This document discusses vesicoureteral reflux (VUR), beginning with its history and definitions. It then covers the demographics of VUR, including higher rates in infants, males, and those with family history or urinary tract infections. Anatomical features like ureteral insertion point influence reflux risk. Evaluation involves imaging like VCUG, DMSA scans, and ultrasound. Associated conditions include duplication, obstruction, and bladder/renal anomalies. Grading systems classify reflux severity. Management considers risk of renal damage from infection versus intervention side effects.

1. VESICOURETERAL REFLUX DR BHARAT SHARMA
MODERATOR- DR GAURAV
KOCHHAR

2. INTRODUCTION
Vesicoureteral ref lux (VUR) represents the retrograde flow of urine
from the bladder to the upper urinary tract
Galen and da Vinci:
- First references to VUR by Western medicine
- UVJ as a mediator of unidirectional flow of urine from the kidneys to
the bladder
Hutch(1952): Relationship between VUR and chronic pyelonephritis in
paraplegic patients
Hodson(1959):UTI and renal scarring carried a high likelihood of VUR
in children

3. DEMOGRAPHY
Incidence 0.4-1.8% in overall pediatric population
VUR in children with UTI- 30 - 50% (more in infants >
70%)
- 17% without UTI.
VUR in Antenatal Hydronephrosis – 15-38%
Highest incidence of VUR – Infants & Post Natal Renal
abnormalities

4. GENDER
 Male
 present at younger
age
 Severe degree of VUR
 Uncircumcised male
12X
INHERITANCE
 Autosomal Dominant
 Identical twins- 80-
100%
 Other siblings 40-50%
 Parent to child
transmission-60%
REFLUX IN FETUS
 Related to fetal/
Antenatal HDN
 HDN has low specificity
for postnatal VUR
 38% VUR in Antenatal
HDN
 19% VUR - Bilaterally

5. Race
Caucasian 3.4:: 1 Africans
Caucasian girls increased risk of scarring associated
with VUR
Reflux in female African tends to resolve faster and
also has lower grade at presentation
Caucasians are likely to develop Anti reflux
mechanism comparatively later in life.
AGE

6. SIBLING REFLUX
Prevalence of VUR in siblings to be approximately 40-50%
Prevalence - 7% in older siblings
- 100% in identical twin siblings.
Now the concern arises if screening should be done in
asymptomatic sibling????
Renal consequences of reflux that are important than
reflux itself
So Initially non invasive screening (Renal USG)
If associated UTI/ BBD in sibling then consider invasive
(Renal Scintigraphy)

7. Age of screening in Sibling Reflux
Not for age>5 yrs (less chances of pyelonephritis or
scarring
Sibling > 5 yrs if normal kidney with or without VUR –
less significant
Sibling< 5 yrs with cortical defects – have most to
lose by febrile UTI

8. GENES
Probably many genes are involved:
- PAX2
- GDNF-RET
- UPK3
- AGTR2-ACE
No specific gene product or functional role for these
loci in reflux has yet been identified

9. ANATOMICAL FEATURES AND
EMBRYOLOGIC ORIGINS OF THE
URETEROVESICAL JUNCTION
The UVJ is anatomically and functionally adapted to
allow intermittent passage of the urinary bolus from
the ureter into the bladder while preventing the
retrograde flow of bladder urine back toward the
kidney during storage and micturition.
Oblique intramural path (intramural ureter) and
extends through a submucosal tunnel of appropriate
length (submucosal ureter) to open onto the trigone

11. PASSIVE MECHANISM
“Flap valve” configuration causes the intramural and
submucosal ureter to be compressed with progressive
bladder filling against the detrusor muscle backing,
Intravesical length of ureter
Neonates -0.5 cm
Adults- 1.3 cms(2-2.5cms), by 10-12 yrs of age

12. Active Ureteral Trigonal
Mechanism
 BELL’S MUSCLE
 Ureteral
longitudinal muscle
extending into the
trigone forming
superficial trigone
 Crosses the other
side to mix with
contralateral
ureteral
longitudinal muscle
 In males – extends
upto proximal
veromontanum
 In females - dorsal

