Elevates the intra-vesical ureter narrowing of
lumen
• Prevents regurgitation of urine & allows
antegrade flow
BIO MATERIALS-
DEFLUX- Dextranomer hyaluronic acid polymer)
DEXELL
42. ENDOSCOPIC MANAGEMENT
ADVANTAGES
• Daycare
• less morbidity, no mortality
• No surgical scar
• Success rate almost equivalent to open surgery for primary reflux.
DISADVANTAGES
• Cost
• Lower success rate compared to surgery for high grade reflux
Indications
• Primary reflux
• Secondary reflux - Dysfn voiding - Neurogenic bladder - Duplex system • Failed open re-
implant
Surgical outcomes Success rates: • Open - 98% • Endoscopic – 80-89%
43. SURGICAL
TYPES
INTRAVESICAL- InfraHiatal- Cohen’s, Gil Vernant
Suprahiatal- Lead Better Politano,
EXTRAVESICAL- Lich Gregoir
METHODS
Open
Laparoscopic
Robotic
Higher success rate 98% for Cohen’s in terms of resolution of reflux and symptoms
44. • SPONTANEOUS RESOLUTION: - At birth, the probability of spontaneous resolution of
primary reflux is inversely proportional to the initial grade - If a patient is encountered
at a later age, resolution from any point in time forward will depend on the initial
grade of reflux
NATURAL HISTORY • Resolution by grade: - Most cases of low-grade reflux (grade I and
II) will resolve : 63-85% - Grade III reflux will resolve in approximately 50% of cases -
Higher-grade reflux (grades IV and V and bilateral grade III) : 9-25%
NATURAL HISTORY • Resolution with age : - Age has greater significance than grade -
Most prevalent in neonates and young children and will demonstrate the greatest
tendency to resolve in this group
VUR & RESOLUTION
45. BBD &VUR
o Most critical and modifiable variables that affect VUR management and attendant UTIs
High incidence of UTI despite prophylaxis
Poor surgical results
Less VUR resolution rate
o Persistence of the expected early attempts to suppress bladder contractions during
the toilet training months by volitional contraction of the external sphincter
o High voiding pressure leads to relux, UTI
In older children
Acquired voiding abnormality
