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Bladder-ureteral reflux in children

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Pathology may be due to:

  • impaired renal function (pyelonephritis),
  • congenital abnormalities of the urinary tract,
  • neurological pathologies of the ureter.

The primary pathology diagnosed in newborns can be associated with congenital malformations: protrusion of the bladder, improper location of the mouth of the ureter, irregular shape of the mouth. Pathology can appear against the background of a loose closure of the sphincter of the bladder. In this case, the disease is also characterized by incontinence.

MTCT in older children and adults is a secondary disease that develops against the background of inflammatory diseases of the bladder and kidneys.

The secondary reflex in children may be due to overactive bladder or wrinkling.

The risk of developing the disease increases many times with abnormal development of the penis in boys, which can cause a malfunction of the urinary system. Timely treatment of this condition will help to avoid PMR in a child.

Degrees of pathology

Depending on the changes occurring in the bladder, there are 5 degrees of severity of the course of reflux:

  1. 1 degree - urine enters the middle section of the ureter,
  2. 2 degree - throwing urine into the pelvis of the kidney,
  3. Grade 3 - expansion of the pelvis-renal system of the kidneys,
  4. 4 degree - change in the diameter (rounding) of the cups and pelvis of the kidney,
  5. Grade 5 - exhaustion of the renal parenchyma, development of dysfunction.

In the first two cases, treatment is often not performed. Expectant tactics are selected, the patient is regularly examined for timely detection of pathological changes in internal organs or the progression of the disease.

Often in a child, a mild form of the disease passes with age, as it grows.

Primary reflux is caused by congenital pathologies and is diagnosed in newborns in the first days of life. A secondary form of pathology is characteristic of children older than a year who have undergone infectious diseases of the kidneys and bladder. MTCT at an early age manifests itself as a complication of cystitis, pyelonephritis or hydronephrosis. You can avoid the violation if the inflammation is treated in a timely manner.

An active, passive and mixed form of pathology is also distinguished. With active reflux, urine reflux occurs only during urination. With a passive form of the disease, this process does not depend on the frequency of going to the restroom. Mixed pathology includes both symptoms.

Symptoms of pathology

With bladder reflux in children, the symptoms of the disease directly depend on the severity of the pathology. A mild form may be asymptomatic.

Starting from the stage of changing the structure and size of internal organs, the following symptoms are noted:

  • fever
  • cloudy urine
  • swelling of the lower extremities,
  • swelling of the skin of the face,
  • general malaise - chills, headache, fatigue.

As you can see, the pathology is characterized by the symptoms of impaired renal function.

The difficulty in the diagnosis lies in the fact that parents of young children often take pathology for a common cold and do not consult a specialist.

It is important to understand that with reflux, taking antipyretic drugs can adversely affect the general well-being of the patient. The child should be shown to the doctor as soon as possible and undergo a comprehensive examination.

What is the disease dangerous?

Reverse urine reflux leads to the development of a number of secondary pathologies of an infectious nature. Urine is a favorable environment for the propagation of pathogenic microorganisms.

Against the background of bladder reflux in children, even with initial degrees of severity of the disorder, pain is observed during urination. Over time, a constant violation of urination leads to the development of an infection of the bladder and kidney disease. Secondary cystitis and pyelonephritis are often diagnosed.

In addition, PMR leads to the development of stagnant processes in the kidneys. In addition to pyelonephritis, against this background, there is a high risk of disruption of the organ and the development of renal failure.

With a change in the structure of the kidneys, drug treatment does not bring results, pathology requires surgical treatment.

Another characteristic complication of reflux is an increase in blood pressure in young children.

It is interesting that reflux can be a consequence of infectious and inflammatory diseases, and the cause of their development. Timely diagnosis plays a crucial role in preventing the development of a number of dangerous complications.

Diagnostic measures

Since the symptoms of the disease are often mistaken for acute respiratory viral infections, a comprehensive diagnosis is necessary, which includes:

  • blood and urine tests,
  • ultrasound examination of the kidneys and bladder,
  • cystourethrographic examination.

Further treatment is determined only by the results of a comprehensive examination.

Treatment principle

In case of a mild (first) degree violation, drug treatment is not prescribed.

Refusal of salt, normalization of the diet and systematic observation by a doctor are shown. The child should regularly take a blood test, undergo an examination of the kidneys and bladder.

Starting with the second degree of severity of the pathological process, drug therapy is used. First of all, it is necessary to minimize the risk of inflammation. The human bladder is practically sterile. Stagnant urine and its reflux violates the normal environment and increases the risk of bacterial infection. Antibacterial therapy is used to minimize the risks of infection.

Additionally, drugs can be prescribed to normalize blood pressure. Non-steroidal anti-inflammatory drugs are not used to relieve pain, as they increase the burden on the kidneys.

