The slightest sign of a health-related problem in a child can incite fear in parents. Because young children cannot always express what is physically bothering them, it can be difficult to distinguish between a minor problem and one that deserves immediate medical attention.

Difficulty urinating may seem like a normal part of toilet training, but it can also be indicative of a urinary infections. Nearly eight percent of girls and two percent of boys experience at least one urinary infection prior to the age of five.

Children who experience repeated urinary tract infections may be suffering from an even more serious condition known as vesicoureteral reflux. This condition brings about painful urination, persistent bedwetting, and other troublesome symptoms. Vesicoureteral reflux is the most common urological diagnosis in young children. Since young children cannot take care of themselves, the best way for parents to battle vesicoureteral reflux in children is to educate themselves about the condition and its associated warning signs.

Understanding Vesicoureteral Reflux

Vesicoureteral reflux (VUR) is an abnormal change in the direction of flow of a person’s urine. Normally, the urine is produced by the kidneys, organs responsible for filtering blood in the body. From the kidneys, the urine passes down two pipes called ureters and into the urinary bladder.

The bladder acts as a storehouse for urine. When full, the bladder experiences an evacuation urge that initiates the act of urination. Normally, any backward flow is prevented by one-way valves that are present at the opening of the ureters. In cases of vesicoureteral reflux, the urine backflows from the bladder into the ureters instead of leaving the body.

Causes and Forms

Vesicoureteral reflux typically develops in children in one of two forms, primary and secondary. Primary vesicoureteral reflux occurs prior to birth and is the most common form found in children.

Vesicoureteral reflux occurs when the valve that prevents backflow is malformed prior to birth and cannot function well. The cause of this defect is unknown. Although there is some debate among researches over the influence of genetics in VUR, many believe that parents who experienced this condition as children have the potential to pass it on to their child.

While it is problematic for affected children, the reflux typically settles down and the condition improves as they grow and the ureters become longer and straighter. This explains why the condition affects young children rather than grown adults.

The secondary form of VUR is one characterized by a blockage in the urinary tract which usually results from a urinary tract infection. The blockage increases the pressure in the urinary bladder. This high pressure is transmitted up the ureters and kidneys, swelling the ureters and disrupting action of the one-way valves at the junction of the ureters and the bladder. Reflux can be caused by the increases in pressure in a dysfunctional bladder that contracts too often and too forcefully.

Urinary tract infections can be both a cause and a consequence of VUR. An infection in the bladder can travel through the urinary system and damage the valves present at the point of junction of the ureters with the bladder. This can lead to reflux of urine in the ureters. All UTIs may not lead to a VUR, but the two often coexist in children. Because an affected child’s urine is retained for too long within the urinary system, he or she may be more prone to kidney infection due to stasis, a stoppage or extreme diminution in urine flow.

The most common symptoms in VUR are those related to infection. These include increased frequency of urination, high blood pressure, and pain or burning while passing urine. Repeated urinary tract infections (UTIs) are common in VUR. Very young babies may develop fever, lethargy, and may show poor weight gain as well as changes in feeding habits as a result of VUR.

Older children may complain of abdominal or flank pain as pressure increases up the urinary system. A swollen kidney can be felt as a mass. The child may have double voiding meaning that a second attempt of urination may be required to expel the refluxed and residual urine. Children may also experience bedwetting despite good toilet training. As the high pressure within the urinary tract system damages the kidneys, there may be an increased quantity of proteins in the urine. This occurs because kidneys normally filter the urine and break down the number of proteins. A sustained level of high pressure can lead to kidney damage which may result in the total failure of kidney functions.

A series of tests will enable doctors to detect VUR and determine how to best treat it.

 

• A renal ultrasound of the kidneys and bladder shows the size and condition of these organs. This test bounces sound waves off the affected organs to detect size and scarring of a kidney. An abnormal kidney size or level of scarring is a good indicator of VUR.

 

 

• A special X-ray called a voiding cystourethrogram (VCUG) is used to check the flow of urine to make sure it is functioning normally. A small tube is inserted through the urinary opening up the urinary tract and the bladder is filled with a special dye called contrast. As the child urinates, the dye can be seen refluxing up the ureters.

 

 

• A radionuclide cystogram may also be used in some cases. The test is similar to VCUG and uses radioactive material (radioisotope) instead of contrast. The radioactive material shows up on a scanner and helps determine whether or not a child’s urinary tract is functioning properly.

 

 

• Blood tests may be useful in diagnosing VUR by measuring kidney function.

 

 

• Urinary analysis can be used to see if a child has a urinary tract infection, a cause or symptom of VUR.

 

The treatment of VUR depends upon the child’s age, overall health, and severity of the condition. Mild and moderate cases of VUR may get resolved over time without treatment, but this may take about five years. During this period, an affected child may develop frequent UTIs and may need treatment with antibiotic medicines to fight infections.

While these antibiotics can cause side effects like nausea and vomiting, they can help speed up the healing process. In mild cases, VUR can be monitored with periodic radiographic studies of the bladder and kidneys and periodic urine testing.

More severe varieties of reflux may require surgical treatment. Surgery can come in several forms. One is known as “open surgery” and uses a flap-valve procedure which prevents reverse flow of urine into the ureters and kidneys. This type of surgery may be done by making an incision in the abdomen or by inserting a flexible tube called an endoscope through the urinary opening permitting visualization of the urinary tract. A gel can be injected through the endoscope to create a little bulge at the point where the ureters open into the bladder.

Endoscopic surgery may be required in other cases. In this procedure, a doctor makes an abdominal incision and inserts a lighted tube (cystoscope) through the urethra. A bulking agent is then injected around the opening of the affected ureter to strengthen the valve's ability to close properly. This method is minimally invasive compared with open surgery and presents fewer risks.

Ureter reimplanation is another treatment option reserved for severe cases. The goals of surgery are to correct the reflux, prevent pyelonephritis (kidney infection), and preserve renal function. The surgical repair of reflux may not totally stop the development of bladder infections, but it will reduce the chance of a bladder infection developing into a kidney infection.

The ureteral reimplantation surgery is completed by creating an extended ureter tunnel through the bladder wall. It is performed through an incision just above the pubic bone. If the ureters and kidneys are extensively damaged, they may need to be removed.

Outlook

Parents should see an urologist if they think their child may have VUR. If the case is mild, then waiting for the child to grow out of the problem may be advised. If the problem is severe and symptoms worsen or cause kidney damage, treatment may be required. Appropriate and timely treatment is important to protect the health of a child.