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Vesicoureteral reflux

PANCE Blueprint Genitourinary (5%)

Patient will present as → a 1-year-old female with a temperature of 103.1 and irritability. A culture of a urine specimen is obtained and shows more than 106 colony-forming units of pansensitive Escherichia coli per milliliter. She is treated with intravenous ampicillin for several days, followed by oral ampicillin, for a total of 14 days of therapy. After the patient no longer had a fever and a urine culture was sterile, voiding cystourethrography was performed while the patient was still receiving ampicillin. The voiding cystourethrogram demonstrates bilateral grade III vesicoureteral reflux, and renal ultrasonography revealed normal findings.

In young female patients, any history that points to recurrent infection, especially cystitis or pyelonephritis, should trigger an evaluation for what?
Vesicoureteral reflux (VUR)

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, an 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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Diagnose by using voiding cystourethrography (VCUG)

  • 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

osmosis Osmosis
Question 1
Which of the following history findings would trigger a workup for vesicoureteral reflux in a young female patient?
A
Dark-colored urine
Hint:
Dark-colored urine and painless hematuria are concerning history findings, but point more toward a renal cause of disease.
B
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.
C
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.
D
Painless hematuria
Hint:
Dark-colored urine and painless hematuria are concerning history findings, but point more toward a renal cause of disease.
E
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?
A
Continue current antibiotic prophylaxis regimen
Hint:
Continuing the ineffective antibiotic prophylaxis would not address the breakthrough infection or high-grade reflux.
B
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.
C
Start cephalexin for UTI treatment
Hint:
Cephalexin would treat the acute UTI but does not correct the underlying reflux.
D
Consider surgical correction
E
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.
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References: Merck Manual · UpToDate

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