Diagnosis of vesico-ureteric reflux

The demonstration and grading of reflux is crucial in examination and follow-up of any child with upper urinary tract infection. A variety of factors can influence the occurrence of reflux, e.g. race, genetics, state of maturation of the ureterovesical valve, diuresis, infection and bladder dysfunction, including obstruction and neurogenic disorders. Even when reflux is investigated under strictly standardized conditions, two consecutive bladder fillings frequently show different grades of reflux. Voiding cystourethrography is, to date, the only method with a generally accepted, well-defined grading of reflux. It also allows detection of intrarenal reflux and anatomical and functional information about the bladder and urethra that is unobtainable by other methods. It is therefore usually considered the method of choice. Radionuclide cystography and, possibly, contrast enhanced ultrasonography can be complementary to voiding cystourethrography, but mainly for postoperative follow-up and screening of siblings.     

Occurrence of reflux in children with ureteral jets

The urograms of 186 boys and 145 girls were scrutinized in order to reveal the incidence of ureteral jets demonstrable during intravenous pyelography (IVP). In this series a unilateral jet was observed in 26 cases and a bilateral jet in 6 cases. Ureteral jets were almost three times as common in patients with normal urograms compared with those revealing urinary abnormalities. The incidence of a positive jet sign, usually unilateral, varies with the employed technique of examination, but the highest incidence in routine IVP seems to be about 30%. Although infrequent, significant ipsilateral vesicoureteral reflux (VUR) may occur. This fact together with the reported low rate of bilateral jets restricts the value of uneteral jets being used as an indicator of absence of gross VUR. The need for micturition cysto-urethography (MCU) at the uro-radiological work-up remains unchallenged.     

Ultrasonography for the detection of ureteric reflux in infants with urinary infection

Several less harmful methods than voiding cysto-urethrography for detecting significant ureteric reflux have been proposed. The present prospective study investigated whether ultrasonography was effective in identifying ureteric reflux in infants with their first febrile urinary infection. The subjects were 27 infants (24 boys and 3 girls) aged from 0 to 8 months. The urinary tract was scanned when the bladder was full, and before and during induced voiding. Infants with abnormal ultrasound findings underwent voiding cysto-urethrography. The other infants were followed and those who had a recurrence of urinary infection underwent voiding cystography. Ten children underwent cysto-urethrography, with eight refluxing ureters identified in six boys. Ultrasound revealed transient dilatation of the renal pelvis on voiding in five kidneys, transient dilatation of distal ureters in 12 and hydro-ureteronephrosis in two. Each of the five kidneys with pelvic dilatation on voiding was associated with ureteric reflux grades III or IV. Of the 17 children who did not undergo cysto-urethrography, only one had recurrence of urinary infection and was diagnosed with ureteric reflux. This girl was one of the three babies who were not scanned during voiding. More than half of the infants with febrile urinary infection were excluded from invasive examination without having recurrence of urinary infection. Thus, ultrasound scanning during voiding was effective for screening infants with their first urinary infection to detect significant ureteric reflux.     

膀胱输尿管反流90例临床回顾分析

目的探讨输尿管膀胱反流(VUR)的临床特征。方法回顾分析2012年1月至2017年12月期间因发热性尿路感染住院治疗并经排泄性尿路造影(MCU)确诊VUR的患儿的临床资料。结果 90例患儿中男41例、女49例,中位年龄0.90岁;双侧反流46例,其中神经源性膀胱4例。51例1岁以下患儿中,男性28例、女性23例;10例5岁以上患儿中,仅1例男性患儿。6例手术治疗,其余84例内科保守治疗,其中随访到48例。随访患儿中,15例尿路感染复发,5例因肾瘢痕、患侧肾小球滤过率下降转为手术治疗;25例于一年后复查MCU,1例反流级别加重、12例无变化、5例减轻、7例消失。8例患儿首次肾静态显像(DMSA)发现肾脏缩小、肾瘢痕形成,36例患儿半年后复查DMSA发现10例出现肾瘢痕。结论婴儿期发热性尿路感染患儿,尤其是男孩应注意是否存在VUR。DMSA、MCU等检查不能相互取代。双侧VUR患儿应排除神经源性膀胱及合并其他畸形。     

