Re: vesicoureteral reflux

Questions posted in the The Urology Forum have been answered by urologists from Henry Ford Health System and by Dr. Kevin Pho.

Subject: Re: vesicoureteral reflux
Forum: The Urology Forum
Topic Area: Urology - General
Posted by HFHS M.D.-MS on July 10, 1998 at 14:19:07:
In Reply to: vesicoureteral reflux posted by Barb` on July 03, 1998 at 00:22:59:

My two year old daughter was diagnosed with vesicoureteral reflux at the age of
six weeks. She has been on antibiotics since. It was grade 1-2 on both sides. A
year ago we were told it was clear on one side and improved on the other side.
Now we have been told it is worse and on both sides. They did not say what grade
it is but that sometimes it gets worse before it gets better. We are wondering
what to expect in the future. Do most people with this end up having surgery? How
common are kidney problems? How long will she have to be retested after it has been
pronounced clear? How do we know if she is immune to the antibiotics, how do we know
she is not having infections which are silently destroying her kidneys? If x-rays are so
dangerous to the reproductive system, why do doctors want to have them done so often,
when there are alternative procedures that can be done.

Dear Barb
You have alot of questions. Did you use the MedHelp Site Search Function? There is lots of information regarding prognosis, treatment , risk and benefits of surgery for and folow-up for VUR (vesicoureteral reflux). Here are some examples:

Posted by Doug Bank on June 13, 1998 at 01:38:12:

In Reply to: VCUG/Nuclear Cystogram posted by JC on June 12, 1998 at 13:22:51:

Topic Area: Urology - General

I am scheduled for a nuclear cystogram to rule out the possibility
of reflux. The hospital has scheduled me for a VCUG although my
Urologists prescription clearly states Nuclear Cystogram. When
I asked why they are calling it a VCUG the nurse told me that a VCUG
and a nuclear cystogram are the same thing. I certainly don't want the test to be done
twice because somebody missed something. Is there a difference
between these two tests??

These two tests are absolutely NOT the same thing, however, they do test the same thing. Now, I'm
not one of the doctors, so keep checking back for their answer, but here is what I know (and my
daughters have had both):

The VCUG involves a flouroscope and a contrast solution. The contrast solution is "injected" into the
bladder via a catheter. I believe that it is a reasonably accurate test, and it is good at gauging the
severity of the reflux. It is often used first to see if there is any reflux. Since it involves a large radiation
dose from the flouroscope, they try to only do it once.

The nuclear cystogram is similar, except they inject a radioactive contrast solution into the bladder
(again, via a catheter) and follow what happens via a gamma camera. I think that it is more sensitive,
and is going to pick up reflux if it exists, but it cannot accurately gauge the severity. (In kids they want
to know the severity in order to decide whether to watch and wait or to perform surgery.) The
radiation dose with this test is very small.

I would call the urologist and tell him what's going on. See if he thinks it makes a difference.

Good Luck!

For more info, take a look at these links:

http://www.um-urology.com/clinic/pediatric/reflux.html
http://www.med.jhu.edu/pediurol/vur.htm

