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Vesicoureteral Reflux (VUR)

Retrograde flow of urine from bladder to the upper urinary tract, 18% of normal children. Risk for: Pyelonephritis, Scarring, Stunned renal growth, Reflux nephropathy (leading to HTN and renal failure). Higher likelihood of VUR: Fam. History of VUR (siblings have much higher - 45% risk), Pyelonephritis, Prenatal or postnatal abnormality, US: infants w/ prenatal hydronephrosis. Postnatal RUS suspicious for VUR: Intermittent hydroureteronephrosis Urothelial thickening Scarring Stunted renal growth VCUG: Voiding cystourethrogram: greater anatomic detail, more radiation RNC: RadioNuclide Cystography: sensitive for VUR, used for screening of siblings and monitor the resolution after treatment. Dilute 99m Te pertechnatate VCUG: water-soluble contrast instilled by gravity. Spot images of abdomen, early filling views of the bladder, bilateral obliques to view uretero-vesical junction and postvoid images are standard. VUR Grades contrast in ureter contrast in ureter and pelvis dilated ureter and pelvis marked dilation of ureter and pelvis convoluted dilation of ureter and pelvis Cyclic study: refill bladder w/ contrast again after voiding around catheter. IRR: IntraRenal Reflux: reflux into collecting tubules of the renal medulla contributes to renal scarring in polar regions. US is not sensitive neither specific for VUR but complements VCUG. Pyelonephritis on US: renal enlargement hypovascular zone in the area of pyelonephritis (Doppler) abscess or scarring VUR associated congenital anomalies and vice versa: Ureteral duplication: Weigert-Mayer rule - The upper pole ureter inserts distally and medialy (DM), the lower pole ureter inserts proximally and laterally, drooping Lilly sign UPJ obstruction: VUR 20%, may amplify the grade of reflux Bladder diverticulum: Occurs in up to 20% of normal children. Retrograde flow of urine from bladder to the upper urinary tract. May lead to pyelonephritis, scarring, stunned growth and nephropathy (HTN and RF). Caucasian >> AA Indications for testing: 1.) Family history of reflux (50% of siblings) 2.) Suspected pyelonephritis 3.) Abnormal prenatal or postnatal US Intravesical part of ureter acts as a valve. Postnatal RUS suspicious for VUR: - Intermittent hydroureteronephrosis - Urothelial thickening - Scarring - Stunted renal growth VCUG: Voiding cystourethrogram: greater anatomic detail, more radiation RNC: RadioNuclide Cystography: sensitive for VUR, used for screening of siblings and monitor the resolution after treatment. Dilute 99m Te pertechnatate VCUG: water-soluble contrast instilled by gravity. Spot images of abdomen, early filling views of the bladder, bilateral obliques to view uretero-vesical junction and postvoid images are standard. VUR Grades: 1.) contrast in ureter 2.) contrast in ureter and pelvis 3.) dilated ureter and pelvis 4.) marked dilation of ureter and pelvis 5.) convoluted dilation of ureter and pelvis Cyclic study: refill bladder w/ contrast again after voiding around catheter. IRR: IntraRenal Reflux: reflux into collecting tubules of the renal medulla contributes to renal scarring in polar regions. US is not sensitive neither specific for VUR but complements VCUG. Pyelonephritis on US: renal enlargement, hypovascular zone in the area of pyelonephritis (Doppler) abscess or scarring Ureteral duplication: Weigert-Mayer rule - The upper pole ureter inserts distally and medialy (DM), the lower pole ureter inserts proximally and laterally, drooping Lilly sign UPJ obstruction: VUR 20%, may amplify the grade of reflux Bladder diverticulum: