Vesicoureteral Reflux: Done By: Khalid Al-Qudsi Faisal Burghal Supervised By: Dr. Osama Bani Hani

Vesicoureteral reflux
Done By : Khalid Al-Qudsi

Faisal Burghal
Supervised by : Dr. Osama Bani Hani
Difinition
Vesicoureteral
reflux(VUR) is an
abnormal backward movement
ofurinefrom
thebladderintouretersorkidneys
( Upper urinary tract).
Why Vesicoureteral reflux Is a

problem ?
Acute
Pyeloneohritis
Multiple
Renal
UTIs
Scarring
Subsequent
Decreased
End-stage
hypertension
renal function
renal disease (ESRD)
Epidemiology
It is the most common urologic finding in

children
Occurring in approximately 1 percent of

newborns
In 30 to 45 percent of young children with

a urinary tract infection (UTI)
In neonates with prenatal hydronephrosis,

the prevalence of VUR is about 15 percent
Etiology: Primary VUR:
The most common form of reflux, Often

Unilateral
It is due to incompetent or inadequate
closure of the ureterovesical junction (UVJ),
which contains a segment of the ureter within the
bladder wall (intravesical ureter).
The failure of this anti-reflux mechanism is due to
the shortening of the intravesical ureter.The
intravesical ureter length may be genetically
dictated, which may explain the increased
incidence in family members of patients with
VUR.
Other Causes : Absence of adequate detrusor backing,
Lateral displacement of the ureteral orifice, Paraureteral
Secondary VUR:
Result of abnormally high pressure in the

bladder that results in failure of the closure of the
UVJ during bladder contraction.
Often associated with anatomic (e.g., posterior
urethral valves) or functional bladder
obstruction (e.g., dysfunctional voiding and
neurogenic bladder)
Often Bilateral
The degree and chronicity of obstruction can
influence the severity of VUR.
The management of secondary VUR is focused on
treating the primary abnormality with the rare
need for direct surgical correction of the VUR
Grading
The
International Reflux Study Group (IRSG) developed a

classification system that grades the severity of VUR
based upon the degree of retrograde filling and dilation of
the renal collecting system demonstrated by VCUG
Grade
I Reflux only fills the ureter without dilation.

Grade II Reflux fills the ureter and the collecting system
without dilation
Grade III Reflux fills and mildly dilates the ureter and the
collecting system with mild blunting of the calyces.
Grade IV Reflux fills and grossly dilates the ureter and the
collecting system with blunting of the calyces. Some tortuosity of
the ureter is also present.
Grade V Massive reflux grossly dilates the collecting system.
All the calyces are blunted with a loss of papillary impression and
intrarenal reflux may be present. There is significant ureteral
dilation and tortuosity.
Clinical Features
The
clinical course and outcome vary

depending upon whether VUR presents
prenatally or postnatally.
Prenatal
presentationThe presence of VUR is

suggested by the finding of hydronephrosis
on prenatal ultrasonography
Postnatal
presentationPostnatal diagnosis of
VUR usually is made after a UTI, and less
commonly, it is detected after screening of
family members
Signs and symptoms

Vesicoureteral
reflux in itself does not produce any

symptoms. These occur when infection of the urinary tract
(UTI) is present.
Older
children
Infection causes symptoms such as fever, pain,
unpleasant smelling urine and a burning sensation when
urinating.
Other
symptoms commonly experienced include:

Bedwetting (nocturnal enuresis).
Lower abdominal pain.
Blood in the urine (haematuria) and/or pus in the urine
(pyuria).
In neonate
irritability,
persistent high fever, and

listlessness. In cases of VUR and
febrile UTI associated with a serious
underlying urinary tract abnormality,
the neonate could present with
respiratory distress, failure to thrive,
renal failure, flank masses, and
urinary ascites.
Investigation
Urine
R/E
Urine C/S
B. urea S. creatinine
X-ray KUB
USG-KUB
IVU Simple cystography
MCUG Voiding cinefluoroscopy
Radionuclide scan
Diagnosis
The
diagnosis of vesicoureteral reflux

