Pediatric Urology

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Treatment

Treatment for grades I – III VUR includes daily low-dose antibiotics (e.g., trimethoprim-sulphamethoxazole, amoxicillin) until the reflux resolves or until the child is at least 5 years old. These cases require regular monitoring by a pediatric urologist to diagnose UTI and prevent the condition from worsening.

Secondary reflux that does not resolve with antibiotic treatment, or that results in UTI despite antibiotic therapy (called breakthrough infections), and primary reflux that is severe (grades IV and V) require surgery to prevent permanent kidney damage.

Nonoperative Management
When reflux is related to an underlying problem such as constipation, infrequent voiding, abnormal bladder activity, or blockages such as strictures or valves, the predisposing factor should be corrected first and the reflux then re-evaluated.

Mild-to-moderate degrees of reflux (grades I to III) have a good chance of spontaneous resolution with age in over 80% of children. This typically occurs over the span of few years. Unfortunately, there is no magic crystal ball that will tell us exactly when the reflux will go away for a particular child. The chance of spontaneous resolution of high grade reflux (IV to V) is much lower.

The key to the nonoperative management of reflux is to buy the children the time to outgrow the reflux without getting into infection problems. Certainly with a high likelihood of spontaneous resolution, most children with mild-to-moderate reflux should be given a chance to outgrow their reflux. While we wait for this to happen, they are protected from urinary infection using low doses of preventive antibiotics.

After an 1- to 2-year interval of treatment with antibiotics, reflux is reevaluated with VCUG. At the same time, doctors check the kidneys with ultrasonography to be certain they are growing properly and no interval damage has occurred.

No antibiotic is risk-free, and likewise no antibiotic will destroy all types of bacteria. Nevertheless, amoxicillin, cephalosporin, trimethoprim-sulfamethoxazole, and nitrofurantoin have proven the most useful and effective preventive antibiotic agents with minimal side effects.

During the course of nonoperative management, any fever, unexplained illness, or urinary tract symptoms (burning, frequency, urgency, foul odor, bloody urine, or unusual urinary accidents) must be aggressively evaluated with urine analysis and urine culture to make certain that it is not a urinary infection.

A breakthrough urinary infection, in spite of preventive antibiotics, is a dangerous situation indicating that there is not enough time for spontaneous resolution and that the next step should be surgical correction of reflux.

Surgical Correction
Correction of reflux (called ureteral reimplantation or ureteroneocystostomy) is recommended for high grades of reflux (because they are unlikely to resolve by themselves), for reflux that fails to resolve on its own despite monitoring over several years, and for patients with breakthrough infections.

The traditional surgical approaches have high degrees of success and usually involve opening the bladder and creating a new, longer tunnel for the ureter to pass through the bladder wall. If the ureter is very wide due to high grade reflux, it may need to be narrowed to make a successful flap valve with at least a 4:1 ratio of tunnel length to ureter width.

Potential complications include bleeding, infection, urinary leakage, and bladder spasms shortly after the surgery (usually resolve in 2 to 3 weeks), and ureteral obstruction or persistent reflux later. The latter two complications are managed differently if they occur.

Sometimes complications improve on their own with time and other times, additional surgery is necessary. The child is left on preventive antibiotics for several months until postoperative VCUG proves that the reflux has been corrected.

Other surgical methods that may be performed include laparoscopic correction and using an endoscope to inject a bulking agent (e.g., Deflux®) at the ureteral opening.

Overall experience with these treatment methods is limited compared to traditional surgical approaches and, in general, they are considered less effective in correcting VUR.

Bulking agents are used to create a bulge in the tissue, making it more difficult for urine to flow back up the ureter. This outpatient procedure usually is performed under general anesthesia and takes about 15 minutes. If VUR does not resolve, this treatment can be repeated. Side effects include urinary tract infections and widening of the ureter.

Prevention
The kidneys filter the blood and extract waste products from the blood to make urine. Urine passes from the kidneys, down the ureters, and into the bladder for storage prior to urination.

The ureter normally enters the bladder wall at an angle so that a flap valve is created. This valve prevents the bladder urine from backing up toward the ureter and kidney. Thus, when the bladder fills and when it squeezes down to empty, backup (also called reflux) is prevented because the valve operates in the same way as you might "step on a straw."

This valve-like action creates an important barrier that helps keep the kidneys free of bacteria. Once urine has passed from the upper urinary tract into the bladder, the normal valve not only makes certain that urine does not reenter the upper tracts, but it also ensures that the high pressures created at the moment of urination are not transmitted to the kidneys. Another important feature of a properly working valve at the ureter-bladder (ureterovesical) junction is that it permits you to remove all of the stored urine from the body with a single act of urination–that is, the bladder urine has nowhere to go other than out the urethra.

Follow-Up
All patients with a history of reflux should be monitored for life. Even if the reflux resolves (either spontaneously or by surgery), the risk of kidney malfunction, hypertension, and pregnancy-related problems still exists. This usually involves periodic visits to the pediatrician's office with measurement of height and weight, blood pressure, and urine analysis. Kidney function can be crudely evaluated by blood tests (creatinine and BUN) or more precisely checked by creatinine clearance or glomerular filtration rate. Occasional ultrasound tests will ensure that kidney growth is on target for age. Female patients should be carefully monitored during their pregnancy.

By the time surgical correction has been performed, some children have already had significant kidney damage. In other patients , the kidney damage from reflux early in life may result in kidneys that don't grow appropriately in size or function and thereby seem to deteriorate with age. When kidney deterioration has been demonstrated, the pediatric nephrologists must begin careful surveillance with appropriate medication and dietary restriction.

Does Reflux Run in the Family?
If a child with reflux has a brother or sister, there is a 1 in 3 chance that the sibling will also have reflux, even in the absence of any urinary infections. Because we know that the chances of kidney damage are highest in the first 6 years of life, we think that brothers and sisters in that age range should be aggressively studied with ultrasonography and VCUG, even though they may not have had any urinary infection. Older siblings, in the absence of symptoms, may be more simply screened with urine analysis and ultrasonography. There is also evidence that offspring of the patients with reflux are more likely to develop reflux.

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