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Diagnosing the Problem
Preventing Kidney Infections
Reflux of urine is one of the more common reasons that children are referred to a pediatric urologist. Reflux simply means that urine goes backwards in the ureter during urination. The ureter is the tube that connects the kidney to the bladder. Urine is supposed to go in one direction: from the kidneys to the bladder. When urine goes up from the bladder to the kidneys, it can result in health problems for the child.
Reflux may have been discovered in your child in one of two common ways. First, the kidney is sometimes seen to be dilated, or “ballooned,” on a prenatal sonogram (ultrasound). At the time of birth, testing may have revealed that this ballooning was due to reflux of urine. The other common presentation of reflux is an unexpected urinary tract infection. Evaluation with X-rays after a urinary infection may reveal reflux as an underlying cause or associated problem.
Sometimes, a child is screened for reflux because a brother or sister has the problem. Reflux is often discovered in this way and many doctors feel that all young brothers or sisters of children with reflux should have at least some screening test performed.
The diagnosis of reflux is made using an X-ray called a voiding cystourethrogram (VCUG), or a nuclear cystogram. Both tests involve a urinary catheter (tube) placed into the child’s bladder. This is used to fill the bladder with X-ray dye or radioactive material (very weak radioactivity). The dye is then observed during urination and, if it is seen going up toward the kidneys, the diagnosis is made. Although this can be an uncomfortable test for your child, the severity of problems that occur with reflux makes the diagnosis very worthwhile.
Your doctors will be concerned about your child’s diagnosis of reflux. This is because reflux can lead to kidney damage. Refluxing urine can carry bacteria to the kidney, where it can establish a kidney infection. Children with reflux of urine are much more likely to have kidney infection than children who do not have reflux. The combination of reflux and infection can lead to areas of permanent kidney damage or “renal scarring.”
This scarring was detected in the past by doing an X-ray called an intravenous pyelogram (IVP), but now is more commonly evaluated with a renal scan. If it is extensive enough, the scarring can lead to loss of function of one or both kidneys. Fortunately, this degree of scarring is rare.
It is important in children with reflux to prevent kidney infections. This is achieved in three ways. In most children, prophylactic antibiotics are given. “Prophylactic” antibiotics are those given to prevent, not treat infection. Therefore, the doses used are low and the antibiotic is usually given only once a day. Antibiotics given in this way are very safe and almost never cause any long-term problems. Certainly the risk of taking low-dose antibiotics is much less than the risk of recurrent kidney infections. The other method of preventing urinary tract infections is surgical correction of the reflux. In most cases, this is not necessary, because the reflux will go away on its own.
The third method of preventing infections involves improving the way that your child voids. A large number of children with reflux and infection have some form of voiding dysfunction, or what is now referred to as dysfunctional elimination syndrome (DES). This might involve urinary frequency, or the opposite—infrequent voiding. Often there are accidents or urgency when voiding occurs. Constipation is almost always present to some degree. It turns out that treating the voiding dysfunction will often dramatically reduce the incidence of urinary infections.
The tendency for reflux to cure itself is the basis for current treatment. Not all reflux will go away, and it is useful to predict the likelihood of this occurring. One of the clues that your doctor will use is the “grade” of the reflux. This refers to how the reflux looks in the X-rays—the more severe the reflux, the higher the grade, with scores from 1-to-5. The higher the grade, the less likely that the reflux will go away. Also, reflux that occurs into both kidneys appears to be less likely to go away than reflux occurring on only one side. Despite these guidelines, it is almost impossible to predict with certainty for the individual patient whether reflux will go away (except in cases of grade 5 reflux, which rarely resolves beyond infancy).
For most children, prophylactic antibiotics are given on a daily basis. As long as there are no urinary infections, a VCUG or nuclear cystogram is obtained yearly to see if the reflux is still present. Most of the time, four or five years will be allowed for the reflux to go away before surgery is suggested. In many cases, the doctor might wait significantly longer. There are reasons, however, that surgery might be performed earlier. The most common reason is “breakthrough” infection: an infection which occurs while taking prophylactic antibiotics. Other reasons might include high-grade reflux, antibiotic allergies, and patient and physician choice.
Surgery for reflux is highly successful and carries relatively little risk. The operation is usually done through a “bikini” incision. The bladder is opened and the ureters are freed from the inside of the bladder. They are then tunneled under the bladder lining, so that the ureter acts as its own flap valve—this is how the ureter is supposed to work in the first place. Alternatively, the ureters are tunneled in the bladder wall from outside the bladder. Usually children are in the hospital overnight. The success of these operations in routine cases is well over 95 percent and complications are rare. There are new operations being developed to try to correct reflux using “minimally invasive” techniques, and we have been involved with some of these. These are things which your doctor can counsel you about before you make a decision concerning surgery.
In summary, vesicoureteral reflux is a relatively common disease which can be benign if treated appropriately. It can also have significant consequences if ignored. Most children will be cured with a few years of antibiotic prophylaxis, treatment of voiding dysfunction, surgery or a combination. This is a small price to pay for a lifetime of healthy kidneys.
Copyright 2000, Steven G. Docimo, MD
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