13.  MIDDLE CIRCULAR MUSCLE
 Extends upto ureteral hiatus
 WALDEYER’S SHEATH
 Adventitia of ureter just outside the bladder wall fuses with
fibromuscular sheath that encircles the ureter
 Due to waldeyers sheath anchorage, ureter can freely slide
leading to efflux of bolus
 INTERMEDIATE LAYER OF URETER
 Likely to have role in ureter trigonal relationship
 Gives contribution to Deep Trigone
 Rich innervation by nor adrenenrgic receptors
 Homologus to BELL’S muscle

14. EVIDENCE OF URETERAL TRIGONE RELATIONSHIP
L3-L5 U/L SYMPATHECTOMY- reflux or dilated ureter
Trigonal stimulation- by electric / epinephrine inj and
bladder distension cause decrease functional
occlusion of ureter
Trigonal and uretric continuation- if surgically
excised VUR present, But with healing VUR resolves

15. RELATION WITH FLAP VALVE
MECHANISM
Trigonal competency- to maintain ureteral length and obliquity
of intravesical ureter
Inadequate Trigonal function- lateral displacement of ureteric
orifice , migration away from bladder neck during filling leading
to reduction in intravesical length
Lateral displacement of ureteric orifice and its abnormal
appearences in association with VUR
 D/t abnormal ureteric bud origin along the developing
mesonephric duct
 Correlation between lateral displacement of ureteric orifice
and degree pf Renal dysplasia and hypoplasia

17. LYON & colleagues
Heale confirmed above findings
that increased chances of VUR/
Scarring with more laterally
placed ureters
Shape of Ureter Chance of VUR(%)
Cone/ volcano 4
Stadium 28
Horseshoe 83
Lateral pillar
defect(stephens)
Golf hole 100

18. PRIMARY V/S SECONDARY VUR
PRIMARY
Functional and anatomical VUJ
Dysfunction
SECONDARY
Neurogenic-
Spina bifida
Infant voiding patterns
Dysfunctional voiding
Uninhibited bladder
contractions is the most
common urodynamic
abnormality associated with
reflux in neurologically
normal children.
Constipation
Non Neurogenic-
Boys- PUV (> 50% VUR),
Resolution of Reflux Post
PUV Ablation about 6
months
Girls – Ureterocele
OTHERS- ureteral duplicaiton

19. •Note – Intravesical pressure > 40 cm of H2O -> 80%
chances of VUR
•In Infants and children – Abnormal LUT function with
VUR without any neurogenic or anatomic cause, VUR is
due to Lower urinary tract function
•On UDS- It is d/t imperfect coordination b/w Detrusor
contraction and sphincter relaxation
•Disappaears after 2 years of age

20. •This is thought to result from a lack of integration
between the bladder, the external urethral sphincter,
the brainstem, and the higher cortical centers.
•Compared with normal infants, those with VUR have
an even higher voiding pressure and abnormal bladder
function, even in the absence of UTI.
•The abnormal urodynamics seen in infants with VUR
may also imply a global maldevelopment of the
trigone and proximal urethral mechanism, which
needs to funnel open in coordination with detrusor
contraction in order to induce efficient, low-pressure
emptying.

21. Symptoms of paediatric voiding dysfunction—
frequency,
urgency, and
Enuresis
lie on a spectrum with detrusor instability (DI) and/or
detrusor sphincter dyssynergia (DSD), and they are
often found in patients with UTI and VUR
Note- No direct causal relationship suggesting that VUR
caused by DI, but in marginally competent VUJ, DI may
exaggerate VUR

22. UTI & VUR
Tanagho & Collegaues- LUT Inflammation> Mildly defective
VUJ > VUR
New VUR reported after UTI
Bacterial Endototxin – ureteral smooth muscle dilation (by
inhibiton of alpha- adrenoreceptor)
UTI- hypercontractility of bladder
Note – VCUG at the time of UTI must be avoided, bcoz of false
VUR demonstration, which will be otherwise absent when
urine is sterile
CONCLUDING REMARKS
- THE CLINICAL SIGNIFICANCE OF VUR MUST BE INTERPRETED
IN CONTEXT OF GLOBAL URINARY TRACT ABNORMALITIES

23. GRADING OF VUR

24. CLINICAL FEATURES
Features of recurrent UTI:
- Fever
- Flank pain
- Pyuria.
Palpable renal mass
Delayed growth
Weight loss

