Vesicoureteral reflux is a pathology characterized by a reverse flow of urine from the bladder to the ureter. It occurs with abnormalities of the excretory system, high pressure inside the bladder or against the background of inflammatory processes. Disease can cause pyelonephritis, hydronephrosis, kidney failure. The main symptoms are pain in the lumbar region after urination, turbidity of urine, swelling, fever. Diagnostic methods: general urine, blood test, kidney ultrasound, intravenous urography, miction cystography. Treatment is reduced to the treatment of an inflammatory disease or surgical elimination of abnormalities of the urinary system.
ICD 10
N13.7 Uropathy caused by vesicoureteral reflux
Meaning
Vesicoureteral reflux is one of the most common urological diseases, especially among children. It is found in 1% of urological patients, the proportion of the bilateral process is 50.9%. Urine regurgitation is detected in 40% of patients with infectious diseases of the urinary tract.
The prevalence of vesicoureteral reflux, high risk of complications (renal insufficiency, secondary arterial hypertension, purulent kidney diseases) cause a large percentage of disability of patients. Congenital reflux is observed in 1 child out of 100, while the ratio of female and male children in the first year of life is 5:1. As they grow older, the incidence of pathology in boys increases with a change in the situation to the opposite.
Causes
Etiological factors of non-physiological movement of urine are the processes leading to insufficiency of the sphincter of the ureteral anastomosis. The sphincter is a physiological barrier separating the ureters and the bladder, preventing the reverse flow of urine. Additional prerequisites for regurgitation are created by high fluid pressure in the bladder. The main groups of factors leading to the development of reflux include:
- Anomalies in the development of the excretory system. A decrease in the closure function of the sphincter develops due to the incorrect formation of this segment of the excretory system at the stage of intrauterine development. The abnormal structure may manifest itself in the form of a constantly open ureter mouth, the absence or reduction of the muscle layer of the constrictor, its dysplasia, tissue degeneration.
- High intravesical urine pressure. Damage to the brain, spinal cord, pelvic nerves leads to a violation of the regulation of the tone of the muscles of the bladder. The muscle wall is in constant tension, which creates increased hydrostatic pressure. This leads to the inability of a healthy sphincter to restrain urine. The causal factors of this condition are congenital (cerebral palsy, sacral agenesis) and acquired (brain tumors, stroke, Parkinson’s disease, diabetes mellitus) pathology.
- Inflammatory process. A decrease in the barrier function of the vesicoureteral anastomosis is possible with inflammation of the urinary tract. Reflux is usually a consequence of neglected acute and chronic forms of cystitis or ascending urethritis. Infection is more often caused by opportunistic microorganisms, especially E. coli, against the background of a decrease in local or general immunity.
- Iatrogenic causes. The formation of retrograde urine discharge through the vesicoureteral anastomosis is possible after surgery in the distal parts of the excretory apparatus. The most frequent operations leading to reflux are prostatectomy, ureterocele dissection, resection of the bladder neck. With any of them, there is a possibility of violation of the normal anatomical structure of the bladder and the vesicoureteral segment.
Factors that increase the risk of developing reflux include its presence in the family history, especially in the closest relatives (parents, brothers, sisters). Also increase the likelihood of violations of the regulation of the tone of the bladder or sphincter of the anastomosis of a spinal cord tumor, congenital anomalies of the spine, for example, its splitting.
Pathogenesis
The area of connection of the ureters with the bladder cavity is anatomically a sphincter antireflux apparatus that provides urine flow only in the downward direction. This is achieved due to a certain angle at which the ureter flows into the bladder, and intrahepatic smooth circular muscles. The main pathological link in the formation of reflux is a decrease in the efficiency of the sphincter as a result of dysplasia of muscle fibers, their inflammatory damage, disorders of nervous regulation. Morphofunctional changes lead to disruption of the antireflux mechanism and non-physiological retrograde movement of urine.
High hydrostatic pressure causes deformation and dilation of the ureter and renal pelvis. Conditions are created for the transfer of bacteria from the lower segments of the excretory system to the upper ones, which leads to the development of acute or chronic recurrent infection in the renal parenchyma with the replacement of renal tissue with non-functional connective tissue. Nephrosclerosis is the cause of renal filter dysfunction and the development of life-threatening conditions.
