Download Grading of Reflux

Anomalies of the lower
Urinary Tract
Vesicoureteral Reflux
Definition:
Retrograde flow of urine from the bladder to the upper urinary tract.
Etiology of Vesicoureteral Reflux
Primary Reflux
primary reflux represents a congenital defect in the structure and function of the
ureterovesical junction..
Secondary Reflux
-Bladder dysfunction e.x neurogenic bladder.
-Bladder outlet obstruction e.x posterior urethral valve.
Grading of Reflux: by the voiding cystourethrogram
GRADE
1
2
3
4
5
DESCRIPTION
Into a nondilated ureter.
Into the pelvis and calyces without dilatation.
Mild to moderate dilatation of the ureter, renal pelvis, and calyces.
Moderate ureteral tortuosity and dilatation of the pelvis and calyces
Gross dilatation of the ureter, pelvis, and calyces and sever ureteral tortuosity
Complication of VUR:
-Infectious pyelonephritis: reflux facilitates the ascension of microorganisms from the
bladder to the kidneys.
-postpyelonephritic scarring:
-Hypertension.: VUR is the primary cause of hypertension in children.
-Renal Failure: high grade bilateral VUR may cause renal failure by back pressure and
infection.
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Diagnosis of Vesicoureteral Reflux
The voiding cystourethrogram (VCUG): the gold standard for reflux detection.
Renal ultrasonography: it is used for serial follow-up of renal growth and development.
Ultrasonography also images the degree of corticomedullary differentiation in the kidney.
Loss of corticomedullary differentiation, or an increase in the overall echogenicity of the
kidney, is associated with some degree of renal functional impairment.
Renal Scintigraphy: The main test for scar detection.
Management of VUR:
Medical Management:
- Spontaneous resolution of reflux is very common (90% for grade 1, 80% of grade 2 ,
50% for grade 3 , 25% for grade 4 and 5% for grade 5).
-. The classic approach is daily low-dose prophylactic antibiotic suppression of infections
as the first line of treatment under the principle that every case of reflux should be offered
time to resolve spontaneously.It is reasonable to wait until approximately 5 years of age
assuming no intercurrent breakthrough infections occur. Beyond this age, it is commonly
believed that the kidneys become less prone to scarring after pyelonephritis .
Endoscopic Treatment of Vesicoureteral Reflux: use of injectable bulking agents to
narrow the ureteral orifice, thereby preventing vesicoureteral reflux.
Surgical treatment: by ureteric reimplantation,indicated in patient with recurrent
breakthrough infections .
Posterior Urethral Valves
It is mucosal fold at posterior urethra causing varying degree of obstruction to voiding
without interfering to retrograde catheterization. The classic posterior urethral valves
occur only in males.
Pathophysiology: The effects of congenital obstruction of the urethra are reflected in
the entire urinary tract above the level of obstruction.
-Bladder: hypertrophy and hyperplasia of the detrusor muscle along with increased
connective tissue. The bladder neck is rigid and hypertrophied.
-prostatic urethra: High voiding pressures distend and thin the prostatic urethra.
-Ureter: The ureteral wall is thickened and the lumen massively dilated.
-Kidney: renal injury is caused by persistent high pressure.
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Clinical Presentation: it depend on age of patient and degree of obstruction.
In utero: today, most patients with posterior urethral valves are diagnosed with prenatal
ultrasound . The observation of marked hydroureteronephrosis, a distended bladder, and a
thickened bladder wall and oligohydramnios in utero strongly support the diagnosis of
valves .
newborn : usually presents with signs of severe systemic illness such as failure to thrive,
lethargy, and poor feeding. The infants may be pale and have poor muscle tone.
Examination of the abdomen may reveal masses due to hydroureteronephrosis and a
distended bladder.
Older Children : present with urinary tract infection and difficulty in urination with poor
urinary stream.
Diagnosis:
Ultrasound : The classic ultrasound findings in patients with valves include bilateral
hydroureteronephrosis, distended bladder, dilated posterior urethra, and a thickened
bladder wall.
Voiding Cystourethrography: The voiding cystourethrogram (VCUG) remains the most
important study in diagnosing posterior urethral valves because it defines the anatomy and
gross function of the bladder, bladder neck, and urethra.
Cystoscope: for direct visualize the valve.
Laboratory Evaluation: serum Creatinine and blood urea to assess renal function.
Management:
Bladder Drainage: Initial management of all patients with posterior urethral valves
requires the immediate urinary catheter drainage from the bladder.
Valve Ablation After successful initial bladder drainage and when the patient’s medical
condition has stabilized, the next step is to permanently destroy the valves by using
pediatric resectoscope with a hook or cold knife to incise the valves.
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Hypospadias
Hypospadias is considered arrested penile development in which the urethral meatus open
on the ventral side of the penis proximal to the tip of the glans usually associated with
ventral curvature of the penis and deficient of foreskin ventally.
Hypospadias occurred in 1 of 300 males.
ETIOLOGY:
Unknown: the underlying etiology is unknown for most cases.
Genetic Factors: Familial aggregation is found in 10% of hypospadias cases, including
first-, second-, and third-degree relatives.
Endocrinopathies Defects in the testosterone biosynthetic or androgen receptor may be
a cause of hypospadias. Assisted reproduction is associated with an increased hypospadias
risk, which has been attributed to hormonal manipulations during and after the procedures.
Other Associations
low birth weight, preterm birth (<37 weeks), maternal obesity and diabetes, and maternal
hypertension. Both decreased (<24 years) and increased (>40 years) maternal
age .
Classification :according to the location of urethral meatus
-glanular
-coronal
-penile
-Penoscrotal
-perineal
DIAGNOSIS:
Hypospadias is diagnosed by physical examination, first suspected by the ventrally
deficient prepuce and confirmed by the proximal meatus.
ASSOCIATED ANOMALIES
Cryptorchidism : approximately 10% of hypospadias patients also have cryptorchidism.
Disorders of Sex Development: hypospadias with cryptorchidism increases the likelihood
for DSD and need karyotyping (chromosomal assessment).
Inguinal hernia : occur in 10% of cases
Management.
The therapeutic objectives are to correct the penile curvature,, to bring the urethral meatus
to the tip of the glans.
The age at surgery for hypospadias repair is usually 6-18 months.
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