加强对儿童尿路感染和膀胱输尿管反流的认识

儿童尿路感染是婴儿和儿童中一种常见的细菌性感染,6岁以内儿童泌尿道感染(UTI)累计发病率女孩为6.6%,男孩为1.8%.UTI与膀胱输尿管反流(VUR)的关系复杂,共同存在是导致持续性的肾脏损害和疤痕化的重要因素.UTI诊断明确后最常应用的影像学检查有肾脏和尿路超声检查、排泄性膀胱尿道造影和核素肾静态显像(DMSA),其中DMSA为目前公认的诊断肾瘢痕的金标准.尽管对在不同年龄、性别和临床表现的患儿中如何正确选择相关的影像学检查有较大的争议,但多数推荐对所有2岁以下的儿童进行超声、VCUG和DMSA检查.研究还显示VUR有其一定的遗传基础,在同胞中的发病率显著高于健康儿童.随时间推移发育逐渐成熟,有部分反流可自行痊愈,大都不需要手术治疗.大多数VUR的病例,尤其是5岁以下的儿童建议使用低剂量持续性抗生素预防治疗.反流性肾病长期的并发症是发生终末期慢性肾功能衰竭.     

影像尿动力学评估先天性膀胱输尿管返流患儿的膀胱功能障碍

目的 采用影像尿动力学评估小儿先天性膀胱输尿管返流(VUR)与膀胱功能障碍的关系.方法 选取2011年4月至2013年7月在郑州大学第一附属医院就诊的67例VUR患儿为研究对象.患儿经影像尿动力学、尿常规、排泄性尿路造影等检查,记录患儿尿路感染、逼尿肌过度活动、逼尿肌括约肌协同失调及VUR程度等情况,根据尿动力学表现的不同分为正常组、单纯逼尿肌过度活动组和逼尿肌括约肌协同失调组(伴或不伴逼尿肌过度活动的逼尿肌括约肌协同失调),另外按照返流级别将患儿分为低级别返流(Ⅰ～Ⅱ度)和高级别返流(Ⅲ～Ⅴ度),分析膀胱功能与VUR侧别、返流程度以及尿路感染的关系.结果 VUR患儿合并膀胱功能异常占73.1％(49/67例),其中膀胱过度活动症占49.3％(33/49例),逼尿肌括约肌协同失调占23.8％(16/49例).单纯膀胱过度活动患儿多为单侧,Ⅰ～Ⅱ度返流,且较少合并尿路感染.而逼尿肌括约肌协同失调的患儿多为双侧,Ⅲ～Ⅳ度返流,且较多见尿路感染.结论 影像尿动力学可以准确诊断VUR,同时对患儿膀胱功能的评估,及临床制定治疗方案提供重要参考.     

Detecting vesico-ureteral reflux in asymptomatic siblings of children with reflux by direct radionuclide cystography

The incidence of vesicoureteral reflux (VUR) among asymptomatic siblings of children with VUR is much higher than the estimated incidence in the general population. It might be expected that identifying them and keeping them under close observation and/or either surgical or conservative treatment, might reduce the risk of renal scarring. Fifty-three asymptomatic children, all under 6 years of age and all siblings of children with proven VUR, were studied with direct radionuclide voiding cystography (DRVC). There were 31 (58%) boys, and 22 (42%) girls. Nine children (17%) were younger than 1 year, 13 (25%) were between 1 and 2 years of age, while 31 (58%) were older than 2 years. VUR was detected in 22 (42%) of the 53 siblings. The incidence of VUR varied considerably according to the age, and sex of the child, the highest being in boys younger than 1 year. Most of the severe reflux was seen in children under 2 years of age. Out of 11 patients with VUR, grade 2 and 3, there were 10 younger than 2 years, whereas, only 2 of the 11 siblings with VUR, grade 1 were younger than 2 years of age. The mean age of children with VUR grades 2 and 3 was 19 months, compared to the mean age of 50 months for those with VUR grade 1. DRVC, a highly sensitive method, exposes the patient to much less radiation than X-ray voiding cystography. We believe that the benefit of detecting VUR in asymptomatic siblings with DRVC outweights the invasiveness of the procedure. The predictive value of positive family history alone in identifying VUR in our study was 42%. This appears high enough to justify the routine investigation of asymptomatic siblings of children with VUR using DRVC at an early age.     

