Does your little one have frequent urinary problems? This could be Vesicoureteral Reflux (VUR)!

Moms and dads, does your little one get frequent urinary tract infections (UTIs)? Or does he have difficulty urinating , or does he have a fever? Sometimes the cause of this can be a condition that we don't talk about much, but it's worth knowing about. Today, let's talk about this condition called Vesicoureteral Reflux , or VUR for short. Don't worry, this is something that can be completely cured in most cases if it is properly understood and treated on time.

What is Vesicoureteral Reflux (VUR)? Let's understand it very simply.

Simply put, VUR means that our urine , that is, urine, flows in the wrong direction. Think of it this way, as it should. Our body's urinary system works like a one-way street.

Here's how it happens:

• Our kidneys produce urine. We usually have two kidneys.
• Then, this urine travels down two thin tubes called ureters and collects in the bladder . The bladder is like a balloon that expands to collect urine .
• When we urinate , the urine collected in the bladder leaves the body through another tube called the urethra .

Do you understand now? This is like water coming from a water tank through a pipe and coming out of a tap. The important thing is that the ureters, where they connect to the bladder, act like a one-way valve . That is, once the urine reaches the bladder, it is not allowed to go back up, that is, along the ureters to the kidneys.

However, in someone with VUR, there's a slight problem with this process. Because that valve doesn't work properly, urine in the bladder flows back up, into one or both ureters, and sometimes all the way to the kidneys. This is what we call reflux .

This condition is most common in newborns, infants a few months old, and children up to about two years of age . However, it can also occur in older children and, very rarely, adults.

The most important thing is that when urine flows backward like this, bacteria in the bladder can travel to the kidneys and cause kidney infections . If these kidney infections are not treated properly, they can cause permanent damage to the kidneys. That's why it's important to be aware of VUR.

But don't worry. There are treatments for VUR. Treatment depends on the child's age, the nature of the symptoms, and the severity of the VUR. Some mild cases don't need treatment and will get better on their own as the child grows older. But some children may need medication or surgery to stop the damage to their kidneys.

Are there types of VUR?

Yes, there are two main types of VUR.

• Primary VUR: This is the most common type. Most of the time, it affects only one side of the urethra and kidney (this is called unilateral reflux ). In primary VUR, there is a small defect at the point where the urethra connects to the bladder at birth. The valve we talked about doesn't close properly, so urine flows backward.
• Secondary VUR: This is caused by a blockage somewhere in the urinary system. For example, a blockage in the urethra can cause the urine to flow backward, causing pressure inside the bladder to build up. Or, it can be caused by a problem with the nerves in the bladder that prevents it from contracting properly and causing urine to flow backward. Children with secondary VUR often have both ureters and kidneys affected (this is called bilateral reflux ).

How is the severity (stage) of VUR determined? (Grades of VUR)

There are five stages, or grades, of how severe VUR is. Grade 1 is the least severe, and Grade 5 is the most severe. This grade determines:

• How far urine flows up and down the urinary system.
• How wide or swollen the urethra is.

Here are those five stages:

• Grade 1: Urine flows backward into the urethra, but the urethra is of normal width.
• Grade 2: Urine flows backward along the ureter until it reaches the first part of the kidney where urine collects (kidney pelvis) . However, neither the ureter nor that part of the kidney has become enlarged.
• Grade 3: The ureters, kidney pelvis, and calyces (the area where urine begins to collect in the bladder) are slightly enlarged due to backward flow of urine .
• Grade 4: The ureters are twisted and slightly dilated because a lot of urine is flowing backward. Those parts of the kidney are also slightly dilated.
• Grade 5: The ureters are severely deformed and enlarged due to excessive backward flow of urine . The collecting ducts of the kidneys are also very large.

How common is VUR?

If you look around the world,It is estimated that between 1% and 3% of children have VUR. Furthermore, only 75% of children with VUR are girls .

What are the symptoms of VUR?

Most of the time, a child with VUR will not show any symptoms. However, if symptoms do occur, the most common symptom is a urinary tract infection (UTI) . Some reports suggest that between 30% and 50% of children who develop a UTI may have VUR!

If a child has a UTI, look for symptoms like these:

• The need to urinate frequently.
• Burning and pain when urinating .
• Flank pain is pain in the abdomen or lower back (side of the abdomen).
• Only a few drops of urine .
• The color of the urine has changed, becoming dark brown and having a bad odor.
• The body becomes hot and feverish.

However, it can be a little difficult to tell if a breastfed baby has a UTI. They may just cry a lot, not drink, or act fussy.

Is VUR painful?

No, VUR itself is not painful. However, if VUR causes a UTI, then you may experience pain when urinating , kidney/abdominal pain.

What causes VUR?

The two types of VUR we discussed earlier, primary VUR and secondary VUR, have different causes.