At the time of treatment, the patient is recommended a special diet, moderate physical activity and physiotherapy (massage).

Timely drug treatment can achieve success in 80% of cases. In severe pathology (grade 4-5), surgical intervention is indicated.

Two operational methods of treatment are practiced - this is laparotomy and valve placement. Laparotomy is indicated in cases where reflux is provoked by a violation of the ureter sphincter. This is a cavity operation, performed under anesthesia.

Often it is practiced to install a special implant (a kind of valve), which prevents the urine from being thrown back during urination.

At the last stages of the disease, surgery is necessary, otherwise the development of renal dysfunction is possible.

Only timely diagnosis and drug therapy will help to avoid surgical intervention. In most cases, this allows you to cure the disease once and for all, without any negative consequences.

Diagnostics

Symptoms will not help diagnose vesicoureteral reflux in children; additional examination methods are also needed:

  • ultrasonography,
  • mycitonic cystourethrography,
  • nephroscintigraphy is static.

Mandatory tests - a general urine test and bacterial culture to isolate the causative agent of the infection. A catheter is needed to collect urine in very young patients.

Ultrasound is performed first. The organs of the genitourinary system are examined before and after the act of urination. The specialist should fix the size of the kidney, as well as confirm or exclude sclerosis, hydronephrosis.

When the diagnosis of vesicoureteral reflux in children is established, the doctor prescribes treatment based on the data obtained. In addition to ultrasound, cystourethrography is also needed. With its help, you can evaluate the pathological changes in the bladder.

The disease is monitored by a radioisotope cystogram. To understand how much the cortical layer suffers when infected, a radionuclide scan of the kidneys is performed with the participation of dimercaptosuccinic acid.

Cystography helps to evaluate bladder reflux in a child. The stages are divided into five degrees. The first two are considered light, and the last two are considered heavy. The evaluation criterion is the work of the bubble and its volume.

What is vesicoureteral reflux?

Vesicoureteral reflux (PMR, urinary reflux, vesicourethral reflux) Is a childhood disease in which urine flows from the bladder, back to the kidneys. Urine backflow (reflux) increases kidney pressure and may contain bacteria that can lead to kidney infection.

A prolonged increase in pressure and repeated infections can lead to damage and scarring of the kidneys (so-called renal dysplasia), which can interfere with the proper functioning of the kidneys in the future life of the child.

Bladder-ureter reflux occurs approximately in one out of 100 children. Most children with this disease do not need treatment, the disease goes away on their own with age.

However, a small number of children may require surgical intervention to correct this condition, as complications (infections, chronic tubulointerstitial nephritis, etc.) may occur.

Prevalence rates are 70% in patients younger than 1 year old, 25% in patients aged 4 years, 15% in patients aged 12 years and 5.2% in adult patients.

The pathogenesis of urinary reflux

The urinary tract consists of the kidneys, ureters, bladder and urethra. Urine produced by the kidneys enters the bladder through the ureters.

The bladder serves as a reservoir for urine until it leaves the body through the urethra. At the junction, where each ureter enters the bladder (ureteral connection), there is a valve mechanism. When the bladder is empty, these valves close, preventing the outflow of urine back (reflux) to the kidneys.

In case of vesicoureteral reflux, urine flows from the bladder through the valves in the ureter node, raises the ureters and returns to the kidneys. This is usually a congenital condition (present at birth) that occurs when one or both valve mechanisms are not working properly. The condition is more common in girls than in boys.

Classification of PMR

Cystic-ureteral reflux is classified from 1 to 5 degrees, where 1 is the weakest degree, and 5 is the most severe:

  1. 1 degree - urine reflux partially rises up the ureter to the kidney,
  2. 2 degree - urinary reflux rises to the ureter itself and enters the kidney,
  3. 3 degree - urinary reflux rises to the ureter itself and enters the kidney. There is some expansion of the ureter and that part of the kidney where urine is collected
  4. 4 degree - urine reflux into the kidneys, there is an expansion of the ureter and that part of the kidney where urine is collected,
  5. 5 degree - a large amount of urine reflux into the kidneys, twisting and expansion of the ureter and that part of the kidney where urine is collected is noted.

Valves in the ureteric joints mature with the age of the child, and most children with vesicoureteral reflux grow out of this condition within a few years after birth.

Spontaneous resolution of the condition is more common in children with mild or moderate reflux. 4-5 degree, severe urinary reflux is less likely to pass on its own.

The cause of the primary reflux defect is unknown.

The presence of a hereditary predisposition is indicated by a high level of reflux in relatives of patients with reflux, but the transmission mechanism is unclear. Some researchers suggest a polygenic type of inheritance, while others suggest an autosomal or sex-related transmission with variable permeability.

