More efforts should be undertaken to raise awareness on vesicoureteral reflux,  where the urine backflows to the tubes (ureter) that connect the kidneys with the urinary bladder to prevent kidney disease in children, says Prof Dr Shilpa Sharma from the Department of Paediatric Surgery. Normally, urine flows from your kidneys through the ureters down to the bladder and is not supposed to flow back.

Prof Sharma shared her views with Drug Today Medical Times on vesicoureteral reflux, its prevalence in India, its symptoms and its complications.

DTMT: What is vesicoureteral reflux? Please tell our readers about it.

Prof Sharma: It is a disease in which when the baby passes urine from the bladder some of it goes back to the urethra while some of it goes back into the kidney via the tubes connecting with kidneys called ureters.

This urine going back into the kidney can damage kidneys by causing infection and scarring. The risk of kidney damage increases manifold if the urine is infected.

The urine tends to become infected as there is stasis when urine stays in the system and does not flow out but circulates from the bladder to the ureter and back, thereby remaining in the urinary system for a long time leading to infection.

This infection and backflow of urine lead to dilatation of the ureter and the kidney. The kidney and ureter get dilated and can become bigger than the bladder. So the child may pass only 20% of the urine while holding back 80%. This condition usually remains asymptomatic at earlier stages if not suspected it can be ascertained only when the child has an infection through investigations.

Any child having recurrent infection should undergo an ultrasound examination to determine the size of the kidney and also to look for dilatation of ureters. So if there is dilatation of the kidney and ureter, this may be due to reflux disease. For this micturating cystourethrogram, a scan that shows how well the bladder of the child is working, in which a dye is passed into the bladder and x-rays are taken while the child is made to pass urine. These x-ray images capture if urine is flowing back from the bladder to the ureter and kidneys.

There are five grades of vesicoureteral reflux. While those suffering from grades one and two may recover back as the reflux settles down with time and may not need much treatment apart from medical treatment in form of prophylactic antibiotic and double voiding, in which the child passes urine and after two minutes again after passing urine because the urine which has gone back into the kidney will now come back into the bladder.

When reflux is in grades three, four and five, it needs treatment depending on the age and symptoms that the child shows.

Dr Prem Puri, a renowned paediatric surgeon in Ireland with 45 years of experience, had found a new way of treating this infection by giving endoscopic injections Dextranomer- hyaluronic acid, which is a suspension of Dextranomer-microparticles and cross-linked hyaluronic acid, into the bladder, wherein the diameter of the ureter at the bladder mouth is narrowed to prevent reflux.

However, it is a costly treatment costing around Rs 40,000 per injection. It is very useful as it can prevent surgery and delay the onset of any damage.

After the injection the child may or may not have reflux and in about 15% of the cases, a second injection may be needed. I would like the stress that girls who have repeated urinary infections should go for an ultrasound examination to look for the size of the kidney, ureter and bladder and to look for the infection. When there is an infection of the urine, it can also be revealed on ultrasound by the appearance of echogenic shadows.

The urine routine examination can also pick up urine infection. So whenever the child has a fever, the urine should be sent for a routine examination, and if there is pus in the routine examination then the urine should be sent for culture. However, if antibiotics are started before sending the urine for examination the infection will not be picked up.

This condition also runs in families. So if there is one child who has kidney problems his brother and sister should also be screened for this disease.

DTMT: What are the symptoms and what is the age group this disease affects?

Prof Sharma: Vesicoureteral reflux can affect anyone immediately after birth up to four-five years of age. If it is missed, the child may remain asymptomatic till ten years. It can even be picked up in the child in the mother’s womb. Even after the mother has a delivery, one can get an ultrasound to screen for dilatation of kidneys during the antenatal period.

DTMT: What exactly are the symptoms of this disease?

Prof Sharma: The baby may present various symptoms, including a burning sensation while passing urine, fever, dirty urine, and may appear like white pus and pain in the abdomen and back. There may be lump formation with kidney dilation.

DTMT: Is this condition often misdiagnosed?

Prof Sharma: Yes, usually the children come after the scarring has already occurred. So in our country, we should stress the need for simple ultrasound and urine tests to diagnose this condition early.

DTMT: How many cases do you see at AIIMS yearly?

Prof Sharma: We come across around 200 patients of Vesicoureteral reflux yearly. It is a very serious disease because once a child has this disease, s/he will have to come to us repeatedly for routine check-ups to see if reflux is occurring or not and whether there is a requirement for injection or surgery.

DTMT: How do you manage such cases?

Prof Sharma: When any child comes to us, we get an ultrasound and urine examination done. If no infection is detected in urine examination, then we go for micturating cystourethrogram to see if there is reflux.

We can also get nuclear medicine tests done to determine if there is any scarring of the kidneys. Then we advise antibiotics as a prophylactic measure, which means before infection, we start on antibiotics with low doses in the night time. This goes on for three to six months but may be needed to be given for a longer duration too.

If the child attains one year of age, we plan treatment in the form of an injection. Though Dr Puri gave the injection even at six months of age, we delayed it because the weight of the child should be good enough to receive the injection and then if any child is four to five years old and still has reflux, they may also need surgery.

DTMT: What complications a child is likely to face if vesicoureteral reflux is not treated in time?

Prof Sharma: If this condition is not presented in time, the child will continue to have reflux and have a recurrent infection which leads to recurrent scarring and hampers the functioning of the kidney. It can lead to complete kidney damage.

If the child is not taken care of in time, chronic kidney disease may develop, leading to end-stage kidney disease that may even require a kidney transplant.