Patient will present as → a 1-year-old girl presents with a temperature of 103.1°F and irritability. This is her second febrile UTI in the last six months. Urine culture reveals >100,000 CFU/mL of E. coli. She is treated with a 10-day course of Cefdinir. Once the infection is cleared, a renal and bladder ultrasound (RBUS) is performed, and is normal. Due to the recurrent nature of her infections, a voiding cystourethrogram (VCUG) is performed, which reveals bilateral Grade III vesicoureteral reflux.
Vesicoureteral reflux (VUR) is a condition in which urine flows retrograde, or backward, from the bladder into the ureters/kidneys
There are two types of vesicoureteral reflux
- Primary vesicoureteral reflux is the most common type and happens when a child is born with a defect at the ureterovesical junction
- In secondary vesicoureteral reflux, there’s an obstruction at some point in the urinary tract that causes an increase in pressure, causing urine to flow backward into the ureters or kidneys
- Secondary vesicoureteral reflux is most commonly caused by recurrent urinary tract infections
- Other causes include posterior urethral valve disorder, and neurogenic bladder
- In young female patients, any history that points to recurrent infection, especially cystitis or pyelonephritis, should trigger an evaluation for vesicoureteral reflux (VUR)
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Renal ultrasound: evaluate for hydronephrosis and renal size/scarring (DMSA scan for scarring)
- Voiding cystourethrogram (VCUG) — gold standard: demonstrates reflux grade and anatomy during voiding
- Monitor by using serial ultrasonography and VCUGs
Vesicoureteral reflux is usually classified by severity ⇒ how far urine refluxes back up into the urinary tract
- Grade I – reflux into non-dilated ureter
- Grade II – reflux into the renal pelvis and calyces without dilatation
- Grade III – mild/moderate dilatation of the ureter, renal pelvis, and calyces with minimal blunting of the fornices
- Grade IV – dilation of the renal pelvis and calyces with moderate ureteral tortuosity
- Grade V – gross dilatation of the ureter, pelvis, and calyces; ureteral tortuosity; loss of papillary impressions
Mild to moderate VUR often resolves spontaneously, but the more serious disease may require surgical intervention
- Children with newly diagnosed VUR are given prophylactic antibiotics depending on their clinical course
- Antibiotics are administered nightly at half the normal therapeutic dose
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Question 1 |
Which of the following history findings would trigger a workup for vesicoureteral reflux in a young female patient?
Dark-colored urine Hint: Dark-colored urine and painless hematuria are concerning history findings, but point more toward a renal cause of disease. | |
Epigastric abdominal pain Hint: Epigastric abdominal pain is not seen in patients with VUR and any pain associated with VUR, if present, would most likely be located in the renal or suprapubic areas. | |
Nocturnal enuresis Hint: Although incontinence can be a sign of cystitis, enuresis limited to night would likely not be present in the presence of infection. | |
Painless hematuria Hint: Dark-colored urine and painless hematuria are concerning history findings, but point more toward a renal cause of disease. | |
Recurrent cystitis |
Question 1 Explanation:
Particularly in young female patients, any history that points to recurrent infection, especially cystitis or pyelonephritis, should trigger an evaluation for vesicoureteral reflux (VUR). Dark-colored urine and painless hematuria are concerning history findings, but point more toward a renal cause of disease. Although incontinence can be a sign of cystitis, enuresis limited to night would likely not be present in the presence of infection. Epigastric abdominal pain is not seen in patients with VUR and any pain associated with VUR, if present, would most likely be located in the renal or suprapubic areas.
Question 2 |
A 5-year-old boy presents with a 2-day history of dysuria, frequency, and fever. He has a history of grade IV vesicoureteral reflux and recurrent UTIs. He is currently taking trimethoprim-sulfamethoxazole for antibiotic prophylaxis. Urinalysis shows pyuria and culture grows >100,000 CFU/mL of E. coli. Which of the following is the most appropriate next step in management?
Continue current antibiotic prophylaxis regimen Hint: Continuing the ineffective antibiotic prophylaxis would not address the breakthrough infection or high-grade reflux. | |
Obtain DMSA (dimercapto succinic acid) renal scan Hint: A DMSA renal scan could evaluate for new scarring but does not address definitive correction of reflux. | |
Start cephalexin for UTI treatment Hint: Cephalexin would treat the acute UTI but does not correct the underlying reflux. | |
Consider surgical correction | |
Stop antibiotic prophylaxis Hint: Stopping antibiotic prophylaxis is not appropriate given his high-grade reflux and recurrent infections. |
Question 2 Explanation:
This 5-year-old boy with known grade IV vesicoureteral reflux has a breakthrough UTI while on antibiotic prophylaxis. Surgical correction should be considered for patients with grade III-IV reflux who have breakthrough infections despite antibiotic prophylaxis. Surgical correction is more definitive for correcting high-grade reflux and reducing recurrent UTIs compared to continued medical management.
There are 2 questions to complete.
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References: Merck Manual · UpToDate