For any parent/carer dealing with a child diagnosed with Vesicoureteral Reflux, the state of alarm is constant, and consequently a certain emotional burden can be identified. For having all possible variables that infer in the child's quality of life, under perfect control, can be time-consuming and quite tricky. Nevertheless, it is primordial to first have a complete understanding of the disease basics, so whoever is caring for the affected child can understand that there are clinical responses addressing the problem and that the issue itself is characterised by grey areas where agreements had to be made between experts in the area. Why? Due to lack of consensus.
Vesicoureteral Reflux is not immediately an easily describable succession of rigid events, there are underlying little aspects that can confuse the diagnostic and bring personal opinions from clinicians to the debate table.
What is Vesicoureteral Reflux?
This relates to a flow of urine that is contrary to normal motion. Going from the bladder into the ureter and, sometimes/eventually, depositing into the renal system (e.g., kidney).
Can it happen to any child?
For most subjects this type of reflux derives from an existing physiological anomaly of the ureterovesical junction occurring from birth (congenital anomaly), but it can also emerge from other origins such as:
a) from high-pressure passing urine from secondary to posterior urethral valves,
b) due to a neuropathic bladder (where associated peripheral nerves are dysfunctional),
c) due to a voiding dysfunction (incapacity to urinate as normally expected).
How many are affected?
About forty percent of children experiencing a urinary tract infection (UTI) show signs of reflux according to [1], thus, considering that two to five percent of girls and one to two percent of boys experience a urinary tract infection before reaching puberty [2] the numbers and their underlying inference speak for itself.
UTIs are the commonest bacterial disease present in the first three 3 months of life in humans, according to [3]; tolling to about over 10% of reported serious febrile events of bacterial origin in infants 2 to 6 months of age [4]; reflux nephropathy is a liability factor when considering inflammation of the lining of renal pelvis and parenchyma, resulting in injury to the kidney and scarring (lesions that are irreversible and that in case of progressive kidney disease can cause kidney failure). In that sense, reflux nephropathy can result in extremely nefarious consequences such as renal insufficiency or end-stage renal disease (that when moderate to severe can then trigger renin-mediated hypertension) [5].
How is the management of disease approached?
The very first objective in the management of vesicoureteral reflux in children is to avoid pyelonephritis [a], renal injury and other complications derived from the impact of reflux in the urinary system.
Clinicians do know that vesicoureteral reflux is common, but presently there is very little consensus to the best way to manage the disease (even among clinical experts) [6]. It is exactly because of the lack of consensus in regard to how this medical issue should be treated that the American Urological Association (AUA) gathered a group of experts to produce a treatment guide directed to children diagnosed with vesicoureteral reflux, with scope on vesicoureteral reflux in children diagnosed following a urinary tract infection [7]. If you happen to visit the document online bear in mind that it is preconditioned to children aged 10 years and younger with unilateral or bilateral reflux with or without scarring. In addition, it also entails that treatment recommendations are to be made jointly with the parents of the sick child. I suspect that is because of individual behavioural patterns of the patient, day-to-day habits and the different spaces the child might be involved in. All this can impact tremendously in the practical outcome.
As stated in the document "Only a few recommendations can be derived purely from scientific evidence of a beneficial effect on health outcomes [...] Evidence of the efficacy of medical management on health outcomes is available only for Grades I–IV reflux".
What is recommended?
To maintain information as reliable as possible in regard to what is postulated in the original document, and because the document is quite long (I had to read it over the course of several weeks, see HERE). I decided to copy directly from the original. However, this is purely a summary of very important information that requires interpreting by involved clinicians. The present information is only for informative purposes to empower parents towards a more informed conversation with their children's doctors. It should not be interpreted as a priori direct medical advice towards a certain decision. Because consensus, as already discussed, is difficult in this area, even among experts, treatment options are the result of a selection by 8 out of 9 panel members and are, therefore, categorised as guidelines. As expected, treatment is advised by the panel based on a number of conditions, for example, nature of injury, grading of injury (I to IV, see end of post) and age.
Having said all this, the available approaches are:
(1) No treatment (including intermittent antibiotic therapy);
(2) Bladder training;
(3) Continuous antibiotic prophylaxis;
(4) Antibiotic prophylaxis and bladder training;
(5) Antibiotic therapy, bladder training and anticholinergics (drugs that block the action of the neurotransmitter acetylcholine);
(6) Open surgical repair: "although proven to cure reflux in 90–98 percent of patients, has not been demonstrated to improve health outcomes other than pyelonephritis; for this outcome, the evidence suggests that children with Grade III or IV reflux receiving continuous antibiotic prophylaxis are 2.5 times more likely to develop pyelonephritis than children who have undergone successful antireflux surgery" [...] Thus, evidence-based recommendations provide limited practical guidance for the clinician.
(7) Endoscopic repair.
"These modalities are described in Chapter 1. The recommendations assume that the patient has uncomplicated reflux (e.g., no breakthrough UTI, voiding dysfunction, duplex systems [where the ureter with the ureterocele can drain the top half of the kidney whereas the other ureter drains the lower half resulting in frequent UTIs, possibly reflux, and if not treated potential kidney damage], or other comorbid conditions); [...]
An important variable in the scope of treatment is the presence of concurrent voiding dysfunction, a common occurrence among children with reflux. Because resolution of voiding dysfunction may be accompanied by resolution or diminution of reflux such children may require more aggressive treatment with antibiotics, anticholinergics, and bladder training (e.g., timed voiding, biofeedback, parental monitoring of voided volumes). Surgical repair of reflux is less successful in children with voiding dysfunction, and thus a higher threshold is necessary before surgery is recommended in such patients. Children with reflux should therefore be assessed for voiding dysfunction as part of their initial evaluation.
[8]
[1] Bourchier, D., Abbott, G. D., Maling, T. M. (1984). "Radiological abnormalities in infants with urinary tract infections". Arch Dis Childv, 59(7); pp. 620–624.
[2] Jodal, U. and Winberg, J. (1987). "Management of children with unobstructed urinary tract infection". Practical Pediatric Nephrology, 1, pp. 647–656(1987).
[3] Krober, M. S., Bass, J. W., Powell, J. M., Smith, F. R., Seto, D. S. (1985). "Bacterial and viral pathogens causing fever in infants less than 3 months old". Am J Dis Child, 139(9):, pp. 89-92.
[4] Allen, L. H., Lei, C., Douglas, B. (2006). "Incidence and Predictors of Serious Bacterial Infections Among 57- to 180-Day-Old Infants". Pediatrics, 117 (5), pp. 1695-1701.
[5] Martínez-Maldonado, M., (1998). "Hypertension in end-stage renal disease". Kidney International, 54(68), pp. S67-S72.
[6] Elder, Snyder, Peters, et al., 1992; International Reflux Study Committee, 1981.
[7] Management and Screening of Primary Vesicoureteral Reflux in Children (2010, amended 2017), American Urological Association, [https://www.auanet.org/guidelines/vesicoureteral-reflux-guideline], last visited on the 8th of January 2020, Last update in 2017.
[8] Image kindly taken from Radiopaedia, [https://radiopaedia.org/cases/illustration-vesicoureteric-reflux-grading].
[a] Inflammation of both the lining of the renal pelvis and the parenchyma of the kidney especially due to bacterial infection, as per the Merriam-Webster dictionary.
Post Photo by Robina Weermeijer on Unsplash.
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