Current Urology Reports

, Volume 2, Issue 2, pp 113–121 | Cite as

Management of vesicoureteral reflux in children

  • Saul P. Greenfield
Article

Abstract

Although much has been learned about the diagnosis and management of vesicoureteral reflux, several important areas of investigation remain. Because not all children with reflux are equally susceptible to renal scarring and the development of reflux nephropathy, controversy surrounds the need to evaluate all children with urinary tract infection or to continue prophylaxis in known refluxing children after a certain age. In addition to age, other factors such as sex, grade of reflux, and the presence of voiding dysfunction can all play a role. The grade of reflux as seen on the contrast voiding cystourethrogram is the best predictor of reflux resolution in large numbers of patients, but grade alone cannot predict spontaneous cessation in any one individual. Attempts at refining more quantitative imaging modalities have so far proved unsuccessful. Open ureteral reimplanta-tion remains the standard for surgical care if surgery is necessary. Both cystoscopic and laparoscopic techniques, however, may ultimately prove to be reliable, minimally invasive approaches to definitive correction. Finally, there are data to support continued diagnosis and treatment of reflux in at-risk populations. The incidence of reflux-related morbidity in children has significantly diminished over the last three decades. A major challenge is to better identify at-risk subpopulations of children with reflux, so that not every child will require intensive, long-term medical treatment or surgery.

Keywords

Urinary Tract Infection Vesicoureteral Reflux Renal Scarring Resolution Rate Pediatric Urology 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
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References and Recommended Reading

