Vesicoureteric reflux (VUR) is a common condition in children where urine flows backward from the bladder into the ureters or kidneys. It can lead to urinary tract infections and renal scarring. The document discusses the anatomy, pathophysiology, diagnosis and management of VUR. Management involves continuous antibiotic prophylaxis, endoscopic injection, or open surgical correction depending on the grade of reflux and individual patient factors. Spontaneous resolution is more likely for lower grades of reflux and in younger children. Bowel and bladder dysfunction can complicate management and decrease resolution rates.

1. VESICOURETERIC REFLUX
VIDHYA.T
MBBS, DNB, Fellowship in Paediatric urology
Apollo Children’s hospital
-A OVERVIEW

2. Paediatrician
Paediatric surgeons/ Paediatric urologist
Nephrologist
Pediatric Radiologist
Nuclear Medicine Radiologist
VUR

3.  Retrograde flow of urine from bladder into the kidney or ureter during emptying or
filling phase of bladder
 Dynamic phenomenon
 First described by GALEN 150 A.D- autopsy specimens
 Human VUR-1893 POZZI- noted efflux of urine into ureter during plevic surgery
VUR is physiological in young of many species, considered abnormal in human!!
INTRODUCTION

4. INCIDENCE
In General pediatric population 0.5-3%
In children presenting with UTI 30-40%
AGE INCIDENCE OF VUR IN UTI
<1yr 70%
4 25%
12 15%
Overall picture
1yrs of life---boys +++
>2yrs --- girls >>> boys
Girls predominate

5.  The prevalence of reflux is higher in siblings -32%, as low as 7% in older, 100% in
identical twins
 Risk increase to 69% if a parent is affected
 VUR is a familial, polygenic disease, has a tendency for an autosomal dominant
pattern of inheritance
 Genes involved
PAX2
GDNF
RET
UPK3
AGTR2
ACE
INHERITANCE & GENETICS

6. VUR & ASSOCIATED CONDITIONS
o Renal agenesis
o Horshoe kidneys with renal ectopia
o Multicystic dysplastic kidneys
o Prune Belly syndrome
o Megacystis megaureter syndrome
o Duplication , Ureterocele, ectopic ureter
o Complex syndrome with genitourinary and neurogenic manifestations

7. Anti-Reflux Mechanism
Active
Passive
• Functional integrity of the ureter: -
Antegrade peristalsis
• Anatomic composition of the UVJ: - 5:1
ratio of tunnel length to ureteral diameter
in nonrefluxing junctions ( Paquin, 1959 )
• Functional compliance of the bladder
VUJ ANATOMY

8. VUJ ANATOMY- ANTI REFLUX MECHANISM
 FILLING- Allows the
intramural ureter to move
in within the hiatus during
bladder filling
 FILLING-Progressive obliquity
of intravesical ureter–trigone
stretched-- increased
resistance– increased
pressure
 VOIDING- Intravesival ureter-
-Pulled down– ureteral wall
compressed against bladder
wall– passive reinforcement
of valvular mechanism
Natural tone of ureteral muscle-
active closure of intravesical
ureter

9. VUJ ANATOMY
Structurally and functionally adapted to allow intermittent passage of urine

10. VUJ ANATOMY- NEURAL INNERVATION
The mechanism requires a complex
of muscular
components that includes ureteral
and vesical muscle bundles
and an elaborate neural influence
Dual autonomic innervation by
cholinergic and noradrenergic
nerves, and there is evidence for
neuropeptides that
may act as neuromodulators

11. VUJ ANATOMY

12. PRIMARY REFLUX SECONDARY REFLUX
VUJ related-
Malfunction
Maldevelopment
Delayed maturity
VUJ affected by bladder abnormalities,
bladder outlet obstruction
Normal function of VUJ overwhelmed
Failure of anti reflux mechanism Congenital- PUV, Neurogenic bladder
secondary to spinal defects, Ureteral
duplication
Acquired- Bowel bladder dysfunction
TYPES OF VUR

