Understanding Vesicoureteral Reflux
Children with vesicoureteral reflux (VUR) have an abnormal urine flow. Normally, urine flows down from the kidneys through tubes called ureters into the bladder. In VUR, the urine can back up from the bladder into the ureters and kidneys.
Sometimes, VUR is caused by a birth defect — specifically, a leaky valve between the ureter and bladder. As a child gets older, the valve may begin to work normally, so VUR may disappear. But sometimes it doesn't. VUR tends to run in families and most often affects girls.
In other children, VUR may be caused by something that blocks the urine flow from the bladder. For example, a child’s habit of "holding in" the urine can sometimes cause VUR. Or, it could be secondary to high bladder pressure or obstruction in the urethra (the tube that takes the urine from the bladder outside the body) in boys.
Symptoms of Vesicoureteral Reflux
Typically, a urinary tract infection is the most common sign of VUR in infants and young children. VUR can lead to infection because bacteria can build up in the urine that doesn't empty from the bladder. This infection can then move up into the kidneys. Older children may have other symptoms, such as failure to thrive, abnormal urination and high blood pressure.
Diagnosing Vesicoureteral Reflux
Imaging tests can help doctors determine if there is a problem with the urinary tract. Some of these tests include:
- Ultrasound, which uses sound waves to check the kidney and bladder
- Voiding cystourethrogram (VCUG), which is a special bladder X-ray that checks the flow of urine. This test is conducted by a pediatric radiologist, who will insert a small tube into the urethra and fill your child's bladder with a special dye. If your child has VUR, the radiologist will see the dye flow backwards up toward the kidneys as the bladder fills or as your child urinates.
These tests can help doctors determine the severity of VUR, which is rated from grade I (very mild) to grade V (very severe).
A DMSA renal scan is a diagnostic imaging exam that evaluates the function, size, shape and position of the kidneys and detects scarring caused by frequent infections. A radioisotope is injected into your child's veins through an IV prior to the scan. The radioisotope is taken up by the kidneys in about three to four hours. A special camera, called a gamma camera, is then used to take pictures of the kidneys and show how the kidneys are working.
Vesicoureteral Reflux Treatments
Without medical attention, VUR can cause infections that move into the kidneys and cause scars. This can permanently damage the kidneys. Fortunately, there are medical and surgical approaches to treating VUR that can help prevent this.
At Comer Children's, children receive comprehensive treatment for VUR from our highly trained pediatric urologist. Some children may only need conservative management. They will require a daily low-dose of antibiotics until they are age 3 to 5 years. This will help prevent urinary tract infections. They'll also need regular imaging tests. If children have started or finished potty training, they will also take part in bladder retraining. Comer Children's is home to a well-respected bladder clinic, where children undergo a customized program that helps them learn dietary changes and new behaviors to prevent infections. Under the guidance of a nurse practitioner, children learn how to empty their bladder on a schedule and avoid holding their urine.
It might be recommended that your child consumes probiotic foods. Probiotics help replenish normal flora to create a better environment in the urinary tract and they are a harmless approach to help prevent urinary tract infections.
When conservative treatment fails or is not the preferred option, children have access to the latest surgical therapies available at Comer Children's. This includes an endoscopic approach to VUR. During this outpatient procedure, the child receives general anesthesia. Then, our pediatric urologist places a small tube through the urethra and into the bladder. The doctor injects a safe, nontoxic gel into the bladder wall, near where the ureters join the bladder. This gel forms a bulge that helps prevent urine from flowing back up into the ureter. Research shows that this treatment has a 70 to 80 percent cure rate with one injection and this could be safely repeated, if needed, to reach a 100 percent cure rate.
Robotic surgery is an option for all grades of VUR, but endoscopic correction is still the best for low grades I-III and it has a role in high grade (IV-V) VUR treatment instead of open surgery. The advantages of the robotic approach are the avoidance of large surgical scars, minimal pain and a faster recovery. The success rate is almost equal to open surgery — 95% with expertise.
Traditional, or open surgery, is another approach for higher grades of VUR. This type of surgery has a higher success rate than the minimally invasive approach. However, it is more invasive. The doctor will make an incision in the lower abdomen and move the ureter to a different angle so that urine will not back up from the bladder.