Campbell Pediatric VUR 2021

Question 1

Indications for VCUG in the newborn period

Answer 1

Findings on renal bladder ultrasonography (RBUS) indicative of HIGHER risk for significant VUR:

• Higher grades of hydronephrosis (particularly bilateral hydronephrosis)
• Renal cortical abnormalities
• Ureteral dilation
• Suspicion of anatomic anomalies such as ureteroceles or duplication of the collecting system
• Bladder abnormalities

Question 2

TRUE or FALSE:

Reflux is significantly more common in younger children and may resolve spontaneously over time

Answer 2

TRUE.

The incidence of VUR for patients ages less than 2, 2 to 6, 7 to 11, and 12 to 21 years was 38.6%, 26.9%, 19.7%, and 7.6%, respectively

Question 3

AUA 2010 VUR Guidelines:

When should siblings with VUR be screened with a VCUG?

Answer 3

Ff there is evidence of cortical abnormalities on ultrasound or a history of UTI.
This is especially important in the presence of grade 3 to 4 hydronephrosis on ultrasonography.
Grade 1 to 2 hydronephrosis: observational approach.

Question 4

Primary reflux

Answer 4

Caused by a fundamental deficiency in the function of the UVJ antireflux mechanism while the remaining factors (bladder and ureter) remain normal or relatively noncontributory.

Question 5

Secondary reflux

Answer 5

1. Increased intravesical pressure
   - Bladder: neurogenic, non-neurogenic
   - Outlet: mechanical (PUV< stricture, mass)
2. Abnormal UVJ
   - Diverticulum
   - Ureterocele/duplication
   - Iatrogenic

Question 6

___ is by far one fo the most critical and modifiable variables that affect VUR resolution.

Answer 6

Bladder and bowel dysfunction (dysfunctional elimination syndrome)

BBD is associated with a higher incidence of UTIs while on antibiotic prophylaxis and after surgical correction of VUR, with less VUR resolution at 24 months from diagnosis and with reduced success of endoscopic surgery. In the studies selected by the panel that qualified as having acceptable levels of evidence, BBD did not appear to reduce the success of open surgical reflux correction.

Question 7

Classic presentation of BBD

Answer 7

Classic CURTSYING behavior in girls and SQUEEZING the penis in boys, which acts to suppress bladder contractions.

** Constipation often leads to sympathetic, concomitant contraction of both anal and urinary sphincters –> frequent constipation and encopresis with reflux and UTI

Question 8

TRUE or FALSE:

Reflux causes UTI.

Answer 8

FALSE.

Reflux is NOT a general cause of UTI, but is perceived to be a clinical accelerant of upper tract bacteriuria by mechanically delivering infected urine to the renal pelvis.

Reflux facilitates pyelonephritis.

Question 9

International Classification of VUR

Answer 9

Grade 1: Into a NON-DILATED ureter
Grade 2: Into the PELVIS and calyces WITHOUT DILATATION
Grade 3: Mild to moderate dilation of the ureter, renal pelvis, and calyces with minimal blunting of the fornices
Grade 4: MODERATE ureteral tortuosity and dilation of the pelvis and calyces
Grade 5: Gross dilation of the ureter, pelvis, and calyces; loss of papillary impressions; and ureteral tortuosity

Question 10

Ureteric orifice position and reflux:
Obstruction occurs in ____ zone.
Reflux occurs in the ____ zone.

Answer 10

Obstruction usually occurs in the caudo zone (more lateral and superior), and ureters positioned in the cranio zone (more medial and inferior) are likely to result in reflux.

Question 11

The greatest risk for postinfectious renal scarring occurs within the ____ of life

Answer 11

The greatest risk for postinfectious renal scarring occurs within the FIRST YEAR of life.

**The kidney’s predilection for postpyelonephritic scarring is inversely proportional to age. This point is a guiding principle that must be considered in all decisions regarding reflux diagnosis and choice of therapy.

Question 12

Define: Bladder diverticulum

Answer 12

The outpouching of mucosa between detrusor muscle bundles, which lacks any true muscle backing itself.

Question 13

Does a paraureteral diverticulum affect VUR?

Answer 13

YES.

