Vesicoureteral Reflux

is the retrograde flow of urine from the bladder into

the upper urinary tract with or without dilation of ureters ,renal pelvis and

calyces .

Vesicoureteral reflux

Is that Normal ???

Normally Reflux is prevented by : • low bladder Pressure .• Efficient ureteric peristalsis . • The ability of the

vesicoureteric junction to occlude the distal ureter during bladder contraction .

• The ureters pass obliquely through the bladder wall (intramural part ).

Vesico uretal Reflux Primary is a defect where the intramural part length is

too short ( ratio < 5:1 )

Secondary Iatrogenic

Following TURP

Functional

Detrusor instability, neurogenic bladder and Urinary tract infections .

Anatomical

Bladder Outlet obstruction

Predisposition

• Although VUR is more common in males antenatally , in later life there is a definite female preponderance with 85% of cases being female.

• VUR has higher predisposition in siblings ranged from 4.7- 51 % , which is higher than general population 1 % .

• Younger children are more prone to VUR because of the relative shortness of the sub-mucosal ureters. This susceptibility decreases with age as the length of the ureters increases as the children grow.

Clinical presentation • Asymptomatic , discovered accidently .• Lower UTI symptoms . • Fever , chills , loin and abdominal pain, nausea and

vomiting .• Loin pain associated with a full bladder or

immediately after micturation . • Recurrent UTI or Loin pain for years .• Antenatal : Hydronephrosis .• Renal Failure , Hypertension .

Why Reflux is a Problem ?

• Recurrent UTI , Cystitis , Pyelonephritis .

• Hydroureteronephrosis. • Renal scarring. • hypertension. • Renal failure. 

Investigations :

Blood : CBC : ↑ WBC → Infection . ↑ Urea , ↑ Creatinie → Renal Impairment Urine analysis : Proteinuria , Radiological : Abdominal ultrasound , specially

antenatal ,young children . Cystography . MCUG : Grading IVU Cytoscopy Radionucleotide scanning : DMSA Scanning

Management depends on : Presence & severity of symptoms .Presence of recurrent infections . Presence of established renal damage .

Recurrent UTI Recurrent UTI Recurrent UTINo symptoms

between UTI Attacks less than 3 Years

No symptoms between UTI Attacks

less than 3 Years.Constitutional symptoms :

Acute pyelonephritis rather than cyctitis

Reflux into non-functioning Kidney (<10 % on DMSA ) .

Normal RFT Normal RFT Deteriorated RFT up normal RFT NO HTN NO HTN HTN

Treat UTI when they occur , give prophylactic

antibiotic

Ureteric implantation Ureteric implantation

Nephroureterectomy

Primary VUR

• Treat the underlying cause … • Patients with no UTI , No high Bladder

pressure → controversial because it’s not known whether low pressure sterile reflux cause deterioration over years .

Secondary VUR

Thanks for Your attention

Ruwida M. S.Ashour Alorfy