vu reflux

When Emma was 3 weeks old she developed a very high fever. It was a Sunday so I had to rush her to the emergency room to be checked out. Because her only symptom was the fever they had to do every test they could to determine what was wrong with her. She had blood taken for a full panel, urine for a urinanalysis, spinal fluid to test for meningitis, and a chest x-ray to check her lungs. They started her on some broad spectrum antibiotics and antivirals and explained that we would be admitted to the hospital until they figured out the origin of the fever. Fast forward 3 (miserable) days in the hospital and we had an answer. Everything came back negative except her urinanalysis. She had a UTI. They did an ultrasound of her kidneys and ureters and it showed hydronephrosis (swelling of the kidney due to the back up of urine) so after we finished her oral course of the antibiotics at home we had to go back for additional testing to determine if the UTI was a fluke or if it was a problem that required more treatment. So we headed back to the hospital two weeks later to have a VCUG..

A VCUG, or a voiding cystourethrogram, is used to visualize a child's urinary tract and bladder. It can help diagnose VU reflux, determine why a child is having recurring UTIs, discover if antibiotic treatment or anti-reflux surgery was effective, and check if there are any abnormalities or blockages of the urethra.

..Emma was catheterized (a small tube was inserted into her urethra). Her bladder was emptied. The tube had to remain in place the entire time she was being tested. A radioactive liquid was then "injected" into her bladder through the tube. The contrast die illuminated her urinary tract on x-ray images. Using a special x-ray technique they obtained images of Emma's bladder filling and emptying. And it was not good...
<-- normal
<--what we saw

Before we left, the radiologist read the films to give us some kind of idea what was going on. The news: Emma had/has vesicoureteral reflux (VU reflux) affecting both her right and left kidneys and ureters.

All you ever wanted or needed to know about the urinary tract and VU reflux...


What is the normal urinary tract?
The urinary tract consists of the kidneys, ureters, bladder and urethra. The kidneys are the organs that are responsible for filtering waste products from the bloodstream and produce urine continuously. The urine drains down tubes called ureters from the kidneys to the bladder, which normally stores urine and empties intermittently by muscular contraction. The urine exits the bladder through the urethra.
When the ureter enters the bladder it travels through the wall for a distance creating a tunnel so that a flap valve is created. This valve prevents urine that is in the bladder from backing up and returning into the ureter. Thus, when the bladder fills and later when it squeezes down to empty, back-up (that is, reflux of urine) is prevented because the valve operates in the same way as when you pinch off a soda straw.
The valves' most important job is to prevent bacteria from getting into the kidneys.
Diagram of the way our ureters enter our bladder.

What is vesicoureteral reflux (VU reflux)?
With normal urination, the bladder contracts and urine leaves the body through the urethra. With vesicoureteral reflux, some urine goes back up into the ureters and possibly up to the kidneys. Reflux exposes the kidneys to infection. In children, particularly those in the first 6 years of life, urinary infection can cause kidney damage. The injury to the kidney may result in renal scarring and loss of future growth potential or widespread scarring and atrophy (muscle death). Even a small area of scarring in one kidney may be a cause of high blood pressure later in life. Untreated reflux on both sides can, in the most severe instances, result in kidney failure requiring dialysis or a kidney transplant.

Why does vesicoureteral reflux occur?
The valve system at the ureterovesical (ureter-bladder) junction may be abnormal:In some children the tunnel of the lower ureter through the muscular wall of the bladder may not be long enough. For these children, there is a good chance that growth may provide the necessary difference to allow the valve to work. In other children, the ureter may enter into the bladder abnormally (usually too much to the side), resulting in a short tunnel. This reflux is less likely to resolve with growth.

The ureter is shown tunneling through the bladder wall. 1-if the tunneling of the ureter ends here, reflux is likely. 2-if the tunneling of the ureter ends here, reflux is possible. 3-if the tunneling of the ureter ends here, reflux is unlikely.

Some children have reflux because of underlying problems such as lower urinary obstruction (such as urethral valves), abnormal bladder behavior (such as uninhibited bladder contractions or hyperreflexic bladders), infrequent voiding, or constipation.