  1. 1.
    Greenfield SP, Ng M, Wan J: Experience with vesicoureteral reflux in children: clinical characteristics. J Urol 1996, 158:574–547. A 9-year review of the clinical experience with almost 1000 children who presented with reflux.CrossRefGoogle Scholar
  2. 2.
    Kunin CM, Deitscher R, Paquin A: Urinary tract infections in school children: an epidemiologic, clinical and laboratory study. Medicine 1964, 43:91–130.PubMedGoogle Scholar
  3. 3.
    Smellie JM, Hodson CJ, Edwards D, et al.: Clinical and radiological features of urinary tract infection in childhood. BMJ 1964, 2:1222–1226.PubMedCrossRefGoogle Scholar
  4. 4.
    Pylkkanen J, Vilska J, Koskimies O: The value of level diagnosis of childhood urinary tract infection in predicting urinary injury. Acta Paediatr Scand 1981, 70:879–883.PubMedGoogle Scholar
  5. 5.
    Winberg J: Commentary: progressive renal damage from infection with or without reflux. J Urol 1992, 148:1733–1734.PubMedGoogle Scholar
  6. 6.
    Winberg J: Management of primary vesicoureteral reflux in children—operation ineffective in preventing progressive renal damage. Infection 1994, 22:4–7.CrossRefGoogle Scholar
  7. 7.
    Ditchfield MR, De Campo JF, Cook DJ, et al.: Vesicoureteral reflux: an accurate predictor of acute pyelonephritis in child-hood urinary tract infection? Radiology 1994, 190:413–415.PubMedGoogle Scholar
  8. 8.
    Ditchfield MR, De Campo JF, Nolan TM, et al.: Risk factors in the development of early renal cortical defects in children with urinary tract infection. Am J Radiol 1994, 162:1393–1397.Google Scholar
  9. 9.
    Cardiff-Oxford Bacteriuria Study Group: Long-term effect of bacteriuria on the urinary tract in school girls. Radiology 1979, 132:343–350.Google Scholar
  10. 10.
    Birmingham Reflux Study Group: Prospective trial of operative versus non-operative treatment of severe vesicoureteral reflux in children: five years’ observation. BMJ 1987, 295:237–241.Google Scholar
  11. 11.
    Smellie JM, Prescod N, Shaw PJ, et al.: Childhood reflux and urinary infection: a follow up of 10–41 years in 226 adults. Pediatr Nephrol 1998, 12:727–736.PubMedCrossRefGoogle Scholar
  12. 12.
    Smellie JM: Reflections on 30 years of treating children with urinary tract infections. J Urol 1991, 146:665–668.PubMedGoogle Scholar
  13. 13.
    Smellie JM, Poulton A, Prescod N: Retrospective study of children with renal scarring associated with reflux and urinary tract infection. BMJ 1994, 308:1193–1196.PubMedGoogle Scholar
  14. 14.
    Naseer SR, Steinhardt GF: New renal scars in children with urinary tract infections, vesicoureteral reflux and voiding dysfunction: a prospective evaluation. J Urol 1997, 158:566–568.PubMedCrossRefGoogle Scholar
  15. 15.
    Shimada K, Matsui T, Ogino T, et al.: Renal growth and progression of reflux nephropathy in children with vesicoureteral reflux. J Urol 1988, 140:1097–1100.PubMedGoogle Scholar
  16. 16.
    Wan J, Greenfield SP, Ng M, et al.: Sibling reflux: a dual center retrospective study. J Urol 1996, 156:677–679.PubMedCrossRefGoogle Scholar
  17. 17.
    Jerkins GR, Noe HN: Familial vesicoureteral reflux: a prospective study. J Urol 1982, 128:774–778.PubMedGoogle Scholar
  18. 18.
    Peeden Jr JN, Noe HN: Is it practical to screen for familial vesicoureteral reflux with a private pediatric practice? Pediatrics 1992, 89:758–760.PubMedGoogle Scholar
  19. 19.
    Kenda RB, Fettich JJ: Vesicoureteral reflux and renal scars in asymptomatic siblings of children with reflux. Arch Dis Child 1992, 67:506–508.PubMedGoogle Scholar
  20. 20.
    Sujka SJ, Piedmonte MR, Greenfield SP: Enuresis and the voiding cystourethrogram: a re-evaluation. Urology 1991, 38:139–142.PubMedCrossRefGoogle Scholar
  21. 21.
    Sillen U, Hjalmas K, Aili M, et al.: Pronounced detrusor hypercontractility in infants with gross bilateral reflux. J Urol 1992, 148:598–599.PubMedGoogle Scholar
  22. 22.
    Sillen U, Bachelard M, Hermanson G, et al.: Gross bilateral reflux in infants: gradual decrease of initial detrusor hypercontractility. J Urol 1996, 155:668–672.PubMedCrossRefGoogle Scholar
  23. 23.
    Chandra M, Maddox H, McVicar M: Transient urodynamic dysfunction of infancy: relationship to urinary tract infections and vesicoureteral reflux. J Urol 1996, 155:673–677.PubMedCrossRefGoogle Scholar
  24. 24.
    Griffiths DJ, Scholtmeijer RJ: Vesicoureteral reflux and lower urinary tract dysfunction: evidence for 2 different reflux/ dysfunction complexes. J Urol 1987, 137:240–244.PubMedGoogle Scholar
  25. 25.
    Jawson MS, Dibble L, Puri S, et al.: Prospective study of outcome in antenatally diagnosed renal pelvis dilatation. Arch Dis Child Fetal Neonatal Ed 1999, 80:135–138.Google Scholar
  26. 26.
    Tibbals JM, De Bruyn R: Primary vesicoureteral reflux—how useful is post-natal ultrasound? Arch Dis Child 1996, 75:444–447.Google Scholar
  27. 27.
    Gordon AC, Thomas DFM, Arthur RJ, et al.: Prenatally diagnosed reflux: a follow up study. Br J Urol 1990, 65:407–412.PubMedGoogle Scholar