The frequency of reflux is likely to increase in conditions of congenital obstruction of the bladder and neurogenic bladder. More than 50% of boys with posterior urethral valves have MTCT. Similar results were seen when a series of children underwent urodynamic studies of a neurogenic bladder.

Dysfunctional urination, with its inherent increase in intravesical pressure, probably also leads to reflux even in healthy children.

Genetic factors clearly affect the incidence of reflux, although specific inheritance methods have not yet been determined.

Signs and symptoms of vesicoureteral reflux

With vesicoureteral reflux, symptoms do not occur. Signs appear when there is a urinary tract infection (UTI). Infection causes symptoms such as fever, pain, unpleasant urine odor, and burning sensation when urinating. Other common symptoms include:

  • bedwetting (nocturnal enuresis),
  • pain in the lower abdomen,
  • blood in the urine (hematuria) and / or pus in the urine (pyuria),
  • high blood pressure,
  • renal failure.

Urinary reflux treatment

The goal of any treatment for vesicoureteral reflux is to prevent damage to the kidneys. Treatment will depend on the severity of the reflux and whether there are ongoing problems with the infection.

In most cases, treatment is not required, and the child’s doctor will monitor the growth and health of the child’s kidneys using ultrasound scans.

You can recommend that your child take regular urine tests to make sure there is no infection. If treatment for vesicoureteral reflux is required, there are two main treatment options.

Drug treatment

UTIs require immediate antibiotic treatment to prevent kidney infections. For children with recurrent UTIs, prophylactic antibiotic therapy (taking antibiotics) can be recommended to prevent the development of a urinary tract infection and, consequently, to prevent damage to the kidneys. Again, kidney health and growth will be regularly assessed by ultrasound scanning.

Surgery

Although surgery for vesicoureteral reflux is no longer routinely performed, a small number of children surgery required to fix the problem. It is especially necessary for children with severe (4-5 stage) vesicoureteral reflux who have the following problems:

  • they continue to develop UTI by taking prophylactic antibiotics,
  • the child is allergic to antibiotics,
  • reflux does not resolve or worsens over time,
  • kidneys show signs of damage.

The operation to restore the valve mechanism in the urethrovesical junction is called Ureteral reimplantation. The operation is performed under general anesthesia and may require 2 or 3 days in a hospital. During surgery, the ureters are released and then “reimplanted” into the wall of the bladder in such a way that an effective valve mechanism is created.

Antibiotic prophylactic treatment may be continued after surgery until a subsequent evaluation shows that the reflux is cured. Ureter reimplantation has a very high success rate in the treatment of vesicoureteral reflux.

Following vesicoureteral reflux therapy, a follow-up evaluation may be recommended. This may include urinalysis, blood tests, ultrasound scans. Blood pressure, height and weight can also be measured. These tests are done to evaluate kidney function and to ensure that reflux is cured.

Children with frequent UTIs have problems with constipation and bad intestinal habits. High fiber diets combined with emollients such as Sodium Docusate, can improve bowel function and reduce the expansion of the colon and rectum. In severe cases, often used daily. Polyethylene glycol.

Bladder-ureteral reflux (PMR), or the process of retrograde urine reflux from the bladder to the ureter, is an anatomical and functional disorder that can lead to significant complications in severe stages, such as acute infections, chronic tubulointerstitial nephritis.

Basically, with a mild stage and timely treatment of the disease, the prognosis is favorable, in most cases, the 1-2 degree of pathology can be decided independently. It is important to get a consultation and conduct a survey.

Ongoing research efforts are aimed at better understanding the genetics of MTCT, refining diagnostic criteria to better identify patients who appear to be at increased risk of kidney damage, and determining who will benefit most from the final therapy. The search for molecular markers associated with kidney damage will also help in the treatment of patients with MTCT.

Pathology Overview

The bladder, connected to the ureters and the urethra, accumulates urine coming from the kidneys before the act of urination. Between the ureters and the bladder there are valves that prevent the return of urine to the kidneys. При пузырно-мочеточниковом рефлюксе клапаны работают слабо, наблюдается возвратный заброс мочи в мочеточники. Поскольку клапаны не функционируют нормально, происходит деформация и растяжение мочеточников.

Разновидности заболевания

ПМР бывает активной и пассивной природы. In the first embodiment, the reflux urine is only with urination. With passive reflux, outflow of urine can occur at any time - with urination and between them. The ailment has two forms:

Reflux can be one-sided and two-sided. In children, one-sided reflux is usually observed. It is constantly present, unlike adult reflux (for the older generation, exacerbation of MTCT with cystitis and prostatitis is typical). Bilateral renal reflux in childhood is rare, but manifests itself vividly.

According to the level of impaired renal function, pathology is of three degrees:

  • moderate - decrease by 30%,
  • medium - drop to 60%,
  • severe - a decrease of 60% or more.

