vesicoureteral reflux
Introduction
Introduction to vesicoureteral reflux Bladder ureteral reflux refers to the loss of anti-reflux effect of the ureteral bladder wall segment due to congenital or acquired causes. When the urine flow accumulates or the detrusor contractes and the intravesical pressure increases, the urine flow falls from the bladder. Flow into the ureter or even the renal pelvis. These causes include vesicoureteral junction flap congenital insufficiency or secondary to urinary tract obstruction and neurogenic bladder dysfunction. basic knowledge The proportion of illness: 0.001% Susceptible people: no special people Mode of infection: non-infectious Complications: urinary tract infection
Cause
Bladder ureteral reflux cause
(1) Causes of the disease
Anatomical defects of the ureter (35%):
The ureter is moved outward, the ureter in the lower mucosa is shortened, and the ability to resist reflux is lost. The ratio of the length of the normal submucosal ureter to its diameter is 5:1, and when there is reflux, it is only 1.4:1.
Increased intravesical pressure (25%):
When the lower urinary tract obstruction (late urethral stricture and benign prostatic hyperplasia) or the neurogenic bladder causes bladder retention in the bladder, elevated intravesical pressure destroys the anti-reflux mechanism of the ureteral junction and produces reflux.
Abnormal ureteral opening (18%):
It is also the cause of reflux, and the sports field shape, horseshoe shape and golf hole-shaped ureteral opening are prone to reflux.
Congenital ureteral dysplasia (15%):
Ureteral ureteral diverticulum, ureteral cyst, ureteral opening in the bladder diverticulum, ectopic ureteral opening and other ureteral abnormalities can also cause vesicoureteral reflux.
(two) pathogenesis
Under normal circumstances, the ureteral junction of the bladder has a similar anti-reflux effect, which only allows urine to flow from the ureter to the bladder, and prevents urine from flowing back into the ureter. This effect mainly depends on the length of the ureter in the lower mucosa of the bladder. The ability of the muscular layer of the triangle to maintain this length and the supporting effect of the detrusor on the posterior wall of the ureter. When the intravesical pressure is increased, the submucosal ureter is compressed and closed without reflux, and the ureteral peristalsis and ureter The ability to close the mouth also has an important anti-reflux effect. Previously, partial vesicoureteral reflux was considered a normal physiological phenomenon. Until 1958, Hutch confirmed that vesicoureteral reflux can cause ureteral dilatation, hydronephrosis, impaired renal function and repeated Upper urinary tract infection.
According to the degree of contrast agent reflux during urinary bladder urethra angiography, the ureteral reflux can be divided into 5 degrees: I degree: the contrast agent only flows back to the lower part of the ureter, and there is no obvious expansion; II degree: contrast agent reflux to Renal pelvis, renal pelvis, but no expansion; III degree: contrast agent reflux to renal pelvis and renal pelvis, and mild or moderate pyelectasis, but no or only mild renal pelvis dull; IV degree: renal pelvis, renal pelvis moderate Dilation and/or ureteral tortuosity, but most renal pelvis maintain nipple morphology; V degree: severely dilated renal pelvis and renal pelvis, most pelvis lost nipple morphology, ureteral distortion.
Prevention
Bladder ureteral reflux prevention
The disease is usually secondary to other congenital diseases, such as congenital ureteral dysplasia, ureteral diverticulum, ureteral cyst, ureteral opening in the bladder diverticulum, ectopic ureteral opening and other ureteral abnormalities can also cause vesicoureteral reflux. It is believed that such diseases are related to autosomal recessive inheritance and are usually related to the marriage of close relatives. This disease cannot be directly prevented. For patients with a family history of suspected chromosomal abnormalities, genetic screening should be carried out to avoid the offspring of the disease caused by chromosome inheritance after marriage. At the same time, attention should also be paid to strengthening nutrition during pregnancy, reasonable diet, and avoiding emotional stimuli that affect embryonic development.
Complication
Bladder ureteral reflux complications Complications, urinary tract infections
1. Urinary tract infection: reflux causes some urine to go retrograde when the bladder is empty, providing a pathway for bacteria to move from the bladder to the renal pelvis. Therefore, reflux often involves urinary tract infection, and clinical symptoms of acute pyelonephritis may occur. Symptomatic pathological process of chronic pyelonephritis, some scholars found that 97% of patients with renal scar have vesicoureteral reflux, while severe reflux is more likely to produce renal scars in small infants.
2. Renal scar: In children with reflux, 30% to 60% of renal parenchymal scars occur. The degree of renal scar is proportional to the severity of reflux. Smellie et al. classify renal scars into 4 grades:
Grade A, there are only 1 or 2 kidney parenchymal scars.
