Vesicoureteral reflux

Disease Description (Causes and Symptoms)

• Definition summary: Vesicoureteral reflux (VUR) is a condition in which urine flows backward from the bladder into the ureter (toward the kidney) during urination or when urine is stored in the bladder. Normally, the valve function between the ureter and bladder (the length of the ureter within the bladder) prevents reflux.
• Main causes
  • Children: Weak valve function due to congenital structural abnormalities (a short tunnel length of the ureter within the bladder or an abnormal location of the ureteral opening).
  • Adults/acquired: Lower urinary tract obstruction (e.g., enlarged prostate), neurogenic bladder (e.g., spinal cord injury), functional abnormalities caused by temporary urinary tract infections, etc.
• Pathophysiology (summary): When the antireflux (valve) mechanism at the ureterovesical junction is incomplete and urine refluxes into the upper urinary tract during urination or bladder distension, a urinary tract infection can progress to pyelonephritis, and repeated episodes may cause kidney scarring (kidney damage).
• Main symptoms
  • Often asymptomatic (especially isolated VUR).
  • When accompanied by a urinary tract infection (especially a febrile urinary tract infection): high fever, painful urination, frequent urination, urinary urgency, and in children, irritability, reduced feeding, poor weight gain, etc.
  • Adults may also have symptoms related to voiding dysfunction (difficulty urinating, a feeling of incomplete bladder emptying).

Treatment Methods

• Diagnosis-based principles: Conservative and surgical treatments are selected based on the reflux grade (I–V), symptoms (especially whether there are recurrent febrile urinary tract infections), whether it is bilateral, kidney function/kidney scarring, and the patient’s age.
• Conservative (non-surgical) treatment
  • Observation for low-grade VUR (I–II, when symptoms are mild) or in children who are likely to experience spontaneous resolution.
  • Prophylactic antibiotics (low-dose antibiotics): Used to prevent recurrent urinary tract infections until the reflux resolves or under specific conditions. (Whether to use them is determined according to the individual risk level.)
  • Prompt culture and appropriate antibiotic treatment when an infection occurs.
  • Lifestyle management: Regular urination (avoid holding urine), adequate fluid intake, treatment of constipation, and maintaining personal hygiene.
• Procedural and surgical treatment
  • Endoscopic ureteral injection (injection of a viscoelastic substance at the ureteral opening: subureteric injection, e.g., Deflux, etc.) — Relatively simple, with a short hospital stay; widely used for moderate reflux.
  • Ureteral reimplantation (open surgery or laparoscopic/robot-assisted surgery): Repositions the ureter beneath the bladder muscle layer to restore the antireflux mechanism. High success rate (approximately 90% or higher in the literature).
  • If the cause in adults is lower urinary tract obstruction (e.g., BPH), treatment of the cause (such as prostate treatment) is considered first.
• General criteria for treatment selection
  • Surgery is considered for recurrent febrile urinary tract infections, high-grade VUR (IV–V), decreased kidney function, or progression of kidney scarring.
  • Conservative management may be possible for low-grade, asymptomatic cases or cases involving only uncomplicated urinary tract infections.
• Precautions / risk of complications / points to note for self-management
  • Assess medication side effects (gastrointestinal symptoms, antibiotic resistance, etc.) and the need for treatment when using antibiotics long term.
  • If an infection is suspected, promptly undergo urinalysis and urine culture.
  • Managing constipation and urinating regularly are important for preventing recurrence.
  • After surgery, monitor urine flow, fever, pain, and any abnormalities in urination.

Outpatient Visit Checklist (Including Sample Questions)

• Items to bring (test results and information)
  • A list of recently taken medications (including antibiotics) and a history of allergies.
  • Previous urine culture results, blood test results, and urinalysis results.
  • Existing imaging data: voiding cystourethrography (VCUG), renal and bladder ultrasound (renal ultrasound), and DMSA kidney function/scar scan results (if available).
  • Symptom records: history of fever (temperature), urination frequency/urgency/pain, presence of constipation, fluid intake, and, for children, growth and feeding patterns.
  • A urination diary (if possible, for 24–48 hours).
• Information to tell the doctor in advance during the outpatient visit
  • The number and severity of recent urinary tract infections (whether hospitalization or intravenous antibiotics were required).
  • Family history (kidney disease or VUR).
• Sample questions (to prepare in advance)
  • Ask whether you should bring recent urine culture results and antibiotic susceptibility results.
  • Bring files or reports of recent imaging (VCUG, ultrasound).

General Sample Questions to Ask the Doctor

• "What grade is my (or my child’s) reflux, and what treatment is recommended based on this grade?"
• "Should we start prophylactic antibiotics? What are the side effects of long-term use, and what are the criteria for stopping them?"
• "If surgery (or an endoscopic procedure) is recommended, what are the advantages and disadvantages, and how long is the recovery period?"
• "Are additional tests needed to check for kidney damage (scarring)?"

Examples of Condition-Specific Questions

• For children (items for parents to ask)
  • "Considering my child’s age and current VUR grade, how likely is spontaneous resolution?"
  • "If recurrent febrile urinary tract infections occur, what are the specific criteria for recommending surgery (number and timing of episodes)?"
• For adults (when accompanied by prostate disease, etc.)
  • "If lower urinary tract obstruction (e.g., an enlarged prostate) is treated, is vesicoureteral reflux likely to improve? How should the treatment priorities be determined?"

(Note: Diagnostic and treatment decisions vary depending on the individual’s clinical condition, test findings, and the treating physician’s judgment. Bringing relevant test results and medical history information to the outpatient visit can help ensure a smooth consultation.)