Vesico-ureteric reflux

Question 1

An 18-month old boy is referred to you following a recent hospital admission with his second febrile E.Coli urinary tract infection. He has completed a course of antibiotics and examines well.

Answer 1

Impression
With recurrent UTI infections in a young male patient, I am provisionally concerned about VUR disease, this being physiological due to short ureters. Higher grade VUR (3-5) may ultimately require surgical fixation.

DDx
- other congenital urogenital abnormalities (multiple ureters, horseshoe kidney, hypospadias)
- Primary/secondary immunodeficiency

Other DDx/complications to be wary of
- recurrent pyelonephritis/urosepsis
- reflux nephropathy
- vulvovaginitis, phalanitis
- urethritis

Question 2

VUR - History

Answer 2

History
- sx: frequency, pain, irritation, difficulties urinating, any deformities of Genitourinary tract, vomiting, bowel/urine changes, poor feeding, poor growth, strong smelling urine
- other infective source: cough, skin wounds, etc
- others: spina bifida, neurogenic bladder, hearing difficulties (related to renal pathology).
- RISKS: diabetes, hypospadias, circumcision, neurogenic (CP, etc)
- REDS: fevers, irritation, developmental regression
- paeds history, growth, obstetric history (scans showing renal tract abnormalities)
- Fam history: VUR

Question 3

VUR - Examination

Answer 3

Examination
- general obs + vitals
- abdo exam: flank/suprapubic tenderness, hernias, peritonitis
- external genitalia assessment: hypospadias, etc
- Neuro exam (spina bifida, other neuro deformities

Question 4

VUR - Investigations

Answer 4

Investigations
Key/diagnostic
- Renal tract US for abnormality of renal tract
- Voiding cystouregram (MCUG)
- Mag3 scan - differential GFR - assess individual kidney function
- DMSA scan for renal scarring (delayed)

Bloods: UEC, FBC, Urinalysis,

Question 5

VUR - Management

Answer 5

Management
Low grade VUR (1 to 2) will likely spontaneously resolve as the child ages, so can be monitored for this. Grade 3 or more is for surgical correction

Supportive
- prophylactic ABx for future infections (controversial) as develop ABx resistance quickly.
o Trimethoprim or Nitrofurantoin
- regular review for symptoms and ongoing prevention of complications (reflux nephropathy, and renal parenchyma disease) - active surveillance as most kids grow out of it.
- good hygiene
- good foreskin care

Definitive
- Paeds uro for anti-reflex surgery to re-implant ureters obliquely through detrusor to prevent reflux
- circumscision to reduce ongoing risks of infection

Ongoing:
- take home urine jars and path forms for future fevers to definitively diagnose UTI.