Vesicoureteric Reflux Flashcards
What is vesicoureteric reflux (VUR)?
The retrograde flow of urine from the bladder into the upper urinary tract
What causes VUR?
When the ureters are displace laterally and enter directly into the bladder rather than at an angle, with a shortened or absent intramural course
What can severe cases of VUR be associated with?
Renal dysplasia
Is all VUR the same?
No, a spectrum of severity
What happens in more mild VUR?
There is reflux into the lower end of an undilated ureter during micturition
What happens in the most severe form of VUR?
Reflux during bladder filling and voiding with a distended ureter, renal pelvis and clubbed calyces
Is mild reflux always significant?
No
What can happen with more severe VUR?
- Intrarenal reflux
What is intrarenal reflux?
Backflow of the urine from the renal pelvis into the papillary connecting ducts
What is intrarenal reflux associated with?
High risk of renal scarring if UTI’s occur
Of what origin is VUR most commonly?
Congenital
When might VUR be acquired?
Post-surgery
What other bladder pathologies might VUR occur with?
- Neuropathic bladder
- Urethral obstruction
- After UTI (temporary)
What are the clinical features of VUR?
There are no specific clinical features of VUR
How is VUR identified?
It is identified by investigation after atypical UTIs or recurrent UTIs
On what basis is VUR graded?
The extent of retrograde reflux from the bladder
What is grade I VUR?
Into ureter only
What is grade II VUR?
Into ureter, pelvis, and calcyes with no dilation
What is grade III VUR?
With mild/moderate dilatation, slight or no blunting of fornices
What is grade IV VUR?
Moderate dilation of ureter and/or renal pelvis, and/or tortuosity of ureter, and obliteration of sharp angle of fornices
What is grade V VUR?
Gross dilation, tortusity, no papillary impression visible in calyces
What is a diagnosis of VUR made on the basis of?
A micturating cystourethrogram (MCUG)
What does a MCUG involve?
Urinary catheterisation, and the administration of radiocontrast medium into the bladder
When is reflux detected in MCUG?
On voiding
What is good about MCUG?
You can see the grade of reflux
What is bad about MCUG?
- Requires catheterisation
- Give radiation dose
What are the differential diagnoses of VUR?
- Antenatal hydronephrosis
- Neurogenic bladder dysfunction
- Posterior urethral valves
- Ureterovesical obstruction
What is the aim of management of VUR?
Prevent infection
Why is it important to prevent infection in VUR?
To prevent renal scarring
What does the medical management of VUR involve?
Prophylactic antibiotics
Is surgery routinely recommended in VUR?
No
What are the indications for surgery in VUR?
- Failed medical therapy
- Poor compliance
What are the surgical options for the management of VUR?
- STING procedure
- Endoscopic injection of maternal behind ureter
- Open surgery with re-implantation of ureters
What is a STING procedure?
Subureteric Teflon injection
What is the purpose of endoscopic injection of material behind the ureter?
To provide a valve mechanism during bladder filling and emptying
What imaging methods are sometimes used for follow-up of VUR?
Indirect cystogram and DMSA
What are the potential complications of VUR?
- Renal scarring
- VUR associated ureteric dilation
- UTI
- Renal damage
What is another term for the renal scarring seen due to VUR?
Reflux nephropathy
What happens in reflux nephropathy?
Untreated UTI’s lead to permanent damage to the kidney tissue
What can extensive renal scarring lead to?
High blood pressure and kidney failure
