Vesicorenal reflux is the backflow of urine from the bladder into the ureters or even back into the renal pelvis. The reflux can occur when the valve function at the point where the ureters enter the bladder is disrupted. Reflux of urine can cause bacteria to enter the renal pelvises and cause renal pelvic inflammatory disease. Chronic reflux of urine can cause kidney dysfunction.
What is vesicorenal reflux?
Schematic diagram showing the anatomy and structure of the urinary bladder. Click to enlarge. The two ureters that open into the bladder from the two renal pelvises in the ureteral orifice normally allow urine to pass only in the direction of the bladder. The ureteral orifice performs a valve function, so to speak, to prevent urine from flowing back toward the kidneys. If the valve function is disrupted, urine may backflow (reflux) into the upper ureters or even into the renal pelvis. The malfunction may occur at one or both upper ureters. The dysfunction at the point where the ureters enter the bladder is usually congenital, but it can also be acquired later. Reflux is assigned to one of five classes ranging from Class I to Class V, depending on severity. Reflux can lead to urinary tract infections and even renal pelvic inflammatory disease, and ultimately – if the condition is not treated – can cause severe kidney damage or even loss of kidney function.
Causes
Primary vesicorenal reflux is present when the reflux results from a genetic abnormality, as in most cases. It usually involves the end course of the ureters in the bladder wall being too short, so that a buildup of pressure in the bladder does not result in complete closure of the ureters, but instead forces some of the urine back. Another form of genetic developmental disorder is when a ureter is duplicated (ureter duplex), which can also cause urinary reflux. Secondary or acquired vesicorenal reflux is when reflux occurs subsequently due to external circumstances. It may be caused by a urinary tract infection or by direct damage, such as may occur during ureteroscopy with dilatation of the ureters. Nerve disease (spina bifida) and congenital narrowing of the urethra may also be considered as causes of reflux.
Symptoms, complaints, and signs
Vesicorenal reflux is associated with symptoms only in the late phase. Affected individuals then complain of pain when they urinate. Reflux can present in varying degrees of intensity. All age groups are affected. Children often experience recovery without medical intervention. Patients regularly report that their urine takes on a foul odor. There is also a marked increase in the urge to empty the bladder. A burning sensation during urination and cramps occur. In many cases, vesicorenal reflux is associated with susceptibility to infection. Pain all over the flank occurs. Abdominal pain and diarrhea are also possible associated symptoms. Vesicorenal reflux makes infection of the kidney likely. As a result, renal pelvic inflammation sets in. Affected individuals then complain of an elevated temperature. Chills are also possible. Severe pain in the kidney occurs when going to the toilet. If medical treatment is omitted, kidney failure is possible. Long-term consequences affect urination. Incontinence or uncontrollable urination accompany everyday life and represent a psychological burden. At night, the bed-wetting familiar from children can be encountered. Sometimes even high blood pressure develops. In minors, even growth disorders can occur.
Diagnosis and course
Because most cases of reflux are congenital abnormalities within the urinary tract and are not visible externally, in infants and young children, underweight and pallor, fever, and rewetting, vomiting or diarrhea, and abdominal pain may be interpreted as symptoms of the presence of primary vesicorenal reflux, especially if there are known cases in the family. In adolescents and adults, urinary urgency with burning during urination, unpleasant smelling urine, kidney pain, and urination associated with pain may indicate reflux.The symptoms should be clarified in more detail. The most important diagnostic procedures for this are ultrasound, urine flow measurement and a micturition cystourethrogram, which can be used to measure the closing ability of the ureters at the entrance to the bladder. Depending on the severity of the reflux, if left untreated, dilated ureters and chronic renal pelvic inflammation and even renal insufficiency may result. In less severe cases, spontaneous cures are also seen in children up to 10 years of age.
Complications
In many cases, there are no particular symptoms or complications associated with this condition, so the disease is discovered relatively late. Those affected primarily suffer from bedwetting. This can also have a very negative effect on the psyche of the affected person and thus also lead to bullying or teasing of the patient. Many affected persons also suffer from depression and a significantly reduced self-esteem or inferiority complexes. The quality of life is significantly limited and reduced by the disease. Furthermore, renal insufficiency also occurs if the disease is not treated. In the worst case, those affected may die. They are then dependent on a kidney transplant or dialysis to avoid dying. Particularly in children, the disease can also lead to growth disorders, so that complications can also arise in adulthood. There is often pain when urinating and the urine smells very unpleasant. Treatment of the disease is usually performed by surgery. Complications do not occur. As a rule, all symptoms can be limited and alleviated. Whether the disease has a negative impact on the patient’s life expectancy depends largely on the time of diagnosis.
