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Vesicoureteral Reflux (VUR) - Coggle Diagram
Vesicoureteral Reflux (VUR)
Incidence
Primary vesicoureteral reflux is the most prevalent urological anomaly in children, occurring in 1-2% of the pediatric population.
It is particularly common, found in 30-50% of children with urinary tract infections (UTI).
Etiology
Normal UVJ
characterized by an oblique entry of the ureter into the bladder and a length of submucosal ureter.
Primary VUR
involve the malformation of the UVJ, in part due to shortening of the submucosal ureteric segment due to congenital lateral ectopia of the ureteric orifice.
Secondary VUR
natomic or functional abnormalities that may lead to reflux such as bladder outlet obstruction (e.g., PUV) or an abnormality of the vesicoureteral junction (e.g., ureterocele or ectopic ureter).
CP
In most cases, VUR is discovered clinically after investigation of urinary tract infection (UTI).
The incidence of VUR in children with UTI is 30-50%, with an even higher incidence in infants.
Infants and children with VUR may also present with symptoms of voiding dysfunction such as frequency, urgency, and incontinence.
Radiographic Evaluation:
US
VUR is suspected in the presence of a dilated pelvi-caliceal system, upper or lower ureter, unequal renal size, or cortical loss and increased echogenicity.
VCUG
VCUG remains the gold standard for detecting VUR.
It is helpful in assessing the grade of reflux and to define secondary causes like PUV and ureterocele.
Grading System.
Grade I: Contrast appears in the non-dilated ureter.
Grade II: Contrast appears in the renal pelvis and calyces, with no dilatation.
Grade III: Mild to moderate dilatation of the ureter, renal pelvis, and calyces, with minimal blunting of the fornices.
Grade IV: Moderate ureteral tortuosity and dilatation of the renal pelvis and calyces.
Grade V: Gross dilatation of the ureter, renal pelvis, and calyces; loss of papillary impressions; and ureteral tortuosity.
DMSA Scan:
The most sensitive technique for detecting renal scarring resulting from prolonged VUR.
Treatment
Medical Treatment:
Low-dose daily antibiotics with or without bladder training and anticholinergics are administered to maintain sterile urine and prevent the development of renal scarring.
Annual ultrasound and VCUG are performed to assess if the reflux has resolved.
Better results are found in unilateral (vs. bilateral); infants (vs. >5 years), nondilated ureters (<1 cm).
Submucosal Injection Therapy:
STING (Subureteral Transuretheral Injection)
Endoscopic treatment using substances like Deflux® to create a bulking agent underneath the intravesical portion of the ureter, preventing regurgitation of urine.
Anti-Reflux Procedures:
Surgical treatment is considered in cases of breakthrough febrile UTIs, severe reflux (grade V or bilateral grade IV), poor compliance with medications, or poor renal growth or function.
Surgical techniques include transtrigonal (Cohen procedure), transvesical (Politano-Leadbetter procedure), and detrusorrhaphy.