| Abstract|| |
There are a few reports about the size of the problem of vesicoureteral reflux (VUR) in developing countries. We attempted in our study to assess the experience of this problem in children in a tertiary care medical center in the period between June 1983 till June 1993. VUR was diagnosed in 24 patients, of whom 71% were boys. The mean age of the patients was 36.5 months; seven (29%) of them were below one year of age. The commonest presentation was urinary tract infection. E. coli was the most common organism and was resistant to the first chpice chemoprophylaxis in 50% of cases. Urine culture was also positive in 37.5% of children who were grossly asymptomatic. Ultrasound study failed to detect VUR in 25% of cases. There were eleven patients with mild to moderate reflux (grades I, II, III) of whom 9% required ureter reimplantation by open surgery. Eleven patients had severe reflux (grades IV,V) of whom 72% required the same procedure. Post-operatively, of the nine patients who had reimplantation, seven (77.5%) had successful surgery and maintained normal renal function after a mean duration of follow up of 30 months (range from 6 to 84 months), one patient developed end-stage renal disease, and one patient was lost to follow-up. We conclude that VUR is not uncommon in early childhood. Early referral of severe cases for surgical reimplantation is recommended.
Keywords: VUR, Urinary tract infection, Prophylaxis, Management.
|How to cite this article:|
Al Mohrij OA, Al Zaben AA, Al Rasheed S. Vesicoureteral Reflux in Children. Experience in Riyadh, Saudi Arabia. Saudi J Kidney Dis Transpl 1996;7:301-4
|How to cite this URL:|
Al Mohrij OA, Al Zaben AA, Al Rasheed S. Vesicoureteral Reflux in Children. Experience in Riyadh, Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2022 Jan 20];7:301-4. Available from: https://www.sjkdt.org/text.asp?1996/7/3/301/39494
| Introduction|| |
Vesicoureteral reflux (VUR) is regurgitation of urine into either one or both ureters  . It may be primary or secondary depending on the etiology. Primary reflux is due to anatomical defects of congenital origin. However, the factors responsible for secondary reflux vary widely from bacterial infection, chemical irritation, stone-disease to bladder dysfunction  . Young children are at higher risk of developing serious complications, including renal scars, impedance of renal growth, hypertension and chronic renal failure if management strategies are not instituted in time  . The actual prevalence of VUR is unknown as all data collected from children are usually from those with documented urinary tract infection who happened to have voiding cystourethrogram performed during follow up  . This is unfortunate because uninfected population with VUR are unaccounted for. Addressing this problem may be important in preventive medicine, since VUR may result in hypertension and chronic renal failure  .
In a developing country like ours, the size of this problem is unclear. Our aim was to study the etiology, pathology, clinical course, management and outcome of the patients who had VUR in our hospital.
| Patients and Methods|| |
The hospital records of patients with the diagnosis of VUR seen at King Fahad National Guard Hospital-Riyadh from June 1983 to June 1993 were reviewed. The diagnosis of VUR was based on the voiding cystourethrogram or other similar radiodiagnostic findings. The data extracted from each record included age at presentation, sex, clinical features, episodes of urinary tract infections, organisms responsible and antibiotic sensitivity, the indications for radiological studies and management outcome. The cases of VUR were stratified into grades according to the international classification.
Urine cultures were obtained initially from all patients and were repeated for some of them later. The patients with hydronephrosis in utero had urine collected two weeks after birth. Urine collection was either by midstream technique or in infants through urine bag after careful washing of the genitalia. UTI was diagnosed if urine showed more than 105colonies/ml of single organism.
| Results|| |
Data of 24 patients with VUR were available for analysis. Seven patients had reflux in the right ureter, seven had it in the left ureter, while ten patients had bilateral reflux. The ages of the patients ranged from two weeks to 10 years with a mean of 36.5 months. Seven (29%) of the cases were infants below one year of age. Seventeen (71%) of the patients were boys with a male: female ratio of 2.5:1. The total number of pediatric urological admissions during the same study period was 429 admissions. Accordingly, the prevalence of VUR was 5.6% of all urological admissions.