(VUR) is based upon the
demonstration of reflux of urine from
the bladder to the upper urinary
tract by either contrast voiding
cystourethrogram (VCUG) or
radionuclide cystogram (RNC). The
VCUG provides greater anatomic
detail but there is increased
radiation exposure with VCUG
In
the larger of the

systematic reviews
conducted by the
American Urological
Association (AUA),
prenatal hydronephrosis
was defined as a renal
pelvic diameter (RPD)
4 mm during the
second trimester and
7 mm during the third
trimester
Ultrasound Scanning:
The
bladder and kidneys are scanned

to survey the anatomy and assess for
any irregularities.
DSMA Renal Scan:
Pictures of the kidneys are taken with a

specialised scanner following the injection of a
weak radioactive solution (radioisotope) into the
bloodstream via a drip in the hand or arm. The
pictures taken by the scanner can assess kidney
size, position and function and check for scarring
of the kidneys as the result of repeated UTIs.
Management
THERAPEUTIC
INTERVENTIONS is principally
based upon the following :
Identification of children with VUR
Prevention of pyelonephritis
Prevention of further renal damage resulting from
infection and inflammation

Minimization of morbidity of treatment and follow-up
Identifying and managing children with bladder and
bowel dysfunction
Therapeutic interventions include medical therapy
(ie, antibiotic prophylaxis), and surgical correction
We
suggest all children with grades III through V

reflux be treated because they are at greatest
risk for recurrent UTI, renal scarring, and
hypertension.
Children
with grade I to II reflux are at the lowest

risk for renal scarring. In our practice, the
different treatment options of observation or
medical therapy (ie, antibiotic prophylaxis) are
presented to the family, which plays a major role
in the final therapeutic decision. We do not
suggest surgical correction in these patients
MEDICAL TRETMENT
(Indications)
Unilateral
reflux
Lower grades of reflux
Earlier age at presentation
Male gender
MEDICAL TRETMENT
Consists of daily prophylactic
administration of antibiotics. It is based
upon the observation that reflux will
spontaneously resolve in most cases,
and the assumptions that use of
continuous antibiotics results in sterile
urine and the continued reflux of
sterile urine does not cause renal
infection
Antimicrobial
agents most commonly used for

prophylaxis include trimethoprim-sulfamethoxazole ,
trimethoprim alone, or nitrofurantoin . One daily
dose is administered at bedtime. The dose is onehalf to one-quarter the usual therapeutic dose for
treating an acute infection. Amoxicillin and
cephalosporins are not recommended because of
the increased likelihood of resistant organisms ,
except in infants below two months of age. Adverse
effects of sulfonamides, trimethoprim, or
nitrofurantoin preclude their use in infants less than
two months of age
Surgical treatment
Surgical
treatment corrects the

anatomy at the refluxing
ureterovesical junction.
The two surgical approaches used
are open surgical reimplantation and
endoscopic correction
Open surgical
reimplantation
Highly
successful procedure, with reported

correction rates of 95 to 99 percent
regardless of the severity of VUR
In open reimplantation, the bladder is opened
(intravesical approach) and the ureters are
reimplanted by tunneling a ureteral segment
through the detrusor (bladder wall muscle),
thereby creating a submucosal tunnel .
Alternatively, reimplantation can be done
without opening the bladder (extravesical
approach).
Endoscopic correction
Subureteric
transurethral injection (STING

procedure), he procedure involves injecting a
copolymer substance, such as
dextranomer/hyaluronic acid (Dx/HA or DEFLUX),
beneath the mucosa of the ureterovesical
junction through a cystoscope. This injection
changes the angle and perhaps fixation of the
intravesical ureter, thereby correcting reflux
The success rate for correcting VUR by STING in
one or more procedures ranges from 75 to
almost 100 percen
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Vesicoureteral reflux

Done By : Khalid Al-Qudsi

Why Vesicoureteral reflux Is a

It is the most common urologic finding in

Occurring in approximately 1 percent of

In 30 to 45 percent of young children with

In neonates with prenatal hydronephrosis,

Etiology: Primary VUR:

The most common form of reflux, Often

Result of abnormally high pressure in the

International Reflux Study Group (IRSG) developed a

I Reflux only fills the ureter without dilation.

clinical course and outcome vary

presentationThe presence of VUR is

Signs and symptoms

reflux in itself does not produce any

symptoms commonly experienced include:

persistent high fever, and

diagnosis of vesicoureteral reflux

the larger of the

bladder and kidneys are scanned

DSMA Renal Scan:

Pictures of the kidneys are taken with a

infection and inflammation

suggest all children with grades III through V

with grade I to II reflux are at the lowest

agents most commonly used for

treatment corrects the

successful procedure, with reported

transurethral injection (STING

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