Vesicoureteral reflux

Vesicoureteral reflux is a condition in which urine abnormally flows

backward, from the bladder back up the ureters/kidneys. Normally, urine
flows from the kidneys to the bladder via the ureters, with a 1-way valve at
the ureterovesical (ureteral-bladder) junction preventing backflow.
The valve is formed by oblique tunneling of the distal ureter through the wall
of the bladder, creating a short length of ureter (12 cm) that can be
compressed as the bladder fills. Reflux occurs if the ureter enters the bladder
without sufficient tunneling, i.e., too "end-on."
Vesicoureteral reflux can develop in two forms, primary and secondary:
Primary vesicoureteral reflux
Insufficient submucosal length of the ureter relative to its diameter causes
inadequacy of the valvular mechanism. This is precipitated by a congenital
defect/lack of longitudinal muscle of the intravesical ureter resulting in an
ureterovesicular junction (UVJ) anomaly.
Secondary vesicoureteral reflux.
In this category the valvular mechanism is intact and healthy to start with
but becomes overwhelmed by raised vesicular pressures associated with
obstruction, which distorts the ureterovesical junction. The obstructions may
be anatomical or functional. Secondary VUR can be further divided into
anatomical and functional groups.
Anatomical
Posterior urethral valves; urethral or meatal stenosis. These causes are
treated surgically when possible.
Functional
Bladder instability, neurogenic bladder and non-neurogenic bladder. Urinary
tract infections may cause reflux due to the elevated pressures associated
with inflammation.
Resolution of functional VUR will usually occur if the precipitating cause is
treated and resolved. Medical and/or surgical treatment may be indicated.

Classification of Vesicoureteral Reflux

Grade I reflux into non-dilated ureter
Grade II reflux into the renal pelvis and calyces without dilatation
Grade III mild/moderate dilatation of the ureter, renal pelvis and calyces
with minimal blunting of the fornices
Grade IV dilation of the renal pelvis and calyces with moderate ureteral
tortuosity
Grade V gross dilatation of the ureter, pelvis and calyces; ureteral
tortuosity; loss of papillary impressions
Symptoms
Can include:
A strong, persistent urge to urinate
A burning sensation when urinating
Passing frequent, small amounts of urine
Blood in the urine (hematuria) or cloudy, strong-smelling urine
Fever
Pain in your side (flank) or abdomen
Hesitancy to urinate or holding urine to avoid the burning sensation

Diagnosis:
Kidney and bladder ultrasound. Also called sonography, this imaging
method uses high-frequency sound waves to produce images of the kidney
and bladder. Ultrasound can detect structural abnormalities. it might suggest
the presence of VUR if ureteral dilatation is present

Voiding cystourethrogram (VCUG). This test uses X-rays of the bladder

when it's full and when it's emptying to detect abnormalities. VCUG is the
method of choice for grading and initial workup
Nuclear scan. This test, known as radionuclide cystogram, uses a procedure
similar to that used for VCUG, except that instead of dye being injected into
the bladder through the catheter, this test uses a radioactive tracer
(radioisotope). The scanner detects the tracer and shows whether the
urinary tract is functioning correctly. It is preferred for subsequent
evaluations as there is less exposure to radiation.
Treatment and management:
Medical Treatment
Medical treatment entails low dose antibiotic prophylaxis until resolution of
VUR occurs. Antibiotics are administered nightly at half the normal
therapeutic dose.
Endoscopic injection
Endoscopic injection involves applying a gel around the ureteral opening to
create a valve function and stop urine from flowing back up the ureter. The
gel consists of two types of sugar-based molecules called dextranomer and
hyaluronic acid. Trade names for this combination include Deflux and Zuidex.
Both constituents are well-known from previous uses in medicine. They are
also biocompatible, which means that they do not cause significant reactions
within the body. In fact, hyaluronic acid is produced and found naturally
within the body.
Surgical treatment

There are three types of surgical procedure available for the treatment of
VUR: endoscopic (STING/HIT procedures); laparoscopic; and open procedures
(Cohen procedure, Leadbetter-Politano procedure).