[Table - 1] shows the frequency of types of presentation in patients with VUR. Urinary tract infection (UTI) was the most common presentation followed by hydronephrosis diagnosed in utero. Two patients were asymptomatic and were incidentally diagnosed by abdominal sonography for non-renal indication. Physical examination was mostly normal and only six patients had abnormally high blood pressure for their age and sex. Hypertension was mild in four of them and severe in the other two. Failure to thrive was the initial presentation in two patients.
Thirty one urine cultures were available for analysis. E. coli grew in 21 cultures; however the organism was resistant to trimethoprimsulphamethoxale in 50% of them. [Table - 2] shows the frequency of UTI in patients whose initial presentation was not UTI. Almost 30% had positive urine cultures. Ultrasonography was done on 18 patients with abnormality detected in 11 (61%) patients.
There were 11 cases with grades I, II or III reflux of which only one case required ureter reimplantation by open surgery. On the other hand, of the 11 cases with grade IV or V, eight cases required the same procedure. Post-operatively, of the nine patients who had reimplantation, seven (77.8%) had successful surgery and maintained normal renal function after a mean duration of follow up of 30 months (range from 6 to 84 months), one patient developed end stage renal disease, and one patient was lost follow-up.
| Discussion|| |
Vesicoureteral reflux is not an uncommon urological problem in children. In our hospital it formed 5.6% of urological admissions. Forty-two percent of our cases had bilateral reflux compared to 50% in another larger study  . Previous reviews demonstrated the prevalence of VUR in uninfected children to be between 0.4% and 1.8%, while in infected children the prevalence was 1.9%  . The disease is more common in younger children and especially in the first year of life. Seven (29%) of the patients in our study were below one year of age. In our study VUR was more common in boys than in girls, which was similar to a recent study from Taiwan  , but more than what was reported in Europe  .
Most of our patients with VUR presented with clinical evidence of UTI, which was comparable to other studies which reported high percentage of UTI (up to 70%) in patients with VUR  . On the other hand, 30% of our patients had no clinical evidence of UTI at presentation but were found to have positive urine cultures. UTI has clear association with reflux and increases the risk of development of renal scars. Unfortunately, intravenous pyelogram (IVP) and dimercapto succinic acid scan (DMSA), were not done on enough patients in this retrospective data collection; so we could not estimate the incidence of renal scars in our study. Hydronephrosis in-utero occurs often secondary to posterior urethral value (PUV) in boys, and these patients are usually diagnosed by antenatal ultrasound screening. However, such patients were excluded from our study.
Though ultrasound is a safe non invasive investigative procedure for patients with renal symptoms, a recent study by Blane, et al on patients with VUR screened by ultrasonography concluded that 74% percent were normal and 28% of the missed refluxing kidneys had grade III or more  . We had similar findings in our study which makes ultrasonography non-reliable to screen children suspected to have VUR. Recent studies suggested increased risk of VUR in other family members of index case with VUR  . No screening studies were done on siblings of our patients. These children require screening method other than ultrasound.
Chemoprophylaxis of UTI in VUR patients is important ,,,, . For the success of chemoprophylaxis obtaining urine culture before the start of antiobiotics cannot be over emphasized. Although the risk of recurrence of UTI is not dependent on VUR, VUR was shown to increase the risk of infection even when chemoprophylaxis is prescribed  . Our patients were put on chemoprophylaxis following VUR documentation and if urine culture was positive at presentation or in any of the monthly follow up cultures, it was appropriately treated. The risk of reflux nephropathy in such patients with VUR is induced by presence of UTI. The two drugs recommended for prophylaxis are trimethoprim-sulphamethoxale and mtrofurantoin  . The common organism was E. coli and sensitivity studies revealed resistance to trimethoprim - sulphamethoxale, the first choice, in 50% of our cases. Most of our patients were shifted to nitrofurantoin during follow up. The second common organism was Klebsiella pneumoniae. These latter were also seen in previous recent studies from same geographic area , . Dunn, et al also found that E. coli was the most common organism and proteus was the second common one  .
