GU - Vesicoureteric Reflux

Question 1

Defintion

Answer 1

Abnormal back flow of urine from the bladder into the ureter and kidney

Question 2

Epidemiology and risk factors

Answer 2

Common in children
Female
FHx
Neurological conditions

Question 3

Aetiology

Answer 3

Primary (MC)
● Congenital defects e.g. short ureter, narrow ureter, abnormal opening of ureter into bladder

Secondary: Urinary tract obstruction
● Recurrent UTIs = inflammation and narrowing of ureters
● Posterior urethral valve disorder
● Flaccid neurogenic bladder:

Question 4

Pathophysiology

Answer 4

In a healthy urinary tract, urine flows unidirectionally from the kidneys to the bladder via the ureters. The ureters have a valve-like mechanism called the vesicoureteral junction (VUJ) that prevents urine from flowing back into the ureters during bladder filling.
In VUR the ureters are displaced laterally, entering the bladder more perpendicularly, therefore there is a shortened intramural course of the ureter. This means the VUJ cannot function properly.

Question 5

Grade

Answer 5

I - Reflux into the ureter only, no dilatation
II - Reflux into the renal pelvis on micturiton, no dilatation
III - Mild/moderate dilatation of the ureter, renal pelvic and calyces
IV - Dilatation of the renal pelvis and calyces with moderate ureteral tortuosity
V - Gross dilatation of the ureter, pelvis, and calyces with ureteral tortuosity

Question 6

Signs and symptoms

Answer 6

● Antenatal period: hydronephrosis on USS
● Recurrent childhood UTIs
● Abdominal/Flank pain
● Urinary symptoms- urgency, frequency, enuresis
● Reflux nephropathy: chronic pyelonephritis secondary to VUR
● Failure to thrive/poor growth
● High blood pressure

Question 7

Diagnosis

Answer 7

FIRST LINE = Urinalysis/urine culture (check for UTIs) + Micturating cystourethrogram (MCUG)

Other: Renal USS + DMSA

Question 8

Management

Answer 8

● Watchful Waiting: For low-grade VUR (grades I to III) without recurrent UTIs or complications,
● Antibiotic Prophylaxis: may be considered for children with higher-grade VUR (grades IV and V), recurrent UTIs, or those at higher risk of complications
● Surgical intervention recommended for more severe cases of VUR or when conservative measures are ineffective or CI.
= Endoscopic injection of a bulking agent (such as Deflux) into the submucosal tissue at the ureterovesical junction can help improve the closure of the valve and reduce reflux.
= Surgical correction, such as ureteral reimplantation, may be considered for cases where endoscopic treatment is not appropriate or unsuccessful

Question 9

Complications

Answer 9

UTIs,
Renal scarring,
Hydronephrosis,
Hypertension,
CKD