eMedicine Specialties > Radiology > Pediatrics

Vesicoureteral Reflux: Multimedia

Author: Kevin F McCarthy, MD, Staff Physician, Department of Radiology, National Naval Medical Center
Coauthor(s): Veronica Rooks, MD, Military Chief of Pediatric Radiology, Pediatric Radiologist, Tripler Army Medical Center; Assistant Professor of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences
Contributor Information and Disclosures

Updated: Nov 12, 2009

Multimedia

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Media file 1: Transverse gray-scale sonogram demonstrates a small left ureterocele in a patient with a low-grade vesicoureteral reflux. Ultrasonography may be the most helpful means to evaluate a patient for a ureterocele, as this is often difficult to visualize on early filling of the bladder during voiding cystourethrography. Patients with gross anatomic abnormalities of the urinary tract are not likely to improve without corrective surgery. In this case, the ureterocele measured less than 1 cm in all dimensions and appeared intermittently throughout the examination.

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Transverse gray-scale sonogram demonstrates a small left ureterocele in a patient with a low-grade vesicoureteral reflux. Ultrasonography may be the most helpful means to evaluate a patient for a ureterocele, as this is often difficult to visualize on early filling of the bladder during voiding cystourethrography. Patients with gross anatomic abnormalities of the urinary tract are not likely to improve without corrective surgery. In this case, the ureterocele measured less than 1 cm in all dimensions and appeared intermittently throughout the examination.

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Media file 2: Sonogram of a large, obstructing ureterocele in a patient with vesicoureteral reflux. The thin rim of the ureterocele is best noted on the inferior most aspect of the bladder. This ureterocele measured 4 cm in greatest dimension and is outlined by contrast material in Image 4. Note the dilated, left-sided refluxing ureter.

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Sonogram of a large, obstructing ureterocele in a patient with vesicoureteral reflux. The thin rim of the ureterocele is best noted on the inferior most aspect of the bladder. This ureterocele measured 4 cm in greatest dimension and is outlined by contrast material in Image 4. Note the dilated, left-sided refluxing ureter.

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Media file 3: Voiding cystourethrogram (VCUG) demonstrates a large, smooth, central filling defect peripherally outlined by contrast material. The catheter is deviated to the patient's right. This finding is consistent with a large ureterocele.

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Voiding cystourethrogram (VCUG) demonstrates a large, smooth, central filling defect peripherally outlined by contrast material. The catheter is deviated to the patient's right. This finding is consistent with a large ureterocele.

(Enlarge Image)

Media file 4: Excretory urogram demonstrates the classic cobra-head appearance of a ureterocele.

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Excretory urogram demonstrates the classic cobra-head appearance of a ureterocele.

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Media file 5: Voiding cystourethrogram (VCUG) demonstrates a posterior urethral valve.

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Voiding cystourethrogram (VCUG) demonstrates a posterior urethral valve.

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Media file 6: Voiding cystourethrogram (VCUG) shows grade I left VUR. Incidentally noted is vaginal reflux.

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Voiding cystourethrogram (VCUG) shows grade I left VUR. Incidentally noted is vaginal reflux.

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Media file 7: Voiding cystourethrogram (VCUG) demonstrates grade II VUR into the upper-pole moiety of a duplex collecting system and grade III VUR to the lower-pole moiety.

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Voiding cystourethrogram (VCUG) demonstrates grade II VUR into the upper-pole moiety of a duplex collecting system and grade III VUR to the lower-pole moiety.

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Media file 8: Grade II vesicoureteral reflux in a patient with ureteral duplication.

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Grade II vesicoureteral reflux in a patient with ureteral duplication.

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Media file 9: Voiding cystourethrogram (VCUG) demonstrates bilateral grade III reflux. The renal pelvis is mildly dilated on the right. There is some mild blunting of the calyceal fornices and loss of papillary impressions in the upper poles bilaterally.

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Voiding cystourethrogram (VCUG) demonstrates bilateral grade III reflux. The renal pelvis is mildly dilated on the right. There is some mild blunting of the calyceal fornices and loss of papillary impressions in the upper poles bilaterally.

(Enlarge Image)

Media file 10: Voiding cystourethrogram (VCUG) of lower ureter and ureterovesical junction in a patient with grade III reflux. The ureteral insertion on the left is between the 3- and 6-o'clock positions. There is a small bladder diverticulum at the ureteral insertion.

[ CLOSE WINDOW ]

Voiding cystourethrogram (VCUG) of lower ureter and ureterovesical junction in a patient with grade III reflux. The ureteral insertion on the left is between the 3- and 6-o'clock positions. There is a small bladder diverticulum at the ureteral insertion.