  28. 28.
    Oliveira EA, Diniz JSS, Silva JMP, et al.: Features of primary vesicoureteral reflux detected by investigation of foetal hydronephrosis. Int Urol Nephol 1998, 30:535–541.CrossRefGoogle Scholar
  29. 29.
    Assael BM, Guez S, Marra G, et al.: Congenital reflux nephro-pathy: a follow up of 108 cases diagnosed perinatally. BJU 1998, 82:252–257.PubMedCrossRefGoogle Scholar
  30. 30.
    Bouachrine J, Lemelle JL, Didier F, et al.: A follow-up study of pre-natally detected primary vesico-ureteral reflux: a review of 61 patients. BJU 1996, 78:936–939.PubMedCrossRefGoogle Scholar
  31. 31.
    Arima M, Matsui T, Ogina T, et al.: Vesicoureteral reflux in infants under one year old. Follow-up study and consider-ation on development of renal scarring. Urology 1993, 41:372–377.PubMedCrossRefGoogle Scholar
  32. 32.
    Scott JS: Fetal ureteric reflux: a follow-up study. BJU 1993, 71:481–483.PubMedGoogle Scholar
  33. 33.
    Belman AB: Vesicoureteral reflux. Pediatr Clin North Am 1997, 44:1171–1190.PubMedCrossRefGoogle Scholar
  34. 34.
    Cooper CS, Chung BI, Kirsch AJ, et al.: The outcome of stopping prophylactic antibiotics in older children with vesicoureteral reflux. J Urol 2000, 163:269–273.PubMedCrossRefGoogle Scholar
  35. 35.
    Hori C, Hiraoka M, Tsukahara H, et al.: Intermittent time-thoprim-sulfamethoxazole in children with vesicoureteral reflux. Pediatr Nephrol 1997, 11:328–330.PubMedCrossRefGoogle Scholar
  36. 36.
    Mansfield JT, Snow BS, Cartwright PC, et al.: Complications of pregnancy in women after childhood reimplantation for vesicoureteral reflux: an update with 25 years of follow-up. J Urol 1995, 154:787–790.PubMedCrossRefGoogle Scholar
  37. 37.
    Weaver E, Craswell P: Pregnancy outcome in women with reflux nephropathy—a review of experience at the Royal Woman’s Hospital, Brisbane 1977–1986. Aust N Z J Obstet Gynaecol 1987, 27:106–110.PubMedGoogle Scholar
  38. 38.
    Jungers P, Houillier P, Chaveau D, et al.: Pregnancy in women with reflux nephropathy. Kidney Int 1996, 50:593–599.PubMedCrossRefGoogle Scholar
  39. 39.
    Koff SA: Relationship between dysfunctional voiding and reflux. J Urol 1992, 148:1703–1705.PubMedGoogle Scholar
  40. 40.
    Snodgrass W: The impact of treated dysfunctional voiding on the nonsurgical management of vesicoureteral reflux. J Urol 1998, 160:1823–1825.PubMedCrossRefGoogle Scholar
  41. 41.
    Koff SA, Wagner TT, Jayanthi VR: The relationship among dysfunctional elimination syndromes, primary vesicoureteral reflux and urinary tract infections in children. J Urol 1998, 160:1019–1022. An excellent presentation of original clinical data along with a discussion of the relationship between voiding dysfunction and reflux.PubMedCrossRefGoogle Scholar
  42. 42.
    van Gool JD, Hjalmas K, Tamminen-Mobius T, et al.: Historical clues to the complex of dysfunctional voiding, urinary tract infection and vesicoureteral reflux. J Urol 1992, 148:1699–1602.PubMedGoogle Scholar
  43. 43.
    Skoog SJ, Belman AB, Majd M: A nonsurgical approach to the management of primary vesicoureteral reflux. J Urol 1987, 138:941–946.PubMedGoogle Scholar
  44. 44.
    Huang FY, Tsai TC: Resolution of vesicoureteral reflux during medical management in children. Pediatr Nephrol 1995, 9:715–717.PubMedCrossRefGoogle Scholar
  45. 45.
    Bellinger MF, Duckett JW: Vesicoureteral reflux: a comparison of non-surgical and surgical management. Contrib Nephrol 1984, 39:81–93a.PubMedGoogle Scholar
  46. 46.
    Arant BS: Medical management of mild and moderate vesicoureteral reflux: follow up studies of infants and young children. A preliminary report of the Southwest Pediatric Nephrology Study Group. J Urol 1992, 148:1683–1687.PubMedGoogle Scholar
  47. 47.
    Greenfield SP, Ng M, Wan J: Resolution rates of low grade vesicoureteral reflux stratified by patient age at presentation. J Urol 1997, 157:1410–1413.PubMedCrossRefGoogle Scholar
  48. 48.
    Kenda RB, Zupancic Z, Fettich JJ, et al.: A follow-up study of vesicoureteric reflux and renal scars in asymptomatic siblings of children with reflux. Nucl Med Commun 1997, 18:827–831.PubMedCrossRefGoogle Scholar
  49. 49.
    Mozley PD, Heyman S, Duckett JW, et al.: Direct vesicoureteral scintigraphy: quantifying early outcome predictors in children with primary reflux. J Nucl Med 1994, 35:1602–1608.PubMedGoogle Scholar
  50. 50.
    Nasrallah PF, Conway JJ, King LR, et al.: The quantitative nuclear cystogram: an aid in determining the spontaneous resolution of vesicoureteral reflux. Trans Am Assoc Genitourin Surg 1979, 70:52–55.Google Scholar
  51. 51.
    Barthold JS, Martin-Crespo R, Kryger JV, et al.: Quantitative nuclear cystography does not predict outcome in patients with primary vesicoureteral reflux. J Urol 1999, 162:1193–1196.PubMedCrossRefGoogle Scholar
  52. 52.