Doug Bank,
Editor, TCRC

Testicular Cancer Resource Center
-----------------------------------------------------------------------------
Posted by Michelle on June 15, 1998 at 21:27:10:
Topic Area: Urology - General
My daughter is 18 months old and at 11 months was diagnosed with Grade 3
reflux. Her VCUG showed 2 normal kidney's with minimal hydronephrosis.
What exactly does minimal hydronephrosis mean? She is on medication and
has to have her urine checked frequently. Will she outgrow this and will
she possibly have any kidney damage from this problem? Also, what is the
severity of a Grade 3 reflux? Thank you for any information that will
help
me to understand the problem that my daughter has.
Sincerely,
Michelle
----------------------------------
Dear Michelle
Thanks for your questions.
Vesicoureteral reflux is a common occurrence.
It is a developmental abnormality when the ureter ( the tube from the kidney ) does not insert into the bladder at the proper angle. The angle is so acute that the urine is able to flow back up toward the kidney. Authors say that reflux itself is not a problem but coupled with bacteria spells trouble. Complications include; renal scarring, fever , UTIs, possible hypertension and infrequent kidney failure.
Reflux is graded by the amount of urine refluxed, from 1 to 5 , 5 being the worst. Grade three has about a fifty -fifty chance of resolving by the age of five. Treatment includes antibiotics to prevent infections while the young kidney is susceptible. There is some debate about adolescent females with reflux and no infections. Will these girls endanger their fetuses if the get a UTI while pregnant? Should they undergo surgery before reproductive years? Hope this has answered your questions and will stimulate dialog with your physician.
More individualized care is available at the Henry Ford Hospital and its urban campuses by calling (1 800 653 6568). We can also arrange local accommodations through this number if this is your need. Please bring any physicians notes and lab test results that you may be able to obtain. These will help us greatly.

This information is provided for general medical education purposes only. Please consult your physician for diagnostic and treatment options pertaining to your specific medical condition.
Sincerely;
HFHS-M.D. MS
* Keyword: reflux
0.4

Posted by Mickey on June 23, 1998 at 09:25:53:
Topic Area: Urology - General
My daughter was diagnosed with VUR when she was 12. By that time there
had been quite a bit of kidney damage. She had surgery at that time to
move the ureter. It was hoped that this would help her to outgrow her
refluxing. She did not.
When she was 15 she had a "sting" operation where they implanted teflon
on her ureteral valve. This did stop the refluxing and one year later
she still had no problem. She is now 22 and is experiencing constant
UTIs again. She's on bactrim constantly and we're just beginning the
IVPs and VCUGs again. But they haven't been able to run them yet because
we can't get her infection free. Is there a possibility that her
implants have failed? I can't find any information on failure rates on
this. If they have, what is the next course of treatment? I'd really
appreciate any information you can give me. Thanks.
-------------------------------------------------------
Dear Mickey
Thanks for your questions.
As you know VUR is repaired surgically because of the risk of continued pyelonephritis. Pyelonephritis is an infection of the kidney from the bacteria being refluxed up from the bladder, into the meat of the kidney. High fevers and flank pain with nausea and vomiting accompany pyelonephritis. Most urologist believe that the adult kidney is not as susceptible to reflux because the very small tubes of the kidney in the papilla ( collecting ducts) , form a somewhat flap valve and will not let the bacteria in. Her scars are probably from early childhood before the flap valves of the papilla formed. Cystitis is another story and is dependent on host defense factors. The risk of a bladder infection after a re implant surgery does not change because the host resistance factors to bacteria are the same immediately before and after the surgery. Adults especially sexually active females are at risk of UTIs . The controversy is whether an asymptotic female teenager should have her reflux corrected surgically for fear that pyelonephritis during a future pregnancy may increase the risk to her fetus. Long-term prophylaxis throughout pregnancy has not been described in the literature to my knowledge.
The treatment and work-up for a uncomplicated UTI in the adult is fairly simple. A cystoscopic exam in clinic and an IVP should be able to rule out any anatomic cause such as a stone. She may need long-term (6 months) prophylaxis if she continues to get repeated infections to let her bladder lining heal. Most sexually active women can take prophylaxis around the time of intercourse to afford an infection.
Failure rates for anti-reflux surgeries are less than 5 %. I am not sure about the recurrence rate after the Sting procedure.
More individualized care is available at the Henry Ford Hospital and its urban campuses by calling (1 800 653 6568). We can also arrange local accommodations through this number if this is your need. Please bring any physicians notes and lab test results that you may be able to obtain. These will help us greatly.

0.5
Barb I hope this info has helped.
More individualized care is available at the Henry Ford Hospital and its urban campuses by calling (1 800 653 6568). We can also arrange local accommodations through this number if this is your need. Please bring any physicians notes and lab test results that you may be able to obtain. These will help us greatly.

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