(Enlarge Image)

Media file 11: Voiding cystourethrogram (VCUG)demonstrates bilateral grade III vesicoureteral reflux.

[ CLOSE WINDOW ]

Voiding cystourethrogram (VCUG)demonstrates bilateral grade III vesicoureteral reflux.

(Enlarge Image)

Media file 12: Longitudinal sonogram corresponding to a voiding cystourethrogram (VCUG) of a grade III vesicoureteral reflux. Note the mild pelviectasis. The degree of pelviectasis or caliectasis does not correlate with the degree of reflux seen on the VCUG.

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Longitudinal sonogram corresponding to a voiding cystourethrogram (VCUG) of a grade III vesicoureteral reflux. Note the mild pelviectasis. The degree of pelviectasis or caliectasis does not correlate with the degree of reflux seen on the VCUG.

(Enlarge Image)

Media file 13: Voiding cystourethrogram (VCUG) demonstrates high-grade IV vesicoureteral reflux in a patient with a duplicated collecting system.

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Voiding cystourethrogram (VCUG) demonstrates high-grade IV vesicoureteral reflux in a patient with a duplicated collecting system.

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Media file 14: Grade III vesicoureteral reflux and periureteral-type diverticulum.

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Grade III vesicoureteral reflux and periureteral-type diverticulum.

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Media file 15: Voiding cystourethrogram (VCUG) of the left kidney demonstrates grade V vesicoureteral reflux.

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Voiding cystourethrogram (VCUG) of the left kidney demonstrates grade V vesicoureteral reflux.

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Media file 16: Voiding cystourethrogram (VCUG) demonstrates a tortuous, dilated ureter in a patient with grade V vesicoureteral reflux.

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Voiding cystourethrogram (VCUG) demonstrates a tortuous, dilated ureter in a patient with grade V vesicoureteral reflux.

(Enlarge Image)

Media file 17: Unilateral grade V vesicoureteral reflux secondary to a posterior urethral valve. There is gross dilatation of the renal pelvis and calyces. Papillary impressions are not visible. Gross intrarenal reflux is also identified.

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Unilateral grade V vesicoureteral reflux secondary to a posterior urethral valve. There is gross dilatation of the renal pelvis and calyces. Papillary impressions are not visible. Gross intrarenal reflux is also identified.

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Media file 18: Nuclear cystograms demonstrate grade III reflux. Reflux to the left kidney is shown, with dilatation of the renal pelvis.

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Nuclear cystograms demonstrate grade III reflux. Reflux to the left kidney is shown, with dilatation of the renal pelvis.

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Media file 19: Dimercaptosuccinic acid (DMSA) scans demonstrate photopenia at the right superior pole consistent with scarring in this patient with vesicoureteral reflux.

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Dimercaptosuccinic acid (DMSA) scans demonstrate photopenia at the right superior pole consistent with scarring in this patient with vesicoureteral reflux.

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Media file 20: Nonenhanced CT scan at a level just above ureteral insertion demonstrates bilateral, markedly dilated ureters in a patient with grade V vesicoureteral reflux.

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Nonenhanced CT scan at a level just above ureteral insertion demonstrates bilateral, markedly dilated ureters in a patient with grade V vesicoureteral reflux.

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Media file 21: Nonenhanced CT scan in a 12-year-old boy demonstrates marked hydronephrosis and cortical thinning in a patient with grade V vesicoureteral reflux and a history of a posterior urethral valve. Note the free fluid in the pararenal space consistent with forniceal rupture after minor trauma to the abdomen (from football practice).

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Nonenhanced CT scan in a 12-year-old boy demonstrates marked hydronephrosis and cortical thinning in a patient with grade V vesicoureteral reflux and a history of a posterior urethral valve. Note the free fluid in the pararenal space consistent with forniceal rupture after minor trauma to the abdomen (from football practice).

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Media file 22: Sagittal sonogram of the bladder. A Foley catheter is surrounded by thickened, hypertrophied bladder wall, the sequelae of posterior urethral valves in this boy with bilateral grade V vesicoureteral reflux. Note the dilated right ureter.

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Sagittal sonogram of the bladder. A Foley catheter is surrounded by thickened, hypertrophied bladder wall, the sequelae of posterior urethral valves in this boy with bilateral grade V vesicoureteral reflux. Note the dilated right ureter.

(Enlarge Image)

Media file 23: Transverse sonogram in a boy with grade V vesicoureteral reflux and posterior urethral valves. Image demonstrates a thickened bladder wall.

