The ureters are the tubes that bring urine from the kidneys to the bladder. (fig 1). On entry into the bladder these tubes have a valve mechanism that prevents urine from refluxing back to the kidneys (fig 2).

This valve mechanism is compromised in children who have reflux. Urine then backs up to the kidneys while the bladder is filling as well as when the child urinates. Since all of the urine is not evacuated with each void, it can be contaminated with bacteria that then has easy access to the kidneys due to the presence of reflux.

The diagnosis of VUR may be considered prior to birth when a prenatal sonogram of the mother indicates the presence of hydronephrosis (swelling of the kidneys).
Girls have a higher incidence of reflux than boys.

Fig 2: Appearance of the ureter in the bladder – Normal patient

Diagnosis of Vesicoureteral reflux -
Reflux in diagnosed with the use of a voiding cystourethrogram. This test is performed by inserting a small catheter (tube) into the bladder through the urethra. A material that can be seen with X rays is then instilled into the bladder. X rays are taken to determine if the material that was put in the bladder goes back up into the ureters or kidneys.

Additional testing
Children who are being considered to have vesicoureteral reflux should also have an initial ultrasound of the kidneys to determine if the anatomy of the kidneys is normal.

If a child is diagnosed with vesicoureteral reflux following a significant urinary tract infection, a DMSA renal scan is recommended to determine if there is any evidence of scarring in the kidneys.

VCU showing presence of reflux on the right

VCU showing reflux on both sides

DMSA renal scan showing scars in the kidneys

Grading of Vesicoureteral reflux
Reflux is graded based on the results of the voiding cystourethrogram in 5 grades (Fig 3). Grade 1 is the lowest grade and has high potential for resolving spontaneously. Grade V is the highest grade and has low potential for spontaneous resolution.

Should your child be checked for vesicoureteral reflux?

• Children who have had a urinary tract infection should have evaluation for vesicoureteral reflux.
  
• Infants who have been noted to have hydronephrosis prior to birth should be evaluated
  
• Siblings of children with reflux should have evaluation for reflux
  
• Children of patients with reflux should also be evaluated for the presence of reflux.

Management of Vesicoureteral reflux
Once the diagnosis of reflux is suspected children should be started on antibiotic prophylaxis to prevent recurrent infections. The antibiotics that are typically used for prevention of infections are Trimethoprim/Sulfamethoxazole (Bactrim™, Septra™). Antibiotic prophylaxis is continued if the diagnosis of reflux is confirmed. Surveillance urine cultures are obtained in infants and all children with the diagnosis of reflux presenting with fever, should have a catheterized (if not toilet trained) or a clean catch (if toilet trained) urine specimen sent for culture prior to starting antibiotic treatment.

Repeat Evaluation
VCU and ultrasound are repeated yearly to determine if reflux has subsided. Use of VCU performed by Nuclear Medicine can help to reduce radiation exposure. DMSA renal scanning is repeated if there is concern of worsening of scar following infections.

Resolution of reflux
VUR has the potential for spontaneous resolution. Resolution rates are based on the degree of reflux and on the presence or absence of other associated factors (anatomic abnormalities or voiding dysfunction – children who delay voiding, etc.). Spontaneous resolution is most likely early after diagnosis. The longer the patient has the diagnosis of reflux, the less likely the reflux is to resolve spontaneously. If reflux resolves during follow-up, continued vigilance should be maintained to make sure that children do not redevelop recurrent infections in the bladder.

Surgical treatment
Those patients who have recurrent infections despite antibiotic prophylaxis are candidates for surgical treatment. Also those children who are unable to take antibiotics are potential candidates for surgery. Finally with the newer less invasive techniques, children may be eligible to have treatment as a primary modality for management.

Open Surgery
The most frequently performed operation for the correction of reflux is the Cohen cross-trigonal reimplantation. This is done through an incision in the bladder and the ureters are relocated into the bladder to prevent reflux. This procedure can be done with a 1-2 day hospital stay and has a very high success rate – approaching 98% at most institutions. Due to the high success rates of this procedure, some surgeons will forego follow-up VCU.

Another procedure that has gained widespread acceptance for open surgery is the Lich-Gregoir (extravesical) technique. The benefit of this procedure is the fact that it is performed outside of the bladder and therefore there is potentially less incidence of blood in the urine after surgery. Cure rates with this procedure are also very high, although some children may develop temporary difficulty voiding when this procedure is performed for reflux on both sides.

Laparoscopic Surgery
Laparoscopic reimplantation of the ureters into the bladder has also been successfully performed. This is usually done in a manner similar to that described for the extravesical reimplant (Lich-Gregoir). This procedure is offered in a few centers and has not had widespread acceptance due to the increased operating time that is required. Most children have similar hospital stays to those have open surgery.

Endoscopic techniques