The most important functions of the kidneys are to remove toxic substances from the blood and to excrete them as urine. After the urine is produced by the kidneys, it is transported to the urinary bladder (bladder) via tubes called ureters and stored. There is almost a valve mechanism between the ureter and the bladder on both sides, preventing the urine from escaping back to the kidneys. During voiding, the bladder contracts and the urethral sphincter (the ring-shaped muscle surrounding the urethra) is opened, allowing urine to flow out of the canal as the urethra from the bladder. Here, the entire system from the kidneys to its opening is called the urinary tract.
Vesicoureteral reflux is a condition in which urine escapes from the bladder to the kidneys. In most children, reflux can sometimes be due to a congenital defect, due to the abnormal connection between the ureter and the bladder and the short and ineffective valve mechanism. . In some children, abnormal voiding features may reveal reflux. Reflux can cause infections in children, for example, pyelonephritis, which we call kidney infection, and ultimately kidney damage. More severe reflux can cause greater kidney damage. In cases where reflux is excessive, the ureter and kidneys may enlarge and deformity may occur.
How Often Does VUR Occur?
Reflux occurs in approximately 1-2% of healthy children. It is usually diagnosed after the child has a urinary infection. The age at diagnosis is 2-3 years, but it can be diagnosed at any age, as in infancy or older children. Three-quarters of the children treated are girls. In some children, reflux may be familial. One third of the sisters or brothers of children with reflux may also have this condition. In addition, if the mother has been treated for reflux, half of her children may have reflux. If any of your children have reflux, show their siblings to your doctor as well.
Urinary tract infection is usually caused by bacteria and can affect the kidneys, bladder, or both. If it affects the kidney it is called pyelonephritis. Typical signs are fever, abdominal or flank pain, chills, nausea or vomiting. If it primarily involves the bladder, that is, the bladder, it is called cystitis. Here, too, typical signs are painful, frequent or urgent urination or urinating on the bed. Newborns do not have these typical signs. Fever, restlessness, vomiting, diarrhea, loss of appetite and delay in weight gain can be observed in these. Bacteria that cause urinary infections are usually present in the child’s own poop. Despite very serious cleaning, bacteria settle in the genital area and eventually enter the bladder and urethra. If the child has reflux, bacteria can reach the kidneys and cause kidney infection.
Voiding cystourethrography (VCUG-Voiding): Diagnosis is made with a test called voiding. A thin and soft tube, called a catheter, is inserted into the urethra, which can be described as the way urine comes out. A medicated liquid that becomes visible on X-ray is filled until the bladder is full. Then the child is asked to pee. In the meantime , movies are shot and it is checked whether there is a backward escape . This test usually takes between 15-20 minutes. Sometimes it is recommended to give antibiotics before and after the test, as some children may develop infection during this test due to the use of a catheter. It is useful to talk to your doctor to reduce the distress that may occur in children due to catheter placement. Usually a mild sedative can be given to the child before the test. It is not recommended to be done with general anesthesia because it is important to observe whether there is reflux during voiding.
Urography (IVP): Ultrasonography, kidney scintigraphy or color film (IVP) may be required to understand whether reflux and urinary infection are damaging the kidneys. In other tests, other than ultrasound, a low amount of radiation is taken, but it is at a very low rate compared to other tests. While these tests are being done, the child may feel restless. In this case, you can ask for help by talking to your child’s doctor.
USG: It is mostly used in follow-ups that do not require radiation.
Urine Culture: The tests for detecting urinary tract infection are urinalysis and urine culture. The only risk that may occur while performing these tests is a reaction to the substances used in serious cleaning before taking urine.
Urodynamics-Uroflowmetry (voiding test): Other tests can be done in children who cannot control their urine during the day. For example, in order to understand whether the size and functions of the bladder are normal or not, the test called the voiding test, in which the child is urination in a special toilet and the speed and shape of the flow is determined, as well as the residual urine amount test, which determines the amount of urine remaining in the bladder after voiding, and finally, the small bladder we call urodynamics. we can count the tests performed by placing a catheter, in which the bladder is filled with sterile serum and the bladder size and pressure are measured.
Vesicoureteral Reflux Grading
Reflux can be measured and graded. The doctor can determine the degree of reflux by looking at the urinary system films. Reflux; It is graded by determining how much urine flows back to the ureters and kidneys and what changes it causes there.
First Degree: Contrast material filling the bladder only reaches the distal part of the ureter during voiding. This degree of VUR accounts for 8% of all cases.
Grade 2: Contrast material goes up to the renal calyces. However, there is no dilatation in the urinary system. 37% of cases are in this stage.
Grade 3: Despite moderate dilatation in the ureter, renal pelvis and calyces, the renal calyces are not blunted yet. 25-37% of the cases are in this group.
Grade 4: In addition to dilatation in the ureter, renal pelvis and calyces, the renal calyces are blunted. 14-24% of the cases are in this group.
