Overview
Vesicoureteral reflux is the abnormal flow of urine from your bladder back up the tubes (ureters) that connect your kidneys to your bladder. Normally, urine flows only down from your kidneys to your bladder.
Vesicoureteral reflux is usually diagnosed in infants and children. The disorder increases the risk of urinary tract infections, which, if left untreated, can lead to kidney damage.
Vesicoureteral reflux can be primary or secondary. Children with primary vesicoureteral reflux are born with a defect in the valve that normally prevents urine from flowing backward from the bladder into the ureters. Secondary vesicoureteral reflux occurs due to a urinary tract malfunction, often caused by abnormally high pressure inside the bladder.
Children may outgrow primary vesicoureteral reflux. Treatment, which includes medication or surgery, aims at preventing kidney damage.
Symptoms
Urinary tract infections commonly occur in people with vesicoureteral reflux. A urinary tract infection (UTI) doesn’t always cause noticeable signs and symptoms, though most people have some.
These signs and symptoms can include:
- A strong, persistent urge to urinate
- A burning sensation when urinating
- Passing frequent, small amounts of urine
- Blood in the urine (hematuria) or cloudy, strong-smelling urine
- Fever
- Pain in your side (flank) or abdomen
- Hesitancy to urinate or holding urine to avoid the burning sensation
A UTI may be difficult to diagnose in children, who may have only nonspecific signs and symptoms. Signs and symptoms in infants with a UTI may also include:
- An unexplained fever
- Diarrhea
- Lack of appetite
- Irritability
As your child gets older, untreated vesicoureteral reflux can lead to:
- Bed-wetting
- Constipation or loss of control over bowel movements
- High blood pressure
- Protein in urine
- Kidney failure
Another indication of vesicoureteral reflux, which may be detected before birth by sonogram, is swelling of the kidneys or the urine-collecting structures of one or both kidneys (hydronephrosis) in the fetus, caused by the backup of urine into the kidneys.
When to see a doctor
Contact your doctor right away if your child develops any of the signs or symptoms of a UTI, such as:
- A strong, persistent urge to urinate
- A burning sensation when urinating
- Abdominal or flank pain
- A hesitancy to urinate
Call your doctor about fever if your child:
- Is younger than 3 months old and has a rectal temperature of 100.4 F (38 C) or higher
- Is 3 months or older and has a fever of 102 F (38.9 C) or higher without any other explainable factors, such as a recent vaccination
In addition, call your doctor immediately if your infant has the following signs or symptoms:
- Changes in appetite. If your baby refuses several feedings in a row or eats poorly, contact the doctor.
- Changes in mood. If your baby is lethargic or unusually difficult to rouse, tell the doctor right away. Also let the doctor know if your baby is persistently irritable or has periods of inconsolable crying.
- Diarrhea. Contact the doctor if several of your baby’s stools are especially loose or watery.
- Vomiting. Occasional spitting up is normal. Contact the doctor if your baby spits up large portions of multiple feedings or vomits forcefully after feedings.
Causes
Your urinary system includes your kidneys, ureters, bladder and urethra. All play a role in removing waste products from your body.
The kidneys, a pair of bean-shaped organs at the back of your upper abdomen, filter waste, water and electrolytes — minerals, such as sodium, calcium and potassium, that help maintain the balance of fluids in your body — from your blood.
Tubes called ureters carry urine from your kidneys down to your bladder, where it is stored until it exits the body through another tube (the urethra) during urination.
Vesicoureteral reflux can develop in two forms, primary and secondary:
- Primary vesicoureteral reflux. The cause of this more common form is a defect that’s present before birth (congenital). The defect is in the functional valve between the bladder and a ureter that normally closes to prevent urine from flowing backward.
As your child grows, the ureters lengthen and straighten, which may improve valve function and eventually resolve the reflux. This type of vesicoureteral reflux tends to run in families, which indicates that it may be genetic, but the exact cause of the defect is unknown.
- Secondary vesicoureteral reflux. The cause of this form of reflux is most often from failure of the bladder to empty properly, either due to a blockage or failure of the bladder muscle or damage to the nerves that control normal bladder emptying.
Risk factors
Risk factors for vesicoureteral reflux include:
- Bladder and bowel dysfunction (BBD). Children with BBD hold their urine and stool and experience recurrent urinary tract infections, which can contribute to vesicoureteral reflux.
- Race. White children appear to have a higher risk of vesicoureteral reflux.
- Sex. Generally, girls have about double the risk of having this condition as boys do. The exception is for vesicoureteral reflux that’s present at birth, which is more common in boys.
- Age. Infants and children up to age 2 are more likely to have vesicoureteral reflux than older children are.
- Family history. Primary vesicoureteral reflux tends to run in families. Children whose parents had the condition are at higher risk of developing it.
Siblings of children who have the condition also are at higher risk, so your doctor may recommend screening for siblings of a child with primary vesicoureteral reflux.
Complications
Kidney damage is the primary concern with vesicoureteral reflux. The more severe the reflux, the more serious the complications are likely to be.
