VESICOURETERAL REFLUX Introduction This form explains about vesico-ureteral reflux (VUR), and what to expect if your child comes to The Children’s Medical Center for evaluation and / or treatment. How does the urinary system work? The urinary system consists of the kidneys, the bladder and ureters. The kidneys filter the blood to remove waste products and form urine. The urine flows from the kidneys down through the ureters to the bladder. From here it passes through another tube called the urethra to the outside when urinating. The ureters join the bladder at an angle so a flap is created. This flap prevents urine flowing back from the bladder into the ureters and the kidneys (vesicoureteral reflux or VUR). This “valve” is also important as it stops the high pressure created at urination from affecting the kidneys. The valve also lets you get rid of the urine in the bladder at once, as urine cannot travel anywhere else. What is Vesicoureteral reflux (VUR)? VUR occurs when the valve between the ureters and the bladder is not working properly. This means that urine can flow back from the bladder into the ureters and from there into the kidneys. The abnormal back flow of urine into these tubes is called vesicoureteral reflux. When the ureters enter the bladder, they travel through the wall of the bladder for a distance in such a way that they create a tunnel so that a flaplike valve is created inside the bladder. This valve prevents urine from backing-up into the ureters and kidneys. In some children, the valves may be abnormal or the ureters in the bladder may not travel long enough in the bladder wall, which can cause vesicoureteral reflux. Vesicoureteral reflux is a condition that allows urine to go back up into the ureters and kidneys causing repeated urinary tract infections. The reflux of urine exposes the ureters and kidney to infection from bacteria and highpressure, which is generated by the bladder during urination. If left untreated, urinary infections can cause kidney damage and renal scarring with the loss of potential growth of the kidney and high blood pressure later in life. Vesicoureteral reflux is treated with antibiotics, and in severe cases surgically. VESICOURETERAL REFLUX The Children’s Medical Center Nephrology Department Phone: 937-641-3304 Fax: 937-641-5091 Page 1 Abiodun Omoloja, M.D. Pediatric Nephrology Tammy Tufts, CPNP Nurse Practitioner Leonardo M. Canessa, M.D. Medical Director One Children’s Plaza, Dayton, Ohio 45404 e-mail: [email protected] VESICOURETERAL REFLUX What causes VUR? The most common cause is the tubes that connect the kidney to the bladder do not join into the bladder properly, resulting in back flow. A less common cause of VUR is blockage in the route of urine passage out of the bladder through the urethra. Severity of VUR There are five types of this condition based on severity. Grade I (1) the least severe, and Grade V (5) the most severe. Your doctor can discuss the grade of VUR your child has. How do I know my child has VUR? A bladder or kidney infection is usually the first sign. These infections might be accompanied with high fevers, vomiting and diarrhea. Other signs may be frequent urination, pain when your child voids daytime urine leak and bed-wetting. In some other kids the diagnosis is done with a family history of VUR in the mother or a sibling; or when the obstetrician diagnoses an abnormal ultrasound in a baby in the womb. One or both of the baby’s kidneys appear swollen and larger than usual. The swollen kidneys (hydronephrosis) may be due to various conditions, one of which is VUR. How common is VUR in children? VUR occurs in about one to two in every 100 children and tends to affect twice as many girls than boys. How is VUR treated? This depends on several things such as the age of your child, if the kidney is affected, severity of back flow and frequency of bladder or kidney infections. Your doctor might recommend on or a combination of the following to treat your child: - Antibiotics: Children tend to be treated with antibiotics on a long-term basis to prevent any urine infections. This is turn will lessen the chance of damage to the kidneys. This will give your child the chance to outgrow VUR. While your child is taking antibiotics, he or she may have to have a urine sample checked on a regular basis. This is carried out to check for a urine infection in the early stages. At the same time, your child’s kidneys will be checked using an ultrasound scan to see that they are growing properly. - Surgery: This involves modifying how the tubes connect to the bladder. The decision to have surgery will depend on several things such as your child’s age, severity of back flow of urine and frequency of infections. - Voiding frequency: Frequent emptying of the bladder prevents