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Vesicoureteral Reflux

Reflux into the ureter

  • The abnormal flow of urine from the bladder, upstream into one or both ureters and thence into the kidneys.

  • Symptoms of bladder infection
  • Incontinence of urine
  • Signs of Pyelonephritis or dilation of the urinary tract on X-ray, ultrasound, or other imaging studies
  • Signs of renal insufficiency (poorly functioning kidneys): high blood pressure, anemia (low red blood cell count), heart enlargement, edema or fluid overload in the tissues, blood in the urine, protein in the urine, decreased amounts of urine

  • Reflux can be primary or secondary.
  • Primary reflux usually means there is a partial or complete anatomic obstruction to the outflow of urine, causing some of the urine to flow upstream.  Common sites of obstruction in the urinary tract are:
    1. At the UP junction (where the urine collecting system at the kidney pelvis joins the ureter)
    2. At the UV junction (where the ureter joins the bladder
    3. In the vicinity of the bladder outlet or in the urethra.  See the chapter on posterior urethral valves.  Vesicoureteral reflux would refer to sites ( 2 ), ( 3 ), or any obstruction within the bladder.
  • Secondary reflux means that the child was born without obstruction in the urinary tract, but later developed a cause for reflux.
  • When partial or complete obstruction to urine flow develops, urine buildup leads to a dilated sac of tissue behind the obstruction, and the blocked urine can develop a backflow upstream, which is the reflux.
  • The urine will flow along the path of least resistance, which might be upstream, in the case of obstruction.

  • Diagnosis is suspected in children after a bacterial cystitis (bacterial infection of the bladder) because reflux commonly occurs during and immediately after bacterial cystitis in children.  Frequently, reflux disappears shortly after the bacterial infection resolves.
  • Reflux may persist.  It can be demonstrated by the upstream flow of dye, which is injected into the bladder and flows up the ureter(s) on sequential X-ray views.
  • The flow study commonly used to demonstrate this reflux is an X-ray study called VCUG (voiding cystourethrogram).

  • Posterior urethral valves
  • Anatomic narrowing in the urinary tract
  • Urinary Tract Infection
  • Bladder stones
  • Bladder spasm or bladder sphincter spasm
  • High pressure in the bladder, from external compression (for example, compression by a large volume of hard stool in the rectum)

  • Treatment of underlying infection, if any
  • Possible surgical treatment:
    1. Correction of posterior urethral valves
    2. Tapering and re-implantation of the ureter or ureters if the ureters have dilated and their insertion into the bladder wall is abnormal

  • If the child is old enough to express himself and is over the age of 3 or 4, he/she may describe symptoms that go along with reflux, which are:
    1. Symptoms of a bladder infection (i.e., pain over the bladder, a feeling that the bladder is bulging, hesitancy to make urine, having to make urine too often, pain while urinating, back pain, fever, cloudy or smelly urine)
    2. Incontinence of urine (wetting oneself frequently) even though toilet trained
    3. A symptom that is understandably a result of reflux: the child empties the bladder completely of urine, and then 5 minutes later, finds that there is a lot more urine in the bladder, and has to "go again"
  • This is a reflux symptom because the bladder squeezes some urine out the urethra and squeezes some urine up the ureters at the same time.  After a few minutes, the urine high in the ureters dribbles down into the bladder again, and the child has to "go again."
  • Discuss any reflux symptoms with your physician, since reflux might mean a defect in the anatomy of the urinary tract, or a reason for having urine infections repeatedly.

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