In this lecture, we’re going to
discuss vesicoureteral reflux.
So this is a very controversial
conversation to be having.
Several people feel passionately about
vesicoureteral reflux one way or the other
in terms of how important it is to
both recognize it and to treat it.
But I’m going to weigh it
in there anyway.
So vesicoureteral reflux is essentially
a refluxing of urine out of the bladder
and back up towards the kidney.
Essentially, for reasons
that are diverse,
as a child tries to pee, the
urine may come out a little bit
but much of it is going backwards up the
wrong way and back into the kidney.
There are five different types
of vesicoureteral reflux
and we typically historically
have graded them thus.
We have grade I vesicoureteral reflux,
where it’s going just up into the ureter.
Grade II where it does the
entirety of the ureter.
Grade III where we start
seeing changes in the calices,
in the urine collecting
system of kidney.
Type IV where we really starting
to see significant renal damage
and grade V which is what we
might call a mega ureter.
A huge ureter that goes up
and back into the kidney.
What’s interesting about this is
vesicoureteral reflux of all types
may well completely resolve
of its own in childhood.
In fact, the majority of grades I and II
will completely resolve on their own,
about half of grades III and then
the minority of grades IV and V.
But it is remarkable that roughly 1 in
8 patients with grade V mega ureters
will completely resolve on their
own as they grow through childhood.
So vesicoureteral reflux when it’s severe,
and the reason why we’re concerned
about it, can cause renal scarring.
This scarring will cause areas of the
kidney that don’t work correctly.
And as you know, eventually if
we keep running out of kidney,
we end up in renal failure
or with hypertension.
So it’s important to know how much renal
scarring is going on in these children
as there is a theoretical concern
they could end up much later in life
with severe kidney disease.
So for the last 20 years, we have
understood a few things to be true.
We have noted that children with reflux
are more likely to get pyelonephritis.
These children with reflux are more
inclined to get kidney infections
because they’re inadequately
emptying their bladder
and because that potentially
bacteriuric urine in the bladder
is going backwards
up to the kidneys.
We also historically have said
that recurrent pyelonephritis
or recurrent kidney infections could
cause worse scarring of the kidneys.
And we have said that pyelonephritis
induced scarred kidneys
could result in adult renal dysfunction.
These are may be sometimes
However, what we’ve discovered in some
studies is that when we look at adults
with end-stage renal disease or
bad glomerular filtration rates,
virtually none of them have that as a result
of recurrent childhood pyelonephritis.
So that third point
probably isn’t true.
The other thing we know is
that while it’s true that
recurrent pyelonephritis causes
scarring of the kidneys,
it’s not clear that it’s the
pyelonephritis that is at fault
and not the vesicoureteral reflux
that’s causing pyelonephritis.
Or perhaps, it’s some other
underlying element of the kidney
that’s going on that
causes it to scar easily.
So these last two points
are somewhat controversial
and we really can’t say for
sure what exactly is going on.
But when we look at
it’s nice to be able to
decide whether this is a
primary problem or a
In other words, do they just have reflux
or is there another structural problem
that we might be able to fix
that’s causing the reflux itself.
Let me be clear, primary
vesico reflux looks like this.
Here, we have a normal bladder with two
normal ureters coming in to the bladder.
And you can see the urine
is flowing through
a slightly angled area
down into the bladder.
The reason that tube slightly changes direction
as it goes through that bladder wall
is because when the child decides
to pee and squeezes that bladder,
the muscle action squeezing the
bladder also kinks off those ureters.
This prevents a natural
back flow of urine
and directs the urine
instead out of the body.
In a patient with primary
the problem is really that
these tubes go straight in.
They fail to angle slightly as the
ureters travel through the bladder wall.
As a result, when this child tries
to bare down and have a micturition,
the urine will also flow
backwards up into the kidneys.
This is usually unilateral
but it can be bilateral
or it could be bilateral
with different grades,
grade I on one side and grade
III on the other for example.
Secondary vesicoureteral reflux
happens as a result of a problem
somewhere else in the tract.
An example would be
posterior urethral valves.
That happens to boys and we’ll
talk about in a little more on.
Or ureteral-pelvic junction obstruction,
that’s an obstruction higher up before
the ureter even gets to the bladder.
Patients may have a neurogenic bladder.
We see this for example
in spina bifida
where their bladder isn’t
capable of constricting right
and as a result, urine
can go backwards.
We also sometimes see it in
renal transplants when they
have to physically put the
ureter into the bladder.