If the UVJ is distorted by a paraureteral diverticulum, which shares an anatomic point of origin at or near the UVJ, it is possible that the diverticulum could compromise the antireflux configuration of the UVJ to cause reflux

Reflux associated with paraureteral diverticula resolves at rates similar to that of primary reflux and should be managed according to the prevailing indications for the reflux itself, irrespective of the diverticulum.

EXCEPT: Refluxing ureter enter diverticulum - it is no longer paraureteral –> reflux is not expected to resolve.

Question 14

Renal anomalies associated with VUR (2)

Answer 14

Multicystic dysplastic kidney
AND
Renal agenesis

** In the largest series to date, 75 patients with MCDK showed a prevalence of contralateral reflux of 26% (19 patients), and one-half of these were low grade (1 to 2).

** 19 cases of contralateral reflux were observed in 51 patients with ipsilateral renal agenesis (Song et al., 1995).

Question 15

Megacystis-megaureter

Answer 15

Massive bilateral VUR –> remodeling of upper urinary tract –> inefficient bladder urine expulsion + return of refluxed urine into bladder –> gradual bladder dilatation –> massive hydroureter + thin-walled bladder

Question 16

VUR-associated congenital syndromes (2)

Answer 16

VACTERL
(Vertebral, Anal, Cardiac, TracheoEsophageal, Renal, Limb)

and

CHARGE (Coloboma, Heart disease, Atresia choanae, Retarded development, Genital hypoplasia, Ear anomalies, + imperforate anus)

Question 17

Spontaneous resolution rates by grade (Estrada et al., 2009)

Answer 17

1: 72%
2: 61%
3: 49%
4/5: 32%

Study by Estrada et al., 2009, with almost 2 years follow-up

Question 18

Most important principle in VUR management

Answer 18

The preservation of renal function and prevention of UTI and renal scarring is paramount.

Question 19

6 Essential Tenets of Reflux Management

Answer 19

1. Spontaneous resolution of reflux is very common and facilitated
   by correction of BBD.
2. Higher grades of reflux are less likely to resolve spontaneously,
   especially when diagnosed in older children after UTI.
3. Sterile reflux is unlikely to cause significant renal damage.
4. Prevention of UTI is more important than VUR resolution.
5. The use of prophylactic antibiotics is safe and beneficial, particularly
   in high-risk patients.
6. There is a role for medical management for most forms of reflux.

Question 20

Classic approach to management of VUR

Answer 20

Offer daily low-dose prophylactic antibiotic suppression of infections as the first line of treatment while awaiting spontaneous reflux resolution, regard- less of grade.

Question 21

Advantage of nighttime dosing in continuous antibiotic prophylaxis

Answer 21

Nighttime dosing allows for antibiotic concentration in the bladder urine over the longest period of expected physiologic retention, when infection is most likely to develop.

Question 22

___ causes jaundice in < 2 months, because of hepatic immaturity.

Answer 22

Sulfamethoxazole

Question 23

___ or ___ while on antibiotic prophylaxis are indications for termination of CAP and correcting reflux

Answer 23

Breakthrough febrile UTIs

Pyelonephritis

Question 24

International Reflux Study in Children

Answer 24

P: High-grade reflux, < 9 years
I/C: Surgery vs. CAP
O: Surgery more effective in reducing but not eliminating PN.
Equal incidence of UTI and effectivity in reducing not eliminating scar formation.

Question 25

Birmingham Reflux Study

Answer 25

P: High-grade reflux 104 patients
I/C: Medical vs surgical
O: Same incidence of new scars with either treatment modality, in 5-year period;

Question 26

Swedish Reflux Study

Answer 26

P: Children with dilating VUR in 23 centers in Sweden
I/C: Surgery vs CAP vs surveillance
O:
there is a role for up-front treatment with either endoscopic injections or CAP, predominantly in girls, with associated reductions in both recurrent UTIs and new renal scars

Question 27

Randomized Intervention for the Management of VUR Study (RIVUR)

Answer 27

P: 607 children, Gr I-IV reflux after initial or 2nd febrile or symptomatic UTI
I/C: Placebo vs. TMP-SMX
O: antibiotic prophylaxis reduced recurrent UTI risk by 50%, but no difference in scarring