儿童泌尿道感染中膀胱输尿管反流发生率的临床研究

目的回顾性分析儿童泌尿道感染中膀胱输尿管反流(VUR)的发生情况,以加强对VUR的认识,提高检出率。方法选择2000年1月到2006年11月因泌尿道感染收治入院的患儿106例,根据年龄分为≤2岁组、～5岁组、>5岁组三组,通过排泄性膀胱尿道造影(VCUG)和直接放射性核素造影诊断VUR;通过肾皮质静态显像(DMSA)检查,了解肾疤痕的形成情况。分析不同年龄组的VUR发病情况、不同等级VUR的程度和肾疤痕的形成分布情况。结果106例中VUR共40例,不同年龄组VUR的所占比例分别是77.78%、46.67%、27.90%(χ2=12.994,P=0.002),差异具有统计学意义。106例中有40例作了DMSA检查,14例形成肾疤痕,三组间肾疤痕的分布情况依次是66.7%、30.77%、28.57%,≤2岁组肾疤痕发生率高。另外,从VUR的等级分布和单、双侧VUR发生的情况来看,≤2岁组中VUR患儿主要是Ⅲ、Ⅳ、Ⅴ级,而～5岁组和>5岁组则随着年龄的逐渐增加Ⅰ、Ⅱ级的例数增加,Ⅲ、Ⅳ、Ⅴ级的例数减少;而且≤2岁组的VUR患儿双侧VUR的例数也较后两组多。结论≤2岁的泌尿道感染患儿最易形成肾疤痕,VUR的发病率高,且高级别、双侧VUR的发生率高,应及时行VCUG和DMSA,及早发现VUR和肾疤痕。     

Comparison of direct radionuclide cystography and voiding cystourethrography in detecting vesicoureteral reflux

BACKGROUND: Fluoroscopic voiding cystourethrography (VCUG) is a widely used imaging test for the diagnosis of vesicoureteral reflux (VUR). However, high gonadal radiation and intermittent imaging are the main disadvantages of VCUG. Direct radionuclide cystography (DRC) has been advocated for the detection of VUR with increased sensitivity and low radiation doses, however, having the disadvantage of providing less anatomical details for urethral evaluation. In this study, DRC has been compared with standard fluoroscopic VCUG for detection of VUR. METHODS: A total of 41 children (82 kidney ureter units, KUU) aged 1 month-126 months (median, 15 months) were studied sequentially using DRC and VCUG. The indications of VUR studied were urinary tract infection in 29 children, VUR follow up in eight children and antenatal dilatation history in four children. RESULTS: A total of 18 refluxing ureters were detected by DRC, 22 refluxing ureters by VCUG and 14 refluxing ureters by both methods. The two methods were concordant for the detection and exclusion of VUR in 85% of KUU. VUR was missed by VCUG in four KUU (three severe, one mild) whereas VUR was missed by DRC in eight KUU (four grade I, four grade III). CONCLUSIONS: There was a good correlation between DRC and VCUG in the evaluation of VUR. DRC provides continuous monitoring and low gonadal radiation exposure. DRC can be used in the diagnosis of VUR as an alternative to VCUG in selected cases.     

Characteristics of primary vesico-ureteral reflux in Thai children

Background: The purpose of the present paper was to evaluate the clinical features of primary vesico-ureteral reflux (VUR) in Thai children.
Methods: Children with primary VUR attending in the Nephrology Division, Department of Pediatrics, Prince of Songkla University between 1987–2002 were studied.
Results: Sixty-five girls and 60 boys with primary VUR were evaluated. Age of diagnosis was significantly younger in boys than girls (median 0.6 and 2.2 years respectively, P  < 0.001). In 73% of boys and 34% of girls VUR diagnosis was made in the first year of life. Hydronephrosis was found in 22% of boys and 8% of girls ( P  = 0.004). Five per cent of children who had VUR grades I–III had hydronephrosis (6/121). Only children who had VUR grades IV and V had significant hydronephrosis: 33% (14/42) and 53% (10/19), respectively. Bilateral VUR was 60% overall and was significantly more common in boys (70% vs 40% P  < 0.028), found in grades I–V at 33%, 61%, 60%, 65%, and 77%, respectively. Of 200 refluxing ureters, the total numbers of VUR grades I–V were 32, 37, 67, 45 and 19 respectively. VUR grade was significantly different by age ( P  = 0.014) but not by left–right side or sex.
Conclusion: Primary VUR occurs equally in boys and girls, but in boys at a younger age. Bilateral VUR and hydronephrosis were significantly more common in boys, and VUR in boys was more severe. But hydronephrosis is a poor indicator for VUR screening even in high-grade VUR.     

