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Urology (Expert Forum)
Vesicoureteral Reflux
Questions in the Urology forum are answered by Dr. Stephen Liroff, affiliated with the Henry Ford Hospital. Topics covered include benign prostate disease, penis curvature, cystisis, kidney stones, pediatric urology, prostate, sexual dysfunction, urinary tract infections (UTI), and urological cancers.
Vesicoureteral Reflux
by E-Johnson, Jan 21, 1998 12:00AM
Our 10 month old son was diagnosed last week with bilateral
Grade II reflux after having a severe UTI, which was initially
thought to be related to a narrowing of his meatus following
hypospadias repair in Dec of 1998. The opening has been widened and he has been placed on a prophylactic dose of SMZ-TMP
and we have been told that there is an excellent chance that he
will outgrow this. After doing a bit of research, I have several
questions.
How likely is it that he will have renal damage and/or
renal growth failure, given the early detection and treatment?
Can his kidneys be damaged by the reflux of
urine if there is no infection present?
What is the longterm prognosis, in terms of renal function and in
developing related problems, such as hypertension?
What sort of testing should he have and when?
What things can we do at home to give him optimum care?
Thank you for taking the time to answer these questions
as we really want to do the best for our child.
Doctor's Answer
by hfhs M.D.-AK, Jan 21, 1998 12:00AM
_
Dear Danielle,
One of the most difficult decisions regarding a child with vesicoureteral reflux is deciding between medical and surgical management. Spontaneous disappearance of reflux is related to the age of the child and degree of reflux. It has been reported that 63% of grade two, 53% of grade three , and 33% of grade four reflux patients have resolved spontaneously if infection is controlled. Reflux that persists in adolescence or adulthood is unlikely to disappear spontaneously.
The most important issue with children with reflux is preservation of the renal function and allowing for normal and complete growth of both kidneys. This means avoiding infections of the kidneys to prevent harmful scarring. If your child has not suffered any scarring after this initial infection, careful follow-up with his doctor should insure normal growth and renal function. Approximately 30 to 50% of patients have renal scarring on initial evaluation. Hypertension develops in those scared individuals about 10-20% of the time, and the severity of the hypertension usually is related to the degree of parenchymal damage. Sometimes patients are placed on long-term prophylactic antibiotic therapy. These regimens are usually safe as long they are tolerated well by the child. It sounds like you have started TMP/SMZ in your child. This is a very good antibiotic for prophylaxis and usually well tolerated.
If your child were to continue to be managed conservatively(medically) periodic follow-up studies must be done to ensure normal scar free growth. Also a physical exam should be performed with special inclusion of height, weight parameters and blood pressure measurements. Laboratory studies should include a urinalysis and urine culture at each visit In terms of radiology tests, an IVP or ultrasound should be obtained every 18-24 months. After the initial VCUG has been performed to establish to current grade, a follow-up study should be performed to establish an interval relationship.
On the other hand surgery or reimplantation of the ureters is a very successful procedure. One should expect success rates as high as 95-98% in patients with normal caliber ureters and normal bladders. With grade one and grade two reflux, a normal caliber ureter is almost always the case. This drops to 54% when the ureter is markedly dilated which is seen in grade four reflux.
There are several schools of thought on whether or not the reflux of sterile urine causes damage to the kidney and alters growth, most pediatric urologist do not believe it causes damage. The decision to proceed either with conservative medical therapy verses surgical therapy will largely be up to you and your Urologist. I don’t think there is a right or wrong decision however if inadequate follow-up could become an issue or the breakthrough infections occur, the one time surgical procedure would probably be the safer option. I think with your child being young and only grade2 reflux, he should certainly have a complete trial of conservative management, but if he ever has a kidney infection or her follow-up radiologic studies show scarring or signs of atrophy in the kidney, I would proceed with surgery.
Depending on your course of management surgical or conservative, the best thing you can do for your child is to make sure he makes his appointment as scheduled, and if he has a high fever, get a urine culture.
This information is provided for general medical educational purposes only. Please consult your physician for diagnostic and treatment options pertaining to your specific medical condition. More individualized care is available at the Henry Ford Hospital and its satellites (1 800 653-6568).
Sincerely,
HFHS M.D.-AK
*keyword:Reflux
