What is Vesicoureteral Reflux?
Vesicoureteral reflux (VUR) is the abnormal flow of urine from the bladder back into the ureters. VUR is most commonly diagnosed in infancy and childhood after the patient has a urinary tract infection (UTI). About one-third of children with a UTI are found to have VUR. VUR can lead to infection because urine that remains in the child's urinary tract provides a place for bacteria to grow. But sometimes the infection itself is the cause of VUR.
VUR can also cause swelling in the ureter and kidney, known as hydroureter and hydronephrosis.There are two types of VUR. Primary VUR occurs when a child is born with an impaired valve where the ureter joins the bladder. This happens if the ureter did not grow long enough during the child's development in the womb. The valve does not close properly, so urine backs up (refluxes) from the bladder to the ureters, and eventually to the kidneys. This type of VUR can get better or disappear as the child gets older. The ureter gets longer as the child grows, and the function of the valve improves.
Secondary VUR occurs when there is a blockage anywhere in the urinary system. The blockage may be caused by an infection in the bladder that leads to swelling of the ureter. This also causes a reflux of urine to the kidneys.
Infection is the most common symptom of VUR. As the child gets older, other symptoms, such as bedwetting, high blood pressure, protein in the urine, and kidney failure, may appear.
Common tests to show the presence of a urinary tract infection include urine analysis and cultures. Because no single test can tell everything about the urinary tract that might be important to know, more than one of the following imaging tests may be needed:
- Kidney and bladder ultrasound
- Voiding cystourethrogram (VCUG) to examine the urethra and bladder while the bladder fills and empties. This test can reveal abnormalities of the inside of the urethra and bladder. The test can also determine whether the flow of urine is normal when the bladder empties.
- Intravenous pyelogram to examines the entire urinary tract.
- Nuclear scans: A number of tests using radioactive materials that are usually injected into a vein to show how well the kidneys work, their shape, and whether urine empties from the kidneys normally. Each kind of nuclear scan gives different information about the kidneys and bladder. Nuclear scans expose a child to about the same amount of radiation as a conventional x ray.
The goal for treatment of VUR is to prevent any kidney damage from occurring. Infections should be treated at once with antibiotics to prevent the infection from moving into the kidneys. Antibiotic therapy usually corrects reflux caused by infection.
Surgery is occasionally needed to correct primary VUR. There are several surgical options.
- Endoscopic injection of Deflux: a camera is inserted into the bladder through the urethra and a bulking agent is injected into the bladder wall around the opening of the ureter. This method can be done as an outpatient without an incision and there is no hospitalization.
- Open ureteral reimplantation: a 4-6cm bikini-line incision is made and the bladder is opened and the ureter is reattached to the bladder at a different angle to prevent urine from backing up into the ureter. This typically involves a 2-4 day hospitalization.
- Robotic-assisted laparoscopic ureteral reimplantation: three key-hole 8mm incisions are made in the belly and the ureters are tunneled into the back of the bladder without opening the bladder. This typically involves a 1-2 day hospitalization.
There are unique risks and benefits associated with each method. To learn what treatment options would be best for your child, call 410-955-6108 to schedule an appointment with one of our experts. Drs. Akhavan, DiCarlo, Gearhart, and Wang all treat vesicoureteral reflux.
Learn more about robotic surgery or call 410-955-3693 to discuss robotic surgery with Dr. Akhavan.
VUR is treated in the Division of Pediatric Urology at Hopkins Children's.