When should you see a doctor?
Irregularity in urination, cramps in the abdomen or a burning sensation in the area of the bladder, kidney as well as ureters are signs of an existing disease. A visit to the doctor is necessary if the symptoms persist over several days or increase. Diarrhea, a general feeling of malaise as well as an inner irritability are further symptoms of a disorder. If there is a loss of appetite, abnormal behavior or inner weakness, the affected person needs a doctor. A general feeling of illness, faintness, incontinence or increased body temperature should be medically examined and treated. Sweating, chills, or abnormalities of the cardiovascular system need to be assessed. A visit to the doctor is necessary if there is an odor abnormality in the urine, a pale appearance, abdominal pain, or hunched posture. Retraction behavior, nocturnal wetting, vomiting and nausea must also be presented to a physician. If children show disturbances in growth, the observations should be discussed with a physician. If there are mental abnormalities, aggressive behavior or apathy, the affected person needs help. A persistently reduced quality of life can lead to serious complications. In the case of a particularly unfavorable course of the disease, the premature death of the affected person may occur. Therefore, cooperation with a physician should be sought at the first irregularities and abnormalities.
Treatment and therapy
For reflux with moderate severity, treatment with low-dose antibiotics is recommended to prevent inflammation in the urinary tract. In the presence of higher severity of reflux and risk of renal dysfunction, surgical intervention is indicated. The ureter is disconnected from the bladder and reimplanted into the bladder in an extended section. Several different surgical methods are available for this open surgical procedure, antirefluxive ureteral reimplantation. The chances of success for the procedure are high and are reported to be over 90%. There is also the option of injecting a drug under the ureter into the bladder wall during a cystoscopy. The drug is designed to constrict the ureter and stop urine from refluxing. This minimally invasive procedure avoids the risks of open surgery, but it has the disadvantage of a lower success rate.
Prevention
Direct prevention to avoid primary reflux is not possible.However, if there are known cases of reflux in the family, examinations are advised to exclude possible reflux. If reflux has already been diagnosed, it is recommended to empty the bladder in at least 2 stages and to wait several minutes after the first emptying, because urine that has been pushed back from the ureters can then flow back into the bladder and be excreted along with it if the 2nd emptying is done with as little pressure as possible.
Follow-up
Follow-up care is required when vesicorenal reflux is treated by surgery, which occurs in childhood. In most cases, surgery takes a successful course. As part of the aftercare, the operated child continues to receive antibiotics for prevention even after he/she has left the hospital. Thus, the administration of antibiotics must be continued for a certain period of time. For about two to four weeks it is necessary that the child rests physically. If, on the other hand, an endoscopic ostium injection is performed, there is no need for physical rest. An important part of the aftercare is the check-up. Three weeks after the procedure, an ultrasound examination (sonography) and an examination of the urine are performed. Further check-ups take place after three months and after one year. In open surgery, the success rate is particularly high. Therefore, in these cases, an additional routine reflux test in the form of a micturition cysturethrogram (MCUG) is not necessary. In the case of endoscopic ostium injection, an MCUG is performed only in exceptional cases three months after surgery, which ultimately depends on the extent of reflux as well as the healing process. A particularly important follow-up measure is the control by sonography, which is carried out with the special 4D ultrasound technique and serves to detect recurrences. It takes place three to six months after the surgical procedure.
Here’s what you can do yourself
Vesicorenal reflux heals on its own in most cases. The most important self-help measure is to prevent infection by maintaining a healthy lifestyle. If vesicorenal reflux persists, therapeutic treatment is necessary. After the procedure, rest and recuperation are the order of the day. Patients should also drink plenty of water to promote the flushing out of any viruses. The attending physician can specify the exact measures to be taken. In any case, close medical monitoring is required in the event of vesicorenal reflux. It is important to have the condition clarified at an early stage. If complaints such as pain or problems with urination occur, the doctor must be informed. In addition to painkillers prescribed by a doctor, various natural painkillers are available, such as preparations containing St. John’s wort or valerian. In addition, cooling and warming compresses help with recovery by relieving pain and promoting circulation in the affected area. Since the urinary tract is very sensitive, the use of irritating home remedies or natural remedies should first be discussed with the attending physician. By taking these measures, vesicorenal reflux should heal reliably after surgery.