25. DIAGNOSIS AND EVALUATION
Confirmation of Urinary Tract Infection
These include
clinical history and presence of fever;
Age of the patient
Circumcision status
Method of urine specimen collection, storage, and delivery; and
Results of urine dipstick and microscopic analyses
Colonization – Bacteriuria– may pose threat in VUR

26. EVALUATING UTI
Radiologic investigation for VUR
Children younger than 5 years old,
All children with a febrile UTI, and
Any male with a UTI regardless of age or fever, unless
sexually
active.
VCUG- < 2 yrs of age
- 2nd UTI with infection based on stricter culture
criteria
USG – Non Invasive – R/O gross structural defects
Prenatal USG- augmented detection of asymp reflux in

27. ASSESMENT OF LOWER URINARY
TRACT
Cystographic imaging
DIRECT CYSTOGRAMS
 Voiding cystourethrogram (VCUG)
 Radionuclide cystogram (RNC)
 Gold standard approaches to reflux detection.
INDIRECT CYSTOGRAMS- eg Excretory urography
Drawback- radiation exposure
Alternates- use of Colour Doppler
-Echo enhancing contrast agents

28. VCUG
Provides information on :
- functional dynamics
- structural anatomy
Parameters observed:
A. Static films
- bladder contour- grade of
reflux
- configuration & blunting of
calyces
- bladder neck anatomy
- urethral patency.
- presence of diverticula
- ureteroceles

29. B.Dynamic films:
- active reflux
C. Delayed or postvoid films:
- Crucial in documenting clearance of contrast from the
upper tracts
- Dilated PCS + Retained contrast = PUJO
Contraindicated in active cystitis
Exceptions: In children with a h/o recurrent
pyelonephritis and repeatedly negative voiding studies in
the intercurrent periods.

30. Single VCUG- may miss mass VUR
Need for cyclic study- improves detection rate – 12-20%

31. RADIONUCLIDE CYSTOGRAM
Radiation exposure 1% of VCUG
Little anatomic detail is afforded
Ideal for:
- screening
- monitoring the natural history of Disease.
- surgical follow-up of reflux
Greater sensitivity in grades II to V reflux
Grade I reflux into distal ureter is poorly detected

32. UROFLOWMETRY & UDS
Full pressure-volume urodynamic studies of the
bladder are not required in all reflux patients, a
minimal survey of bladder emptying characteristics
can be obtained by uroflowmetry.
May need UDS
Lack of smoothness of the flow-velocity curve shows
incomplete relaxation of the bladder outlet that delays
the natural history of reflux resolution or even
promots reflux.
Increased PVR may be a risk factor for UTI

33. TOP DOWN APPROACH
CONCEPT- Only clinically relevant reflux with potential
to cause renal injury is worthy of uncovering, with
critical assumption that VUR in absence of
scintigraphic Renal abnormality is unlikely to cause
future Renal damage.
DMSA> if negative> No evaluation > if Recurrent UTI –
VCUG
Drawback- further need of prospective evidence for
validity

34. NICE GUIDELINES
USG
CYSTOGRAPHY-
 < 6 months,
 > 6 months if dilatation on USG
DMSA (early DMSA) not recommended
Drawback-
Poor correlation b/w appearance of kidney on USG and presence of
Renal parenchymal changes or presence and grade of VUR
Need prospective study before including in clinical use

35. AAP GUIDELINES

36. CYSTOSCOPY
Routine use is not mandated.
Role immediately prior to surgery for confirming:
- orifice position
- duplication
- proximity of diverticula to the orifice
- urethral patency

37. PIC TECHNIQUE
POSITION OF THE INSTILLATION OF CONTRAST AT
URETERIC ORIFICE
Detects reflux under GA
Cystoscopy – 9.5 to 14 fr
Aims to detect reflux under general anesthesia in
patients with a history of febrile UTIs but a normal
VCUG
Drawbacks – Not allow for age adjusted instillation
pressures causing Iatrogenic VUR

38. ASSESSMENT OF UPPER TRACTS
Renal Sonography
The mainstay of renal imaging in VUR management is
ultrasonography
Quantitative assessment of renal dimensions :
- used to monitor renal growth
- impact of any intercurrent febrile episode on renal growth
- need for further assessment of renal function by
scintigraphy or the need for correction of reflux