Complications may include:
- Kidney (renal) scarring. Untreated UTIs can lead to scarring, also known as reflux nephropathy, which is permanent damage to kidney tissue. Extensive scarring may lead to high blood pressure and kidney failure.
- High blood pressure (hypertension). Because the kidneys remove waste from the bloodstream, damage to your kidneys and the resultant buildup of wastes can raise your blood pressure.
- Kidney failure. Scarring can cause a loss of function in the filtering part of the kidney. This may lead to kidney failure, which can occur quickly (acute kidney failure) or may develop over time (chronic kidney disease).
Male cystoscopy
Your doctor will conduct a physical exam, which might reveal a nontender mass above your testicle that feels like a bag of worms. If it’s large enough, your doctor will be able to feel it.
If you have a smaller varicocele, your doctor might ask you to stand, take a deep breath and hold it while you bear down (Valsalva maneuver). This helps your doctor detect abnormal enlargement of the veins.
If the physical exam is inconclusive, your doctor might order a scrotal ultrasound. This test, which uses high-frequency sound waves to create precise images of structures inside your body, might be used to ensure there isn’t another reason for your symptoms. In certain cases, further imaging might be recommended to rule out other causes for the varicocele, such as a tumor compressing the spermatic vein.
Treatment
Varicocele treatment might not be necessary. Many men with varicoceles are able to father a child without any treatment. However, if your varicocele causes pain, testicular atrophy or infertility or if you are considering assisted reproductive techniques, you might want to undergo varicocele repair.
The purpose of surgery is to seal off the affected vein to redirect the blood flow into normal veins. In cases of male infertility, treatment of a varicocele might improve or cure the infertility or improve the quality of sperm if techniques such as in vitro fertilization (IVF) are to be used.
Clear indications to repair a varicocele in adolescence include progressive testicular atrophy, pain or abnormal semen analysis results. Although treatment of a varicocele generally improves sperm characteristics, it’s not clear if an untreated varicocele leads to progressive worsening of sperm quality over time.
Repair methods include:
- Open surgery. This treatment usually is done on an outpatient basis, during general or local anesthetic. Commonly, your surgeon will approach the vein through your groin (inguinal or subinguinal), but it’s also possible to make an incision in your abdomen or below your groin.
Advances in varicocele repair have led to a reduction of post-surgical complications. One advance is the use of the surgical microscope, which enables the surgeon to see the treatment area better during surgery. Another is the use of Doppler ultrasound, which helps guide the procedure.
You might be able to return to normal, non-strenuous activities after two days. As long as you’re not uncomfortable, you might return to more strenuous activity, such as exercising, after two weeks.
Pain from this surgery generally is mild but might continue for several days or weeks. Your doctor might prescribe pain medication for a limited period after surgery.
Your doctor might advise you not to have sex for a period of time. Most often, it will take several months after surgery before improvements in sperm quality can be seen with a semen analysis. This is because it takes approximately three months for new sperm to develop.
Open surgery using a microscope and subinguinal approach (microsurgical subinguinal varicocelectomy) has the highest success rates when compared with other surgical methods.
- Laparoscopic surgery. Your surgeon makes a small incision in your abdomen and passes a tiny instrument through the incision to see and to repair the varicocele. This procedure requires general anesthesia.
- Percutaneous embolization. A radiologist inserts a tube into a vein in your groin or neck through which instruments can be passed. Viewing your enlarged veins on a monitor, the doctor releases coils or a solution that causes scarring to create a blockage in the testicular veins, which interrupts the blood flow and repairs the varicocele. This procedure isn’t as widely used as surgery.
After embolization, you can often return to work after two days, and begin exercising after seven to 10 days.
Preparing for your appointment
You’re likely to start by seeing your primary care doctor. However, in some cases when you call to set up an appointment, you might be referred immediately to a urologist.
Here’s some information to help you get ready for your appointment, and know what to expect from your doctor.
What you can do
- Write down any symptoms you’re experiencing, including any that might seem unrelated to the reason for which you scheduled the appointment.
- Write down key personal information, including any major stresses or recent life changes.
- Make a list of all medications, vitamins and supplements that you’re taking.
- Take a family member or friend along, if possible. Sometimes it can be difficult to remember all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
- Jot down questions to ask your doctor.
Preparing a list of questions will help you make the most of your time with your doctor. List your questions from most important to least important. For varicocele, some questions to ask include:
- What’s the most likely cause of my symptoms?
- What kinds of tests do I need?
- Is my condition likely temporary or more permanent?
- Will this condition affect my fertility?
- What treatments are available? Which do you recommend?
- I have these other health conditions. How can I best manage these conditions together?
- Are there any restrictions on sexual activity that I need to follow?
- Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?
In addition to the questions you’ve prepared, don’t hesitate to ask questions that arise during your appointment.
What to expect from your doctor
Your doctor is likely to ask you a number of questions, including:
- When did you begin experiencing symptoms?
- Have your symptoms been continuous or occasional?
- How severe are your symptoms?
- What, if anything, seems to improve your symptoms?
- Does anything appear to make your symptoms worse?
What you can do in the meantime
Take an over-the-counter pain reliever and wear an athletic supporter to relieve pressure.
