In the latest article in our Clinical Therapeutics series, a 7-year-old girl with persistent, moderately severe vesicoureteral reflux has recurrent urinary tract infections while receiving prophylactic antibiotic therapy. Endoscopic correction of vesicoureteral reflux is recommended. The technique is described.
Primary vesicoureteral reflux is the most common urologic abnormality in children. The overall prevalence of the disorder is typically estimated to be about 1%. However, it has been suggested that the actual prevalence may be substantially higher. The frequency with which it is detected depends on the indication for testing that leads to the diagnosis. For example, vesicoureteral reflux is diagnosed in about one third of children (mostly girls) who are evaluated after urinary tract infection and in about 10% of infants (mostly boys) with antenatal hydronephrosis. Vesicoureteral reflux is much less common in black children as compared to white children.
• What is the natural course of vesicoureteral reflux?
The natural course of the disorder is spontaneous resolution, which has been reported to occur in anywhere from 25 to 80% of patients. Resolution may be delayed by voiding dysfunction (the inability to release urine with a coordinated bladder contraction and sphincter relaxation), which increases the risk of recurrent urinary tract infection.
• What are the complications of vesicoureteral reflux?
Vesicoureteral reflux in a child with urinary tract infection may predispose that child to pyelonephritis and renal scarring, termed reflux nephropathy. The renal scarring may be congenital or acquired in origin. The former appears to be a result of segmental renal dysplasia and is seen mostly in boys with high-grade vesicoureteral reflux with no history of urinary tract infection. The latter is a result of renal injury caused by acute pyelonephritis and is seen mostly in girls. Patients with reflux nephropathy may be completely asymptomatic. The known complications of reflux nephropathy include hypertension and proteinuria. In addition, pregnancy-related complications and chronic kidney disease with end-stage renal failure may occur in some patients.
Morning Report Questions
Q: What is the standard diagnostic test for vesicoureteral reflux?
A: The standard diagnostic test for vesicoureteral reflux is voiding cystourethrography. This study is typically performed by filling the bladder with a radiocontrast agent through a urethral catheter and then using fluoroscopy to observe the distribution of the dye. Retrograde filling of the upper urinary tract is diagnostic of vesicoureteral reflux, which is graded from I to V, with grade V being the most severe.
Q: What is the optimal management of vesicoureteral reflux?
A: The optimal management of vesicoureteral reflux remains a subject of debate. Although it is clear that surgical intervention can eliminate or reduce the severity of reflux itself, the clinical trials do not provide convincing evidence that either surgery or antibiotic prophylaxis can reduce the incidence of recurrent urinary tract infection or, more important, the incidence of renal damage, as compared with surveillance alone. In addition, it is important to recognize that vesicoureteral reflux has a tendency to resolve in many patients with conservative management. However, the currently available data do not answer the question of whether more selective intervention may be helpful for the subgroup of patients at greatest risk for complications, and enrollment in clinical trials has typically not been restricted to such patients. The authors of this review recommend consideration of surgical treatment for patients with higher-grade reflux (grade III, IV, or V), for those in whom antimicrobial prophylaxis has proved to be ineffective (as shown by recurrent urinary tract infections while receiving such therapy), for those who cannot or do not consistently use antimicrobial therapy, and for those with progressive renal scarring. They also recommend consideration of surgical repair in girls with vesicoureteral reflux that persists as puberty approaches given risk of pregnancy-related complications. Voiding dysfunction is a relative contraindication to surgical correction of reflux because the likelihood of treatment failure and recurrent urinary tract infection is substantially increased.