Have you ever heard of vesico-ureteral reflux (VUR)? This is a problem that I have be seeing lately which occurs in the urinary tract.
In the normal scenario urine is produced in the kidneys and then travels through the ureters (which are like a straw) from the kidneys to the bladder. The urine is supposed to only proceed in one direction, and only down and into the bladder and then out the urethra when you urinate. But in some children, the kidneys are fine and doing their work of making urine but the ureters (the straws) allow the urine to go in a retrograde fashion (both up and down, or back and forth or whatever terminology you want) from bladder to kidney, and this is termed vesico ureteral reflux (not to be confused with gastro-esophageal reflux).
Vesico-ureteral reflux is often diagnosed in infants and young children who present with prolonged fever which may be an indicator of a urinary tract infection.
When a child under the age of 2 has persistent fever (usually over 72 hours), without any other focus of infection, a urinalysis and culture is often performed to rule out a urinary tract infection. It is also more prevalent to see this occur in little girls rather than in boys.
If a urinary tract infection is confirmed it was previously the “standard of care” to perform a VCUG (voiding cystourethrogram) which is a radiographic study where dye is injected via a catheter into the bladder to look for retrograde flow of urine (the back and forth, up and down) to rule out VUR. In the past several months there have been changes in the management of VUR especially as it relates to first urinary tract infections.
The new recommendations state that, “children of any age, regardless of gender, with a first febrile UTI should undergo a renal/bladder ultrasound, rather than a VCUG.” In other words, no more radiation and dye (not to mention the associated trauma) that went along with the voiding study.
Years ago a VCUG was performed without any sedation, but over time it became standard to sedate the children before this procedure, and with that there were other issues about safety etc. It was also recommended that a VCUG be done yearly to watch the regression or progression of reflux. That yearly VCUG just sent some kids and parents over the edge (including me!).
The concern with VUR is that over the years this retrograde flow of urine could cause damage and scarring to the kidneys. This scarring could cause numerous problems (high blood pressure, kidney disease etc) for a child later in their life. The problem was figuring out who might go on to scar and need surgery etc. The new guidelines recommend using a different type of scan in management of reflux.
If your child has a urinary tract infection in association with a fever you might want to discuss whether they should see a pediatric urologist, and/or have an ultrasound. But if someone mentions a VCUG consider the newest guidelines. And, if you have a child with VUR, talk to your doctor about the changes in management and don’t stress about a VCUG this year!
That’s your daily dose for today. We’ll chat again tomorrow.