Vesicoureteral reflux (Vesicoureteral reflux). Vesicoureteral reflux in children and adults. Symptoms, diagnosis, treatment

Vesicoureteral reflux in urology is not a widespread disease, and is still recorded in 1% of newborns. PMR is found an order of magnitude more often in children than in adults. You need to figure out why it is dangerous, how it manifests itself, and what needs to be done to get rid of the problem.

Vesicoureteral reflux

The bladder is a muscular hollow organ designed to store urine before urination. Three openings open into the bladder - two connect to the ureters, one to the urethra. The ureters are funnel-shaped tubes that enter the bladder at an acute angle and are equipped with valves. The valve system is needed to prevent urine from flowing back into the ureter and kidneys.

Vesicoureteral reflux (VUR, ICD-10 code No. 13.7) is a pathology in which retrograde urine flow from the bladder back into the ureter is observed.

In people with this condition, the mechanism to protect against backflow of urine does not function, so it flows in two directions. The result is stretching and deformation of the ureters. If reflux becomes severe, urine leaks into the kidneys. In the vast majority of cases, VUR is observed in children; it is less common in adults.

Formation of vesicoureteral reflux

Classification

The classification divides the disease into two forms:

1. Primary PMR. It occurs against the background of congenital anomalies in the structure and functioning of the urinary system, and is associated with intrauterine disorders in the development of the ureteric orifice or bladder wall. Found in children.
2. Secondary PMR. Develops due to chronic or acute diseases of the urinary system (usually due to cystitis), as well as after operations. It can occur at any age and is mainly diagnosed in adults.

Another classification identifies the following types of vesicoureteral reflux:

1. Passive. Backflow of urine occurs between and during urination.
2. Active. Urine reflux is observed only during urination.

In most cases, reflux in children is unilateral, but sometimes it occurs on both sides. In adults, bilateral VUR is also rare.

According to the time of occurrence of PMR, it can be as follows:

1. Transitional. It develops only during exacerbation of other diseases of the urinary system (often in women - with cystitis, in men - with prostatitis).
2. Constant. Always present, characteristic of childhood.

Based on the severity of the decline in renal function, the following degrees of the disease are distinguished:

1. PMR 1st degree (moderate) – function drops by 30%.
2. PMR stage 2 (moderate) – function decreases by 60%.
3. PMR grade 3 (severe) – function decreases by more than 60%.

Causes

In children, the primary forms of pathology are congenital. Various anomalies in the development of the nervous system and muscular membrane of the ureter are prerequisites for the appearance of VUR from birth.

The reasons are the following deviations:

• Duplication of the ureter.
• Dystopia of the ureteric orifice (the orifice is located below or above the area where it enters the bladder).
• The intravesical ureteric tunnel is too short.
• Persistent gaping of the ureteral opening in the bladder (it looks like a funnel).
• Protrusion of the bladder wall (paraurethral diverticulum) and incomplete closure of the ureteric orifice.

All these anomalies in children lead to early development incompetence of the ureteral sphincter and the appearance of VUR. If they are mild, reflux may occur later, during adolescence.

In addition to these prerequisites, a disease of nervous etiology – an overactive bladder – can cause PMR in children.

In adults, the causes of the disease almost always lie in past pathologies. genitourinary area. In men, the cause may be prostate adenoma, a benign tumor that compresses the urethra. In women, PMR often develops against the background of chronic cystitis. Urolithiasis can cause reflux in both women and men, because regularly passing stones can injure the ureter and disrupt the transmission of nerve impulses to its valve.

Others possible reasons for secondary vesicoureteral reflux:

• Obstruction of the urethra - its stricture (narrowing), tumor, cyst, proliferation of connective tissue in the urethral area.
• Sclerosis of the bladder neck with thickening of the wall in the area of ​​the ureteric orifice.
• Shrinkage of the bladder.
• Surgeries on the ureters and bladder.
• Other dysfunctions of the urinary system.

Stages and symptoms

Vesicoureteral reflux can occur with to varying degrees gravity.

Objective data, depending on the degree of the disease, will be as follows:

1. First degree. The expansion of the ureter is not visible; urine flows into its pelvic part, and no further.
2. Second degree. Urine reflux occurs along the entire length of the ureter.
3. Third degree. As urine flows back, it reaches the pyelocaliceal apparatus of the kidney, and it expands.
4. Fourth degree. Both the ureter and the renal pelvis are dilated and deformed against the background of VUR.
5. Fifth degree. Kidney function begins to decline.