13. INTERNATIONAL GRADING OF VUR- MCU based

14. CLINICAL IMPLICATIONS
UTI
Pyelonephritis
Renal Scarring
Hypertension
Reflux Nephropathy
End stage renal disease
Renal failure

15.  Gram negative coliform bacteria arising from faecal flora colonising the perineum
 Escherichia coli (E. coli) most common uropathogen (80% of paediatric UTI)
 Colonisation and ascends into upper tract due to underlying reflux
URINARY TRACT INFECTION
DEFENCE AGAINST UTI
Urothelium
 Low virulence strain of local bacteria
Wash out effect of urine
 Acidic pH
Mucosal IgA
Anti reflux mechanism

16. PATHOGENS
GRAM STAINS ORGANISMS INCIDENCE
GRAM NEGATIVE E COLI 75-80%
Non E COLI
Klebsiella
3-5%
Pseudomonas
Proteus
GRAM POSITIVE Enterococcus
Staphylococcus

17. PATHOGENESIS OF PYELONEPHRITIS

18. PATHOGENESIS OF PYELONEPHRITIS

19. PATHOGENESIS OF PYELONEPHRITIS

20. SCARS in VUR
Happens where ?!
Why!
Reason?

21. PAPILLAE- SIMPLE & COMPOUND

22. COMPOUND PAPILLAE ALLOWS REFLUX & SCARS –Happens
in poles

23. HYPERTENSION ?
Renal scarring
Arterial damage in scarred areas
Segmental ischaemia
Hypertension
Renin mediated
Elevated renin release
 Incidence- 17-30%
 34-38% of adults
 Risk of HTN increases
with age

24. PRESENTATION
‡ Antenatal hydronephrosis -15% of ANH is due to VUR
‡ Urinary tract infection
‡ Pyelonephritis- in infants
‡ Incidental detected VUR - Hydro/ hydroureteronephrosis, small sized kidney
‡ Cystitis- in older children
‡ Bowel bladder dysfunction
‡ Hypertension

25.  Physical examination
 Height and weight
 Blood pressure
 Serum Creatinine
 Urine analysis (protienuria, bacteriuria)
 High ESR, CRP
 S.Procalcitonin ( APN related renal injury, DETERMINES CLINICALLY SIGNIFICANT VUR)
CLINICAL &LAB ASSESSMENT

26. DIAGNOSIS
 Ultrasound
 MCU
 DMSA
 DRC

27.  EAU, ESPU- USG in initial assessment of UTI followed by MCU
 AAP- USG in first episode of UTI, MCU in recurrent episodes, renal anomaly,
presence of uretral dilatation in USG
 The EAU, ESPU and AUA (American urological association) guidelines – recommended DMSA
in patients who have high grade of VUR, high creatinine levels and intercurrent UTI
 ESPR- Top down approach USG folllowed by DMSA
 Recommned MCU only in case of renal involvement
 Targeted to reduce urethral cathterisation, detetcing clinically insignificant VUR,
 ionising radiation to gonads
RECOMMENDATIONS & PRACTICES

28. USG
Pyelonephritis
Hydroureteronephrosis
Small sized kidney
Scarred kidney
Altered echogenic kidneys

29. MCU
Diagnostic of reflux
Invasive procedure
Delineates the anatomical
details of bladder, urethra,
ureter
Preferred for initial tests in
diagnosis of VUR, not
routinely done for follow up
of children
with VUR

30. DMSA
• Tracer Uptake
• Function
o Inflammation- acute phase
o Cold areas/ scars- late phase
o Contour
o “Biscuit bite deformity”
DMSA provides info of

31. Scar- location
Progressive
New scars?
DMSA

32. Radionuclide Classification(DRCG)
grade 1 = grade I of the international grading system
grade 2 = grade II-III
grade 3 = grade IV-V
DRC- DIRECT RADIONUCLEOTIDE CYSTOGRAM

33. AIM OF THE TREATMENT
 To Prevent Recurrent Febrile UTIs
 New Renal Parenchymal Damage
 Minimize The morbidity of therapy and follow-up procedures.
Consider these factors prior to decision making of VUR management
 Age
 Gender,
 Reflux grade,
 History of recurrent UTI
 Renal dysfunction
 Associated BBD

