Ever since your three year old child was born, you have noticed some problems in urination. Earlier you thought this was just a part of toilet training, but the problems persisted. Your child has been treated for urinary infections often and cries while passing urine. Bedwetting still persists and you are now anxious as to why your child is difficult to train for toilet. Repeated episodes of urinary infection should never be ignored in a child as these could imply another existing problem in the urinary tract. One such problem is vesicoureteral reflux that is common in children. You need to learn more about this condition and make sure your child does not have one.
Understanding vesicoureteral reflux
Vesicoureteral reflux (VUR) is an abnormal change in direction of flow of urine. Normally, the urine is synthesized in the kidneys, which act as filters of blood in the body. From the kidneys, the urine passes down two pipes called the ureters into the urinary bladder. The bladder is the storehouse for urine, and only when sufficiently distended with urine, causes an urge for evacuation that initiates the act of urination. The ureters open into the bladder at an angle such that the flow if urine is always from the ureters to the bladder. Retrograde flow is prevented by one way valves present at the opening of the ureters in to the bladder. In vesiocureteral reflux, urine back flows from the bladder into the ureters.
Causes
VUR may be genetic and may affect several members in the family. The valve that prevents backflow is malformed and does not function well. As the child grows, and the ureters become longer and straighter, the reflux settles and the condition improves. In other cases, the VUR is caused by a blockage in the urinary tract that increases the pressure in the urinary bladder. This high pressure is transmitted up the ureters and kidneys, hence disrupting the action of the one way valves at the junction of the ureters and the bladder. Reflux can be caused by the increases in pressure in a dysfunctional bladder that contracts too often and too forcefully. Urinary tract infections are more likely in vesicoureteral reflux and precipitate the problem.
UTIs are more common in VUR. UTI can be both a cause and a consequence of VUR. An infection in the bladder can pass up the urinary system and damage the valves present at the pint of junction of the ureters with the bladder. This can lead to reflux of urine up in the ureters. All UTIs may not lead to a VUR yet the two coexist in many children. On the other hand, the urine in VUR is retained for long in the urinary system, it is more prone to infection due to stasis.
Symptoms
The commonest symptoms in VUR are those related to infection. These include increased frequency of urination, and pain or burning while passing urine. Repeated urinary tract infections (UTIs) are common in VUR. The very young babies may develop fever, lethargy, and may show poor weight gain and changes in feeding habits. The older kids may complain of abdominal or flank pain as the pressure increases up the urinary system. A swollen kidney can be felt as a mass. The child may have double voiding, i.e. a second attempt of urination may be required to expel the refluxed and residual urine. Children may have bed wetting despite of good toilet training. As the high pressure damages the kidneys, a high pressure may develop and there may be an increase in quantities of proteins in the urine. A sustained high pressure can lead to kidney damage resulting in failure of kidney functions.
Diagnosis
A series of tests will enable detection of a VUR. An ultrasound of the kidneys and bladder shows the size and condition of these organs. A special X-ray called a Voiding cystourethrogram (VCUG) is done to check the flow of urine. A small tube is inserted through the urinary opening up the urinary tract and the bladder is filled with a special dye called contrast. As the child urinates, the dye is seen refluxing up the ureters in VUR. Another test called a radionuclide cystogram, is similar to VCUG and uses radioactive material (radioisotope) instead of a contrast.
Treatment
The treatment of VUR depends upon the child’s age, overall health, and severity of the condition. Mild and moderate VURs may resolve over time as the child grows. This may take around 5 years. In this period, the child may develop frequent UTIs and may need treatment with medicines to fight infections, called antibiotics. The common antibiotics used in UTIs are trimethoprim-sulfamethoxazole, trimethoprim, and nitrofurantoin. The VUR can be monitored with periodic radiographic studies of the bladder and kidneys. Such children need periodic urine testing. More severe varieties of reflux may need surgical treatment.
The severe types of reflux need a surgical correction. A flap-valve is created to prevent reverse flow of urine into the ureters and kidneys. Surgery may be done by making an incision in the abdomen or by inserting a flexible tube, called endoscope, through the urinary opening that permits visualization of the urinary tract. A gel can be injected through the endoscope to create a little bulge at the point where the ureters open into the bladder. Another common procedure done by making an abdominal incision is that of ureter reimplantation. The ureters are implanted at a new suitable site in the bladder and a longer tunnel if the ureter is created through the bladder wall at this point. If the ureters and kidneys have been extensively damaged, these may need to be removed.
Outlook
You should see an urologist if you think your child has VUR. If mild, then waiting for the child to grow out of this problem may be advised. But if it is severe, then definite treatment may be required. A proper correction of this condition at the right time is important to protect the health of your child.