Classification
Modern clinical urology strives to develop a unified universally recognized classification, since the choice of further therapeutic tactics largely depends on the degree of vesicoureteral reflux (PMR). To date, the most widespread systematization of the process has been received depending on the level of reverse urine casting:
- I degree. Due to the insufficiency of the sphincter, the reflux of a small amount of urine is limited to the distal pelvic part of the ureter. There is no enlargement of the ureter. The risk of complications of an infectious and non-infectious nature is minimal, there are no symptoms. Detection of PMR usually occurs during examination for other diseases of the excretory system.
- II degree. The casting of urine is noted throughout the ureter, but without its dilation. At the same time, urine does not reach the kidneys, the cup-pelvic system. This degree is characterized by the absence of pronounced symptoms, a small risk of infectious complications, but a high rate of progression of reflux, a rapid transition to the next levels of development. It is detected accidentally during a routine preventive examination or diagnosis of other pathologies.
- III degree. Urine reaches the kidneys, but there is no expansion of the pelvis. There may be a decrease in renal function by 20%, detected by biochemical analyses. The ureter is dilated, there are signs of degenerative trophic degeneration of tissues. The risk of infection increases due to stagnation of urine in the excretory system, which is often a reason to consult a specialist. Symptoms have an average degree of severity.
- IV degree. There is a significant expansion, deformation of the calyx-pelvic region and ureters. Kidney function decreases significantly (up to 50%) with a decrease in urine production, especially against the background of infectious complications. Symptoms are pronounced, with febrile temperature, generalized edema. With a bilateral process, the development of life-threatening conditions is possible, which requires early access to specialists.
- V degree. A severe degree of kidney damage with thinning of their parenchyma is diagnosed along with all the signs characteristic of previous degrees. The ureter has knee-shaped bends due to excessive expansion. The increasing symptoms of renal insufficiency (decreased diuresis, nausea, vomiting, itching) require immediate treatment for qualified help.
There are classifications of vesicoureteral reflux based on other signs, for example, on the etiological factor (congenital, acquired), the nature of the process (single, bilateral), clinical course (intermittent, permanent). But the key indicator is the expansion of the structures of the urinary tract. Even minor dilation of the ureter or pelvis of the kidneys can significantly impair their function.
Symptoms of vesicoureteral reflux
There are no specific manifestations of vesicoureteral reflux, it may be asymptomatic in the early stages. The appearance of signs of PMR is most often the result of a prolonged absence of treatment or associated infectious complications. The symptoms of the exacerbation period are similar to the manifestations of inflammatory pathologies of the kidneys and depend on the age of the patient.
Children with congenital or acquired reflux at an early age are characterized by pallor of the skin, painful appearance, reduced body weight, growth and development that do not correspond to age, restless behavior, abdominal pain, lower back. Parents are often forced to turn to a nephrologist by the aggravation of the child’s condition (high fever, urinary retention), which indicates the addition of infection.
No specific signs of reflux have been described in adults. In most cases, they are layered on the manifestations of other diseases of the urinary system. Common symptoms include generalized edema, increased thirst, increased diuresis (subject to normal or slightly reduced kidney function), a feeling of bursting and aching pain in the lower back, lower abdomen.
In acute pyelonephritis, turbidity of urine due to pus, the appearance of bloody discharge, an increase in temperature to 39-40 ° C. There may be signs unusual for urinary tract infection: diarrhea, lack of appetite, enuresis, increased nervous excitability, tachycardia.
Complications
The occurrence of reflux, regardless of its etiological factors, is a possible cause of the development of additional pathologies that worsen kidney function and, consequently, the patient’s condition. The most common complications in practice include pyelonephritis, hydronephrosis, renal hypertension, and chronic renal failure. These conditions, despite their different nature, are caused by a single pathogenetic link — a violation of the normal flow of urine.
Stagnant phenomena in the urinary system increase the risk of infectious complications, which lead to a decrease in the flow of oxygenated arterial blood to the kidneys. Hypoxia stimulates the release of biologically active substances by renal cells that constrict blood vessels and cause arterial hypertension.
Diagnostics
Elimination of reflux and its consequences begins with a full-fledged diagnosis, establishment of the cause and degree of pathology. The first and second degrees of regurgitation are detected by urologists accidentally during a preventive examination or during an examination for another disease of the urinary system with similar symptoms. Diagnostics includes:
- Objective examination of the patient. The anamnesis of the patient’s life and illness is collected, the transferred pathologies of the excretory system are clarified to identify the probable etiology of reflux. An examination, palpation of the suprapubic region and the lower back is also performed. It is mandatory for any renal pathology to measure blood pressure to confirm or exclude renal hypertension.