They believe Emma has reflux because her ureters enter into her bladder abnormally. They also believe Emma's reflux will not "fix" itself through growth (20% chance) and so surgery is in her future.

How is reflux evaluated?
Children who are suspected of having reflux should have a renal ultrasound and a voiding cystourethrogram (VCUG). Based on these studies, reflux can be classified into five grades - grade 1 is the least and grade 5 is the worst. Mild degrees of reflux have a good chance of resolving spontaneously with age. Chances of resolution with high-grade reflux (grade 4-5, or reflux related to an anatomic problem such as a long-standing obstruction) are much lower.

Normal kidney, ureter, and bladder	Grade I Vesicoureteral Reflux: urine (shown in blue) refluxes part-way up the ureter	Grade II Vesicoureteral Reflux: urine refluxes all the way up the ureter
Grade III Vesicoureteral Reflux: urine refluxes all the way up the ureter with dilatation of the ureter and calyces (part of the kidney where urine collects)	Grade IV Vesicoureteral Reflux: urine refluxes all the way up the ureter with marked dilatation of the ureter and calyces	Grade V Vesicoureteral Reflux: massive reflux of urine up the ureter with marked tortuosity and dilatation of the ureter and calyces

Emma had an ultrasound in the hospital as I said earlier and then on a later date had a VCUG done. Her reflux was graded as a 4-5 on the right and 5 on the left.

How is reflux treated?
Since many children will outgrow their reflux, they can be followed carefully, with their reflux monitored at intervals by tests such as VCUG, renal ultrasound, or nuclear voiding cystogram. During this follow-up period they are kept on a prophylactic (low-dose) antibiotic to keep the urine free of infection. Any fever or urinary tract symptoms (such as burning, frequency, urgency, straining, foul odor, bloody urine, or unusual incontinence) must be evaluated with urine analysis and urine culture. Children who develop breakthrough urinary infections in spite of prophylaxis are at risk for kidney damage and need to be considered for surgical correction of reflux.

Emma is on a low-dose prophylactic antibiotic called Septra. She takes it once-a-day. She just went for her 6 month follow up in April. She had an ultrasound and a nuclear medicine study called a mag 3 scan done to check her kidney function. There was no good or bad news to be reported from that. They did not repeat the VCUG so we have no idea if her reflux is better or worse (I don't think it has changed for the better or worse) but we do know that there is only minimal (if any) damage to her left kidney from her infection when she was 3 weeks old. She has been infection free since her hospital stay in September '10 so that's good. She will go back in October to have another ultrasound and VCUG done.

How is reflux treated surgically? Correction of reflux (ureteral reimplantation or ureteroneocystostorny) is recommended for high grades of reflux, for reflux that fails to resolve, or for patients with breakthrough infections. The traditional surgical approach involves opening the bladder and creating a new longer tunnel for the ureter through the bladder wall.

I'm not sure of the time frame for when they plan on doing this. I know they will make a decision around her 2nd birthday to give her body a chance to grow and change. Unless of course she starts having several breakthrough infections.

What about long-term follow-up?
Children with a history of reflux should probably be monitored life-long with measurement of height and weight, blood pressure, and urine analysis. Occasional ultrasound tests will assure that kidney growth is on target for age and size. If kidney function from previous reflux should deteriorate, the pediatric nephrology team can begin appropriate medication and dietary restriction.

What about other family members?
If one child in a family has reflux, there is a 1 in 3 chance of having an affected sister or brother. Because we know that the chances of kidney damage are highest in the first 6 years of life, we think that brothers and sisters in that age range should be studied (with examination, ultrasound and voiding study) even though they may not have been known to have urinary infections.

Sorry for such a long winded (maybe boring) post but I needed to get this written down so I have a record of it and also I wanted to share this with our families. It is so hard to explain it all correctly over and over. And sometimes I forget and leave some parts out. Happy reading.

I will leave you with a picture of our precious baby girl from a couple weeks ago when Granny was visiting. We went to a carnival just to get out of the house for the day and here is one of the pictures she took.
"Hello I look so much like my daddy!!"