39. Modern enhancements in ultrasound technology
In reflux nephropathy using adjunts such as
Color Doppler ultrasound,
Renal resistive index measurements

40. RENAL SCINTIGRAPHY
DMSA:
- detection of reflux-associated
renal damage
- acute pyelonephritic changes
- follow-up of reflux
SPECT imaging
-3D reconstruction

41. ASSOCIATED ANOMALIES
PUJ OBSTRUCTION
URETERAL DUPLICATION
BLADDER DIVERTICULA
RENAL ANOMALIES
MEGACYSTIS- URETER SYNDROME

42. PUJ OBSTRUCTION
- Incidence of VUR associated with PUJO = 9% - 18%
- The incidence of PUJO in patients with reflux =
0.75% to 3.6%
- Incidence with high-grade reflux = five times more
likely than lower grades of reflux

43. Three radiology - UPJO with reflux.
1. the pelvis shows little or no
filling, while the ureter is
dilated by contrast, this may
indicate a point of kinking
secondary to reflux or from a
primary UPJO (Fig. 137-13).
2.Contrast that does enter the
pelvis may be poorly visualized
because of dilution in a large
pelvic volume and exhibits a
markedly reduced radiodensity
compared with the ureter or
bladder.
3.Large pelvis that fails to exhibit

44. Hollowell and colleagues (1989) - three clinical categories of
concomitant obstruction and reflux.
Group 1- Primary UPJO and incidental low-grade reflux,
Group 2- Secondary UPJO from high-grade reflux. These two groups
represent true anatomic obstruction for which pyeloplasty is
recommended.
Group 3 represents only significant dilation of the upper tracts,
which is confirmed by documenting good drainage images by
cystography or renal scintigraphy
.

45. Cause of Secondary UPJO-
1. High-grade reflux may result in kinking of the upper ureter
and adjacent pelvic junction.
2. The chronic effects of reflux also may stretch the renal
pelvis so that atonicity and an inability to propel urine
through the UPJ may occur (Whitaker, 1973).
3. In the setting of UTI propagated to the upper tracts by
reflux, inflammation and ureteritis also can contribute to
transient or chronic obstruction at the UPJ.

46. Nevertheless, the guiding therapeutic principle is the
preservation of renal function.
Although sterile reflux may be observed,
UPJ obstruction even in the absence of infection may jeopardize
renal function. Therefore, in the presence of reflux, if
scintigraphy with catheter drainage confirms obstruction,
pyeloplasty should be performed.

47. URETERAL DUPLICAITON
- VUR is the most common abnormality associated with complete
ureteral duplication.
- reflux occurs most commonly into the lower pole.
This relationship is based on the studies of Weigert and Meyer, who
documented the more lateral and proximal insertion of the lower pole
ureter associated with a shorter intramural ureter at VUJ

48. BLADDER DIVERTICULA
- Outpouching of mucosa between detrusor muscle bundles without
any true muscle backing itself
- Cause of reflux:
Paraureteral diverticulum- anatomic point of origin at or near the UVJ,
compromise the antireflux configuration of the UVJ to cause reflux
Large paraureteral diverticulum could expand within the Waldeyer
fascia to cause ureteral obstruction or project forward into the
bladder to obstruct the bladder outlet, much as a ureterocele, and
incite secondary reflux
Reflux associated with paraureteral diverticula resolves at rates
similar to that of primary reflux and should be managed according to
the prevailing indications for the reflux itself, irrespective of the
diverticulum

49. RENAL ANOMALIES
- Renal agenesis:
 Rate of contralateral renal pathology -46%
 VUR – MC contralateral defect(28%)
- MCDK: contralateral reflux 26% , majority were low grade I & II
- Presence mandates VCUG

50. MEGACYSTIS-MEGAURETER
SYNDROME- More common in males
- Differentiation from PUV
Massive bilateral VUR can cause a gradual remodeling of the entire
upper urinary tract
Voiding studies - demonstrate an open posterior urethra and
differentiate from
 posterior valves or
 prune-belly syndrome
Vesicostomy – temporary

