Campbell Pediatric VUR 2021 Flashcards
Indications for VCUG in the newborn period
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
TRUE or FALSE:
Reflux is significantly more common in younger children and may resolve spontaneously over time
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
AUA 2010 VUR Guidelines:
When should siblings with VUR be screened with a VCUG?
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.
Primary reflux
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.
Secondary reflux
- Increased intravesical pressure
- Bladder: neurogenic, non-neurogenic
- Outlet: mechanical (PUV< stricture, mass) - Abnormal UVJ
- Diverticulum
- Ureterocele/duplication
- Iatrogenic
___ is by far one fo the most critical and modifiable variables that affect VUR resolution.
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.
Classic presentation of BBD
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
TRUE or FALSE:
Reflux causes UTI.
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.
International Classification of VUR
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
Ureteric orifice position and reflux:
Obstruction occurs in ____ zone.
Reflux occurs in the ____ zone.
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.
The greatest risk for postinfectious renal scarring occurs within the ____ of life
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.
Define: Bladder diverticulum
The outpouching of mucosa between detrusor muscle bundles, which lacks any true muscle backing itself.
Does a paraureteral diverticulum affect VUR?
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.
Renal anomalies associated with VUR (2)
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).
Megacystis-megaureter
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
VUR-associated congenital syndromes (2)
VACTERL
(Vertebral, Anal, Cardiac, TracheoEsophageal, Renal, Limb)
and
CHARGE (Coloboma, Heart disease, Atresia choanae, Retarded development, Genital hypoplasia, Ear anomalies, + imperforate anus)
Spontaneous resolution rates by grade (Estrada et al., 2009)
1: 72%
2: 61%
3: 49%
4/5: 32%
Study by Estrada et al., 2009, with almost 2 years follow-up
Most important principle in VUR management
The preservation of renal function and prevention of UTI and renal scarring is paramount.
6 Essential Tenets of Reflux Management
- Spontaneous resolution of reflux is very common and facilitated
by correction of BBD. - Higher grades of reflux are less likely to resolve spontaneously,
especially when diagnosed in older children after UTI. - Sterile reflux is unlikely to cause significant renal damage.
- Prevention of UTI is more important than VUR resolution.
- The use of prophylactic antibiotics is safe and beneficial, particularly
in high-risk patients. - There is a role for medical management for most forms of reflux.
