Vesicoureteral reflux (VUR)

Diagnosis  

The most commonly used imaging tests for diagnosing vesicoureteral reflux (VUR) are as follows: 

• Voiding cystourethrogram (VCUG): This is an x–ray image of the bladder and urethra taken before, during, and after urination. A small catheter is inserted into the urethra to fill the bladder with a special dye visible on x–rays. VCUG helps determine if urine is flowing backward from the bladder into the ureters. It can be done in a healthcare provider’s office, outpatient center, or hospital. While anesthesia is not usually required, sedation may be used for some children. 
• Radionuclide cystogram (RNC): RNC is a nuclear scan involving the introduction of radioactive material into the bladder. A scanner detects the radioactive material during urination or after the bladder is emptied. This procedure is typically performed by a specially trained technician in a healthcare provider’s office, outpatient center, or hospital. The images are then interpreted by a radiologist. Anesthesia is generally not necessary, but sedation might be used for certain children. RNC is more sensitive than VCUG but provides less detailed information about the bladder’s anatomy. 
• Dimercaptosuccinic acid (DMSA) scan: This imaging test helps identify any kidney scars resulting from a urinary tract infection (UTI) affecting the kidney. It is usually recommended when a kidney ultrasound shows abnormalities. 
• Ultrasound: This painless and safe imaging technique uses sound waves to produce images of the entire urinary tract, including the kidneys and bladder. However, it does not provide detailed information about the grade of VUR. Ultrasound can be performed in a healthcare provider’s office, outpatient center, or hospital, and anesthesia is typically not required. It may be used before a VCUG or RNC if you or your healthcare provider wish to avoid exposure to x–ray radiation or radioactive material. It is often used in the following situations: 

• Infants diagnosed during pregnancy (while they’re still in the uterus) with urine blockage affecting the kidneys. 
• Children under the age of five who have a urinary tract infection (UTI). 
• Children with a UTI and fever, known as febrile UTI, regardless of their age. 
• Males with a UTI who are not sexually active, regardless of their age or presence of fever. 
• Children with a family history of VUR, including those with an affected sibling. 

• Children who are five years of age or older and have a UTI. 

If your child has been diagnosed with vesicoureteral reflux (VUR), the following tests should be conducted: 

• Blood pressure checks: Children with kidney problems are at a higher risk of developing high blood pressure. Regular monitoring is necessary to identify any abnormalities. 
• Blood tests: These tests measure the levels of protein and creatinine in the blood. High protein levels or elevated creatinine levels indicate kidney damage. 
• Urine tests and culture: Urine tests are performed to detect the presence of protein, which is a sign of kidney damage, and to identify any bacteria, which may indicate an infection. 

Treatment  

The treatment choices for vesicoureteral reflux are determined by the extent of the condition. If a child has a mild case of primary vesicoureteral reflux, they may eventually overcome the disorder without intervention. In such instances, a doctor might advise a watchful waiting approach. 

 In cases where vesicoureteral reflux is more severe, there are various treatment options available, including: 

Medication 

Medications play a crucial role in the treatment of vesicoureteral reflux. When it comes to urinary tract infections (UTIs), prompt administration of antibiotics is necessary to prevent the infection from spreading to the kidneys. Additionally, doctors may prescribe lower doses of antibiotics as a preventive measure against UTIs. During medication treatment, it is important to closely monitor the child with regular phvysical exams and urine tests to detect any breakthrough infections. Periodic radiographic scans of the bladder and kidneys may also be conducted to assess whether the child has outgrown vesicoureteral reflux. 

Surgery 

Surgery for vesicoureteral reflux aims to correct the defect in the valve between the bladder and the affected ureter, which causes urine to flow backward. There are different methods of surgical repair available: 

• Open surgery: This procedure is performed under general anesthesia and involves making an incision in the lower abdomen. The surgeon accesses the valve and repairs the problem. After the surgery, a catheter is usually left in place to drain the bladder, and the child may need to stay in the hospital for a few days. In most cases, vesicoureteral reflux resolves on its own without further intervention, although it may persist in a small number of children.
• Robotic–assisted laparoscopic surgery: Similar to open surgery, this technique also involves repairing the valve between the ureter and the bladder. However, it is performed using small incisions and with the assistance of a robotic system. The advantages of this approach include smaller incisions and potentially fewer bladder spasms compared to open surgery. However, preliminary findings suggest that robotic–assisted laparoscopic surgery may have a lower success rate than open surgery. It also tends to have a longer operating time but results in a shorter hospital stay.
• Endoscopic surgery: This minimally invasive procedure involves the insertion of a cystoscope, a lighted tube, through the urethra to visualize the inside of the bladder. The doctor then injects a bulking agent around the opening of the affected ureter to strengthen the valve’s ability to close properly. Endoscopic surgery carries fewer risks compared to open surgery and can often be performed as outpatient surgery. However, it may not be as effective in treating vesicoureteral reflux. General anesthesia is required for this procedure.