34. Principles of management:
1. Spontaneous resolution of reflux is very common
2. High-grade reflux is less likely to resolve spontaneously
3. Extended use of prophylactic antibiotics & “ Watchful waiting”
4. The success rate with surgical correction is very high
Management of VUR cannot be based simply on VUR grade or broad statements of the
utility of CAP, but must be individualized
It is prudent to consider UTIs not only as acute episodes of illness but also as a first
step to possible renal damage
STRATEGY IN VUR

35. CAP- CONTINUOUS ANTIBIOTIC PROPHYLAXIS
 International reflux trial
 Birmingham reflux trial
 Swedish trial
 RIVUR trial
GROSS RECOMMENDATION
Antibiotic upto 1 yr of age
Until circumcision in boys
CAP is widely accepted as a revolutionary conservative therapy for VUR, because it
prevents recurrent episodes of UTI and consequent new renal scarring

36.  Antibiotic prophylaxis has been shown to be effective in preventing UTI in some
children with VUR but is not required for all
 Although strict criteria for the identification of those who are best managed with
CAP have yet to be defined, there is evidence to guide us today
 Children with a clear history of recurrent UTI
 The child with documented renal abnormalities on US or DMSA scanning
 The child with abnormal voiding patterns or BBD should be offered CAP while an
attempt is made to correct his or her voiding patterns.
 Parental understanding of the risks of renal injury from infection must be clear
 If CAP is to be used, the obligation of education is equally strong in that failure to
follow the medication program may lead to a false sense of security among both
parents and caregivers
CAP- CONTINUOUS ANTIBIOTIC PROPHYLAXIS

37. AUA- AMERICAN UROLOGICAL ASSOCIATION
An option of not using CAP in selected children-
 children less than 1 year and with grade I or II VUR, no history of febrile UTI, and no
renal cortical abnormalities.
 For children over 1 year, those without history of febrile UTI, no history of BBD, and no
renal cortical abnormalities
CAP- CONTINUOUS ANTIBIOTIC PROPHYLAXIS

40. RESULTS OF VARIOUS TRIALS

41. 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
BIO MATERIALS-
DEFLUX- Dextranomer hyaluronic acid polymer)
DEXELL

42. ENDOSCOPIC MANAGEMENT
ADVANTAGES
• Daycare
• 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
Indications
• Primary reflux
• Secondary reflux - Dysfn voiding - Neurogenic bladder - Duplex system • Failed open re-
implant
Surgical outcomes Success rates: • Open - 98% • Endoscopic – 80-89%

43. SURGICAL
TYPES
INTRAVESICAL- InfraHiatal- Cohen’s, Gil Vernant
Suprahiatal- Lead Better Politano,
EXTRAVESICAL- Lich Gregoir
METHODS
Open
Laparoscopic
Robotic
Higher success rate 98% for Cohen’s in terms of resolution of reflux and symptoms

44. • SPONTANEOUS RESOLUTION: - At birth, the probability of spontaneous resolution of
primary reflux is inversely proportional to the initial grade - If a patient is encountered
at a later age, resolution from any point in time forward will depend on the initial
grade of reflux
NATURAL HISTORY • Resolution by grade: - Most cases of low-grade reflux (grade I and
II) will resolve : 63-85% - Grade III reflux will resolve in approximately 50% of cases -
Higher-grade reflux (grades IV and V and bilateral grade III) : 9-25%
NATURAL HISTORY • Resolution with age : - Age has greater significance than grade -
Most prevalent in neonates and young children and will demonstrate the greatest
tendency to resolve in this group
VUR & RESOLUTION

45. BBD &VUR
o Most critical and modifiable variables that affect VUR management and attendant UTIs
High incidence of UTI despite prophylaxis
Poor surgical results
Less VUR resolution rate
o Persistence of the expected early attempts to suppress bladder contractions during
the toilet training months by volitional contraction of the external sphincter
o High voiding pressure leads to relux, UTI
 In older children
 Acquired voiding abnormality

46. THANK YOU!