排尿性膀胱尿路造影术在诊断儿童膀胱输尿管反流中的意义

目的 探讨排尿性膀胱尿路X线造影术(MCU)在尿路感染患儿中的检查时机,为早期诊断膀胱输尿管反流提供依据.方法 分析2003年1月-2007年12月我院住院患尿路感染并行排尿期膀胱尿路X线造影术检查的患儿,分析相关的B超,放射性核素肾静态扫描,肾功能(血尿素氮、血肌酐),尿常规,尿微量蛋白(尿IgG、Alb、TRF、RBP、NAG、a1-MG),中段尿培养等检查.结果 [1]进行MCU检查的患儿共392例,年龄1个月-14岁,平均年龄(2.43±3.10)岁.无膀胱输尿管反流者230例;有膀胱输尿管反流者162例;其中原发性膀胱输尿管反流150例,男女比为1.23:1.[2]原发性膀胱输尿管反流阳性、阴性两组患儿间,放射性核素肾静态扫描(DMSA)中表现为急性期放射稀疏、肾疤痕、尿微量蛋白,差异有统计学意义(P<0.05).[3]原发性膀胱输尿管反流患儿年龄分布为<2岁93例(62%),2-7岁39例(26%),>7岁18例(12%).结论 对尿路感染伴随DMSA异常,尿微量蛋白明显增高的患儿应提高警惕,积极行MCU检查,特别是<2岁的男童更应重视.     

Management of children with dilating vesico-ureteric reflux in Sweden

AIM: To evaluate the management and outcome of children with dilating vesico-ureteric reflux diagnosed before 2 y of age. METHODS: This retrospective, multicentre study was part of a programme for quality assurance in Sweden. A total of 2309 unselected children, aged 0-2 y, were investigated after the first urinary tract infection. Voiding cystourethrography was performed in a total of 1953 children, of whom 584 had reflux. Of these children, 303 (119 boys and 184 girls) had reflux with dilatation (grade 3-5). RESULTS: Follow-up after 4-6 y was reported in 272 of the 303 children. Spontaneous regression of dilating reflux occurred in more than half of the patients and was significantly more frequent in boys than in girls (p = 0.047). In children with grade 3 reflux and grade 4-5 reflux, there were pyelonephritic recurrences in 18% and 45% of the boys and 28% and 70% of the girls, respectively (p < 0.001). One hundred and eighty-one children (65%) were managed conservatively, 58 (21%) were treated with subureteric injection and 33 (12%) with ureteric reimplantation. There were considerable differences in treatment strategies between centres. CONCLUSION: This study of an unselected cohort of children with urinary tract infection and dilating reflux showed spontaneous resolution of dilating reflux in more than half of the subjects and more often in boys than in girls. Pyelonephritic recurrences were more common in girls than in boys, and more frequent in grade 4-5 reflux than in grade 3. The results indicate important differences between the sexes and that boys and girls should be assessed separately when treatment strategies are studied.     

Age at diagnosis of vesicoureteric reflux after urinary infections: historical changes

AIM: Efforts are currently made to detect vesicoureteric reflux (VUR) early after urinary infections in order to limit secondary renal damage. This study investigated the extent to which recommendations for the detection of VUR are put into practice, and their influence on the age at diagnosis. METHODS: The age at diagnosis of VUR after urinary tract infections was analysed in 126 patients (48M, 78F) referred to a tertiary centre in Milan between 1976 and 1999. RESULTS: The median age at diagnosis was 34 mo in subjects born before and 8 mo (p < 0.001) in those born after 1988. The difference was statistically significant in female but not in male subjects. The figures from Milan were compared with those for 102 patients (35M, 65F) born between 1946 and 1970, treated in Melbourne and reported in 1976. In Melbourne the median age at diagnosis was 1-2 y for boys and 5-6 y for girls; in Milan, the corresponding figures were <1 y and 1-2 y. The difference between Melbourne and Milan was statistically significant for both genders. CONCLUSION: In Milan VUR is now detected earlier than in the past. This trend is more marked in females than in males, but reflux is still detected earlier in boys.     

