Vesicoureteral Reflux

A guide for families of children with vesicoureteral reflux

What is vesicoureteral reflux?

The most important functions of the kidneys are to clean the toxic substances from the blood and ensure that they are excreted as urine. After the urine is produced by the kidneys, it is transported to the urinary bladder via tubes called ureters and stored. There is almost a valve mechanism between the ureter and the bladder on both sides, preventing the urine from escaping back to the kidneys. During voiding, the bladder contracts, and the urethral sphincter (the ring-shaped muscle surrounding the urethra) is opened, allowing urine to flow out of the canal as the urethra from the bladder. Here, the entire system from the kidneys to its opening is called the urinary tract. Vesicoureteral reflux is a condition in which urine escapes from the bladder to the kidneys.  

In most children, reflux can sometimes be due to a congenital defect, due to the abnormal connection between the ureter and the bladder and the short and ineffective valve mechanism. In some children, abnormal voiding features may reveal reflux.

Reflux can cause infections in children, for example, pyelonephritis, which we call kidney infection, and ultimately kidney damage. More severe reflux can cause greater kidney damage. In cases where reflux is excessive, the ureter and kidneys may enlarge, and deformity may occur.

In whom does reflux occur?

Reflux occurs in approximately 1-2% of healthy children. It is usually diagnosed after the child has a urinary infection. The age at diagnosis is 2-3 years, but it can be diagnosed at any age, as in infancy or older children. Three-quarters of the children treated are girls.

In some children, reflux may be familial. One third of the sisters or brothers of children with reflux may also have this condition. In addition, if the mother has been treated for reflux, half of her children may have reflux. If any of your children have reflux, show their siblings to your doctor as well.

Urinary tract infection is usually caused by bacteria and can affect the kidneys, bladder, or both. If it affects the kidney, it is called pyelonephritis. Typical signs are fever, abdominal or flank pain, chills, nausea, or vomiting. If it primarily involves the bladder, that is, the bladder, it is called cystitis. Here, too, typical signs are painful, frequent, or urgent urination or urinating on the bed. Newborns do not have these typical signs. Fever, restlessness, vomiting, diarrhea, loss of appetite and delay in weight gain can be observed in these.

Bacteria that cause urinary infections are usually present in the child's own poop. Despite very serious cleaning, bacteria settle in the genital area and eventually enter the bladder and urethra. If the child has reflux, bacteria can reach the kidneys and cause kidney infection.

How is reflux diagnosed?

Diagnosis is made with a test called voiding cystourethrography. A thin and soft tube, called a catheter, is inserted into the urethra, which can be described as the way urine comes out. A medicated liquid that becomes visible on X-ray is filled until the bladder is full. Then the child is asked to pee. In the meantime, films are taken to see if there is a backward escape. This test usually takes between 15-20 minutes. Sometimes it is recommended to give antibiotics before and after the test, as some of the children may develop an infection during this test due to the use of a catheter.

What other tests can be done in children with reflux?

Ultrasonography, kidney scintigraphy or color film (IVP) may be required to understand whether reflux and urinary infection are damaging the kidneys.

Other tests other than ultrasonography receive a low amount of radiation, but it is quite low compared to other tests. While these tests are being done, the child may feel restless. In this case, you can ask for help by talking to your child's doctor.

The tests for detecting urinary tract infection are urinalysis and urine culture. The only risk that may occur while performing these tests is a reaction to the substances used in serious cleaning before taking urine.

Other tests may be done in children who cannot control their urine during the day. For example, to understand whether the size and functions of the bladder are normal or not, the test called the voiding test, in which the child is urinated into a special toilet and the speed and shape of the flow is determined, as well as the residual urine amount test, in which the amount of urine remaining in the bladder after voiding is determined. Finally, we can count the tests performed by placing a small catheter in the bladder, which we call urodynamics, and filling the bladder with sterile serum and measuring the bladder size and pressure.

How is reflux measured?

Reflux can be measured and graded. The doctor can determine the degree of reflux by looking at the urinary system films. It is graded by determining how much urine flows back to the ureters and kidneys and what changes it causes there. The most serious level is grade V.

What are the risks of reflux?