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Transverse sonogram in a boy with grade V vesicoureteral reflux and posterior urethral valves. Image demonstrates a thickened bladder wall.

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Media file 24: Renal sonogram in a patient with high-grade vesicoureteral reflux secondary to a posterior urethral valve demonstrates moderate hydronephrosis and cortical thinning.

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Renal sonogram in a patient with high-grade vesicoureteral reflux secondary to a posterior urethral valve demonstrates moderate hydronephrosis and cortical thinning.

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Media file 25: Sonogram of the right kidney in a patient with grade V vesicoureteral reflux. Hydronephrosis and increased echogenicity indicating renal dysplasia secondary to reflux nephropathy. This kidney measured 6.7 cm, while the left one measured 8.3 cm.

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Sonogram of the right kidney in a patient with grade V vesicoureteral reflux. Hydronephrosis and increased echogenicity indicating renal dysplasia secondary to reflux nephropathy. This kidney measured 6.7 cm, while the left one measured 8.3 cm.

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Media file 26: Transverse sonogram of the bladder demonstrates left ureteral dilatation near the level of the ureteral insertion.

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Transverse sonogram of the bladder demonstrates left ureteral dilatation near the level of the ureteral insertion.

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Media file 27: Longitudinal sonogram demonstrates dilatation of the mid aspect of the ureter. The ureter could be visualized in its entirety and was dilated throughout.

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Longitudinal sonogram demonstrates dilatation of the mid aspect of the ureter. The ureter could be visualized in its entirety and was dilated throughout.

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Media file 28: Longitudinal sonogram of the left kidney in a patient with grade V vesicoureteral reflux and a duplex collecting system. There is hydronephrosis of the lower pole moiety and dilatation of the proximal ureter. The upper pole of the kidney was normal on ultrasonography and did not demonstrate reflux on voiding cystourethrography (VCUG).

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Longitudinal sonogram of the left kidney in a patient with grade V vesicoureteral reflux and a duplex collecting system. There is hydronephrosis of the lower pole moiety and dilatation of the proximal ureter. The upper pole of the kidney was normal on ultrasonography and did not demonstrate reflux on voiding cystourethrography (VCUG).

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Media file 29: Voiding cystourethrogram (VCUG) show a large, distended bladder with irregular and trabeculated margins. This patient had posterior urethral valves.

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Voiding cystourethrogram (VCUG) show a large, distended bladder with irregular and trabeculated margins. This patient had posterior urethral valves.

(Enlarge Image)

Media file 30: Excretory urogram demonstrates the position of surgically reimplanted ureters after correction of vesicoureteral reflux.

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Excretory urogram demonstrates the position of surgically reimplanted ureters after correction of vesicoureteral reflux.

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Media file 31: Vesicoureteral reflux assessment and treatment algorithm.

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Vesicoureteral reflux assessment and treatment algorithm.

