Vesicoureteric reflux (VUR) (Children)

ℹ️ About

• 🔄 Vesicoureteric Reflux (VUR) = abnormal backward flow of urine from bladder → ureter → kidney
• ⚠️ Increases risk of recurrent UTIs and long-term renal scarring
• 👧 Affects ~10% of children; many cases improve spontaneously with age

🧬 Aetiology

• 🚪 Normally a flap-valve at ureter–bladder junction prevents backflow
• 🔁 In VUR this mechanism fails, allowing reflux
• May be unilateral or bilateral
• 👨‍👩‍👧 Family history ↑ risk; also associated with spina bifida and neurogenic bladder

🧩 Types

• 🍼 Primary VUR: congenital abnormality of ureteric insertion; tends to improve with age
• ⚡ Secondary VUR: due to obstruction (bladder neck, urethra) or neurological dysfunction; often bilateral and more severe

⚠️ Risks / Associations

• 🧬 Bladder exstrophy (rare congenital defect)
• ⚪ Ureterocele (cystic dilation of distal ureter)
• ➕ Ureteral duplication (two ureters draining one kidney)
• 🚽 Bladder and bowel dysfunction – constipation, urgency, daytime wetting ↑ risk of VUR

🩺 Clinical Features

• 🔥 Recurrent UTIs: dysuria, frequency, urgency, fever
• 📉 Poor growth, lethargy, failure to thrive
• 🪙 Suprapubic mass (distended bladder)
• 📈 Hypertension (secondary to renal scarring)
• 💤 Enuresis (bedwetting), constipation

🔎 Investigations

• 🧪 Bloods: FBC, U&E, LFTs, CRP; Urinalysis (nitrites, leukocytes, culture)
• 📸 Voiding cystourethrogram (VCUG): gold standard; contrast via catheter → demonstrates reflux
• ⚛️ Radionuclide cystogram (RNC): sensitive, less radiation; good for follow-up
• 🖥️ Abdominal ultrasound: hydronephrosis, renal size, structural anomalies; can detect prenatal hydronephrosis
• 📊 Urodynamics: evaluate bladder function in neurogenic causes

📊 Grading of VUR

• Grade I – reflux into ureter only; no renal pelvis involvement
• Grade II – reflux reaches renal pelvis; no dilatation
• Grade III – mild/moderate dilatation of ureter ± collecting system
• Grade IV – moderate dilatation, blunt fornices, papillae impressions still visible
• Grade V – gross dilatation/kinking of ureter, severe collecting system dilatation; papillae impressions lost, intraparenchymal reflux

💊 Management

• 💧 General: good hydration, treat constipation, toilet training (voiding regularly, wiping front→back)
• 💊 Antibiotic prophylaxis: low-dose long-term in high-risk/recurrent UTI cases
• 💉 Prompt antibiotic treatment of UTIs to prevent renal scarring
• 🧴 Endoscopic injection (Deflux): bulking agent at ureteric orifice → reduces reflux
• 🔪 Surgery (ureteric reimplantation) reserved for high-grade (IV–V) or refractory VUR with renal scarring

📚 References

• EAU Guidelines on Vesicoureteral Reflux in Children

💊 Case Reports

• 🧒 Case 1 – Age 3 (Post-UTI Investigation): Toddler hospitalised for febrile UTI with E. coli bacteraemia. Renal ultrasound showed mild pelvicalyceal dilatation. MCUG confirmed grade II vesicoureteric reflux (VUR). Management: Low-dose antibiotic prophylaxis (trimethoprim), bladder training, and follow-up imaging at 12 months. Outcome: Reflux resolved spontaneously by age 5. Teaching point: Low-grade VUR (I–II) often resolves as the ureterovesical junction matures — the focus is on preventing recurrent infection and renal scarring.
• 🚼 Case 2 – Age 9 months (Congenital Anomaly): Antenatal hydronephrosis detected on routine scan; postnatal ultrasound confirmed persistent unilateral hydronephrosis. MCUG showed grade IV VUR with renal scarring on DMSA scan. Management: Continuous antibiotic prophylaxis, urology referral, and regular blood pressure and renal function monitoring. Teaching point: High-grade VUR (III–V) may cause renal parenchymal scarring and chronic kidney disease — early diagnosis and multidisciplinary follow-up are crucial.
• 👧 Case 3 – Age 7 (Recurrent UTI and Voiding Dysfunction): Girl with multiple UTIs and daytime wetting. Imaging showed bilateral grade III VUR with normal renal function. History revealed withholding behaviour and constipation. Management: Treat constipation, establish timed voiding, and continue antibiotic prophylaxis. VUR improved with bladder retraining, avoiding the need for surgery. Teaching point: Functional bladder dysfunction and constipation can exacerbate reflux — behavioural management is a vital part of conservative therapy for VUR.