Pediatric Vesicoureteral Reflux

The urinary tract consists of the kidneys, ureters, bladder and urethra. The kidneys are the organs that are responsible for filtering waste products from the bloodstream and produce urine continuously. The urine drains down tubes called ureters from the kidneys to the bladder, which normally stores urine and empties intermittently by muscular contraction. The urine exits the bladder through the urethra in a process is called voiding or urination.

When the ureter enters the bladder it travels through the wall for a distance creating a tunnel so that a flap valve is created. This valve prevents urine that is in the bladder from backing up and returning into the ureter. Thus, when the bladder fills and later when it squeezes down to empty, back-up (that is, reflux of urine) is prevented because the valve operates in the same way as when you pinch off a soda straw. This valve-like action is important for several reasons:

• Prevents bacteria (that often get into the urine)
• Protects the ureters and kidneys from high pressure generated by the bladder during urination
• Permits removal of all of the stored urine with a single act of urination, because the bladder urine has nowhere to go other than out of the urethra

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What Is Vesicoureteral Reflux?

With normal urination, the bladder contracts and urine leaves the body through the urethra. With vesicoureteral reflux, some urine goes back up into the ureters and possibly up to the kidneys. Reflux exposes the kidneys to infection. In children, particularly those in the first 6 years of life, urinary infection can cause kidney damage. The injury to the kidney may result in renal scarring and loss of future growth potential or widespread scarring and atrophy. Even a small area of scarring in one kidney may be a cause of high blood pressure later in life. Untreated reflux on both sides can, in the most severe instances, result in kidney failure requiring dialysis or kidney transplantation.

The valve system at the ureterovesical (ureter-bladder) junction may be abnormal:

• In some children the tunnel of the lower ureter through the muscular wall of the bladder may not be long enough. For these children, there is a good chance that growth may provide the necessary difference to allow the valve to work.
• The ureter may enter into the bladder abnormally (usually too much to the side), resulting in a short tunnel. This reflux is less likely to resolve with growth.
• Some children have reflux because of underlying problems such as lower urinary obstruction (such as urethral valves), abnormal bladder behavior (such as uninhibited bladder contractions or hyperreflexic bladders), infrequent voiding, or constipation.

Children who are suspected of having reflux should have a renal ultrasound and a voiding cystourethrogram (VCUG). Based on these studies, reflux can be classified into five grades - grade 1 is the least and grade 5 is the worst. Mild degrees of reflux have a good chance of resolving spontaneously with age. Chances of resolution with high-grade reflux (grade 4-5, or reflux related to an anatomic problem such as a long-standing obstruction) are much lower.

Since many children will outgrow their reflux, they can be followed carefully, with their reflux monitored at intervals by tests such as VCUG, renal ultrasound, or nuclear voiding cystogram. During this follow-up period they are kept on a prophylactic (low-dose) antibiotic to keep the urine free of infection. Any fever or urinary tract symptoms (such as burning, frequency, urgency, straining, foul odor, bloody urine, or unusual incontinence) must be evaluated with urine analysis and urine culture. Children who develop breakthrough urinary infections in spite of prophylaxis are at risk for kidney damage and need to be considered for surgical correction of reflux.

How Is Reflux Treated Surgically?

Correction of reflux (ureteral reimplantation or ureteroneocystostorny) is recommended for high grades of reflux, for reflux that fails to resolve, or for patients with breakthrough infections. The traditional surgical approach involves opening the bladder and creating a new longer tunnel for the ureter through the bladder wall.

What Is Ureteral Reimplant Surgery?

Ureteral reimplant is a procedure used to treat vesicoureteral reflux (VUR), which contributes to recurrent urinary tract infections (UTI) in infants and children. During this procedure, one or both ureters are reimplanted into proper position within the bladder.

Post-Operative Care Instructions for Ureteral Reimplant Surgery

What to Expect After Surgery

After surgery, your child may have a suprapubic tube/catheter or a stent in place. If so, the surgeon will tell you how to care for and monitor it. Your child will most likely spend 1 to 2 nights in the hospital.

There may be some uncomfortable side effects after surgery, which will usually lessen over the course of a few weeks. Urinary frequency, urgency, burning with urination, or blood in the urine may occur while recovering. This is all normal, especially when a tube/catheter or stent is in place.

Your child may also experience bladder spasms, which can cause pain. If this happens, your surgeon can prescribe medication to manage the pain.

At-Home Care

Please keep the surgical incision clean and dry. You may wash the incision with soapy water, as needed, and pat dry. If your child has steri-strips on the incision, these will fall off on their own in 1 to 2 weeks.

Your child should not engage in strenuous or high-intensity activities for 4 to 6 weeks or until you follow up with your surgeon. Please refrain from swimming while a tube/catheter or stent is in place.

Post-Surgery Follow Up

• Your child will need to be seen in the clinic, 1 to 2 weeks after surgery.
• There will be an additional follow-up, 4 to 6 weeks after surgery (or 4 to 6 weeks from the date the stent or tube was removed). Your child will have a renal ultrasound to re-evaluate any swelling in the kidney or urinary tract. Your physician may recommend antibiotics until this repeat imaging is completed.

You should call the doctor if your child experiences any of the following:

• The dressing around the tube/catheter or stent is completely saturated and requires changing every few hours, or is soaked with blood.
• Pain is uncontrolled by pain medications.
• Inability to urinate.
• Infection symptoms: fever greater than 101° F, spreading/increasing redness or swelling around the site, or pus around the incision site.
• New or worsening symptoms of a urinary tract infection (UTI): frequency, burning with urination, urgency, increase in wet accidents, fever, back/abdominal pain, nausea or vomiting.

Children with a history of reflux should probably be monitored life-long with measurement of height and weight, blood pressure, and urine analysis. Occasional ultrasound tests will assure that kidney growth is on target for age and size. If kidney function from previous reflux should deteriorate, the pediatric nephrology team can begin appropriate medication and dietary restriction.

What About Other Family Members?

If one child in a family has reflux, there is a 1 in 3 chance of having an affected sister or brother. Because we know that the chances of kidney damage are highest in the first 6 years of life, we think that brothers and sisters in that age range should be studied (with examination, ultrasound and voiding study) even though they may not have been known to have urinary infections.

UT Pediatric Urology
UT Physicians Professional Building
6410 Fannin St. Suite 950
Houston, Texas 77030
Phone: (832) 325-7234