Stages of vesicoureteral reflux


The clinical picture of vesicoureteral reflux in children is as follows:

• Developmental delay by age;
• Low body weight, head circumference, height;
• Sick, pale appearance of the child;
• Frequent restlessness, crying;
• Abdominal pain up to colic.

Typically, such signs occur if the pathology remains untreated for a long time. Often, parents are forced to see a doctor by an acute condition - elevated temperature body, abdominal pain, malaise, urinary retention. It means joining infectious process– cystitis, pyelonephritis. During an examination in the hospital, the baby is diagnosed with VUR, if this was not done during a routine examination at 1 month.

In adults specific symptoms PMR has not been described. All of them are layered with signs of chronic or acute diseases of the urinary system.

The components of the clinical picture of vesicoureteral reflux in adults include:

• Increased body temperature (up to 39 degrees at acute illness or up to 37.2-37.5 with prolonged low-grade fever);
• Aching pain in the lower abdomen and in the projection of the kidney;
• Bloody discharge in the urine;
• Frequent urge to urinate;
• Feeling of fullness in the bladder;
• Edema;
• Thirst.

With a long course of PMR, it leads to weakness, headaches, and chronic high blood pressure. Some people have dark spots, spots before their eyes, dizziness, and even fainting.

In the video about the causes, symptoms and diagnosis of vesicoureteral reflux:

Diagnostics

The most important method for diagnosing this pathology is cystography. During this procedure, a contrast agent is injected into the bladder through a catheter until the organ is filled. Then an x-ray is taken, the second one is taken directly during urination. This method allows not only to establish the type of PMR, but also to clarify its degree. Cystography also helps to identify the cause of reflux (for example, ureteral stricture, etc.).

Additionally, children and adults may be prescribed:

1. Intravenous.
2. and bladder.
3. Cystoscopy.
4. or MRI.
5. General urine analysis.
6. Biochemistry of urine.
7. Blood test for kidney parameters.
8. Urine culture.

It is advisable to perform urine tests if you suspect inflammatory process. Outside of inflammation, they do not show any abnormalities.

Treatment

At the initial stage, wait-and-see tactics are most often used. A sick child or adult is regularly examined by a urologist, and cystoscopy is performed to assess the dynamics of reflux. If the pathology progresses, surgery is usually recommended.

There are no special restrictions on diet and lifestyle, but if kidney function is impaired, you should follow a diet with limited fluid, salt, and protein.

Conservative treatment helps relieve inflammation and slow down the progression of pathology. For girls and women, treatment is carried out together with a gynecologist.

Medication

After the course drug therapy 70% of adults experience improvement. In children with primary VUR, this figure is lower.

Treatment may include the following types of drugs:

1. Antibiotics - penicillins (Amoxiclav), cephalosporins (Cefuroxime, Cefixime).
2. Uroantiseptics (after a course of antibiotics) – Nitrofurantoin, Nalidixic acid, Co-trimoxazole.
3. Intravesical installations with silver solutions, Hydrocortisone, Solcoseryl, Chlorhexidine.

If the cause of vesicoureteral reflux in a child lies in a neurogenic (overactive) bladder, additional treatment methods are prescribed by a neurologist. In parallel with conservative therapy, the patient is recommended to undergo forced urination (every 2 hours), baths with sea salt, and electrophoresis. If hypertension develops, antihypertensive drugs are prescribed. Treatment in childhood usually performed in a hospital, in adults - on an outpatient basis.

Surgical

The operation is prescribed in the following cases:

• Lack of effect from medications and other types of conservative therapy.
• Serious decline in kidney function.
• 3-5 degree of vesicoureteral reflux.
• Frequent relapses of cystitis and.
• Congenital anomalies of the structure of the urinary system.

The purpose of the operation is to eliminate the reverse reflux of urine by forming a new sphincter. There are several surgical and endoscopic techniques, the choice will depend entirely on the severity of the pathology, its form and the presence of additional anomalies and dysfunctions. Most often, a new valve is made in the form of a fold of the bladder, which will prevent urine from flowing back into the ureter.

The best method, many experts consider installation artificial valve, but this operation has a high cost. Endoscopic correction is possible for grades 1-3 of VUR, taking into account the preservation of contractile activity of the ureteral orifice. Open operations done for grade 4-5 pathology and in the presence of severe anomalies in the structure of organs in children.
Endoscopic injection correction PMR:

Prognosis and possible complications

Without treatment, a number of complications develop - acute and chronic pyelonephritis, hydronephrosis, urolithiasis, etc. In children, PMR is the most common cause of secondary kidney shrinkage, disruption of its function and development.