More on Vesicoureteral Reflux

Overview: Vesicoureteral Reflux

Imaging: Vesicoureteral Reflux

Follow-up: Vesicoureteral Reflux

Multimedia: Vesicoureteral Reflux

References

Fefferman NR, Sabach AS, Rivera R, Milla S, Pinkney LP, Strubel NA, et al. The efficacy of digital fluoroscopic image capture in the evaluation of vesicoureteral reflux in children. Pediatr Radiol. Aug 29 2009;[Medline].
Novak TE, Mathews R, Martz K, Neu A. Progression of chronic kidney disease in children with vesicoureteral reflux: the North American Pediatric Renal Trials Collaborative Studies Database. J Urol. Oct 2009;182(4 Suppl):1678-81. [Medline].
Menezes M, Puri P. Familial vesicoureteral reflux--is screening beneficial?. J Urol. Oct 2009;182(4 Suppl):1673-7. [Medline].
Mingin G. Vesicoureteral reflux, urinary tract infection and renal scarring: sorting it all out. J Urol. Nov 2008;180(5):1884-5. [Medline].
Zaffanello M, Franchini M, Brugnara M, Fanos V. Evaluating kidney damage from vesico-ureteral reflux in children. Saudi J Kidney Dis Transpl. Jan 2009;20(1):57-68. [Medline].
Acar B, Arikan FI, Germiyanoglu C, Dallar Y. Influence of high bladder pressure on vesicoureteral reflux and its resolution. Urol Int. 2009;82(1):77-80. [Medline].
Papadopoulou F, Anthopoulou A, Siomou E, Efremidis S, Tsamboulas C, Darge K. Harmonic voiding urosonography with a second-generation contrast agent for the diagnosis of vesicoureteral reflux. Pediatr Radiol. Mar 2009;39(3):239-44. [Medline].
Sjöström S, Jodal U, Sixt R, Bachelard M, Sillén U. Longitudinal Development of Renal Damage and Renal Function in Infants With High Grade Vesicoureteral Reflux. J Urol. Mar 18 2009;[Medline].
Sjöström S, Bachelard M, Sixt R, Sillén U. Change of urodynamic patterns in infants with dilating vesicoureteral reflux: 3-year followup. J Urol. Nov 2009;182(5):2446-53. [Medline].
Ziessman HA, Majd M. Importance of methodology on (99m)technetium dimercapto-succinic acid scintigraphic image quality: imaging pilot study for RIVUR (Randomized Intervention for Children With Vesicoureteral Reflux) multicenter investigation. J Urol. Jul 2009;182(1):272-9. [Medline].
Belman BA, Lowell RK, Kramer SA. Clinical Pediatric Urology. 4th ed. 2002.
Chudleigh T. Mild pyelectasis. Prenat Diagn. Nov 2001;21(11):936-41. [Medline].
Darge K. Diagnosis of vesicoureteral reflux with ultrasonography. Pediatr Nephrol. Jan 2002;17(1):52-60. [Medline].
Devriendt K, Groenen P, Van Esch H, et al. Vesico-ureteral reflux: a genetic condition?. Eur J Pediatr. Apr 1998;157(4):265-71. [Medline].
Dunnick NR, Sandler CM, Newhouse JH. Textbook of Uroradiology. 3rd ed. 2001: 330-3.
Hellstrom M, Jacobsson B. Diagnosis of vesico-ureteric reflux. Acta Paediatr Suppl. Nov 1999;88(431):3-12. [Medline].
Joyner BD, Atala A. Endoscopic substances for the treatment of vesicoureteral reflux. Urology. Oct 1997;50(4):489-94. [Medline].
Koff SA, Wagner TT, Jayanthi VR. The relationship among dysfunctional elimination syndromes, primary vesicoureteral reflux and urinary tract infections in children. J Urol. Sep 1998;160(3 Pt 2):1019-22. [Medline].
Lebowitz RL, Olbing H, Parkkulainen KV, et al. International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children. Pediatr Radiol. 1985;15(2):105-9. [Medline].
McNeil DR, Tukey JW. Higher-order diagnosis of two-way tables, illustrated on two sets ofdemographic empirical distributions. Biometrics. Jun 1975;31(2):487-510. [Medline].
Noe HN. The current status of screening for vesicoureteral reflux. Pediatr Nephrol. Oct 1995;9(5):638-41. [Medline].
Pollack HM, McClennan BL. Clinical Urography, Vol 1. 2nd ed. 2000.
Ritchey ML, Bloom D. Report of the American Academy of Pediatrics Section of Urology meeting. Pediatr Nephrol. Oct 1995;9(5):642-6. [Medline].
Sargent MA. What is the normal prevalence of vesicoureteral reflux?. Pediatr Radiol. Sep 2000;30(9):587-93. [Medline].
Shaikh N, Hoberman A, Wise B, et al. Dysfunctional elimination syndrome: is it related to urinary tract infection or vesicoureteral reflux diagnosed early in life?. Pediatrics. Nov 2003;112(5):1134-7. [Medline].
Sillen U. Vesicoureteral reflux in infants. Pediatr Nephrol. May 1999;13(4):355-61. [Medline].
Thrall JH, Ziessman HA. Nuclear Medicine: The Requisites. 2nd ed. 2001: 351-7.

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Keywords

vesicoureteral reflux, VUR, reflux nephropathy, posterior urethral valves, urinary tract infection, UTI

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Contributor Information and Disclosures

Author

Kevin F McCarthy, MD, Staff Physician, Department of Radiology, National Naval Medical Center
Kevin F McCarthy, MD is a member of the following medical societies: American College of Radiology and Radiological Society of North America
Disclosure: Nothing to disclose.

Coauthor(s)

Veronica Rooks, MD, Military Chief of Pediatric Radiology, Pediatric Radiologist, Tripler Army Medical Center; Assistant Professor of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences
Veronica Rooks, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Association of Program Directors in Radiology, Radiological Society of North America, and Society for Pediatric Radiology
Disclosure: Nothing to disclose.

