Vesicoureteric reflux

Definition/diagnostic criteria Vesicoureteric reflux (VUR) is a condition characterised by the backward flow of urine from the bladder into the ureters or kidneys. Diagnostic criteria involve the identification of VUR grades I to V, based on the International Reflux Study Committee classification. This classification is determined through imaging studies, with grade I indicating reflux into the ureter only and grade V indicating severe reflux with twisting of the ureter and renal pelvis.

Epidemiology VUR is more prevalent in infants and young children, with a higher incidence in the first year of life. It affects approximately 1% of children, with a higher incidence reported in Caucasians. There is a familial tendency, suggesting a genetic predisposition. The condition is more common in females than in males, except in infancy where the prevalence is higher in males.

Diagnosis
Clinical features:
Clinically, VUR is often suspected in children with a history of urinary tract infections (UTIs), particularly those with atypical or recurrent infections. Symptoms may include a poor urine stream, dribbling, incontinence, and signs of kidney impairment in more severe cases.

However, a significant number of cases are asymptomatic and are diagnosed incidentally.

Investigations:

• The gold standard for diagnosing VUR is a micturating cystourethrogram (MCUG), which involves the instillation of contrast medium into the bladder and X-ray imaging during voiding.
• Renal and bladder ultrasound may also be used as initial investigations to assess kidney size, signs of scarring and bladder abnormalities.
• Dimercaptosuccinic acid (DMSA) scintigraphy is useful for identifying renal scarring.

Typical abnormalities include dilatation of the ureter(s) and the presence of urine in the ureter(s) or renal pelvis during voiding.

Treatment The treatment of VUR aims to prevent UTIs and subsequent renal damage. Management is individualised based on age, severity of reflux, and presence of complications like renal scarring.

Conservative management: Involves long-term antibiotic prophylaxis, regular monitoring, and bladder and bowel management. This approach is more common in younger children with lower grades of VUR, as spontaneous resolution is possible.

Surgical management: Indicated in high-grade VUR, failure of conservative management, or the presence of significant renal scarring. Surgical options include endoscopic injection of bulking agents or ureteric re-implantation surgery. The choice of surgery depends on the specific anatomical and clinical scenario.

Prognosis The prognosis of VUR is generally good, especially for low-grade VUR, which often resolves spontaneously. High-grade VUR has a risk of leading to renal scarring, hypertension, and impaired renal function. Long-term follow-up is essential to monitor renal function and growth, blood pressure, and resolution of VUR.