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Paediatrica Indonesiana the Management of Vesicoureteral Paediatrica Indonesiana VOLUME 50 September NUMBER 5 Review Article The management of vesicoureteral reflux in children Nurul Akbar, Arry Rodjani Epidemiology Vesicoureteral reflux (VUR) is defined as retrograde flow of urine from the bladder to the ureter. It is usually asymptomatic but commonly found in children with urinary tract infection (UTI). The prevalence is about LQJHQHUDOSHGLDWULFSRSXODWLRQ However, the prevalence in children with UTI is much higher, UHDFKLQJ 6LPLODUSUHYDOHQFH LV also reported in CiptoMangunkusumo Hospital.(3) Etiology Primary vesicoureteral reflux Primary VUR is a congenital lesion not associated Figure 1. Vesicoureteral junction in normal state and with any underlying obstructive or neuromuscular TGƀWZ6) phenomenon. It is suggested to be related to the failure of antireflux mechanism at the vesicoureteral junction (VUJ) resulting in regurgitation. This regurgitation Secondary vesicoureteral reflux can cause spread of infection from the bladder to the ureter and kidney. Once the infection has reached the Secondary reflux is not a congenital primary pelviocalyceal system of the kidney, microorganism disorder. It is caused by anatomical or functional can invade the parenchyma through intrarenal reflux obstruction, bladder inflammation, or direct injury (IRR).(3) Primary VUR is usually detected during to orifice which is previously intact. It is suggested radiologic evaluation of children with UTI. It can also found prenatally by the finding of hydronephrosis.(5) Congenital primary VUR is characterized by short From The Department of Urology Medical School University of Indonesia intramural ureter length relative to its diameter. The – Cipto Mangunkusumo Hospital, Jakarta, Indonesia QRUPDOUDWLRLV(6) however in some conditions, the ratio is less causing dysfunction of normal antireflux Reprint request to: Nurul Akbar, MD, Department of Urology Medical School University of Indonesia – Cipto Mangunkusumo Hospital, Jakarta, mechanism (Figure 1). Indonesia Paediatr Indones, Vol. 50, No. 5, September 2010259 Nurul Akbar et al: The management of vesicoureteral reflux in children WKDWWKHPDMRULW\RIORZJUDGHUHIOX[ JUDGH,,,, LV VHJPHQWDOLVFKHPLDZKLFKLQWXUQDFWLYDWHVWKHUHQLQ a secondary reflux which may improve with bladder angiotensin system. The activation of this system, maturation. along with the abnormality of sodium transport due One of the commonest cause of secondary VUR to reduced area containing the Na/K ATPase pumps is voiding dysfunction, which is abnormality of one or and renal artery stenosis found in neuromuscular more phase of voiding cycle. In a normal cycle, the dysplasia, can result in hypertension. bladder dilates as the urine fills in before contracts +\SHUWHQVLRQRFFXUVLQXSWRDGXOW normally at voiding or emptying. During the filling SRSXODWLRQLQZHVWHUQFRXQWULHVRIZKLFKLV phase, there should be no contraction or premature idiopathic. Renal abnormality comprises a significant increase of pressure, while in the voiding phase, proportion in the etiology of hypertension in adult. external urethral sphincter should completely relax %DUDLHWDOUHSRUWHGWKDW985LVIRXQGLQ so that urine will flow continuously until the bladder of adult population accidentally diagnosed to have is emptied. Interrupted urine flow or incomplete hypertension without any obvious renal parencyma or emptying is a sign of voiding dysfunction.(8) vascular abnormality. This prevalence is tenth times In children with voiding dysfunction, secondary of that was previously reported in children. VUR is usually resulted from the high bladder pressure. The high pressure can also cause the development of diverticulum which is a local outpouching of bladder Classification wall due to muscular weakness. It also cause bladder dysfunction responsible for frequency or incontinentia ,QWKH,QWHUQDWLRQDO5HIOX[6WXG\&RPPLWWHH symptoms.(8) established a reflux classification system. VUR is classified into five degree of severity based ureter and renal pelvicalyceal morphology seen in VCUG. The Patophysiology classification is useful for standardized description of reflux severity which is particularly important Vesicoureteral reflux occurs due to increase of in clinical management, subject classification intrabladder pressure causing pathogen organism in research, clinical course documentation, and to be transmitted to the ureter and pelvis, or in quantification of association between reflux and other severe cases, to the collecting duct and papillary clinical parameters that might affect the resolution tubules, a phenomenon called intrarenal reflux of reflux. (IRR). Intrarenal reflux usually occurs in polar The classification of VUR severity is described area. On voiding cystourethrogram (VCUG), it is as follows: grade I, backflow of urine into the ureter characterized by the presence of contrast material in without any sign of dilatation; grade II, backflow renal parenchyma, both in the collecting duct and of urine into the ureter and pelvicalyceal system nephron. Intrarenal reflux can result in formation without any sign of dilatation; grade III, mild to of renal scar.