Background :

Vesicoureteral reflux (VUR) or the retrograde flow of urine from the bladder into the ureter is an anatomic and functional disorder with potentially serious consequences.

The objectives in the current treatment of VUR are 2-fold. The first goal is the prevention of episodes of acute pyelonephritis with its associated morbidity and mortality. The second goal is to prevent the scarring of the kidney associated with VUR (reflux nephropathy), which increases the risk of hypertension and renal failure in children and adults with VUR. Advances in medical and surgical management of children with VUR now are resulting in measurable decreases in the incidence of reflux nephropathy and its sequelae: hypertension, renal insufficiency, and end-stage renal disease.

Clinical Features :

Most children with VUR present in 1 of 2 distinct groups.

• The first group presents with hydronephrosis, often identified antenatally by ultrasound. These children typically progress through evaluation and treatment in the absence of clinical illness.
 
• The second group presents with clinical UTI.
  
  
  • Children often present with nonspecific signs and symptoms. Infection in infants can manifest as failure to thrive, with or without fever. Other features include vomiting, diarrhea, anorexia, and lethargy.
    
    
  • Older children may complain of voiding symptoms or abdominal pain.
    
    
  • Pyelonephritis in young children is more likely to present with vague abdominal discomfort rather than with the classic flank pain and tenderness observed in adults. The presence of fever, while highly suggestive of pyelonephritis, is not reliable enough to lead to the diagnosis.
    
    
  • Even today, children occasionally present with advanced reflux nephropathy, manifesting as headaches or congestive heart failure from untreated hypertension, or with uremic symptoms from renal failure.
    
    

Lab Studies

• Diagnosis of UTI is dependent on obtaining accurate urine cultures.
  
  
  • Growth of more than 100,000 colony-forming units (CFU)/mL is a significant finding on a midstream-voided specimen.
    
    
  • Urethral catheterization provides substantially better specificity; more than 1000 CFU/mL is considered significant for these samples.
    
    
 
• Although the WBC count, serum levels of C-reactive protein, and other blood tests often are used to assist with the diagnosis, no laboratory tests can reliably distinguish cystitis from pyelonephritis.
  
  
  • Other laboratory testing should include serum chemistries to assess for baseline renal function.
    
    
  • CBC can assist in tracking the response to treatment.