Prediction of vesico-ureteric reflux in childhood urinary tract infection: a multivariate approach

In this study, independent predictors obtained from patient history, physical examination and laboratory results for vesico-ureteric reflux (VUR) in children of 0-5 y with a first urinary tract infection (UTI) were assessed and the added value of renal ultrasound (US) investigated. Information was collected from children visiting the paediatric outpatient department with a first proven UTI, defined as a urine monoculture with ≥105 organism/ml, with clinical symptoms and possible white cell count ≥20 per high-power field of spun fresh urine. Children with neurologic bladder dysfunction were excluded. VUR was determined by voiding cystourethrography (VCUG) and graded from I to V. The diagnostic value of predictors was judged using multivariate logistic modelling with the area under the receiver operating characteristic (ROC area). A risk score was derived based on the regression coefficients of the independent predictors in the logistic model. In 140 children (51 boys and 89 girls) VUR was diagnosed in 37. Independent predictors for VUR were male gender, age, family history for uropathology, serum C-reactive protein level (CRP) and dilatation of the urinary tract on US. The ROC area of this model was 0.78 (95% CI: 0.69-0.87). This prediction model identified 12% (95% CI: 7-18) of the patients without VUR without missing one case of VUR. If we used VUR ≥ grade 3 as a threshold, the model assessed VUR to be absent in 34% (95% CI: 26-42). Conclusion: A prediction rule based on age, gender, family history, CRP and US results is useful in assessing the probability of VUR in the individual child with a first UTI and may help the physician to make decisions about performing additional imaging techniques. Prospective validation of the model in future patients, however, will be necessary before applying the rule in practice.     

Outcomes of vesicoureteral reflux in children with non-neurogenic lower urinary tract dysfunction treated with dextranomer/hyaluronic acid copolymer (Deflux)

ObjectiveThere has been hesitancy to use dextranomer/hyaluronic acid copolymer (DHXA, Deflux for vesicoureteral reflux (VUR) in the setting of lower urinary tract (LUT) dysfunction because of the limited number of published studies, the possibility of less success, and the manufacturer's recommendations contraindicating its use in patients with active LUT dysfunction. We report on our experience using DXHA in this subset of patients whose VUR persisted despite targeted therapy for their LUT condition.Materials and methodsWe reviewed patients diagnosed with both a LUT condition and VUR who underwent subureteric DXHA while still undergoing treatment for their LUT dysfunction. Persistence of VUR was confirmed by videourodynamic studies (VUDS)/VCUG (voiding cystourethrogram) and all patients were on targeted treatment (TT) and antibiotic prophylaxis prior to and during DXHA injection. VUR was reassessed post-injection.ResultsFifteen patients (22 ureters; 21F,1M) met inclusion criteria (mean age 6.1 years, range 4–12). Following one to three DXHA injections, VUR resolved in 17 ureters (77%) including eight of nine ureters in dysfunctional voiding (DV) patients, five of nine in idiopathic detrusor overactivity disorder (IDOD), and four of four in detrusor underutilization disorder (DUD) patients.ConclusionsDXHA is safe and effective in resolving VUR in children with associated LUT dysfunction, even before their LUT condition has fully resolved. Highest resolution rates were noted in patients with either DV or DUD or who were least symptomatic prior to injection.     

Vesicoureteral reflux in boys

Vesicoureteral reflux is seen less frequently in boys than in girls, but is more likely to present a higher grade than that seen in girls. In this series, 65% of the patients presented with reflux of grade III or greater. Despite this higher grade, recurring urinary infection has been less frequently encountered in these boys. This has prompted us to be more comfortable following these patients expectantly — without surgery or chemoprophylaxis — especially in older boys with milder grades of reflux.