• Kidney damage: Kidney damage (kidney scar) may occur in children with reflux and urinary infections. High-grade reflux has a high risk of kidney damage. Generally, reflux without infection does not cause damage. High blood pressure can occur because of kidney damage. In addition, if both kidneys are damaged, kidney function may be affected. If both kidneys are severely affected, kidney failure may result.
• Urinary infection: Kidney infection (pyelonephritis) is observed more frequently in children with reflux than in those without reflux. Some children may require hospitalization to treat their infection. Severe infections have a high risk of kidney damage.
• Pregnancy complications: Premature birth, growth retardation in the baby, termination of pregnancy and worsening of the kidney functions of the mother can be observed in pregnant women with obvious kidney damage due to urinary infection.

How is reflux treated?

The aim of treatment in children with reflux is to prevent the kidney from becoming infected and damaged and the complications mentioned above. There are three treatment options: medical treatment, surgical treatment, observation.

1. Medical treatment: Its basis is the disappearance of reflux over time. This period is on average 5-6 years. The aim of medical treatment is to protect the child from kidney damage and urinary infection. In most children, reflux disappears over time due to the maturation and normalization of the connection between the bladder and ureter. The smaller the degree of reflux, the easier it is to disappear. Unilateral reflux is easier to correct than bilateral reflux. Medical treatment includes antibiotic prophylaxis (use of antibiotics to prevent infections), bladder training, and other treatments to prevent infections. The child should be examined periodically, and urinalysis should be performed. Radiological examinations should also be performed at certain intervals.

• Antibiotic prophylaxis: Urinary infections can be prevented by giving low-dose antibiotics every night before going to bed (this way they can stay in the bladder longer). A quarter or a third of the full dose may be given for this purpose. In this way, antibiotics can be used for a long time. Antibiotic prophylaxis does not correct reflux but prevents urinary infection. Reflux that is not accompanied by urinary infection does not cause damage to the kidney. Antibiotic prophylaxis is continued until reflux disappears or the risk of reflux decreases.
• Bladder training: Here the child's voiding intervals are regulated. In addition, techniques to improve bladder functions are taught to the parent and child. The aim is to prevent the development of urinary infections by teaching the normal way of voiding. Bladder training is combined with antibiotic prophylaxis. The doctor can also show the parent and child how to clean the genitals and anal area. It is also important to be taught how to avoid constipation.
• Other treatments: These include anticholinergics. These drugs are very effective in restoring bladder functions and can be used safely for many years.

2. Surgical treatment: The aim is to protect the child from potential risks by treating reflux with surgical treatment. It is applied with a lower abdominal incision under general anesthesia. In this way, the valve mechanism between the bladder and ureters is corrected and reflux is prevented. No artificial material is required for this. A wide variety of effective operating techniques are available. A catheter is placed in the bladder for a few days after the operation. The patient is kept in the hospital for approximately 2-5 days. Follow-up films are taken to see if the operation was successful. If reflux is successfully corrected, it is very difficult to relapse. Antibiotic prophylaxis is discontinued.

In recent years, there have been studies on performing surgery with the least invasive methods. It is possible to perform these operations with the laparoscopic method or the robot-assisted laparoscopic method. One of the most important robot-assisted extravesical ureteroneocystostomy children's series in our country and Europe belongs to me and my success rate is over 95%. 

Another surgical correction method is endoscopic surgery. Under general anesthesia, the surgeon repairs the reflux by entering the urethral opening with a device called a cystoscope and injecting a substance into the place where the ureter enters the bladder . It is not as successful as standard surgical techniques. 

1. Observation: Here, antibiotic therapy is given only when urinary infection occurs. The rationale here is a prompt diagnosis and treatment of urinary infection, and prevention of reflux-related kidney damage and treatment of infection. However, it should not be forgotten that urinary infection can develop rapidly and affect the child. Taking a urine sample for testing and starting treatment accordingly can waste time and lead to infection-related kidney damage.

What are the benefits and risks of each treatment?

1. Benefits:

• Healing: Elimination of reflux with medical treatment depends on the degree of reflux and the age of the child. High-grade reflux is more difficult to correct. The improvement of reflux in older children is more difficult than in younger children. Antibiotic prophylaxis prevents urinary infection and associated kidney damage. Abnormal children are more likely to have reflux if they are treated with antibiotics along with bladder training and other treatments. Standard surgery usually corrects all cases. While the chance of success is highest in grades I and II, it is seen less in grades III and IV, and the lowest in grade V. The probability of success is approximately 85%. Antibiotic therapy is discontinued following successful surgery.