Medical Editor

Henrique M Lederman, MD, PhD, Consulting Staff, Department of Radiology, LeBonheur Children's Medical Center and St Jude Children's Research Hospital; Professor of Radiology and Pediatric Radiology, Chief, Division of Diagnostic Imaging in Pediatrics, Federal University of Sao Paulo, Brazil
Henrique M Lederman, MD, PhD is a member of the following medical societies: Society for Pediatric Radiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

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eMedicine Specialties > Radiology > Pediatrics

Vesicoureteral Reflux: Multimedia

Multimedia

Voiding cystourethrogram (VCUG) demonstrates a large, smooth, central filling defect peripherally outlined by contrast material. The catheter is deviated to the patient's right. This finding is consistent with a large ureterocele.

Excretory urogram demonstrates the classic cobra-head appearance of a ureterocele.

Voiding cystourethrogram (VCUG) demonstrates a posterior urethral valve.

Voiding cystourethrogram (VCUG) shows grade I left VUR. Incidentally noted is vaginal reflux.

Voiding cystourethrogram (VCUG) demonstrates grade II VUR into the upper-pole moiety of a duplex collecting system and grade III VUR to the lower-pole moiety.

Grade II vesicoureteral reflux in a patient with ureteral duplication.

Voiding cystourethrogram (VCUG) demonstrates bilateral grade III reflux. The renal pelvis is mildly dilated on the right. There is some mild blunting of the calyceal fornices and loss of papillary impressions in the upper poles bilaterally.

Voiding cystourethrogram (VCUG) of lower ureter and ureterovesical junction in a patient with grade III reflux. The ureteral insertion on the left is between the 3- and 6-o'clock positions. There is a small bladder diverticulum at the ureteral insertion.

Voiding cystourethrogram (VCUG)demonstrates bilateral grade III vesicoureteral reflux.

Longitudinal sonogram corresponding to a voiding cystourethrogram (VCUG) of a grade III vesicoureteral reflux. Note the mild pelviectasis. The degree of pelviectasis or caliectasis does not correlate with the degree of reflux seen on the VCUG.

Voiding cystourethrogram (VCUG) demonstrates high-grade IV vesicoureteral reflux in a patient with a duplicated collecting system.

Grade III vesicoureteral reflux and periureteral-type diverticulum.

Voiding cystourethrogram (VCUG) of the left kidney demonstrates grade V vesicoureteral reflux.

Voiding cystourethrogram (VCUG) demonstrates a tortuous, dilated ureter in a patient with grade V vesicoureteral reflux.

Unilateral grade V vesicoureteral reflux secondary to a posterior urethral valve. There is gross dilatation of the renal pelvis and calyces. Papillary impressions are not visible. Gross intrarenal reflux is also identified.

Nuclear cystograms demonstrate grade III reflux. Reflux to the left kidney is shown, with dilatation of the renal pelvis.

Dimercaptosuccinic acid (DMSA) scans demonstrate photopenia at the right superior pole consistent with scarring in this patient with vesicoureteral reflux.

Nonenhanced CT scan at a level just above ureteral insertion demonstrates bilateral, markedly dilated ureters in a patient with grade V vesicoureteral reflux.

Sagittal sonogram of the bladder. A Foley catheter is surrounded by thickened, hypertrophied bladder wall, the sequelae of posterior urethral valves in this boy with bilateral grade V vesicoureteral reflux. Note the dilated right ureter.

Transverse sonogram in a boy with grade V vesicoureteral reflux and posterior urethral valves. Image demonstrates a thickened bladder wall.

Renal sonogram in a patient with high-grade vesicoureteral reflux secondary to a posterior urethral valve demonstrates moderate hydronephrosis and cortical thinning.

Sonogram of the right kidney in a patient with grade V vesicoureteral reflux. Hydronephrosis and increased echogenicity indicating renal dysplasia secondary to reflux nephropathy. This kidney measured 6.7 cm, while the left one measured 8.3 cm.

Transverse sonogram of the bladder demonstrates left ureteral dilatation near the level of the ureteral insertion.

Longitudinal sonogram demonstrates dilatation of the mid aspect of the ureter. The ureter could be visualized in its entirety and was dilated throughout.

Voiding cystourethrogram (VCUG) show a large, distended bladder with irregular and trabeculated margins. This patient had posterior urethral valves.

Excretory urogram demonstrates the position of surgically reimplanted ureters after correction of vesicoureteral reflux.

Vesicoureteral reflux assessment and treatment algorithm.

More on Vesicoureteral Reflux

References

Further Reading

Keywords

Contributor Information and Disclosures

Author

Coauthor(s)

Medical Editor

Pharmacy Editor

CME Editor

Chief Editor