If the pathology is detected in a timely manner, the prognosis is positive. 20-40% of children have the disease initial stages goes away on its own with age, but scar changes it can remain in the tissues. At 3 or more stages of PMR without treatment it threatens with the consequences described above. The operation gives excellent results - up to 75-98% of children and adults make a full recovery.

Vesicoureteral reflux (VUR) is the return flow of urine from the bladder through the ureter into the kidney. Normally, urine moves unidirectionally from the kidney through the ureter to the bladder, and the return flow of urine is prevented by a valve formed by the vesical section of the ureter. When the bladder fills, the pressure in it increases, which leads to the closure of the valve. With reflux, the valve is damaged or weakened, causing urine to flow back toward the kidney. Approximately 20% of children with a urinary tract infection are diagnosed with vesicoureteral reflux.

Why is vesicoureteral reflux dangerous?

In children, PMR is the most common reason secondary renal shrinkage and renal dysfunction. Reflux interferes with the removal of penetrating urinary tract microflora, leading to chronic inflammation of the kidneys (pyelonephritis). In addition, when urinating, the pressure in the renal pelvis increases sharply, causing damage to the kidney tissue. The outcome chronic inflammation occurring against the background of impaired urine outflow is scarring of the kidney tissue with loss of kidney function (secondary kidney shrinkage, nephrosclerosis). Scarring of the kidney is often accompanied by persistent high blood pressure, difficult to respond to conservative therapy, which necessitates kidney removal.

What are the causes of PMR?

There are several main factors leading to dysfunction of the valve in lower section ureter. High blood pressure in the bladder, together with insufficient fixation of the ureteric orifice, are accompanied by shortening of the valve section of the ureter and the occurrence of VUR. Chronic cystitis(inflammation) disrupts the elasticity of the tissues at the mouth of the ureter, contributing to the disruption of valve closure. A special place among the causes of VUR is occupied by congenital anomalies cystic ureter, including various options violations of the anatomy of the ureterovesical junction.

How does PMR manifest?

The attack of acute pyelonephritis is the first clinical manifestation the presence of vesicoureteral reflux in most children. The disease begins with an increase in temperature above 38.0 without catarrhal symptoms. In urine tests, the number of leukocytes and the amount of protein increase. Blood tests also determine high level leukocytes. increase in ESR. Children with acute pyelonephritis are referred to hospital treatment, after which a urological examination is usually carried out. Occasionally there are complaints of pain in the abdomen or lumbar region side of the lesion. In newborns, suspicion of reflux most often arises when dilation of the pelvis (pyelectasia) is detected according to ultrasound.

How is the diagnosis made?

The main method for diagnosing VUR is voiding cystography: A 15-20% solution of a radiopaque substance is injected into the bladder through a catheter passed through the urethra until the urge to urinate appears. 2 x-rays are taken: the first - immediately after filling the bladder, the second - during urination. Based on cystography, PMR is divided into grades from 1 to 5 grades (Fig. 1). The criteria are the level of urine reflux and the severity of dilatation of the ureter. The mildest is the first degree, and the most severe is the 5th degree of reflux.

Figure 1. Degrees of vesicoureteral reflux.

Refluxes detected by cystography are also divided into active(during urination) and passive(outside urination with low bladder pressure). In addition to detecting reflux and determining its degree, cystography allows you to obtain important information about the patency of the urethra, and suspect bladder dysfunction. Vesicoureteral reflux, which appears from time to time, is called transient .

What other methods are used for examination?

Additional information about the condition of the urinary organs in children with VUR allow you to obtain intravenous urography, bladder function testing (urodynamic study), cystoscopy and lab tests. Kidney function is determined based on radioisotope studies (nephroscintigraphy). As a result of these studies, refluxes are further divided into primary(pathology of the ureteric orifice) and secondary. caused by inflammation and increased pressure in the bladder.

How is secondary reflux treated?

In case of secondary VUR, the diseases leading to its occurrence are treated (treatment of cystitis, bladder dysfunction, restoration of urethral patency). The probability of disappearance of secondary reflux after eliminating the cause ranges from 20 to 70%, depending on the disease. Less commonly, “self-healing” of secondary VUR occurs in congenital pathology. Often, even after eliminating the cause, secondary reflux persists, then treatment is carried out operational methods.