(3, 6, 9) moderate dilatation of ureter dan renal pelvicalyces Initial studies about IRR were conducted by with minimal blunting of fornices; grade IV, moderate 5ROOHVWRQLQDQG5RVHLQZKRREVHUYHG dilatation of pelvicalyceal system with turtuous ureter; reflux in neonates and infants. The studies revealed grade V, severe dilatation of ureter and pelvicalyceal that renal scar is always formed in parenchyma system, blunted round calyces, and severely dilated VHJPHQWH[SRVHGWR,555DQVOH\DQG5LVGRQLQ turtuous ureter (Figure 2). also reported that scar is only formed in exposed area, either to infected urine or IRR.(6) Not all VUR result in renal scar. Low or moderate grade VUR do not The characteristics of VUR increase the incidence of renal scar or UTI, while WKHKLJKJUDGHRQH JUDGH,99 KDVWKHKLJKHUULVN The main symptom of VUR is recurrent UTI which is often accompanied by fever. Other symptoms could Renal scar will cause arterial disruption and be day or night incontinence; irritable symptoms 260Paediatr Indones, Vol. 50, No. 5, September 2010 Nurul Akbar et al: The management of vesicoureteral reflux in children (KIWTG874FGITGGQHUGXGTKV[DCUGFQP+PVGTPCVKQPCN4GƀWZ5VWF[ such as frequency, urgency, and/or painful urination; The association between VUR, obstructive symptoms such as hesitance, dribbling, voiding dysfunction, and UTI intermittent and/or straining at urination; back, loin, or abdominal pain, and/or hematuria.(8) Proteinuria, Urinary tract infection can result in reflux. Inflammation nephrolithiasis, or hematuria during pregnancy can occuring at the vesicoureteral junction and bladder also be found. Radiological examination shows wall can cause edema and loss of junction flexibility. XQLODWHUDORUELODWHUDOUHIOX[LQRIFDVHV Moreover endotoxin also can disrupt ureter peristaltic VUR can also be suspected by the presence which results in incompetent vesicoureteral junction. of its complications, such as hypertension, voding (3) On the other hand, VUR is also a risk factor for dysfunction,(8) impaired renal growth, or chronic renal recurrent UTI. Controversies exist regarding the failure. Undiagnosed reflux can cause the formation effectivity of VUR surgical repair to overcome recurrent of renal scar and reflux nephropathy (RN). Those 87,VLQFHPRUHWKDQRISDWLHQWVVWLOOH[SHULHQFH complications often occur in VUR patients with recurrency after surgery. UTI.(5) Vesicoureteral reflux also can result from high Reflux nephropathy is defined as focal renal intrabladder pressure due to voiding dysfunction.(8, scar in one or both kidneys due to primary VUR and $SUHYLRXVVWXG\UHYHDOHGWKDWRISDWLHQWV UTI. It is the most common etiology of childhood with voiding dysfunction experience VUR. Voiding hypertension. In an England survey, the dysfunction mainly occurred in female children SUHYDOHQFHRI51LVHVWLPDWHGWREHLQFKLOGUHQ with UTI. Indeed, it underlies the development of and adults.(4),Q&LSWR0DQJXQNXVXPRKRVSLWDO infection. Many studies reported that the frequency of UTI children with VUR have already had reflux of recurrent UTI is higher in children with voiding QHSKURSDWK\DQGKDGH[SHULHQFHGFKURQLF dysfunction compared to those without. The renal failure.(3) In other studies, the prevalence of improvement of voiding dysfunction decreases the UHIOX[QHSKURSDWK\YDULHGEHWZHHQ The incidence of UTI and enhances VUR resolution. prevalence of hypertension in reflux nephropathy is parallel to the severity of renal impairment and decreased function. Management of VUR However, VUR can resolve spontaneously in RIFDVHV In fact, the rate of spontaneous Several treatment choices are available, which are FORVXUHFDQEHDVKLJKDVDVWKHFKLOGUHQJURZ observation guarded by prophylactic antibiotic, older. Hutch proposed the theory of intramural endoscopy using dextranomer hyaluronic acid ureter maturation to explain the spontaneous FRSRO\PHU '[+$ DQGVXUJLFDOFRUUHFWLRQ resolution of reflux. As children grow older, the length Ureteroneocystostomy is the gold standard therapy of intramural ureter will also increase so that antireflux IRU985ZLWKVXFFHVVUDWHRIDQGIRUJUDGH mechanism will function more properly.(3) Paediatr Indones, Vol. 50, No. 5, September 2010261 Nurul Akbar et al: The management of vesicoureteral reflux in children ,,9DQGJUDGH9UHIOX[UHVSHFWLYHO\ or chronic renal failure. Various outcomes have been In Cipto Mangunkusumo Hospital, the reported in mild VUR, but in severe VUR, prophylactic management is
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