Vesicoureteral reflux in adults

Primary vesicoureteral reflux is defined as the dysfunction of the vesicoureteral junction in the absence of any other bladder pathology. Most works in the literature focus on pediatric vesicoureteral reflux, paying little attention to reflux in adults. There is not much knowledge about the real incidence of this pathology in adults and there are few published papers about what are the situations in which we should suspect, perform a diagnostic work up and treat reflux in adult patients. It is article we perform a bibliographic review on topics as important as epidemiology, diagnosis and treatment of reflux in adults. The objective of this article is to transmit what are the clinical manifestations in front of which we should look for adult reflux and when to treat when it is diagnosed.     

Vesicoureteral reflux in adults: a review of 95 patients

Ninety-five adult patients with primary vesicoureteral reflux were reviewed concerning the presenting symptoms, radiological findings, associated renal damage, treatment and results of follow-up. We found a relatively high incidence of reflux in adult males. Although urinary tract infection and flank pain were the most common presentation, others had a wide variety of complaints not directly attributable to reflux. Renal anomalies were present in 37 patients. We found surgical correction of reflux useful in preventing infection, and recommend it especially in young women who may become pregnant.     

Vesicoureteral reflux in patients with obstructive prostatic disease

We present our experience during a 22-year period with the management of 53 patients in whom vesicoureteral reflux was associated with obstructive prostatic disease. There were 45 cases of benign prostatic hyperplasia and 8 cases of carcinoma of the prostate. After prostatectomy medical management of reflux was successful in controlling urinary infection in 34 patients and an operation was performed in 19. Each patient was followed for at least 1 year.     

Vesicoureteral reflux: A historical perspective

The management of vesicoureteral reflux is a mainstay of pediatric urology. This management however, has evolved considerably throughout the years due to a dynamic understanding of both pathology and the relationship between surgical and medical therapies. The purpose of this article is to provide the reader with a historical perspective on management and delineate how its past has shaped current therapies and guidelines.     

Vesicoureteral reflux in infants

 Grade 5 vesicoureteral reflux (VUR) is almost exclusively seen in male infants, and in one-third of cases occurring with a generalized small kidney with decreased renal function without a previous history of urinary tract infection. In females, however, high-grade reflux is rare and kidney damage almost always less severe and of the focal type, as in older children. Assessment of the bladder function with urodynamic and free voiding studies also indicates a difference between male and female reflux during infancy. Half of the males with dilating reflux initially have a hypercontractile urodynamic pattern indicating small functional capacity with high voiding pressures and often instability during filling. This pattern changes during the first couple of years to high-capacity overdistended bladders, often with incomplete emptying. In females, hypercontractility is seldom seen, but bladder function is characterized by high capacity and there is an increase in residual urine from presentation. The pathogenesis of VUR has also been suggested to differ between the sexes. Transient anatomical obstruction during fetal life has been proposed as the cause of gross VUR in males. The spontaneous resolution rate of dilating infant VUR seems to be significantly higher than in older children. A resolution of 40% of grades 4 and 5 has been reported during the first couple of years in prenatally diagnosed cases, suggesting that antireflux surgery should be postponed until after the infant year. Received: 29 July 1998 / Accepted: 13 October 1998     

Vesicoureteral reflux in patients with double pigtail stents

A prospective study of 30 renal units in 27 patients with double pigtail ureteral stents seen at our hospital was done. The aim of the study was to confirm or rule out the occurrence of vesicoureteral reflux radiologically, and to define its degree in stented patients. During the filling phase of the cystourethrogram, reflux occurred in 19 of the 30 renal units (63%). Of those 19 renal units the reflux was grade 1/4 in 15 (79%), while in 4 (21%) it was of higher grades (2 to 3/4). During the voiding phase of the cystourethrogram reflux was observed in 24 of 30 renal units (80%). Of those 24 renal units reflux was of high grade (2 to 4/4) in 20 (83%), while it was low grade (1/4) in 4 (17%). In the presence of a double pigtail stent the ureteral peristaltic waves were sluggish and averaged 1 to 2 waves per minute in the 15 patients observed fluoroscopically for 1 minute after voiding. We conclude that in the majority of patients with double pigtail ureteral stents vesicoureteral reflux occurs at a low grade during vesical filling and at a high grade during voiding. Also, the stents adversely affect the ureteral peristaltic activities.     

Vesicoureteral reflux in triplets

Between 1977 and 1981, 106 children were operated on for hypospadias anomalies. Of these patients 51 have undergone the modified flip-flap urethroplasty or meatal advancement and glanuloplasty, 30 were repaired using a 1-stage Hodgson or Duckett tube urethroplasty, 10 have completed a 2-stage Belt-Fuqua procedure and 15 were treated for multiple complications. A urethrocutaneous fistula developed in 4 patients (4 per cent), meatal stenosis in 3 (3 per cent) and a transient urethral stricture in 1 (1 per cent). All procedures were performed using optical magnification, 2.5 times during the first 1 1/2 years followed by 4.5 times during the subsequent years. In addition, 58 children completed repair before age 2 years, with a mean age of 16 months, with no difference in complication rate. These results indicate that through the use of optical magnification hypospadias surgery can be accomplished safely using a 1-stage reconstruction repair before the child is 2 years old.     

Vesicoureteral reflux detected among patients with nocturnal enuresis

OBJECTIVES: To clarify the characteristics of vesicoureteral reflux detected in patients with nocturnal enuresis. METHODS: Voiding cystourethrography (VCUG) was applied in 1,088 patients who visited our outpatient clinic with the chief complaint of nocturnal enuresis. The clinical features of reflux were evaluated and the prognosis of reflux and nocturnal enuresis was analyzed. RESULTS: Reflux was detected in 86 ureters in 70 patients (6.4%) out of the 1,088 patients. The grade of reflux was 3 or less in all cases. The incidence of pyuria was 5 (7%) and that of renal scar during first examination was 1 (1%). The incidence of unstable bladder was 30 (75%) in 40 patients. The resolution rate of reflux in the cases which were followed-up for 2 years or more by conservative treatment was 50-66% for each grade of reflux. The percentage of patients who had siblings with a positive history of nocturnal enuresis and the incidence of frequency differed significantly between the enuretics with reflux and the 507 enuretics without urological abnormalities. CONCLUSIONS: Our data suggest that the incidence of reflux in patients with nocturnal enuresis was rather low in comparison with the past literature, the severity was mild and the resolution rate by conservative treatment was rather high.