In our last journal, I told you what vesicoureteral reflux, or VUR, or urine reflux is, and how we diagnose it. Today, in the Pediatric Surgeon’s Journal, I wrote about how we treat this disease, why does it happen and possible consequences.
Let me start with the good news first. If we are talking about primary urinary reflux and if the cause of the reflux is not due to the increase in pressure in the bladder caused by reasons such as a stenosis at the urinary bladder outlet or voiding disorder, if there is no anatomical defect, if the only reason is the shortness of the ureter in the bladder wall that I have explained before, reflux in most patients disappears by itself. This chance is higher as the degree of reflux decreases, the age of diagnosis decreases, and especially if it is unilateral.
If you want to hear some more details.
80% of minor-grade reflux and 70% of moderate-grade reflux, that are unilateral and diagnosis age below two years, disappear spontaneously. However, if the diagnosis age is as high as five or ten in moderate reflux and if it is bilateral, this chance is only 20%. If there is an advanced leak, regardless of the age of diagnosis, 60% improvement is seen in unilateral and 10% in bilateral cases. If there is very advanced reflux, the chance of regression is very low, it is observed that only 30% of boys can recover within the first year.
So, if it disappear spontaneously, shall we not treat then?
Our aim is to prevent recurrent urinary tract infections, to ensure that kidney damage does not get worse, to adjust the treatment-follow-up protocol to be the most effective, to identify and treat children with bladder-bowel disorders.
What are we doing to move forward with a purpose? First of all, we know that primary VUR patients, especially low grade ones, can regress. We follow these patients. We try to minimize the risk of possible infection during the follow-up process. If it is a boy, we recommend circumcision. In fact, this is perhaps one of the rare indications that circumcision is necessary. We ensure that they are under our constant control with monthly urinalysis. We give preventive, prophylactic antibiotics to children who have not yet been toilet trained. In other words, we try to minimize the risk of urinary tract infection by giving low-dose antibiotics once a day in the evening.
Giving preventative antibiotics should be debated. There are physicians who don’t give antibiotics and just follow the process. However, if the patient is young, especially if he has a history of febrile urinary tract infection, and they cannot be followed up properly, if he has advanced reflux and accompanying signs of bowel-bladder disorder, we definitely follow up with preventive antibiotics.
If there are signs of Bladder Bowel Disorder, which is more common in girls, the risk of urinary tract infection is higher, and even if the reflux will go away on its own, it will take longer. In these children, complaints such as urinary incontinence, frequent or very little small toileting, constipation, poop incontinence, painful urination, abdominal pain are observed. We also use pelvic muscle exercises, urination teaching exercises, biofeedback therapies, constipation treatments, laxatives, anticholinergic drugs to prevent bladder contraction for these complaints.
What I have told so far is actually mostly handled by pediatric nephrologists. Except for circumcision. If children with severe reflux have reached the age of 2-3 and their reflux still continues, or if there are patients who have moderate reflux but do not or cannot take their preventive antibiotics properly, if urinary tract infections cannot be prevented, then surgical treatment comes into play.
As always in surgical treatment, our priority is to start with methods that will cause the least damage and require the least intervention.
We see the inside of the bladder with a camera that we insert through the urethra, which we call cystoscopy. Wee see the ureter orifices, and inject a material right underneeath these orifices to block the upward reflux of the urine. The chance of success is 75-90%. VUR can develop again in up to 20% of those who are successful, but overall we are very satisfied with the injection results. If we are unsuccessful, or if there is a significant anatomical defect causing VUR; just like the opening of the urinary tract into pockets we call diverticulum, then we need to do open surgery. Our chance of success with open surgery is 95-99%.
There are different surgical techniques available. If we are going to do an operation to open the bladder, we prefer to wait until the age when toilet training starts and the neural development of the bladder is completed. In any case, in order for the surgical treatment to be successful, the bladder and bowel disorder must not be present, and if any, it must be treated. If there is no febrile infection after surgical treatment, there is no need to prove that the reflux is gone by taking voiding radiographs again. But there are also those who do routine x-ray examinations after the injection.
As a result, these patients need to be followed up for a long time. It should not be forgotten that especially girls are at risk of having serious kidney infections during pregnancy, and all patients’ growth, weight-height follow-ups, blood pressures, and urinalysis should be followed up for possible protein and bacteria. Of course, families should be informed that their first-degree relatives may also have have hypertension, kidney failure, and increased risk of VUR.
Yes. It is an inconvenience that we see this problem frequently and that we sometimes have difficulty in making a decision, although it may not seem very complicated. Vesicoureteral reflux, aka VUR. Fortunately, as I said before, in our pediatric nephrology-urology meetings, in which pediatric surgeons, pediatric urologists, pediatric nephrologists, radiologists and nuclear medicine doctors actively participate, we try to find the best approach by discussing our patients one by one.
So let’s wrap up one more Journal.
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Prof. Dr. Egemen Eroğlu
June 2022