51. OTHER ASSOCAITIONS
VACTERL association (Vertebral, Anal, Cardiac, TracheoEsophageal,
Renal, and Limb anomalies),
CHARGE syndrome (Coloboma, Heart disease, Atresia choanae,
Retarded development, Genital hypoplasia, and Ear anomalies), and
Imperforate anus.
VCUG is the initial study of choice to disclose both dysfunction at the
UVJ and overall bladder and bladder outlet anatomy
PREGNANCY AND REFLUX
Bladder tone decreases because of edema and hyperemia, changes
that predispose the patient to bacteriuria. In addition, urine volume
increases in the upper collecting system as the physiologic dilation

52. MANAGEMENT
NON SURGICAL
SURGICAL

53. NON SURGICAL MANAGEMENT
Nonsurgical therapy is based on the following principles:
(1) Higher grades of VUR - increased risk of pyelonephritis
(2) VUR often resolves over time
(3) Sterile VUR is not harmful to the kidneys, if bladder function is
normal
(4) UTI with VUR - pyelonephritis, l/t renal scarring
(5) Morbidity or complications of VUR can be decreased by preventing
UTI.

54. OPTIONS FOR NON SURGICAL
MANAGEMENT
1. Antibiotic prophylaxis
 a. Daily
 b. Intermittent (i.e., treatment of UTIs
when they are diagnosed)
2. Bladder training (urotherapy)
3. Treatment of BBD: Timed
voiding
 a. Treatment of constipation
 b. Anticholinergic
 c. Alpha-blocker
 d. Biofeedback
4. Periodic assessment of reflux
and child well-being
 a. Serial assessment of blood pressure,
renal function,
 and somatic growth
 b. Serial urinalysis or urine culture

55. REFLUX RESOLUTION
Exact mechanism not known-
Probable mechanisms are –
 Intramural ureteral lengthens
 Bladder growth and bladder function maturation
Grade Resolution rate (%)
Grade I 92
Grade II 81
Grade III 70
Grade III B/L 12.5
Grade IV 50
Grade IV B/L 10

56. ANTIBIOTIC PROPHYLAXIS
Controversial data from studies
2010- AUA- VUR Guidelines
Recommended Ab Prophylaxis- < 1 year of age
> 1 yr of age – optional treatment
If child with VUR develops febrile UTI- Initiate prophylaxis
Daily prophylaxis for GIRLS – III- IV VUR
BOYS- IV- V VUR
Note- Children with Grade I & II , Boys with Grade III may not benefit
form Antibiotic prophylaxis until they have Bowel Bladder
Dysfunction.

57. Common drugs-
 TMP-SMZ- excreted in urine
 Allergic skin reactions(MC)
 Anaphylaxis(Rare)
 Neutropenia, Thrombocytopenia
 Eosinophilia
 Photosensitivity
 Dental caries- d/t fructose in liquid preparation
 Stevens Johnson Syndrome
 Nitrofurantoin – excreted in urine,
 S/E gastric upset,
 nausea,
 poor medication taste
 Amoxicillin – babies upto 2 months (50-75 mg OD or BD)
 cephalexin

58. BOWEL BLADDER DYSFUNCTION
BBD is used to describe children with
Abnormal lower urinary tract symptoms of storage and/or emptying,
which include lower urinary tract conditions,
 overactive bladder and urge incontinence,
 Voiding postponement,
 underactive bladder, and
 Dysfunctional voiding,
Abnormal bowel patterns
 constipation and
 encopresis.

59. BBD IN INFANTS
BBD in >2-year-old children is characterized by a combination of the
following symptoms:
 urgency,
 urge incontinence,
 frequency,
 Infrequent voiding, and
 constipation.
Nearly half of infants with dilating VUR have dysfunctional voiding,
 including enlarged bladder capacity,
 overactive bladder, and
 incomplete bladder emptying;
 bowel dysfunction has not been systematically assessed in this patient population.

