Vesicoureteral Reflux (VUR) Assessment

Study Notes

Vesicoureteral reflux (VUR) is the abnormal retrograde flow of urine from the bladder into the ureters and sometimes the kidneys.

History taking is crucial in identifying potential risk factors and understanding the clinical context of VUR.
Inquire about a family history of VUR, as it has a genetic component.
Ask about a history of recurrent urinary tract infections (UTIs), especially in young children.
Investigate any prenatal history of hydronephrosis (swelling of the kidney due to urine back-up), which can be a sign of VUR.
Gather information on bowel and bladder habits, including constipation or dysfunctional voiding, as these can contribute to VUR.

Signs and symptoms of VUR are often subtle and may be absent, especially in mild cases.
Recurrent UTIs, particularly with fever, are a common presentation.
In infants and young children, symptoms may include unexplained fever, poor feeding, irritability, or failure to thrive.
Older children may report dysuria (painful urination), frequency, urgency, or abdominal/flank pain.
In severe cases, VUR can lead to hypertension or renal insufficiency, although these are late manifestations.

Urinalysis (UA) and urine culture are essential in the initial evaluation of suspected VUR.
UA can detect signs of infection, such as pyuria (white blood cells in urine) or hematuria (blood in urine).
A urine culture confirms the presence of a UTI and identifies the causative organism, guiding antibiotic selection.
It is important to obtain urine samples via appropriate methods (e.g., clean-catch, catheterization, suprapubic aspiration) to minimize contamination.

Renal ultrasound is a non-invasive imaging technique used to evaluate the structure of the kidneys and ureters.
It can detect hydronephrosis, a common finding in VUR, which indicates urine back-up in the kidneys.
Ultrasound can also identify other abnormalities such as renal scarring or duplication of the collecting system.
While ultrasound can suggest the presence of VUR, it cannot definitively diagnose it or grade its severity.

VCUG is the gold standard for diagnosing and grading VUR.
It involves inserting a catheter into the urethra and filling the bladder with contrast dye.
Fluoroscopic images are taken while the bladder is filled and during voiding to visualize the flow of urine.
VCUG can detect reflux of contrast into the ureters and kidneys, confirming the diagnosis of VUR.
The severity of VUR is graded from I to V based on the extent of reflux and dilation of the ureters and renal pelvis.

DMSA scan is a nuclear medicine imaging technique used to assess renal parenchymal damage (scarring).
Dimercaptosuccinic acid (DMSA), a radioactive tracer, is injected intravenously and taken up by the functional renal tissue.
Images are acquired to evaluate the distribution of DMSA in the kidneys.
Areas of decreased DMSA uptake indicate scarring, which can be a consequence of recurrent UTIs and VUR.
DMSA scan is typically performed to assess long-term renal damage rather than to diagnose VUR itself.

Surgical intervention is considered for VUR when conservative management fails or in cases of high-grade reflux with breakthrough infections.
The primary surgical approach is ureteral reimplantation, which involves repositioning the ureter into the bladder to create a longer submucosal tunnel, preventing reflux.
Surgical correction has high success rates in resolving VUR and preventing recurrent UTIs.
Minimally invasive techniques, such as laparoscopic or robotic-assisted surgery, are increasingly used for ureteral reimplantation.

Antibiotic prophylaxis is a common conservative management strategy for VUR.
Low-dose antibiotics are administered daily to prevent UTIs and reduce the risk of renal damage.
Antibiotics commonly used for prophylaxis include trimethoprim-sulfamethoxazole (TMP-SMX), nitrofurantoin, or cephalexin.
The duration of antibiotic prophylaxis is determined by the grade of VUR, the frequency of UTIs, and the patient's age and overall health.
Antibiotic stewardship is important to minimize the risk of antibiotic resistance.

Monitoring intake and output (I&Os) is an important nursing intervention for patients with VUR, particularly those with recurrent UTIs or renal involvement.
Accurate I&O measurement helps assess fluid balance and renal function.
Inadequate urine output may indicate impaired renal function or dehydration, requiring further evaluation and intervention.
Encourage adequate fluid intake to promote urine output and flush bacteria from the urinary tract.