• Primary VUR: This is caused by a congenital defect in the valve between the ureter and the bladder. It doesn't close properly, allowing urine to flow backward into the kidneys. The good news is that as the child grows older, as the body's organs mature, this valve will begin to close properly, and primary VUR can usually get better on its own.
• Secondary VUR: The main cause of this is a blockage or narrowing of the bladder neck or urethra. This problem causes urine to flow backward up the urinary tract instead of out. Or, the nerves that control the bladder may not be working properly. This problem causes the bladder to contract and relax, preventing urine from being released. In secondary VUR, bilateral VUR is more common.

What are the risk factors for this condition?

There are some risk factors that can affect the development of VUR:

• Genetics: VUR tends to run in families. If one child in the family has VUR, there is a slightly greater than one in four chance that a brother or sister will also develop VUR. If either parent had VUR as a child, there is a roughly one in three chance that the child will also develop VUR.
• Birth disorders:Children with congenital abnormalities of the kidneys or urinary system are more likely to develop VUR.
• Bladder and bowel dysfunction (BBD): Children with BBD have trouble urinating and defecating properly. This is often caused by problems with the muscles or nerves.
• Race and sex: White, female children are said to be more likely to develop VUR (but it can happen to any child).

What are the possible complications of VUR?

Children with VUR may develop complications such as:

• Urinary tract infections (UTIs): Bladder infections, including kidney infections.
• Bladder problems: urinary incontinence, bedwetting , urinary retention.
• High blood pressure.
• Kidney scarring, kidney damage (e.g., nephrotic syndrome), and rarely, chronic kidney failure.

But remember, most children with VUR recover without long-term complications. So it's important not to panic and follow your doctor's instructions.

How does VUR develop in adults? (This is not just for young children)

Although rare, adults can also develop VUR. Possible causes include:

• Enlargement of the prostate gland (`Benign prostate hyperplasia` - for men)
• Bladder dysfunction due to nerve damage (`Neurogenic bladder`)
• A surgery performed on the ureters.

Can VUR cause kidney stones?

Yes, VUR can cause kidney stones. It can also cause stones to form in other parts of the urinary system, such as the bladder.

Is VUR life-threatening?

VUR itself is not life-threatening. However, VUR can cause frequent urinary tract infections (UTIs), which can lead to kidney damage, and over time, kidney disease can lead to high blood pressure (renal hypertension) and kidney disease. If you develop end-stage kidney disease, you may need dialysis or a kidney transplant. That's why you should be concerned about VUR.

How do you diagnose VUR? (Diagnosis)

If your child is suspected to have VUR, your pediatrician will refer you to either a pediatric nephrologist or a pediatric urologist .

To accurately determine whether you have VUR, you can do the following tests:

• Voiding Cystourethrogram (VCUG): This is an X-ray test. A small, thin tube (catheter) is inserted into the child's urethra and a special dye is poured into the bladder. Then, X-rays are taken while the child urinates , before and after urination . These X-rays show whether urine flows back from the bladder into the urethra. This can be done in a doctor's office, outpatient clinic, or hospital. Anesthesia is not required, but some children may be given medicine to help them relax.
• Ultrasound scan: This is a painless, safe test. It uses sound waves to take pictures of your baby's entire urinary system (including the kidneys and bladder). This is also done in a doctor's office, outpatient department, or hospital. If you want to avoid exposure to X-rays or radioactive materials, you may want to have an ultrasound before the VCUG. Remember, sometimes an ultrasound scan during pregnancy can show signs that your baby may have VUR (such as swollen kidneys).
• Dimercaptosuccinic acid (DMSA) scan: This checks to see if the child's kidneys have been damaged by the UTI.
• Radionuclide cystogram (RNC): This is also a type of nuclear scan. A small amount of radioactive material is placed in the child's bladder. Then, either when the child urinates or after the bladder is empty, a scanner looks for the radioactive material. This is also done by a specially trained technician, and a radiologist analyzes the images. This also does not require anesthesia, but some children may be given medicine to help them relax. RNC is more sensitive than VCUG, but it does not provide as much detail about the structure of the bladder.

What other tests should be done for children with VUR?

If your child is confirmed to have VUR, these tests will be done regularly:

• Checking blood pressure: Children with kidney problems are more likely to have high blood pressure.
• Blood tests: High levels of protein or creatinine in the blood are a sign of kidney damage.
• Urine tests and culture: Protein in the urine is a sign of kidney damage. Bacteria in the urine is a sign of infection.

Your child's doctor will also check for bladder and bowel dysfunction (BBD) . Symptoms of BBD include:

• Frequent, urgent need to urinate .
• I rarely go to urinate , and it's been a long time.
• Daytime wetting .
• Constipation - having bowel movements less than three times a week.
• Inability to control stool (Fecal incontinence).

Children who have symptoms of BBD along with VUR are at increased risk of kidney damage due to infections.

How is VUR treated?

Treating VUR requires the help of a doctor. Treatment depends on your child's age, symptoms, the type of VUR, and its severity. Treatment options include antibiotics and other medications, an injection of a soluble filler, short-term catheterization, and surgery. You, your pediatrician, and other specialists will discuss these treatment options and choose the one that's best for your child.

Treatment of Primary VUR

Primary VUR may get better on its own as the child gets older (usually around age 5). Sometimes, a "wait-and-see" approach is successful. But other times, surgery or medication is needed.