In our study VUR was also detected in asymptomatic patients with sterile urine. In absence of UTI, high pressure at renal level may lead to renal scars  . Reflux nephropathy is an important cause of hypertension in children  . Up to 15% of those children reach adulthood with no history of urinary tract infection. In our study 25% of patients presented with hypertension and increased risk of renal insufficiency.
When the need for corrective surgery was considered, this was necessary in only 9% of mild to moderate VUR (grades I-III). On the other hand 72.9% of severe VUR cases (grades IV and V), required reimplantation surgery. Reflux resolved in most of the cases of the first group with medical therapy. Same conclusion was reached in other international studies in which the spontaneous resolution rate was 61%-92% in grade I-III and 32%33% in grade IV  . Those who underwent surgical reimplantation did well, since seven out of eight patients improved and prophylactic medication could be discontinued. Occasional cases may develop renal impairment  , and our study supports such reports.
We conclude that VUR is a common pediatric problem in early childhood which may present with UTI or other renal sequale. High index of suspicion should be maintained to detect these cases. Medical follow-up with appropriate prophylaxis according to local geographic sensitivity pattern is recommended. Severe VUR in persistent cases should be referred for surgical reimplantation.
| Acknowledgement|| |
The authors are grateful to Dr. A Adeyokunnu for revising the paper. We are also grateful to Ms Jan Yorke for secretarial assistance for typing the manuscript.
| References|| |
|1.||Thomsen HS. Vesicoureteral reflux and reflux nephropathy. Acta Radiol Diagn Stockh 1985;26:3-13. |
|2.||Turner WR Jr. Reflux. Semin Urol 198 6;4(2):63-69. |
|3.||Schulman SL, Synder HM 3d. Vesicoureteral reflux and reflux nephropathy in children. Curr Opin Pediatr 1993;5:191-7. |
|4.||Huang PY, Tsai TC. Resolution of vesicoureteral reflux during medical management in children. Pediatr Nephrol 1995;9:715-7, |
|5.||Five-year study of medical or surgical treatment in children with severe reflux: radiological renal findings The International Reflux Study in Children. Pediatr Nephrol 1992;6:223-30. |
|6.||Mininberg DT. Urinary tract infection and vesicoureteral reflux in children: a review and management plan. Semin Urol 1985;3(4):287-300. |
|7.||Blane CE, Diuietro MA, Zerin JM, Sedman AB, Bloom DA. Renal sonography is not a reliable screening examination for vesicoureteral reflux. J Urol 1993;150:752-5. |
|8.||Gonzalez R. Vesicoureteral reflux in pediatrics. Behrman RE, Vaughan VC. Nelson text book of pediatrics. Fourteenth edition, W.B. Saunders company. Philadelphia 1991;1363-65. |
|9.||Kenda RB, Zupancic Z. Ultrasound screening of older asymptomatic siblings of children with vesicoureteral reflux: is it beneficial? Pediatr Radiol 1994;24:-146. |
|10.||Olbing H. esico-ureteral-renal reflux and the kidney. Pediatr Nephrol 1987;l:638-46. |
|11.||Brandell RA, Brock JW 3d. Common problems in pediatric urology. Compr Ther 1993; 19(1): 11-6. |
|12.||Al Mugeiren MM, Qadri SMH. Etiology of childhood urinary tract infections and antimicrobial susceptibility of uropathogens at a teaching hospital in Saudi Arabia Current Therapeutic. Research 1991;50(4):454-9. |
|13.||Dunn M, Smith PJ. Results of conservative management of vesicoureteric reflux in children. Br J Urol 1982;54:672-6. |
|14.||Al Mugeiren MM, Al Rasheed SA, Abdurrahman MB, Al Oufi MA, Patel PJ, Al Boukai AA. Are children with urinary tractinfection adequately managed? Saudi Med J 1992;13(4):300-4. |
|15.||Lerner GR, Fleischmann LE, Perlmutter AD. Reflux nephropathy. Pediatr Clin North Am 1987;34(3):747-70. |
Othman A Al Mohrij
Department of Pediatrics, King Fahad National Guard Hospital, P.O. Box 22490, Riyadh 11426
[Table - 1], [Table - 2]