VEsicoureteral REflux
Nephrology
Urology
Vesicoureteric junction is the boundary between upper and lower urinary tracts
Definition: retrograde flow from bladder to ureter/kidney
Epidemiology: 1% of children
Etiology:
Primary
Dx
Antenatal US: hydronephrosis / pelvicalyceal dilation (80% male ?because M>F) is suggestive (multiple other causes)
Postnatal on MCUG
- indications
MCUG
Mild = non-dilated ureter
1) into ureter
2) into upper collecting system ie calyx
Moderate = dilated ureter
3) dilated ureter, blunted calyceal fornix
Severe
4) gross dilation, mild tortuosity
5) Tortuous ureter, loss of papillary impression in calyx
(constipation can exacerbate mild grades)
(in severe, urethral resistance relatively higher than ureteral = megacystitis megaureter)
Complications:
> Pyelonephritis (Urine MCS)
> Pyelonephritis OR pressure can cause scarring aka reflux nephropathy
Scarring Dx on DMSA
(6% of Grd 1-3 get scarring, 50% of Grd 4-5)
>> scarring can cause renin-mediated hypertension (BP monitoring)
>> scarring can cause renal insufficiency/ESRF/death (Serum Cr, Urine protein monitoring)
>>> somatic growth impairment (Ht/Wt monitoring)
Associations
Natural history (resolution within 5y)
Rx
Treat bladder dysfunction
Treat bowel dysfuction
Propylaxis (1/4 of total daily dose once daily cephalexin or bactrim)
Reimplantation if unlikely to resolve ie 4/5 and older 3
MCUG (and ?DMSA) annually
Urine MCS with any fever/urinary symptoms
Renal scarring
Etiology
- pyelonephritis
- pressure
--neurogenic bladder
--bladder outlet obstruction
Urology
Vesicoureteric junction is the boundary between upper and lower urinary tracts
Definition: retrograde flow from bladder to ureter/kidney
Epidemiology: 1% of children
Etiology:
Primary
- short or absent oblique submucosal tunnel between mucosal and detrusor (AD with variable penetrance)
- Ureteral duplication
- partial = join above bladder, complete = 2 orifices
- lower pole is superolat and 50% are incomp
- upper pole sometimes ectopic
- Ureterocele (cystic swelling within tunnel)
- Ectopic ureter (drains outside bladder eg bladder neck)
- Paraureteral bladder diverticula
- neuropathic bladder (25% reflux)
- myelomeningocele, sacral agenesis, high imperforate anus
- non-neuropathic bladder dysfuction
- non-neurogenic neurogenic bladder (i.e. Hinman syndrome)
- non-neurogenic neurogenic bladder (i.e. Hinman syndrome)
- bladder outlet obstruction
- PUV (50% reflux)
- detrusor-sphincter dyssynergia
- Foreign body
- Bladder stones
- Iatrogenic trauma
Dx
Antenatal US: hydronephrosis / pelvicalyceal dilation (80% male ?because M>F) is suggestive (multiple other causes)
Postnatal on MCUG
- indications
- UTI (80% female ?because UTIs M>F)
- voiding dysfunction
- renal insufficiency
- hypertension
MCUG
- low pressure aka passive reflux = during filling phase
- high pressure aka active reflux = during voiding)
- high pressure more likely to self resolve
Mild = non-dilated ureter
1) into ureter
2) into upper collecting system ie calyx
Moderate = dilated ureter
3) dilated ureter, blunted calyceal fornix
Severe
4) gross dilation, mild tortuosity
5) Tortuous ureter, loss of papillary impression in calyx
(constipation can exacerbate mild grades)
(in severe, urethral resistance relatively higher than ureteral = megacystitis megaureter)
Complications:
> Pyelonephritis (Urine MCS)
> Pyelonephritis OR pressure can cause scarring aka reflux nephropathy
Scarring Dx on DMSA
(6% of Grd 1-3 get scarring, 50% of Grd 4-5)
>> scarring can cause renin-mediated hypertension (BP monitoring)
>> scarring can cause renal insufficiency/ESRF/death (Serum Cr, Urine protein monitoring)
>>> somatic growth impairment (Ht/Wt monitoring)
Associations
- Multicystic dysplasic kidney
- Renal Agenesis
- PUJ obstruction
- Prune-Belly syndrome
Natural history (resolution within 5y)
- Gd 1: 90%
- Gd 2: 80%
- Gd 3 uni and <2y: 70% older ~50%
- Gd 3 bil and <2y: 60% older ~20%
- Gd 4 unilat: 60%
- Gd 4 bilat: 10%
- Gd 5 rare
Rx
Treat bladder dysfunction
Treat bowel dysfuction
Propylaxis (1/4 of total daily dose once daily cephalexin or bactrim)
Reimplantation if unlikely to resolve ie 4/5 and older 3
- 5 : 1 ratio of intramural ureter length:ureteral diameter
- success 97% for Gd 1-4 (2% presistant reflux 1% ureteral obstruction) 80% for Gd 5
MCUG (and ?DMSA) annually
Urine MCS with any fever/urinary symptoms
Renal scarring
Etiology
- pyelonephritis
- pressure
--neurogenic bladder
--bladder outlet obstruction