While the success rate of endoscopic treatment is highest in moderate reflux, it is least in severe reflux. If this method fails, it has the advantage of being repeated. However, tests regarding the long-term benefit and reliability of this method are ongoing.

1. Risks:

• Urinary infection: About one-third of children treated for reflux may develop urinary infections after treatment, regardless of the treatment method. However, since successful surgery prevents reflux, it is very difficult for bacteria that can reach the bladder to reach the kidney. The incidence of kidney infection in children receiving medical treatment is 2.5 times higher than in children receiving successful surgical treatment.
• Kidney damage: The main goal in reflux treatment is to protect new or additional kidney damage due to kidney infection. Kidney damage can be detected by radiological tests. Short-term studies have shown that the risk of new kidney damage in children receiving medical treatment or surgically treated as a cure is approximately the same and is between 15-20%. Kidney damage increases the risk of high blood pressure in a child. In this way, severely damaged kidneys can fail. These require either a kidney transplant or dialysis. Pregnant women with kidney damage are at risk of premature birth, high blood pressure, small babies and worsening of kidney functions.
• Problems due to drugs: Minor side effects associated with antibiotic therapy are rash, nausea, vomiting, abdominal pain, and bad taste in the mouth. Skin rash is the most common side effect. Other minor side effects have a less than 10% chance of occurring. The dose of antibiotics given prophylactically in children should be taken every evening at bedtime. Parents should ask the doctor for how long their child may need to take antibiotics and how to act if there is a problem while taking antibiotics. Reactions to other drugs, such as anticholinergics, can also occur in children. These include facial flushing, dry mouth, decreased sweating, increased heart rate, blurred vision, drowsiness, and constipation. Parents should discuss such side effects with their doctor.
• Surgical complications: The most common complications related to reflux surgery are continued reflux, ureteral obstruction, and reflux to the opposite side. The chances of complications occurring depend on the condition of the children.
  • The chance of reflux continuing after standard reflux surgery is 2-4%. In grade V reflux, this risk is slightly higher. If the reflux continues and does not disappear over time, correction may be required.
  • The chance of obstruction of the ureters is about 2%. Many of these needs fixing.
  • In 5% of cases, reflux may occur in the contralateral ureter after surgery on one side. This is independent of the surgery performed for reflux or the degree of reflux. These refluxes may disappear over time. Almost all children experience pain after the operation. The parent should ask the doctor what to do if such a situation arises. Recently, developments aimed at relieving children's pain have been used successfully in children.

Some children may develop urinary infections after surgery. However, they are easily treated with antibiotics. In some children, pain when urinating and urinary control problems occur during the healing of the bladder. These problems go away on their own within a week or two. Blood in the urine may take up to a week. Very rarely it may be necessary to donate blood.

Difficulty in urinating is noted in 2-3% of cases. This problem disappears after a short time. However, the catheters used during this period can sometimes cause pain in the child.

What should be considered when choosing the treatment method?

Several factors should be considered when deciding on the best treatment option for your child. These are the severity of reflux, unilateral or bilateral reflux, the child's age, gender, kidney damage, presence of voiding problems such as incontinence, and the family's opinion.

In general, the lower the reflux degree, the higher the chance of success. Children with low-grade reflux (grades I and II) have a high chance of spontaneous recovery and benefit from antibiotics or surgery. However, in more severe reflux cases, this chance is lower even if urinary infection is prevented by using antibiotics. Standard surgery is effective in 96% of cases.

In general, scientific data reveal that in most of the children with grade I-III reflux, regular daily antibiotic use provides spontaneous improvement in reflux over time. Antibiotic therapy is the first choice in children with grade I-IV reflux. Because there is less risk in this in the short run. In children with severe reflux, surgical treatment is decided. Infections that occur despite the use of prophylactic antibiotics have a high risk of kidney damage and surgery is recommended, as these can be difficult to prevent.

Surgical treatment is recommended in children with grade V reflux. Because they don't have a chance to recover on their own.

Surgical treatment is recommended more in girls than boys. Because girls are at higher risk of developing urinary infections.

Apart from these, whether the child is a suitable candidate for surgery, health problems, whether he can tolerate antibiotics, financial and other social factors should also be considered.

The opinion of the family is also important when deciding on medical or surgical treatment. Families should be informed about the cost of the treatment, the difficulties they may experience, how often they will visit their doctor and which tests will be followed. The personal views of the family should be taken when choosing the treatment method.