What is a urinary tract infection (UTI)?
A UTI is a bacterial infection that affects any part of the urinary tract. Although urine contains a variety of fluids, salts, and waste products, it usually does not have bacteria in it.When bacteria get into the bladder or kidney and multiply in the urine, they cause a UTI. The most common type of UTI is a bladder infection which is also often called cystitis. Another kind of UTI is a kidney infection, known as pyelonephritis, and is much more serious. Although they cause discomfort, urinary tract infections can usually be quickly and easily treated with a short course of antibiotics.
What is vesicoureteral reflux (VUR)?
To understand vesicoureteral reflux, one needs to understand the normal structure and function of the urinary tract.
The urinary system
The kidneys clean and filter blood to produce urine. Urine is liquid waste. Urine travels from the kidneys down the ureters and into the bladder. The bladder holds the urine and acts as a storage tank. As the bladder fills, the wall of the bladder relaxes to hold more urine. The control muscle (sphincter) remains tight to prevent leakage of urine. Once in the bladder, the urine is stopped from going back into the ureters by a valve mechanism. When the bladder gets full, it sends a message to the brain. The brain decides when urination should start. The bladder contracts while the sphincter muscle relaxes allowing the bladder to squeeze all of the urine out.
The Urinary System
Kidneys shown in red; Bladder and ureters in blue
VUR seen on VCUG
Vesicoureteral reflux is a condition in which urine from the bladder flows back up into the ureter and kidney. It is caused by a problem with the valve mechanism. Pressure from the urine filling the bladder should close the tunnel of the ureter. It should not allow urine to flow back up into the ureter. When the ureter enters the bladder at an unusual angle or when the length of the ureter that tunnels through the bladder wall is too short, reflux can occur. VUR is seen in 30 to 50 percent of children with kidney infections.
Vesicoureteral reflux becomes a problem when the urine in the bladder becomes infected. The infected urine easily travels backwards to the kidney and can cause a kidney infection. Kidney infections lead to kidney damage. Most children with kidney infections have high fevers and may not eat well or have little energy.
Vesicoureteral Reflux is usually discovered during an evaluation for UTI by your child's primary care provider. After a UTI, a variety of tests can be ordered.
A voiding cystourethrogram (VCUG) is an X-ray test where a small tube or catheter is placed into the bladder through the opening where the urine comes out. A special liquid called X-ray contrast is used to fill the bladder through the catheter. When the child's bladder is full, the child will urinate into a special container while on the X-ray table. While the bladder is filling and the child is urinating, X-rays are taken. A similar test called nuclear cystogram may be used instead of the VCUG. A catheter is placed and the procedure is similar to the above test.
A kidney (renal) and bladder ultrasound is a test using sound waves to look for kidney scarring and to measure kidney size. During the ultrasound, a technologist will rub warm gel on the child's belly and back. Then, the technologist will move a device that looks like a microphone on the same areas. Other studies may be used to determine kidney scarring and function.
The management of vesicoureteral reflux depends on the grade of reflux, which is determined by the VCUG. Also taken into consideration are the frequency of urinary tract infections, the presence and progression of any kidney damage, and parental opinion.
Treatment Options for VUR
For grades 1 to 3, there is a good chance that the reflux will disappear as the child grows and the bladder matures. These children are given low-dose antibiotics daily to suppress bacteria from growing. Occasional blood tests and urine cultures may be ordered. However, recent evidence suggests that long-term antibiotics may not be effective and may increase bacterial resistance – making antibiotics ineffective. Additionally, long-term radiation exposure from X-rays may have risk. For these reasons, surgery may be advocated. In some children with low grade VUR in whom there have been no further urinary infections, antibiotics may be stopped. Close follow-up is needed in cases of the return of urinary infections.
Outpatient endoscopic injection procedure
A minimally invasive option for patients with grades 1 to 4 is a cystoscopy with injection of gel. This is a procedure where, under general anesthesia, a small telescope is inserted into the bladder through the urinary opening. There are no incisions and no need for pain medicine afterwards. A gel is injected where the ureters enter the bladder. A little bulge is formed in the bladder wall, preventing the backflow of urine.
After surgery, there are no limitations and your child may return to school the day after surgery.
Ureteral reimplantation surgery
Patients with high grade reflux, grades 4 to 5, will take low-dose antibiotics and have periodic blood tests, X-rays and urine cultures. These children will often need ureteral reimplantation surgery to correct the reflux and prevent progressive damage of the kidneys.
The goals of surgery are to correct the reflux, prevent pyelonephritis (kidney infection), and preserve renal function. The surgical repair of reflux may not totally stop the development of bladder infections. It will reduce the chance of a bladder infection developing into a kidney infection.
The ureteral reimplantation surgery consists of creating a longer tunnel of the ureter through the bladder wall. The surgery is performed through an incision (cut) just above the pubic bone (bikini incision). If both ureters need to be reimplanted, this is done through one incision.
This surgery usually lasts approximately two hours. Afterward, the child will be admitted to the hospital for up to four days, but many are discharged home the next day. Before surgery, the anesthesiologist will discuss a pain management plan with the family.
After open surgery, activity will be limited for four to six weeks. Patients can return to school one week after surgery or when no longer taking narcotics for pain control.
Healthy bladder habits, including an adequate intake of water and avoidance of dietary bladder irritants is important. Good perineal hygiene, particularly in girls, along with voiding every three to four hours is also good prevention to ward off urinary tract infections.