So in general, how do we manage reflux?
This is controversial.
We do want to actively treat
all urinary tract infections.
Clearly, urinary tract
infections are uncomfortable.
They can cause fever.
Children don’t like them, so we
should treat them with antibiotics.
One idea that’s come up is
prophylactic antibiotic use.
This is where we take children
who have vesicoureteral reflux
and put them on daily
antibiotics, one dose once a day.
The idea being that let’s
reduce the likelihood
of getting urinary tract
infection in the first place.
Most commonly, folks use
although other antibiotics
have also been used.
This does prevent UTIs,
but it does it badly.
So it generally takes of over
6,000 doses of daily Bactrim
before, on average, you
prevent a single UTI.
The problem is it would only
take 20 doses of Bactrim
to, in fact, cure UTI that
that child would have had.
So doing urinary tract
results in massive exposures to
massive amounts of antibiotics
and we actually are coming to learn that
antibiotics are pretty bad for you.
Also even though this
may reduce UTIs rarely,
let’s do the math again,
you need to be on prophylaxis for 18 years
before you prevent urinary tract infection.
It does not prevent scarring.
In other words, these patients don’t
have a change in the actual damage
that we’re actually concerned about
in terms of long term issues.
And children who are on daily prophylaxis
to get resistant urinary tract infections
and those can be
challenging to treat.
Patients for example on daily Bactrim are
more likely to have urinary tract infection
with an extended spectrum beta lactamase
inhibiting producing bacteria.
As a result, that child may only respond
to a drug such as say meropenem
which is only
available through IV.
And so we have to hospitalize children for
what would otherwise be a simple cystitis.
So this is where the controversy
in UTI prophylaxis lies.
We aren’t really clear that it’s actually
preventing the thing we are worried about,
In fact, the evidence shows it does not.
And it may cause an increase
in resistant forms.
However, this therapy currently is
still being used fairly frequently.
Another way we can prevent urinary tract
infections in children is by doing surgery.
This is an example of a cystoscopic surgery
that a surgeon is doing where they’re
attempting to re-implant the ureter
at a better angle so that when
this child bares down to pee,
it doesn’t reflux
back into the kidney.
Another alternative technique
is to inject a polymer
just underneath where
that valve empties.
As you can see in this
picture, by injecting polymer,
that may allow for that kink in the ureter
which will allow it to close
off during muscle contraction.
Unfortunately, this is also a problem.
While this is commonly done for children
with severe, say grade V reflux,
we unfortunately have to remember that
it’s not as effective as we want it to be.
In one Cochrane review, it took nine
surgeries to prevent a single UTI.
And once again, while the surgery
maybe minimally effective
at preventing future
urinary tract infection,
it does not seem to prevent
any renal scarring
which is the thing we’re actually
worried about for the long term.
So this is a complicated
picture, vesicoureteral reflux.
It’s a changing dynamic picture
and it's one we are different
doctors feel different ways.
I’m trying to portray a
general picture here for you,
so you’ll be ready for your exam
and know how to treat these
children when you encounter them.
Thanks for your attention.