    Edwards D, Normand IC, Prescod N, et al.: Disappearance of vesicoureteral reflux during long term prophylaxis of urinary tract infection in children. BMJ 1977, 2:285–288.PubMedGoogle Scholar
  53. 53.
    Tamminen-Mobius T, Brunier E, Ebel KD, et al.: Cessation of vesicoureteral reflux for 5 years in infants and children allocated to medical treatment. The International Reflux Study in Children. J Urol 1992, 148:1662–1666.PubMedGoogle Scholar
  54. 54.
    Wan J, Greenfield SP, Talley M, et al.: An analysis of social and economic factors with followup of patients with vesicoureteral reflux. J Urol 1996, 156:668–672.PubMedCrossRefGoogle Scholar
  55. 55.
    Elder JS, Peters CA, Arant BS, et al.: Pediatric vesicoureteral reflux guidelines panel summary report on the management of primary vesicoureteral reflux in children. J Urol 1997, 157:1846–1851. A short summary of the conclusions of the AUA guidelines panel with practical recommendations for the clinician.PubMedCrossRefGoogle Scholar
  56. 56.
    The American Urologic Association: Report on the manage-ment of primary vesicoureteral reflux in children. Baltimore: American Urologic Association; 1997. The complete AUA guidelines panel report with detailed discussion and analysis of the data. There are many excellent tables clearly showing much of the known literature on the subject of reflux.Google Scholar
  57. 57.
    Puri P, Granata C: Multicenter survey of endoscopic treatment of vesicoureteral reflux using polytetrafluoroethylene. J Urol 1998, 160:1007–1011.PubMedCrossRefGoogle Scholar
  58. 58.
    Aaronson IA: Current status of the STING: an American perspective. BJU 1995, 75:121–125.PubMedGoogle Scholar
  59. 59.
    Aaronson IA, Rames RA, Greene WB: Endoscopic treatment of reflux: migration of Teflon to the lungs and brain. Eur Urol 1993, 23:394–399.PubMedGoogle Scholar
  60. 60.
    Malizia AA, Reiman HM, Myers RP: Migration and granulo-matous reaction after periurethral injection of polytef (Teflon). JAMA 1984, 251:3277–3281.PubMedCrossRefGoogle Scholar
  61. 61.
    Frey P, Burger D, Jenny P, et al.: Endoscopic subureteral collagen injection for the treatment of vesicoureteral reflux in infants and children. J Urol 1995, 154:804–807.PubMedCrossRefGoogle Scholar
  62. 62.
    Diamond DA, Caldamone AA: Endoscopic correction of vesicoureteral reflux in children using autologous chondro-cytes: preliminary results. J Urol 1999, 162:1185–1188.PubMedCrossRefGoogle Scholar
  63. 63.
    Lakshmanan Y, Steiger CA, Fung LCT: Laparoscopic ureteral reimplantation for minimally invasive correction of vesicoureteral reflux: technique and results. J Urol 1999, 161(suppl):89.CrossRefGoogle Scholar
  64. 64.
    Wacksman J, Gilbert A, Sheldon CA: Results of the renewed extravesical reimplant for surgical correction of vesicoureteral reflux. J Urol 1992, 148:359–361.PubMedGoogle Scholar
  65. 65.
    Lipski BA, Mitchell ME, Burns MW: Voiding dysfunction after bilateral extravesical ureteral reimplantation. J Urol 1998, 159:1019–1021.PubMedCrossRefGoogle Scholar
  66. 66.
    Barrieras D, Lapointe S, Reddy PP, et al.: Urinary retention after bialteral extravesical ureteral reimplantation: does dissection distal to the ureteral orifice have a role? J Urol 1999, 162:1197–1200.PubMedCrossRefGoogle Scholar
  67. 67.
    Bomalaski MD, Ritchey ML, Bloom DA: What imaging studies are necessary to determine outcome after ureteroneo-cystostomy? J Urol 1997, 158:1226–1228.PubMedCrossRefGoogle Scholar
  68. 68.
    El-Ghoneim A, Odet E, Lamer S, et al.: Cystography after the Cohen ureterovesical reimplantation: is it necessary at a training center? J Urol 1999, 162:1201–1202.CrossRefGoogle Scholar
  69. 69.
    Still JL, Cottom D: Severe hypertension in children. Arch Dis Child 1967, 42:34–39.PubMedGoogle Scholar
  70. 70.
    Londe S: Causes of hypertension in the young. Pediatr Clin North Am 1978, 25:55–65.PubMedGoogle Scholar
  71. 71.
    Wyszynska T, Chichocka E, Wietska-Klimczak A, et al.: A single pediatric center’s experience with 1025 children with hyper-tension. Acta Paediatr 1992, 81:1244–1246.Google Scholar
  72. 72.
    Bakshandeh K, Lynne C, Carrion H: Vesicoureteral reflux and end stage renal disease. Int J Urol 1976, 11 6:557–558.Google Scholar
  73. 73.
    Warady BA, Herbert D, Sullivan EK: The 1995 annual report of the North American pediatric renal transplant cooperative study. Pediatr Nephrol 1997, 11:49–64.PubMedCrossRefGoogle Scholar
  74. 74.
    Vallee JP, Vallee M, Greenfield SP, et al.: Contemporary incidence of morbidity related to vesicoureteral reflux. Urology 1999, 53:812–815. This study shows that the diagnosis and treatment of reflux has resulted in a decrease in the sequelae of reflux nephropathy—renal insufficiency and hypertension.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 2001

Authors and Affiliations

  • Saul P. Greenfield
    • 1
  1. 1.Department of Pediatric UrologyChildren’s Hospital of BuffaloBuffaloUSA

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