Vesicoureteral Reflux (VUR)

Urinary system.To understand vesicoureteral (ves-ih-ko-yu-ree-ter-ul) reflux, one needs to understand the normal structure and function of the urinary tract.

The Urinary System

The kidneys clean and filter blood to produce urine. Urine is liquid waste. Urine travels from the kidneys down the ureters and into the bladder. The bladder holds the urine and acts as a storage tank. As the bladder fills, the wall of the bladder relaxes to hold more urine. The control muscle (sphincter) remains tight to prevent leakage of urine. Once in the bladder, the urine is stopped from going back into the ureters by a valve mechanism. When the bladder gets full, it sends a message to the brain. The brain decides when urination should start. The bladder contracts while the sphincter muscle relaxes allowing the bladder to squeeze all of the urine out.

Vesicoureteral reflux (VUR) is a condition in which urine from the bladder is able to flow back up into the ureter and kidney. It is caused by a problem with the valve mechanism. Pressure from the urine filling the bladder should close the tunnel of the ureter. It should not allow urine to flow back up into the ureter. When the ureter enters the bladder at an unusual angle or when the length of the ureter that tunnels through the bladder wall is too short, reflux can occur.

Vesicoureteral reflux becomes a problem when the urine in the bladder becomes infected. The infected urine easily travels backward to the kidney and can cause a kidney infection. Kidney infections lead to kidney damage.  

Vesicoureteral reflux is usually discovered during an evaluation for a urinary tract infection (UTI) by your child's primary care provider. After a urinary tract infection, a variety of tests can be ordered.

A voiding cystourethrogram (sis-toe-yu-ree-thro-gram) (VCUG) is an X-ray test where a small tube or catheter is placed into the bladder through the opening where the urine comes out. A special liquid called X-ray contrast is used to fill the bladder through the catheter. When the child's bladder is full, the child will urinate into a special container while on the X-ray table. While the bladder is filling and the child is urinating, X-rays are taken.

A similar test called nuclear cystogram may be used instead of the VCUG. A catheter is placed and the procedure is similar to the above test.

A kidney (renal) and bladder ultrasound is a test using sound waves to look for kidney scarring and to measure kidney size. During the ultrasound, a technologist will rub warm gel on the child's belly and back. Then, the technologist will move a device that looks like a microphone on the same areas.

The management of vesicoureteral reflux depends on the grade of reflux, which is determined by the VCUG. Also taken into consideration are the frequency of urinary tract infections, the presence and progression of any kidney damage, and parental opinion.

Grades of reflux.
International Reflux Classification. Adapted from (2002) Vesicoureteral Reflux. In: Belman, King, Kramer (eds.) Clinical Pediatric Urology. London, England: Martin Dunitz, Ltd., 753.

For grades I-III there is a good chance that the reflux will disappear as the child grows and the bladder matures. These children are given low-dose antibiotics daily, to suppress bacteria from growing. Occasional blood tests and urine cultures may be ordered.

An option for patients with grades I-IV is a cystoscopy with injection of Deflux. This is a procedure where under general anesthesia; a small telescope is inserted into the bladder through the urinary opening. A gel (Deflux) is injected where the ureters enter the bladder. A little bulge is formed in the bladder wall, preventing the backflow of urine. This is an outpatient procedure.

Patients with "high grade" reflux, grades IV-V, will take low dose antibiotics and have periodic blood tests, X-ray tests and urine cultures done. These children will often need ureteral reimplantation surgery to correct the reflux and prevent progressive damage of the kidneys.

Ureteral Reimplantation Surgery

The goals of surgery are to correct the reflux, prevent pyelonephritis (kidney infection), and preserve renal function. The surgical repair of reflux may not totally stop the development of bladder infections. It will reduce the chance of a bladder infection developing into a kidney infection.

The ureteral reimplantation surgery consists of creating a longer tunnel of the ureter through the bladder wall. The surgery is performed through an incision (cut) just above the pubic bone (bikini incision). If both ureters need to be reimplanted, this is done through one incision.

This surgery usually lasts between 2½ and three hours. Afterwards, the child will be admitted to the hospital for two to four days. Before surgery, the anesthesiologist will discuss a pain management plan with the family.

After Surgery

After open surgery, activity will be limited for four to six weeks. No tub baths for five days. Return to school can be one week after surgery or when no longer taking narcotics for pain control.

After reflux surgery, there may be limitations on physical activity depending upon your surgeon. Voiding every two to three hours as well as drinking adequate fluids helps healing. Your child may return to school the day after surgery.

Healthy bladder habits, including an adequate intake of water and avoidance of dietary bladder irritants, are important. Good perineal hygiene, particularly in girls, along with voiding every three to four hours are also good preventions to ward off urinary tract infections.


Last Updated 10/2012