Grade 5: There is advanced hydroureteronephrosis and a convoluted ureter on the side of the reflux. 5% of the cases are in this group.
Complications-Damages of VUR
Kidney damage: Kidney damage (kidney scar) may occur in children with reflux and urinary infections. High-grade reflux has a high risk of kidney damage. Generally, reflux without infection does not cause damage. High blood pressure can occur as a result of kidney damage. In addition, if both kidneys are damaged, kidney function may be affected. If both kidneys are severely affected, kidney failure may result.
Urinary infection: Kidney infection (pyelonephritis) is observed more frequently in children with reflux than in those without reflux. Some children may require hospitalization to treat their infection. Severe infections have a high risk of kidney damage.
Pregnancy complications: Premature birth, growth retardation in the baby, termination of pregnancy and worsening of the kidney functions of the mother can be observed in pregnant women with obvious kidney damage due to urinary infection.
The aim of treatment in children with reflux is to prevent the kidney from becoming infected and damaged and the complications mentioned above. There are three treatment options: medical treatment, surgical treatment, observation.
1-Medical treatment: Its basis is the disappearance of reflux over time. This period is on average 5-6 years. The aim of medical treatment is to protect the child from kidney damage and urinary infection. In most children, reflux disappears over time due to the maturation and normalization of the connection between the bladder and ureter. The smaller the degree of reflux, the easier it is to disappear. Unilateral reflux is easier to correct than bilateral reflux. Medical treatment includes antibiotic prophylaxis (use of antibiotics to prevent infections), bladder training, and other treatments to prevent infections. The child should be examined periodically and urinalysis should be performed. Radiological examinations should also be performed at certain intervals.
Urinary infections can be prevented by giving low doses of antibiotics each night before going to bed (this way they can stay in the bladder longer). A quarter or a third of the full dose may be given for this purpose. In this way, antibiotics can be used for a long time. Antibiotic prophylaxis does not correct reflux, but prevents urinary infection. Reflux that is not accompanied by urinary infection does not cause damage to the kidney. Antibiotic prophylaxis is continued until reflux disappears or the risk of reflux decreases.
Here, the child’s voiding intervals are regulated. In addition, techniques to improve bladder functions are taught to the parent and child. The aim is to prevent the development of urinary infections by teaching the normal way of voiding. Bladder training is combined with antibiotic prophylaxis. The doctor can also show the parent and child how to clean the genitals and anal area. It is also important to be taught how to avoid constipation. Other treatments: These include anticholinergics. These drugs are very effective in restoring bladder functions and can be used safely for many years.
2- Surgical treatment: The aim is to protect the child from potential risks by treating reflux with surgical treatment. It is applied with a lower abdominal incision under general anesthesia. In this way, the valve mechanism between the bladder and ureters is corrected and reflux is prevented. No artificial material is required for this. A wide variety of effective operating techniques are available. A catheter is placed in the bladder for a few days after the operation. The patient is kept in the hospital for approximately 2-5 days. Follow-up films are taken to see if the operation was successful. If reflux is successfully corrected, it is very difficult to relapse. Antibiotic prophylaxis is discontinued. In recent years, there have been studies on performing surgery with the least invasive methods. It is possible to perform these surgeries with the laparoscopic method or robot-assisted laparoscopic method and the success rate is over 95%.
Injection Treatment: Another surgical correction method is endoscopic surgery. Under general anesthesia, the surgeon repairs the reflux by entering the urethral opening with a device called a cystoscope, injecting a substance into the place where the ureter enters the bladder. It is not as successful as standard surgical techniques.
3- Observation: Here, antibiotic treatment is given only when urinary infection occurs. The rationale here is a prompt diagnosis and treatment of urinary infection, and prevention of reflux-related kidney damage and treatment of infection. However, it should not be forgotten that urinary infection can develop rapidly and affect the child. Taking a urine sample for testing and starting treatment accordingly can waste time and lead to infection-related kidney damage.
Additional care in children with reflux: These children should be followed up periodically and observed for urinary infection. In sick children, urinalysis and urine culture should be performed to show whether the disease is due to urinary infection. The doctor will also want to check your child’s blood pressure. This is especially important in kidney damage. Bladder films are taken and reflux is monitored for improvement, persistence or worsening. Other tests described above are also used for follow-up.
Risks of treatment (advantages and disadvantages)
1-Benefits: The disappearance of reflux with medical treatment depends on the degree of reflux and the age of the child. High-grade reflux is more difficult to correct. The improvement of reflux in older children is more difficult than in younger children. Antibiotic prophylaxis prevents urinary infection and associated kidney damage. Abnormal children are more likely to have reflux if they are treated with antibiotics along with bladder training and other treatments. Standard surgery usually corrects all cases. While the chance of success is highest in grades I and II, it is seen less in grades III and IV, and the lowest in grade V. The probability of success is approximately 85%. Antibiotic therapy is discontinued following successful surgery.