How is primary VUR treated?

At primary refluxes arising against the background of pathology of the ureteric orifice are performed surgical or endoscopic operations, aimed at restoring the valve function of the ureter. Surgical operations are more difficult for children to carry and are performed on an open bladder. Endoscopic operations are much easier and safer for the child and are performed during cystoscopy through the urethra.

How is the reflux treatment method chosen?

With both surgical and endoscopic treatment, good treatment results can be obtained. However, in practice, treatment results in different clinics vary significantly. As a rule, the surgeon uses the method that he is better at and which allows him to obtain acceptable treatment results. IN Russian healthcare the choice of surgical method is determined by the guidelines adopted in a given institution. Nephrologists are less likely to refer patients for surgical treatment, observing children and conducting antibacterial treatment and infection prevention. It should be noted that this approach is justified with low degrees of reflux and the absence of urinary tract infection.

Can primary VUR go away without surgery?

If primary reflux is not treated with surgical methods, then over the years it can disappear on its own in 10-50% of cases, however, during this time, changes occur in the kidney irreversible changes. The higher the degree of reflux, the lower the likelihood of its self-healing. The disappearance of stage 1 reflux is most likely, therefore, with PMR stage 1. operations are usually not performed. Self-healing of grade 3-5 reflux is unlikely - therefore they are subject to surgical treatment. Reflux of the 2nd degree and transient reflux are operated on for recurrent pyelonephritis. The method of choice is endoscopic.

How urgent is it to treat VUR?

Absolutely shown surgical treatment reflux endoscopic or surgical method, regardless of the degree and age of the patient, with recurrent acute pyelonephritis. Reflux of 3-5 degrees without exacerbations of pyelonephritis is also, as a rule, treated with surgical methods. Sterile reflux of 1-3 degrees without inflammatory changes in urine tests can be left under observation.

What is the principle of surgical treatment of VUR?

Until now, most urology departments carry out surgery vesicoureteral reflux. Operations are performed on an open bladder. The goal of antireflux surgery is to create a tunnel under the mucous membrane of the bladder, into which a section of the ureter is placed. In this case, the urine filling the bladder presses the elastic upper wall of the ureter to the lower one, preventing the penetration of urine from the bladder into the ureter.

What are the disadvantages of surgical treatment for VUR?

Various surgical techniques in different hands allow us to achieve positive results in 75 - 98% of cases. Disadvantages: traumatic, prolonged anesthesia, long postoperative period. When reflux recurs, reoperations are difficult and have a higher risk of failure.

What is endoscopic treatment for VUR?

The essence of the method is to restore the impaired anti-reflux function of the ureter by introducing collagen protein or an inert paste (“indifferent” to human tissue) under its outlet section (Fig. 2). The polymer forms a tubercle that presses the lower wall of the ureter to the upper, restoring valve function.

Rice. 2 Endoscopic implantation of polymer under the orifice of the ureter.

How is endoscopic treatment performed?

The intervention is carried out during cystoscopy, under short-term inhalation (mask) or intravenous anesthesia. Modern pediatric operating cystoscopes from the company and special needles are used. The duration of the procedure is 10-15 minutes. After 1-3 hours the patient’s condition returns to normal. After 2-4 days, children are discharged for outpatient observation. Before discharge, antibacterial prophylaxis for urinary infection is carried out. Follow-up examination - after 3-6 months.

What are the benefits of endoscopic treatment?

Advantages endoscopic operations with reflux are obvious: low trauma, short hospital period, minimal risk complications. If high efficiency is achieved (at least 70-80% of permanent cure after the first procedure), then the advantages of endoscopic treatment are undeniable. At the same time, with low efficiency, the number of repeated interventions and anesthesia increases, which reduces the feasibility of using the method, so surgical treatment of reflux remains relevant. It should be noted that an incorrectly performed primary endoscopic procedure sharply reduces the effectiveness of treatment, since the orifice of the ureter is fixed in a disadvantageous position.

What determines the results of endoscopic treatment?

The method has many technical nuances, so the results of its application vary significantly. Cure after one endoscopic procedure ranges from 25 to 95%. and the final treatment results in different hands range from 40 to 97%. More reliable results were obtained when using non-absorbable pastes - Teflon, Deflux, Dam+. top scores marked at. primary procedures, low-grade reflux, the absence of gross anomalies of the ureteric orifice and bladder pathology.

What are your own results of endoscopic treatment of VUR?