62. PHARMACOLOGIC THERAPY
ANTICHOLINERGIC THERAPY
Oxybutynin - 2.5–5 mg tid
approved for use in children
Hyoscyamine- 0.125-0.25 mg qid
sunlingual
Tolterodine- 1-2 mg bd
Tropsium 10- 25 mg bd
Dairfenacin
Solifenacin
propiverine
ALPHA BLOCKER THERAPY
For pelvic floor overactivity and
significant post void residual urine
volumes
Doxazosin 0.5 mg- decrease in
incontinence

63. SURGICAL MANAGEMENT
PRINCIPLES OF SURGICAL MANAGEMENT
1. Exclude secondary reflux
2. Adequate ureteral mobilization without tension and protection of the
ureteral blood supply
3. A generous submucosal tunnel should be fashioned
4. Attention should be directed to prevent angulation and twisting
bladder tissues must be handled gently
5. Attention to muscular backing of ureter to achieve effective anti refux
mechanism.
6. Creation of submucosal tunnel that satisfy 5:1 ratio of length and
width recommended by Paquin.

64. INDICATIONS
ABSOLUTE INDICATIONS :
Breakthrough urinary tract infections
Failure of medical management
- patient noncompliance
- persistance of reflux with prolonged medical management.
- progressive deterioration in renal function.
Ureteral obstruction assoc with VUR
Refluxing ureter opening into bladder diverticulum
Cystoscopic observation of golf hole orifice

65. RELATIVE INDICATIONS :
Presence of massive reflux – gr IV & V
Reflux associated with paraureteral diverticulum
In girls whose reflux persists after they have reached the full
somatic growth potential at puberty.
Parental preference

66. CLASSIFICATION
According to approach :
Intravesical
Extravesical
Combined
According to the position of the sub mucosal
tunnel in relation to the original hiatus :
Suprahiatal
Infrahiatal

68. FOLLOW UP
Discharged on uro-prophylaxis
Monitoring of pt’s
- BP
- renal function
- urine analysis
Follow up USG and urine c/s after 6-12 weeks.
VCUG after 3 mnths
Discontinuation of uroprophylaxis on resolution of
reflux
DMSA after 1 yr (not mandatory)

69. COMPLICATIONS
Persistent Reflux.
Early reflux following ureteroneocystostomy is usually not a
significant clinical problem and commonly resolves by 1 year on
repeat cystography.
Contralateral reflux
Seen in 5-11% cases
There was no difference noted among the various surgical
techniques, but there was a significant trend toward
development of contralateral reflux with the higher grades of
ipsilateral corrected reflux and correction of reflux in duplex
systems.

70. Prophylactic bilateral reimplantation for unilateral reflux, to
avoid Contralateral reflux, is not warranted on the basis of the
high spontaneous resolution rates.
Obstruction
Due to odema , clot ,twisting or kinking of ureter.
Diagnosis made by USG showing severe HDUN.
PCN or stenting has to be done.
Redo surgery may be required

71. ENDOSCOPIC MANAGEMENT
Injection of a bio- compatible
bulking agent beneath
intravesical portion of ureter in
sub-mucosal tunnel
Elevates the intra-vesical
ureter
narrowing of lumen
Prevents regurgitation of
urine & allows antegrade flow

72. ADVANTAGES
OPD based treatment
less morbidity, no mortality
No surgical scar
Success rate almost equivalent to open surgery forprimary
reflux.
DISADVANTAGES
Cost
Lower success rate compared to surgery for high grade
reflux,upto 90%.

73. ADVANTAGES
OPD based treatment
less morbidity, no mortality
No surgical scar
Success rate almost equivalent to open surgery for primary
reflux.
DISADVANTAGES
Cost
Lower success rate compared to surgery for high grade
reflux,upto 90%.

74. DEFLUX
Dextranomer/Hyaluronic Copolymer (DX/HA) is formed of crosslinked
dextranomer microspheres (80 to 250 μm in diameter) suspended in
a carrier gel of stabilized sodium hyaluronate.
DX/HA is biodegradable, the carrier gel is reabsorbed, and the
dextranomer microspheres capsulated by fibroblast migration and
collagen ingrowth.
DX/HA loses about 23% of its volume beyond 3 months of follow-
up
The appeal of Deflux is that it is a natural product that is easily
administered without a ratcheted syringe through a smaller-gauge
needle.
It is currently the preferred agent for endoscopic correction in most

75. TEFLON PASTE
Teflon paste is relatively inexpensive; it is viscous and requires
a ratcheted syringe for injection.
Less used now because of concerns regarding distant
migration of the PTFE particles.
Particle size 10-100μm.
Malizia demonstrated in experimental studies that the
particles can migrate to regional lymph nodes and to
distantorgans including the lung and the brain

76. THANK YOU