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Experience with vesicoureteral reflux in children: clinical characteristics
1Department of Pediatric Urology, Children's Hospital of Buffalo, New York, USA.
Insights
Vesicoureteral reflux (VUR) in children often presents without urinary tract infections. Continuous antibiotic prophylaxis effectively prevents new kidney scarring, but breakthrough infections can occur, necessitating ongoing monitoring post-reimplantation.
Area of Science:
- Pediatric Urology
- Nephrology
- Infectious Diseases
Background:
- Vesicoureteral reflux (VUR) is a common condition in children.
- Understanding the presentation, progression, and management of VUR is crucial for preventing renal damage.
Purpose of the Study:
- To review a 9-year experience with a large pediatric population diagnosed with VUR.
- To evaluate contemporary concepts in the evaluation and treatment of VUR in children.
Main Methods:
- A retrospective review of 1040 children (288 boys, 752 girls) with VUR from 1985 to 1993.
- Management included antibiotic prophylaxis and regular imaging (cystography, renal scans); surgery was performed selectively.
Main Results:
- 54% of initial evaluations were due to urinary tract infections; 15% due to voiding dysfunction.
- Renal scarring was present at diagnosis in 132 children (10%), associated with various reflux grades.
- No new scars developed in children on prophylaxis without breakthrough infections; reimplantation occurred in 20% of cases.
Conclusions:
- VUR diagnosis in children may not always involve a history of culture-proven UTI.
- Continuous prophylaxis is effective in preventing new renal scarring.
- Post-reimplantation monitoring for UTIs is essential.
Purpose:
We reviewed our 9-year experience with a large population of children with vesicoureteral reflux who were evaluated and treated according to contemporary concepts.
Materials And Methods:
From 1985 to 1993 we followed 288 boys and 752 girls with vesicoureteral reflux. If surgery was not performed, patients were on antibiotic prophylaxis and evaluation was done every 18 months with contrast voiding cystography and radionuclide renal imaging. Urine cultures were obtained every 4 months. Two negative voiding cystourethrograms 1 year apart were required to discontinue prophylaxis.
Results:
The major reasons for initial evaluation were urinary tract infection in 560 children (54%), voiding dysfunction without urinary tract infection in 156 (15%), sibling surveys in 122 (12%) and prenatal hydronephrosis in 23 (2%). In 150 kidneys (10%) in 132 children scarring at presentation was grade 0 in 10 (7%), I in 18 (12%), II in 27 (18%), III in 30 (20%), IV in 48 (32%) and V in 17 (11%). Of these 132 patients 17 presented at ages less than 1 year (13%), 29 at ages 1 to 3 (22%), 50 at ages 4 to 6 (38%), 24 at ages 7 to 9 (18%) and 12 at ages greater than 10 (9%). No new scars were seen in children on prophylaxis without breakthrough infection. After 1 negative voiding cystourethrogram reflux was noted again in 27% of the cases. Breakthrough infections developed in 62 children of whom a third were older than 7 years. Reimplantation in 205 children (20%) was performed for grade IV to V reflux (101), breakthrough infection (62), advanced age (18), large periureteral diverticulum (12) and noncompliance (3). Five boys and 57 girls (30% of all children) had urinary tract infections after successful reimplantation.
Conclusions:
Almost half of the children with vesicoureteral reflux have no history of culture proved urinary tract infection. Scarring may be associated with any reflux grade and it may be initially diagnosed at any age. Only half of the scars are noted with higher grades of reflux (IV and V). Continuous prophylaxis prevents new scarring. Breakthrough infections are rare but they can occur at ages greater than 7 years. Two consecutive negative cystograms are necessary before discontinuing prophylaxis. Children should be monitored after reimplantation for recurrent urinary tract infection.