VESICO URETERIC REFLEX

BY : DR SONAM
MODERATOR : DR ABHISHEK
INTRODUCTION
 Vesicoureteral reflux (VUR) describes the retrograde flow of urine from the
bladder to the ureter and kidney.
 The ureteral attachment to the bladder normally is oblique, between the
bladder mucosa and detrusor muscle, creating a flapvalve mechanism that
prevents VUR
 VUR occurs when the submucosal tunnel between the mucosa and detrusor
muscle is short or absent.
 Affecting 1–2% of children, VUR usually is congenital and often is familial.

 VUR predisposes to kidney infection (pyelonephritis) by facilitating the

transport of bacteria from the bladder to the upper urinary tract .
 The inflammatory reaction caused by pyelonephritis can result in renal injury
or scarring, also termed reflux-related renal injury or reflux nephropathy.
Normal and abnormal configuration of the ureteral orifices. Shown from
left to right, progressive lateral displacement of the ureteral orifices and
shortening of the intramural tunnels. Top, Endoscopic appearance.
Bottom, Sagittal view through the intramural ureter.
CLASSIFICATION
 VUR severity is graded using the International Reflux Study (IRS) Classification
of I-V and is based on the appearance of the urinary tract on a contrast
voiding cystourethrogram (VCUG)
 The higher the VUR grade the greater the likelihood of renal injury.
 VUR severity is an indirect indication of the degree of abnormality of the
ureterovesical junction.
 Grading of VUR. Grade I: VUR into a nondilated ureter. Grade II: VUR into the
upper collecting system without dilation. Grade III: VUR into a dilated ureter
and/or blunting of the calyceal fornices. Grade IV: VUR into a grossly dilated
ureter. Grade V: massive VUR, with significant ureteral dilation and tortuosity
and loss of the papillary impression.
VUR GRADING
Grading of VUR.

 Grade I: VUR into a nondilated ureter.

 Grade II: VUR into the upper collecting system without dilation.
 Grade III: VUR into a dilated ureter and/or blunting of the calyceal
fornices .
 Grade IV: VUR into a grossly dilated ureter.
 Grade V: massive VUR, with significant ureteral dilation and
tortuosity and loss of the papillary impression.
VUR GRADING
CLASSIFICATION OF VESICOURETERAL REFLUX
 Primary VUR appears to be an autosomal dominant inherited trait with
variable penetrance.
 Approximately 35% of siblings of children with VUR also have VUR, and VUR is
found in nearly half of newborn siblings.
 The likelihood of a sibling having VUR is independent of the grade of VUR or
sex of the index child.
 Approximately 12% of asymptomatic siblings with VUR have evidence of renal
scarring. In addition, 50% of children born to women with a history of VUR
also have VUR.
VARIOUS ANATOMIC DEFECTS OF THE URETEROVESICAL JUNCTION
 Approximately 1 in 125 children has a duplication of the upper urinary tract,
in which two ureters rather than one drain the kidney. Duplication may be
partial or complete.
 In partial duplication, the ureters join above the bladder and there is one
ureteral orifice. In complete duplication, the attachment of the lower pole
ureter to the bladder is superior and lateral to the upper pole ureter.
 Duplication anomalies also are common in children with a ureterocele, which
is a cystic swelling of the intramural portion of the distal ureter. These
patients often have VUR into the associated lower pole ureter or the
contralateral ureter. In addition, generally VUR is present when the ureter
enters a bladder diverticulum
 VUR is present at birth in 25% of children with neuropathic bladder, as occurs
in myelomeningocele , sacral agenesis, and many cases of high imperforate
anus. VUR is seen in 50% of males with posterior urethral valves.
CLINICAL MANIFESTATIONS
 VUR usually is discovered during evaluation for a UTI . Among these children,
80% are female, and the average age at diagnosis is 2-3 yr.
 In other children, a VCUG is performed during evaluation of bladder–bowel
dysfunction, renal insufficiency, hypertension, or other suspected pathologic
process of the urinary tract.
 Primary VUR also may be discovered during evaluation for antenatal
hydronephrosis. In this select population, 80% of affected children are male,
and the VUR grade usually is higher than in females whose VUR is diagnosed
following a UTI. The UTI may be symptomatic, an isolated febrile event, or
more often both febrile and symptomatic (abdominal pain, dysuria).
 Bladder and bowel dysfunction (constipation) may be present in 50% of
children with reflux and a UTI.
DIAGNOSIS
 Diagnosis of VUR requires catheterization of the bladder, instillation of a
solution containing iodinated contrast or a radiopharmaceutical, and
radiologic imaging of the lower and upper urinary tract: a contrast VCUG or
radionuclide cystogram, respectively.
 The bladder and upper urinary tracts are imaged during bladder filling and
voiding. VUR occurring during bladder filling is termed lowpressure VUR; VUR
during voiding is termed high-pressure VUR.

 Radionuclide cystogram
shows bilateral VUR
 After VUR is diagnosed, assessment of the upper urinary tract is important.
 The goal of upper tract imaging is to assess whether renal scarring and
associated urinary tract anomalies are present.
 The child should be evaluated for bladder–bowel dysfunction (also termed
BBD), including urgency, frequency, diurnal incontinence, infrequent voiding,
or a combination of these.
 Children with an overactive bladder often undergo a regimen of behavioral
modification with timed voiding, treatment of constipation, and, on occasion,
anticholinergic therapy.
 After diagnosis, the child's height, weight, and blood pressure should be
measured and monitored. If upper tract imaging shows renal scarring, a serum
creatinine measurement should be obtained. The urine should be assessed for
infection and proteinuria.
TREATMENT
 The goals of treatment are to prevent pyelonephritis, VUR-related renal
injury, and other complications of VUR.
 Medical therapy is based on the principle that VUR often resolves over time
and that if UTIs can be prevented, the morbidity or complications of VUR may
be avoided without surgery.
 Medical therapy includes observation with behavioral modification or
behavioral modification with antimicrobial prophylaxis in some patients.
 The basis for surgical therapy is that in selected children, ongoing VUR has
caused or has significant potential for causing renal injury or other VUR-
related complications, and that elimination of VUR minimizes the risk of
these problems.