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Bladder and ureter reflux in children
Last reviewed: 23.04.2024
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Bladder-ureteral reflux in children is a pathological condition characterized by the return of urine from the bladder to the upper parts of the urinary system due to a violation of the valve mechanism of the uretero-vesicle segment.
Anatomy of the vesicoureteral segment: uretero-vesicular cohust (UCS) consists of a juxtavezic part, an intramural part and a submucosal part ending with the ureteral anterior. The length of the intramural region increases from 0.5 to 1.5 cm, depending on the age.
The anatomical characteristic of the normal mechanism of uretero-vesicular anastomosis includes an oblique incidence of the ureter in the Lieto triangle and a sufficient length of its intravesical section. The ratio of the length of the submucosal tunnel to the diameter of the ureter (5: 1) is the most important factor determining the effectiveness of the valve mechanism. The valve is basically passive, although there is an active component provided by ureterotrigonal muscles and urethral membranes that, at the time of detrusor reduction, cover the mouth and submucosal tunnel of the ureter. Active peristalsis of the latter also prevents reflux.
The peculiarity of the vesicoureteral segment in young children is the short internal ureter, the absence of the Valdeier's fascia and the third layer of the muscles of the lower third of the ureter, the varying angle of the intravesical part of the ureter to the intra-wall part of the ureter (the right angle in the newborns and the oblique in older children) elements of the pelvic floor, the intra-wall section of the ureter, the fibrous-muscular vagina, the luteuldic triangle of Lieto.
In newborns, the triangle of Lieto is located vertically, being, as it were, an extension of the posterior ureteral wall. In the first year, it is small, poorly expressed and consists of very thin, tightly adjacent smooth muscle bundles, separated by fibrous tissue.
The development and progression of vesicoureteral reflux at an early age is facilitated by the underdevelopment of the neuromuscular apparatus and the elastic framework of the ureter wall, a low contractility, a disruption of the interaction between the peristalsis of the ureter and contractions of the bladder.
[Causes of vesicoureteral reflux in children
The etiology and pathogenesis of vesicoureteral reflux has been studied for more than 100 years, but to date they have not become more understandable for a significant number of clinicians and morphologists. Existing points of view on the causes of the onset and the mechanism of the development of vesicoureteral reflux are sometimes so contradictory that even now this problem can not be considered solved to the end.
Bladder and ureter reflux with the same frequency occurs in boys and girls. However, at the age of up to one year, the disease is predominantly diagnosed in boys in a 6: 1 ratio, whereas after 3 years with the greatest frequency, it is diagnosed in girls.
Symptoms of vesicoureteral reflux in children
The clinic of vesicoureteral reflux can be erased, and this condition is revealed when examining children with complications of vesicoureteral reflux (for example, pyelonephritis).
Nevertheless, there are general symptoms that are characteristic of children with vesicoureteral reflux: physical retardation, birth weight deficit, a large number of stigmas of dysembryogenesis, neurogenic dysfunction of the bladder, repeated "causeless" temperature rises, abdominal pains, especially those associated with act of urination. However, these symptoms are typical for many diseases.
Diagnosis of vesicoureteral reflux in children
Inflammatory changes in the kidneys and urinary tract can be accompanied by isolated urinary syndrome, mainly leukocyturia. Proteinuria is more common in older children, and its appearance in young children indicates gross renal changes against a background of vesicoureteral reflux.
The main method of diagnosis of vesicoureteral reflux is the mictorial cystography, in which, depending on the degree of casting of the X-ray contrast medium, five degrees of vesicoureteral reflux are isolated.
How to examine?
What tests are needed?
Treatment of vesicoureteral reflux and reflux nephropathy in children
When choosing a treatment plan for vesicoureteral reflux and its complications, a thinly differentiated approach is necessary, since surgical intervention on a relatively immature vesicoureteral segment can interrupt the natural maturation process and affect the functions of the organs of the vascular system in the future. In addition, differential diagnosis of the causes of reflux (developmental defect, morphofunctional immaturity or inflammation) is difficult, which is especially characteristic for children under three years old.
But it must be remembered that treatment of vesicoureteral reflux follows from the time of pathology. Indications for surgical treatment of vesicoureteral reflux are considered to be vesicoureteral reflux of grade 3 with ineffectiveness of conservative therapy for 6-12 months; vesicoureteral reflux of 4-5 degree.
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