Urinary Reflux means that urine is able to get back up into the kidney after it has drained down into the bladder. It is usually present from the time of birth. It may occur in one or both sides, and is more likely to be present in children with abnormal urination or an obstructed bladder.
How is reflux discovered?
Reflux is usually discovered during an investigation of a urinary tract infection (UTI). Also, it may be suspected because there is enlargement of the kidney drainage system on an ultrasound test done either before or after birth. The test that detects reflux is called the voiding cystourethrogram (VCUG). This test is an X-ray of the bladder that is performed in the radiology department. A small catheter (tube) is passed into the bladder and the bladder is filled with a substance that allows us to see the bladder. Pictures are then taken until the bladder is full and then the child urinates. If the x-ray material is seen in the ureters or kidneys then we know that reflux is present. Urination is an important part of the test, since sometimes reflux does not appear until the bladder starts to empty. That's why we do not usually give sedation or anesthesia to do this test.
What is the significance of reflux?
Reflux alone does not usually cause a problem unless there is blockage of urine flow in the urinary tract. The problem with reflux is that if an infection (UTI) starts in the bladder, it may easily ascend to the kidney, leading to a kidney infection. If not treated soon or completely, kidney infections can cause permanent scarring of the kidneys. When this scarring is severe, the result may be high blood pressure and/or kidney failure. Therefore, in cases of severe reflux, we recommend that a scan of the kidneys be done to see if scarring is present. This scan is performed in the nuclear medicine department. Your child is injected with a tracer and pictures of the kidneys are taken.
What causes reflux?
Normally, urine is made in the kidney and travels down a tube, the ureter, into the bladder. As the bladder fills, the normal ureter becomes compressed, not permitting urine to pass up into the kidney. If this "valve" does not work properly, reflux will occur. Reflux tends to run in families; therefore, your doctor may recommend that siblings of children with reflux should be checked for the condition as well.
How is reflux treated?
Once reflux is identified, treatment depends on how severe the reflux is and the age of your child. Reflux is graded on a scale of 1 (mildest) to 5 (most severe). Since the milder forms may go away with time, the goal of treatment is to prevent urinary tract infection until the reflux has a chance to subside. Reflux may take several years to resolve. To prevent infection, your child may be placed on a low dose of an antibiotic once daily to prevent urinary tract infection. The 2 drugs used most often are: Cotrimoxazole (Bactrim, Septra) or Macrodantin (Furadantin, Macrobid). These drugs appear to have the fewest effects on other parts of the body. If your child is less than 2 months old, Amoxicillin is used most often. If your child has symptoms of a urinary tract infection you will need to see your pediatrician. A voiding cystourethrogram (VCUG) and an ultrasound are usually repeated every year as long as the reflux persists.
Surgery may be recommended by your urologist for the following reasons:
- The reflux is high grade (grade 4 or 5)
- Your child continues to have urinary infections even on antibiotic treatment
- Your child is unable to take antibiotics as prescribed
- The reflux has persisted after several years or your child is reaching adolescence
There are three general types of surgery used to treat VUR. They are:
- minimally invasive endoscopic injections
- traditional open surgery
- robotic surgery
How does surgery prevent reflux?
Ureteral reimplantation is performed by making a small incision in the lower abdomen, or making 3 or 4 small abdominal incisions and using the operating robot. We then move the ureter(s) to a new location in the bladder to fix the refluxing one-way valve. This is done by tunneling the ureter along the wall of the bladder. Your child will need to stay in the hospital after surgery for 1 to 2 days. An IV, or catheter (tube) in a vein will be placed at the time of surgery and will remain until your child is tolerating liquids. Pain medication will be available as needed. A catheter will drain urine from the bladder for at least 24 hours and a small drainage tube may come through the skin at or near the incision. The tubes may be removed before your child goes home or may remain in place for a week or longer in selected cases. Your child may go to the bathroom frequently or complain of burning with urination. Even after the tubes are removed, you may continue to notice blood in the urine for 1 or 2 weeks. The stitches will dissolve on their own. Your child will be checked in the office and the doctor may order an ultrasound 4 to 6 weeks after surgery.
What are the possible complications of surgery?
General anesthesia is used for the surgery, and is low risk in healthy children. The most common problems, which may occur in 1-2% of patients, include blockage (obstruction) of the ureter(s) or persistent reflux. Obstruction may be temporary, but the kidney may need to be drained temporarily with a tube in the side or through the bladder. Rarely, surgery needs to be performed again to treat the blockage or correct persistent reflux. Other rarer problems after surgery include infection of the incision or elsewhere and bleeding. Your child will be encouraged to take deep breaths and cough after surgery to prevent infection of the lungs.
What happens after surgery?
Your child will remain on the daily dose of antibiotics until your doctor confirms decides that it is best to stop it. He/she will need to get yearly ultrasounds of the kidneys to make sure blockage is not present. Urinary tract infections may occur after surgery, but they are usually limited to the bladder. We recommend a blood pressure should be checked by us or by your primary doctor at least yearly if your child has kidney scarring.
How do you diagnose vesicoureteral reflux (VUR)?
If your child has frequent or severe urinary tract infections or has difficulty with urination, his or her doctor will likely recommend testing to rule out vesicoureteral reflux. The only way to definitively diagnose VUR is through a test called a cystogram.
There are two types of cystogram that are used in the diagnosis of vesicoureteral reflux.
- Voiding cystourethrogram (VCUG) – This is an imaging test that uses X-ray technology to view the urinary tract. Using a contrast dye, the technician will fill the bladder using a urinary catheter and will take X-ray images. These images will show the flow of the urine, which will tell the technician whether the urine flows back to the kidneys.
- Radionuclide cystogram (RNC) – This test is similar to a VCUG, but it uses a nuclear medicine contrast medium to visualize the urinary tract and flow of urine rather than a contrast dye.
If your child is diagnosed with VUR, his or her doctor may also recommend additional testing to evaluate the severity of the reflux and whether or not it has damaged the kidneys. Those tests may include:
- an ultrasound of the kidneys to determine their size, shape and condition and to look for any abnormalities
- DMSA renal scan to evaluate the shape, condition and functioning of the kidneys
- urodynamic testing to test bladder function
- urinalysis and urine culture
- blood tests
How do you treat vesicoureteral reflux (VUR)?
Most children who are born with vesicoureteral reflux will outgrow the condition on their own without treatment. Because of that, we treat VUR conservatively unless your child has severe VUR or frequent or severe kidney infections. Treatments for VUR range from preventive antibiotics and watchful waiting to surgical correction of the malfunctioning valves.
For mild VUR, we tend to treat with a low dose of preventive antibiotics and perform regular tests to evaluate the VUR and kidney function. The antibiotics help prevent urinary tract infections (UTIs). If your child continues to get urinary tract infections despite low-dose antibiotic treatment, surgery may be necessary.
There are risks and benefits to all three types of surgery. Your child’s surgeon will talk with you about which option he or she recommends. At Beaumont, every child receives care tailored to his or her condition and symptoms. No matter what treatment(s) your child needs, we will keep you informed at all times. You are an important part of your child’s treatment team, and we value your input.