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Vesicoureteric reflux

  1. Refers to the retrograde flow of urine from the bladder to the upper urinary tract.
  2. VUR is present in 20-35 % of children with febrile UTI and is a major risk factor for acute pyelonephritis and reflux nephropathy.
  3. The radiocontrast MCU is most commonly used since in addition to showing VUR it provides excellent anatomical details.
  4. Isotope radio nucleotide cystography is more sensitive for detecting VUR and causes less radiation exposure than the former out provides less anatomical details.
  5. The severity is graded from I to V. 

Natural History.

  1. The incidence of renal scarring or reflux nephropathy increases with the grade of reflux.
  2. Lower grades of reflux are much more likely to resolve than are higher grades.
  3. For grades I and II reflux, the likelihood of resolution is similar irrespective of age at diagnosis and whether it is unilateral or bilateral.
  4. For grade III, a younger age at diagnosis and unilateral reflux generally are associated with a higher rate of spontaneous resolution.
  5. Bilateral grade IV reflux is much less likely to resolve than is unilateral grade IV reflux.
  6. Grade V reflux rarely resolves.
  7. The mean age at reflux resolution is 6–7 yr.
  8. Reflux is unlikely to cause renal injury in the absence of infection.
  9. However, in situations with high-pressure reflux, as in children with posterior urethral valves, neuropathic bladder, and non-neurogenic neurogenic bladder (Hinman syndrome), sterile reflux can cause significant renal damage.
  10. Children with high-grade reflux who acquire a UTI are at significant risk for pyelonephritis and renal scarring.
  11. Continuous antibiotic prophylaxis is recommended as the initial management.
  12. Medical management with antibiotic prophylaxis is considered successful if the child remains free of infection and has no new renal scarring and if the reflux resolves spontaneously.
  13. Breakthrough UTI, development of new renal scars, and failure of reflux to resolve are examples of failed medical management.  

TABLE :Treatment Recommendations for Vesicoureteral Reflux Diagnosed Following a Urinary Tract Infection[*]
 

GRADE

AGE (YR)

SCARRING

INITIAL TREATMENT

FOLLOW-UP

I–II

Any

Yes/No

Antibiotic prophylaxis

No consensus

III–IV

0–5

Yes/No

Antibiotic prophylaxis

Surgery

III–IV

6–10

Yes/No

Unilateral:antibiotic prophylaxis

Surgery

 

 

 

Bilateral:surgery

 

V

<1

Yes/No

Antibiotic prophylaxis

Surgery

V

1–5

No

Unilateral:antibiotic prophylaxis

Surgery

V

1–5

No

Bilateral:surgery

 

V

1–5

Yes

Surgery

 

V

6–10

Yes/No

Surgery

 

 

*

Summary of guidelines developed by American Urological Association;age refers to age at diagnosis.

 

Surgical treatment

  1. Grade IV to V reflux (especially if persisting beyond infancy)
  2. Non compliance or intolerance to medication.
  3. Appearance of new renal scars or deterioration of renal function during medical therapy
  4. Multiple recurrent UTI desptie prophylaxis.




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