Clinical presentation, diagnosis, and course of primary vesicoureteral reflux
- Tej K Mattoo, MD, DCH, FRCP
Tej K Mattoo, MD, DCH, FRCP
- Section Editor — Pediatric Nephrology
- Professor of Pediatrics
- Wayne State University School of Medicine
- Saul P Greenfield, MD
Saul P Greenfield, MD
- Clinical Professor of Urology, State University of New York at Buffalo School of Medicine & Biomedical Sciences
- Director of Pediatric Urology, Children’s Hospital of Buffalo
- Section Editors
- Laurence S Baskin, MD, FAAP
Laurence S Baskin, MD, FAAP
- Section Editor — Pediatric Urology
- Frank Hinman, Jr., MD, Distinguished Professorship in Pediatric Urology
- Chief Pediatric Urology
- Professor of Urology and Pediatrics
- UCSF Benioff Children's Hospital
- F Bruder Stapleton, MD
F Bruder Stapleton, MD
- Editor-in-Chief — Pediatrics
- Section Editor — Pediatric Nephrology
- Professor and Chair, Department of Pediatrics
- University of Washington School of Medicine
Vesicoureteral reflux (VUR) is the retrograde passage of urine from the bladder into the upper urinary tract. The clinical significance of VUR has been based on the premise that VUR predisposes patients to acute pyelonephritis by transporting bacteria from the bladder to the kidney and recurrent urinary tract infection, which may lead to renal scarring, hypertension, and end-stage renal disease (ESRD). However, aspects of this long-held belief have been increasingly questioned. As a result, the clinical impact of VUR and its management remain uncertain and controversial.
The presentation, diagnosis, and clinical course of primary VUR will be reviewed here. The management of primary VUR is discussed elsewhere in the program. (See "Management of vesicoureteral reflux".)
DEFINITION AND PATHOGENESIS
VUR is the retrograde passage of urine from the bladder into the upper urinary tract. It is divided into two categories: primary and secondary based on the underlying pathogenesis.
Primary VUR — Primary VUR, the most common form of reflux, is due to incompetent or inadequate closure of the ureterovesical junction (UVJ), which contains a segment of the ureter within the bladder wall (intravesical ureter). Normally, reflux is prevented during bladder contraction by fully compressing the intravesical ureter and sealing it off with the surrounding bladder muscles.
In primary VUR, failure of this anti-reflux mechanism is due to a congenitally short intravesical ureter (figure 1). The intravesical ureter length may be genetically determined, which may explain the increased incidence in family members of patients with VUR.
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- DEFINITION AND PATHOGENESIS
- Primary VUR
- Secondary VUR
- CLINICAL PRESENTATION
- Prenatal presentation
- Postnatal presentation
- Diagnostic approach
- - Prenatal presentation
- - Postnatal presentation
- - VCUG versus RNC
- - Grading
- - Other imaging modalities
- Indirect lab tests: Not clinically useful
- FURTHER EVALUATION
- Index patient
- Screening of family members
- PROGNOSIS AND COMPLICATIONS
- Likelihood of resolution
- Recurrent urinary tract infection
- Loss of renal parenchyma
- - Renal scarring
- - Congenital renal hypodysplasia
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS