Pediatric Vesicoureteral Reflux Clinical Presentation

Updated: Jul 09, 2020
  • Author: Caleb P Nelson, MD, MPH; Chief Editor: Marc Cendron, MD  more...
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Presentation

History

Most children with vesicoureteral reflux (VUR) present in two distinct groups, as follows:

  • The first group presents with hydronephrosis, often identified antenatally via ultrasonography (US); these children typically progress through evaluation and treatment in the absence of clinical illness
  • The second group presents with clinical urinary tract infection (UTI)

Even for experienced pediatricians, the diagnosis of UTI in children can be difficult. Children often present with nonspecific signs and symptoms. Infection in infants can manifest as failure to thrive, with or without fever. Other features include vomiting, diarrhea, anorexia, and lethargy.

Older children may report voiding symptoms or abdominal pain. Pyelonephritis in young children is more likely to manifest with vague abdominal discomfort rather than with the classic flank pain and tenderness observed in adults. The presence of fever, while highly suggestive of pyelonephritis, is not reliable enough to lead to the diagnosis.

Even today, children occasionally present with advanced reflux nephropathy, manifesting as headaches or congestive heart failure from untreated hypertension, or with uremic symptoms from renal failure.

A small group of children without evidence of UTI present with symptoms of sterile reflux, which can include flank or abdominal pain before or during voiding, as well as double voiding or incomplete emptying resulting from delayed drainage of urine out of the upper tracts.

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Physical Examination

As with the history, few findings on physical examination suggest VUR or UTI. Fever, flank or abdominal tenderness, or an enlarged palpable kidney may be present. In the absence of reliable historical or physical findings, diagnosis depends on laboratory testing and imaging (see Workup), as well as family history.

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Complications

Morbidity associated with VUR is substantial, both from acute infection and from the sequelae of reflux nephropathy.

Changes in renal function

Decreases in urine-concentrating ability (proportional to the degree of reflux) and in glomerular filtration rate (proportional to the degree of renal scarring) have been measured in children with VUR.

Decreased renal and somatic growth

Although renal growth assessment in children is difficult because of imaging variability, several studies have documented smaller kidneys in children with reflux and recurrent infections. Surgery may improve growth rates, but small, scarred kidneys are unlikely to grow. Although early studies suggested that somatic growth is negatively affected in children with reflux, subsequent data showed that carefully monitored, properly treated children with VUR have growth rates within normal ranges. In contrast, children with significant renal insufficiency or end-stage renal disease clearly have decreased growth rates.

Hypertension and renal failure

Reflux nephropathy may be the most common cause of childhood hypertension. Presence of hypertension correlates well with the degree of renal scarring, especially when scarring is bilateral. The mechanism is thought to be elevated renin levels produced by damaged renal tissues.

Although not all scarred kidneys in children with hypertension produce excess renin, resection of renal units in cases where unilateral renal vein renin levels are elevated substantially (ratio >1.5) can result in resolution of hypertension.

Improvements in management may result in decreased rates of hypertension among adults who had childhood reflux.

The most devastating outcome of reflux nephropathy is renal failure. The true incidence of chronic renal insufficiency among refluxing children is uncertain. Older studies consistently attributed 15-30% of renal failure in children and young adults to chronic pyelonephritis and reflux nephropathy. However, one transplant series attributed just 2.2% of cases to chronic pyelonephritis. Most authorities now agree that although renal failure is a devastating complication of VUR, it actually affects only a small minority of children with reflux.

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