Causes of reflux

Primary vesicoureteral reflux occurs with congenital shortening of the intramural ureter. This leads to the fact that the valves between the bladder and ureters cannot close completely and urine comes back. The formation of primary PMR is also due to:

Among the possible causes of secondary reflux in babies are:

  • overactive bladder
  • muscle puckering,
  • narrowing, swelling of the urethra,
  • excess connective tissue in the urethra,
  • previous operations and organ dysfunctions.

Symptoms of reflux in children

Reflux can be suspected while carrying a child. On ultrasound, the doctor may notice a transient expansion of the upper urinary tract. In 10% of infants, the diagnosis is confirmed with birth.

Usually pathology does not have specific signs, features, symptoms. Doctors and parents may not know about it until the infection has joined.

The clinical picture of PMR in children is formed by the following symptoms:

  • development lag
  • shortage of weight, height,
  • anxiety,
  • colic
  • painful appearance.

The doctor makes the child feel unwell. Parents may be disturbed by his pallor, lethargy, fever, cramping abdominal pain, and urinary retention. These signs are evidence of pyelonephritis or cystitis requiring hospitalization. After the examination, the doctor can make the correct diagnosis and identify its cause (reflux).

Treatment methods

When identifying the initial stage of the pathology, doctors use waiting tactics. Usually, doctors do not require changes in nutrition and the usual regimen, but with renal dysfunction, a diet can be prescribed with a restriction of protein foods, salt, and liquid. Regular visits to the doctor, cystography to determine whether the disease is progressing are necessary. If the examination shows that the child’s health is rapidly deteriorating, surgical intervention cannot be avoided.

PMR treatment

With inflammation, antibiotic courses are necessary. Rarely prescribed drug (injection), which affects the formation of volume. Ureters are also replaced - reimplantation.

Kidney reflux in children, to a mild or even moderate degree, can go away on its own for up to three years. During this period, infections should be avoided.

Earlier, to ensure safety, it was necessary to take antibiotics daily. Today, urologists advise such tactics only in severe stages of the disease. For children under two years of age, such therapy is also suitable, starting from the second degree. Note that there is no such therapy in American pediatrics.

The choice of drug is the doctor’s task. Usually prescribed Sulfametok, Trimethoprim, Sazol at night. Cephalexin is used twice a day. Nitrofurantoin works best if taken at lunchtime.

In severe cases, ureteral reflux in children occurs with increased pressure inside the bladder. In this case, drugs such as solifenacin succinate, oxybutynin are needed. Surgical methods are rarely used. Their goal is to increase the size of the bladder.

If reflux affects the state of health - the kidneys lag behind in development, infections constantly occur, nephrosclerosis progresses, only then injections are needed that increase the volume of the organ.

Conservative treatment

Conservative treatment is indicated in the absence of recurrence of the disease and the pathological structure of the urinary apparatus. It is also carried out during preparation for surgery and in the postoperative period. Children are shown:

  • diet - a minimum of salt, protein, fat, more fresh herbs, fruits and vegetables,
  • medicines to lower blood pressure,
  • antibacterial drugs
  • forced urination program (under the supervision of staff, the bladder should be empty every 2 hours),
  • physiotherapy,
  • periodic catheterization.

Observation

Regular monitoring of the condition of the body depends on the severity of the pathology. Patients should be tested for urine as well as blood to determine creatinine in it. Ultrasound and cystography are also performed.

For babies up to 2 years, an ultrasound scan is necessary every six months, or even more often - once every four months. Older children can be monitored once a year. Cystography is done less often - once every 2 years, but sometimes more often.

If the diagnosis of renal reflux in children is approved, the symptoms are very important. They are easier to evaluate in older children who independently go to the toilet. For any violations, appropriate treatment is required.

Update date: 09/02/2018, date of the next update: 09/02/2021

Endoscopic surgery

Endoscopy helps restore valvular function of the ureters. Collagen or a special inert paste is injected under the outlet of the ureters. In this case, a tubercle is formed, pressing the walls of the ureter and normalizing the operation of the valves. Endoscopy is performed with cystoscopy under anesthesia. It takes 15 minutes. After 3 hours, the condition of the children is normalized and after a day they are discharged for outpatient treatment. A follow-up examination is required after 4-6 months.

Preventive measures

MTCT of congenital nature is almost impossible to avoid. However, the occurrence of a secondary form and complications of the disease can be prevented. For this, there are such rules:

  • treatment of diseases of the urinary system in the early stages,
  • protection of the pelvic area and abdomen from injury,
  • salt restriction,
  • strengthening immunity
  • regular examination by a urologist.

Urological pathologies seriously affect the quality of life and normal development of children. Preventive measures will help to detect MNR at an early stage and take measures to prevent dangerous complications.

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