Medications

Primary VUR often gets better as your child gets older and their urinary system matures. Until then, your doctor will prescribe an antibiotic to either prevent a UTI from occurring or to treat it if it does occur.

There are mixed opinions about giving antibiotics long-term to prevent UTIs. This is because long-term use of antibiotics can lead to antibiotic resistance in bacteria. The American Academy of Pediatrics (AAP) recommends that preventive antibiotics be given only to children with higher grades of VUR (while they wait for their VUR to grow out of their old age).

Surgery

Doctors use a variety of surgical procedures to treat primary VUR. The main goal of surgery is to repair the one-way valve (the one-way valve) at the junction between the bladder and urethra, preventing urine from flowing backward.

• Ureteral reimplantation: This is considered the "gold standard" of surgery for VUR. The goal is to reposition the ureter so that it passes through a tunnel of the appropriate length through the bladder wall, creating a valve that prevents urine from flowing backward. Your child's surgeon can perform this surgery either as an open surgery (through an incision in your child's abdomen) or laparoscopically (through just a few small incisions). Your surgeon will explain the advantages and disadvantages of each method, as well as possible side effects. The surgery requires general anesthesia , and you may need to stay in the hospital for a few days.

• Injectable bulking agent: Another treatment option for primary VUR isUsing a gel-like liquid called hyaluronic acid/dextranomer (Deflux®) . Your child’s doctor will inject a small amount of this into the wall of your child’s bladder, near the entrance to the urethra. The injection causes the tissue there to swell, acting like a valve and making it difficult for urine to flow back up. This is done on an outpatient basis (your child can go home the same day), but it also requires general anesthesia. Your doctor will talk to you about the pros and cons of this treatment.

Treatment of Secondary VUR

Secondary VUR is treated by either removing the blockage or improving the way the bladder empties. Treatments may include:

• Surgery to remove an obstruction or to repair an irregularly shaped bladder or urethra.
• Giving antibiotics to prevent or treat a UTI.
• Intermittent catheterization: This involves inserting a thin tube through the urethra into the bladder to empty the bladder.
• Medicine for the bladder muscles.

What happens if my child has VUR?

If your child is diagnosed with VUR, work closely with your medical team to develop a treatment plan that works for your family. Managing a condition like VUR can be overwhelming for you and your other caregivers. Talk to your child's medical team about your concerns and questions. The good news is that VUR is largely treatable, and for most children, it doesn't have any long-term effects.

How long does VUR last? / Does VUR decrease with age?

Your child may have VUR for less than a year, but there is no exact time frame, as it varies depending on the child's condition. Sometimes your doctor will recommend a "watchful waiting" approach, or surgery if tests show severe VUR or kidney damage.

Yes, your child can grow out of VUR, especially if the initial VUR is low grade (grade one or two). Children with this condition can usually recover on their own within a few years.

Can a child with VUR go to school?

It depends on the severity of your child's symptoms. Remember, VUR itself is not a problem for your child's daily life, but it can be a problem if a UTI develops. Your child may have pain, constipation, or incontinence . Talk to your doctor about sending your child to school or playing with friends.

Is there a way to prevent VUR?

There is no known way to prevent VUR - not through diet, lifestyle changes, or medication. However, your child'sThere are things you can do to maintain good overall urinary system health:

• Giving the child enough water to drink .
• Changing the diaper quickly after the child has urinated or pooped.
• Encouraging the child to urinate frequently, not "holding it in."
• Seek treatment for problems such as constipation, incontinence, or incontinence as soon as possible.

It is also important to encourage exercise and provide balanced, nutritious meals to keep your child healthy.

When should I see a doctor about VUR?

If you suspect a UTI (which is often the first sign of VUR), see your child's pediatrician right away. Symptoms like urinary incontinence, unexplained fever, and pain when urinating can also indicate VUR. If your pediatrician suspects VUR, he or she will refer you to a specialist.

What questions should you ask the doctor?

Talk to your child's doctor to get answers to any questions you have about VUR. Here are some questions you can ask:

• Will my child's primary VUR get better without treatment?
• Does my child also have kidney problems?
• Should I see a specialist?
• How do you treat my child's VUR?
• What are the possible consequences of leaving VUR untreated?
• What can I do at home to help my child's condition improve?
• Will this condition cause my child pain?
• How do I know if VUR is affecting other organs or body functions?
• How can you prevent a urinary tract infection?
• Should my other children be tested for VUR?

Finally, what to remember (Take-Home Message)

VUR is not usually painful or life-threatening. It can be managed, and treatment is often successful. While there is no way to prevent it, you can help your child stay hydrated, exercise, and eat a nutritious diet to maintain their overall health. Trust your doctor’s expertise. They can help you diagnose and treat your child’s VUR. Don’t hesitate to talk to them about your questions and concerns. Be open and honest about your child’s symptoms, even if they are difficult to talk about. Your awareness and following your doctor’s advice are the best way to help your child get better.

` Vesicoureteral reflux, VUR, urinary tract infection, pediatric urinary tract disease, urinary tract infection, UTI, kidney infection, child health