While the success rate of endoscopic treatment is highest in moderate reflux, it is least in severe reflux. If this method fails, it has the advantage of being repeated. However, tests regarding the long-term benefit and reliability of this method are ongoing.
2-Risks: Urinary infection: Urinary infections may occur after treatment in approximately one third of children treated for reflux, regardless of the treatment method. However, since successful surgery prevents reflux, it is very difficult for bacteria that can reach the bladder to reach the kidney. The incidence of kidney infection in children receiving medical treatment is 2.5 times higher than in children receiving successful surgical treatment.
Kidney damage: The main goal in reflux treatment is to protect new or additional kidney damage due to kidney infection. Kidney damage can be detected by radiological tests. Short-term studies have shown that the risk of new kidney damage in children who receive medical treatment or who are treated surgically as a cure is almost the same and is between 15-20%. Kidney damage increases the risk of high blood pressure in a child. In this way, severely damaged kidneys can fail. These require either a kidney transplant or dialysis. Pregnant women with kidney damage are at risk of premature birth, high blood pressure, small babies and worsening of kidney functions.
3-Drug-related problems: Minor side effects associated with antibiotic treatment are rash, nausea, vomiting, abdominal pain and bad taste in the mouth. Skin rash is the most common side effect. The chance of other minor side effects occurring is less than 10%. The dose of antibiotics given prophylactically in children should be taken every evening at bedtime. Parents should ask the doctor for how long their child may need to take antibiotics and how to act if there is a problem while taking antibiotics. Reactions to other drugs, such as anticholinergics, can also occur in children. These include facial flushing, dry mouth, decreased sweating, increased heart rate, blurred vision, drowsiness, and constipation. Parents should discuss such side effects with their doctor.
4-Surgical complications: The most common complications related to reflux surgery are continued reflux, ureteral obstruction and reflux to the opposite side. The chances of complications occurring depend on the condition of the children. The chance of reflux to continue after standard reflux surgery is 2-4%. In grade V reflux, this risk is slightly higher. If the reflux continues and does not disappear over time, correction may be required. The chance of obstruction of the ureters is about 2%. Many of these need fixing. In 5% of cases, reflux may occur in the contralateral ureter after surgery on one side. This is independent of the surgery performed for reflux or the degree of reflux. These refluxes may disappear over time. Almost all children experience pain after the operation. The parent should ask the doctor what to do if such a situation arises. Recently, developments aimed at relieving children’s pain have been used successfully in children.
Some children may develop urinary infections after surgery. However, they are easily treated with antibiotics. In some children, pain when urinating and urinary control problems occur during the healing of the bladder. These problems go away on their own within a week or two. Blood in the urine may take up to a week. Very rarely it may be necessary to donate blood.
Difficulty urinating is noted in 2-3% of cases. This problem disappears after a short time. However, the catheters used during this period can sometimes cause pain in the child.
5-Hospital stay: If the child develops a serious urinary infection, he is hospitalized for 2-4 days and intravenous medication and fluid therapy are administered. The average hospital stay after reflux surgery is 2-5 days and varies according to the surgical technique used. In recent years, the length of hospital stay and the duration of the operation have been shortened.
What should be considered when choosing the treatment method?
Several factors should be considered when deciding on the best treatment option for your child. These are the severity of reflux, unilateral or bilateral reflux, the child’s age, gender, kidney damage, presence of voiding problems such as incontinence, and the family’s opinion.
In general, the lower the reflux degree, the higher the chance of success. Children with low-grade reflux (grades I and II) have a high chance of spontaneous recovery and benefit from antibiotics or surgery. However, in more severe reflux cases, this chance is lower even if urinary infection is prevented by using antibiotics. Standard surgery is effective in 96% of cases.
In general, scientific data reveal that in most of the children with grade I-III reflux, daily regular antibiotic use provides spontaneous improvement in reflux over time. Antibiotic therapy is the first choice in children with grade I-IV reflux. Because there is less risk in this in the short run. In children with severe reflux, surgical treatment is decided. Infections that occur despite the use of prophylactic antibiotics have a high risk of kidney damage and surgery is recommended, as these can be difficult to prevent.
Surgical treatment is recommended in children with grade V reflux. Because they don’t have a chance to recover on their own.
Surgical treatment is recommended more in girls than boys. Because girls are at higher risk of developing urinary infections.
Apart from these, whether the child is a suitable candidate for surgery, health problems, whether he can tolerate antibiotics, financial and other social factors should also be considered.
The opinion of the family is also important when deciding on medical or surgical treatment. Families should be informed about the cost of the treatment, the difficulties they may experience, how often they will visit their doctor and which tests will be followed. The personal views of the family should be taken when choosing the treatment method.