- Laboratory methods. A general urinalysis allows you to detect the presence of erythrocytes, leukocytes, bacteria in the urine, determine the amount of protein, glucose. An increase in the values of ESR, the number of leukocytes when interpreting the data of the general blood test indicates the presence of an inflammatory process in the body. Blood biochemistry allows to identify a low concentration of plasma proteins as a possible cause of edema, as well as to assess kidney function by the level of nitrogenous compounds, creatinine.
- Contrast urography. The pattern of the X-ray contrast substance reveals indirect signs of reflux, the one- or two-sided nature of the process. Radiological markers of PMR are dilated distal sections and knee-shaped bends of the ureters, signs of pyelonephritis or hydronephrosis in combination with narrowing of the ureteral anastomosis. Excretory urography also helps in detecting developmental abnormalities — doubling of the ureter or kidneys.
- Echography of the excretory system. Ultrasound of the kidneys and bladder before and after emptying the bladder helps to assess the size of organs, to identify the irregularity of their contours, the presence of sclerosis, neoplasms, omission, deformation of cavities, increased echogenicity of renal tissue, developmental abnormalities. After urination, the amount of residual urine is assessed to detect urethral stenosis.
- Miction cystography. The technique is the “gold standard” for diagnosing the presence of reverse urine current and determining its degree. The obtained images assess the contour of the bladder, the uniformity of its wall, the vesicoureteral segment is visualized, the presence and level of urine injection with a contrast agent is diagnosed. Also, cystography allows you to identify urethral stenosis as a probable cause of high pressure in the bladder cavity.
Differential diagnosis of vesicoureteral reflux is performed with ureteral stenosis, which gives a similar clinical picture. Urolithiasis, cancer of the uterus and prostate, tuberculosis of the excretory system are also excluded.
Treatment of vesicoureteral reflux
The choice of therapeutic tactics depends on a number of factors: the cause of the disease, gender, age, severity, duration of conservative therapy. If reflux is caused by inflammatory processes of the lower urinary system, then most often the changes correspond to the I-II degree, do not affect the kidneys and make it possible to limit conservative therapy. With timely treatment for help and the absence of organic causes, this type of treatment can eliminate PMR in 60-70% of cases. Conservative reflux therapy includes the following components:
- Diet. Special nutrition increases the excretion of metabolic products and has an anti-inflammatory effect. The patient is recommended to limit the intake of salt to 3 grams per day, significantly or completely exclude fatty dishes, but increase the amount of vegetables, fruits, grains. It is forbidden to drink alcohol, carbonated drinks, strong coffee.
- Medications. In the presence of inflammatory or infectious foci, appropriate medications are indicated — antibiotics, anti-inflammatory, antispasmodic agents. High blood pressure figures require the use of antihypertensive drugs. In order to prevent stagnation in the organs of the excretory system, the patient is recommended to empty the bladder every 2 hours, for which the use of medium-strength diuretics is possible.
- Physical therapy. Additionally, it is possible to use physiotherapy procedures: electrophoresis, magnetic therapy, therapeutic baths. The effect of physical factors helps to eliminate the inflammatory process, spasm of the smooth muscles of the urinary tract, restores the physiological flow of urine. Persons with chronic renal insufficiency developed as a result of pyelonephritis are shown sanatorium treatment.
The absence of significant changes in the condition within six months or its possible deterioration (recurrent pyelonephritis, a decrease in kidney function by 30% or more, a high degree of pathology severity), requires planned surgical intervention in a urological hospital. The basic options for surgical treatment of reflux include:
- Endoscopic correction. At the initial (I-II) stages of the process, endoscopic injection of volume-forming implants that strengthen these structures into the ureteral mouth area is possible. The basis can be collagen, silicone, Teflon, which have a low risk of allergic reactions, strength, biocompatibility.
- Laparoscopic ureterocystoneostomy. It is carried out at III-V degree of PMR. Severe changes in the ureter wall, organic pathology of the sphincter require the creation of a new artificial connection of the ureter with the bladder (ureterocystoanastomosis) and the removal of pathologically altered tissues. It is possible to combine surgery with resection of the distal part of the ureter or kidney transplantation.
Prognosis and prevention
Timely diagnosis of reflux, the appointment of complex treatment gives a positive outcome of therapeutic measures. The addition of complications accompanied by irreversible damage to the kidneys with their insufficient function significantly worsens the prognosis. Specific prevention of this pathology has not been developed. Common measures are timely treatment to doctors with any diseases of the excretory system, reduction of salt intake, prevention of injuries to the back, pelvis, consumption of sufficient fluid, periodic preventive examinations.