Vesicoureteral Reflux Treatment
The tendency for reflux to cure itself is the basis for current treatment. One of the clues that your doctor will use to determine if the reflux is likely to go away on its own is the "grade" of the reflux. This refers to how the reflux looks in the x-rays: t he more severe the reflux, the higher the grade, with scores from 1-to -5. The higher the grade, the less likely that the reflux will go away. Also, reflux that occurs into both kidneys appears to be less likely to go away than reflux occurring on only one side. Despite these guideli nes, it is almost impossible to predict with certainty for the individual patient whether reflux will go away (except in cases of grade 5 reflux, which rarely resolves beyond infancy).
For most children, prophylactic antibiotics are given on a daily basis. As long as there are no urinary infections, a VCUG or nuclear cystogram is obtained yearly to see if the reflux is still present. Most of the time, four or five years will be allowed for the reflux to go away before surgery is suggested. In many cases, the doctor might wait significantly longer. There are reasons however, that surgery might be performed earlier. The most common reason is "breakthrough" infection: an infection that occurs while taking prophylactic ant ibiotics. Other reasons might include high-grade reflux, antibiotic allergy, and patient and physician choice.
Surgery for reflux is highly successful and carries relatively little risk. The operation is usually done through a "bikini" incision. The bladder is opened and the ureters are freed from the inside of the bladder. They are then tunneled under the bladder lin ing, so that the ureter acts as its own flap valve. This is how the ureter is supposed to work. Alternatively, the ureters are tunneled in the bladder wall from outside the bladder. Usually children are in the hospital for one to two days. The success of these operations in routine c ases is more than 95 percent and complications are rare. There are new operations being developed to try to correct reflux using "minimally invasive" techniques, and we have been involved with some of these.
Preventing Infections
It is important in children with reflux to prevent kidney infections. This is achieved in three ways:
- Prophylactic antibiotics. Most children are given "prophylactic" antibiotics to prevent, not treat, infection.
Therefore, the doses used are low and the antibiotic is usually given only once a day. Antibiotics given in this way are very safe and rarel y cause any long-term problems. Certainly the risk of taking low-dose antibiotics is much less than the risk of recurrent kidney infections.
- Surgical correction of the reflux. In most cases, this is not necessary, because the reflux will go away on its own.
- Improving the way that your child voids. A large number of children with reflux and infection have some form of voiding dysfunction, or what is now referred to as dysfunctional elimination syndrome (DES). This might involve urinary frequency or infrequent voi ding.
Often there are accidents or urgency when voiding occurs. Constipation is almost always present to some degree. Treating voiding dysfunction will often dramatically reduce the incidence of urinary infections.
Treatment at UPMC
For patient referral or consultations, contact the Department of Pediatric Urology at UPMC Children's Hospital of Pittsburgh at 412-692-4100.