Class B, a wider range of irregular scars.
Grade C, all kidney parenchyma is thin, with extensive renal pelvis deformation.
Grade D, kidney atrophy.
Symptom
Bladder ureteral reflux symptoms common symptoms urinary frequency urgency urinary pain drowsiness anorexia fatigue nausea hypertension pyuria secondary infection
Infants and young children often present non-specific symptoms of urinary tract infection and reflux, including fever, fatigue, lethargy, anorexia, nausea and vomiting and growth retardation, renal colic and renal tenderness, such as secondary infection, will appear Frequent urination, urgency, symptoms of dysuria, severe infection, pyuria may occur, and occasionally fatigue may occur after stagnation, patients with renal scar formation may be treated for hypertension, the most serious consequence is the occurrence of pyelonephritis scar, leading to Hypertension and chronic renal insufficiency. In addition to the enlarged kidneys, physical examination can occasionally touch the thickened ureter. The kidney area may have mild sputum pain. Bilateral vesicoureteral reflux may be used. There are symptoms of renal insufficiency.
Examine
Bladder ureteral reflux examination
Routine examination of urine and bacteriological examination: to determine the existence of urinary tract infection, the type of pathogenic bacteria and sensitivity to antibiotics, blood urea nitrogen, creatinine will increase when renal insufficiency.
1. Ultrasound examination: B-ultrasound can be used in older children, can show the size of kidneys on both sides, kidney scar formation, ureteral dilatation, hydronephrosis, estimated renal parenchyma thickness and follow-up observation of kidney growth, more color The Pu'er examination can observe the blood supply of the renal parenchyma to determine renal scar and renal function.
2.IVU: It can display the renal pelvis and ureter morphology, understand the degree of hydronephrosis and renal function, and estimate the thickness of renal parenchyma and the growth and development of the kidney.
3. Urinary bladder urinary tract angiography (vUG): an important method for the diagnosis of vesicoureteral reflux, which can be used as a screening test for vesicoureteral reflux, especially for children under 5 years of age. After filling the contrast agent, the patient is urinated, and the contrast agent is seen to flow upward along the ureter.
4. Cystoscopy: mainly used to understand the shape, location and size of the ureteral orifice.
5. Urodynamic examination: understanding the lower urinary tract obstruction and bladder detrusor contraction function, can be used to determine the primary cause of secondary reflux.
6. Examination of the primary disease: such as benign prostatic hyperplasia, bladder neck obstruction, neurogenic bladder, urethral stricture, posterior urethral valve.
Diagnosis
Diagnosis of vesicoureteral reflux diagnosis
diagnosis
According to clinical manifestations and imaging, endoscopy, diagnosis is not difficult.
Differential diagnosis
1. Congenital giant ureter: can also cause kidney, ureteral dilated water, especially ureteral dilatation is more significant, similar to the effusion caused by vesicoureteral reflux, clinical manifestations are similar, but congenital giant ureteral lesions at the end of the ureter, IVU or retrograde urography showed ureteral stenosis, contrast agent excretion obstruction, cystography without ureteral reflux, and cystoscopy for normal ureteral opening.
2. Ureteral tumor: can cause kidney and ureteral hydrops, but ureteral tumor with painless gross hematuria as a clinical feature, IVU or retrograde angiography can be seen in the ureteral filling defect, urinary bladder angiography without bladder ureteral reflux, cystoscopy see A new ureteral opening or a papillary or cauliflower-like new organism protrudes from the ureteral orifice into the bladder.
3. Ureteral calculi: can cause kidney and ureteral hydrops, but there are repeated episodes of lumbar and abdominal cramps or soreness with hematuria. IVU examination shows ureteral calculi and excretion obstruction, a small amount of negative stones, B-ultrasound or CT examination Gravel can be found, no vesicoureteral reflux in cystography, and normal ureteral opening in cystoscopy.
4. Ureteral cyst: can cause renal ureteral hydrops, IVU shows filling defects in the bladder due to cysts protruding into the bladder, there is a "cobra head"-like negative, no ureteral reflux, but B-ultrasound and CT examinations show bladder cyst Sexual mass, cystoscopy, ureteral cystic mass, central porcine urination, rhythmic filling and collapse.
5. Lower urinary tract obstructive disease: Lower urinary tract obstructive diseases such as benign prostatic hyperplasia, urethral stricture, neurogenic bladder and other diseases can cause vesicoureteral reflux, regardless of physical examination, X-ray examination, etc. The performance of the primary disease, more importantly, the vesicoureteral reflux caused by the lower urinary tract obstruction disease is bilateral.