the build up of pressure. - Diet change: Increase fiber in diet reduces constipation and decreases the frequency of bladder infections. Increase fluid intake to facilitate voiding and emptying of the bladder. Your doctor will discuss with you the treatment options that work best for your child. Symptoms of a urine infection can include: burning sensation during urination, urinating more often than usual, abdominal pain, a high temperature, vomiting, reduced appetite or foul smelling urine. If you suspect your child has a urine infection, please contact your primary physician to have a urine sample tested. VESICOURETERAL REFLUX The Children’s Medical Center Nephrology Department Phone: 937-641-3304 Fax: 937-641-5091 Page 2 Abiodun Omoloja, M.D. Pediatric Nephrology Tammy Tufts, CPNP Nurse Practitioner Leonardo M. Canessa, M.D. Medical Director One Children’s Plaza, Dayton, Ohio 45404 e-mail: [email protected] VESICOURETERAL REFLUX How does VUR affect the kidney? The back flow of urine can be severe enough that the back flow reaches the kidney with pressure causing damage. The presence of reflux will keep the bladder with urine increasing the possibilities of urine infections. Repeated infections can lead to scars on the kidney, high blood pressure, or kidney failure and in girls, toxemia at childbearing age. What can I do to help my child? Follow up appointments with your child’s doctor is very important. Encouraging your child to void frequently and preventing constipation are ways you can help your child. Informing your doctor if you think your child has a bladder infection is also very important. Will my child need dialysis or a kidney transplant? Several factors will help determine this, such as severity of the condition, amount of scarring of the kidney, and kidney function as determined by blood tests. Your doctor will discuss this issue with you. For the most part, this rarely happens. Report on the Management of Primary Vesicoureteral Reflux in Children. This report has been published in the Journal of Urology, May 1997. Vesicoureteral reflux refers to the retrograde flow of urine from the bladder into the ureter and, usually, into the collecting system of the kidney. In most individuals, reflux results from a congenital anomaly of the ureterovesical junction, whereas in others it results from high-pressure voiding secondary to posterior urethral valves, neuropathic bladder or voiding dysfunction. Between 3–5 percent of girls and 1–2 percent of boys experience a urinary tract infection before puberty (Jodal and Winberg, 1987). Approximately 40 percent of children with a urinary tract infection have reflux (Bourchier, Abbott and Maling, 1984; Drachman, Valevici and Vardy, 1984). Urinary tract infection is the most common bacterial disease during the first 3 months of life (Krober, Bass, Powell, et al., 1985) and accounts for approximately 6 percent of febrile illnesses in infants (Hoberman, Chao, Keller, et al.,1993). Reflux is a predisposing factor for pyelonephritis, which can result in renal injury or scarring, also termed reflux nephropathy. The most serious late consequence of reflux nephropathy is renal insufficiency or end-stage renal disease. Between 3.1–25 percent of children and 10–15 percent of adults with end-stage renal disease have reflux nephropathy (Arant, 1991; Avner, Chavers, Sullivan, et al., 1995; Bailey, Maling and Swainson, 1993). In addition, reflux nephropathy may result in renin-mediated hypertension and cause morbidity in pregnancy (Martinell, Jodal and Lidin-Jason, 1990). The primary goals in the management of vesicoureteral reflux in children are to prevent pyelonephritis, renal injury and other complications of reflux. Children with reflux may be managed either medically or surgically. The rationale for medical management is prevention of urinary tract infection with daily antimicrobial prophylaxis, regular timed voiding and, in some cases, anticholinergic medication. These children also undergo periodic screening of the urine for infection and radiologic reassessment of the urinary tract for reflux and renal injury. Many children show spontaneous reflux resolution while receiving medical management. Surgical management of reflux consists of repair of the ureterovesical junction abnormality. You can seek more information from our Family resource canter on the 2nd Floor of the Taggart Pavilion or from the following websites: http://www.nlm.nih.gov/medlineplus http://www.niddk.nih.gov LC 04/15 VESICOURETERAL REFLUX The Children’s Medical Center Nephrology Department Phone: 937-641-3304 Fax: 937-641-5091 Page 3 Abiodun Omoloja, M.D. Pediatric Nephrology Tammy Tufts, CPNP Nurse Practitioner Leonardo M. Canessa, M.D. Medical Director One Children’s Plaza, Dayton, Ohio 45404 e-mail: [email protected]