Vesicoureteral reflux (VUR) is a condition in which urine from the bladder backs up into the ureters and kidneys. When this happens, bacteria from the bladder can enter the ureters and kidneys. Left untreated, the microbes can multiply, causing infection that can result in permanent damage to the kidney. Treatment for vesicoureteral reflux depends on the severity of the condition and its underlying cause.
Initial Treatment of VUR
Vesicoureteral reflux is often diagnosed after patients experience recurrent urinary tract infections or flank pain. If the cause is structural—i.e. an abnormality in the ureter or bladder—the doctor may take a wait-and-see approach. It's not uncommon for children born with ureter defects (e.g., the ureter is too small) to outgrow this condition as they age. In these cases, a physician will prescribe antibiotics to treat and prevent urinary tract infections.
Antibiotics prescribed to treat urinary tract infections include amoxicillin, nalidxic acid, bactrim, trimethoprim, and cephalosporins. They are typically prescribed for three to 10 days and are generally well-tolerated. However, side effects may include diarrhea, abdominal pain, nausea and vomiting.
Treatment for Underlying Conditions Causing VUR
In some instances, vesicoureteral reflux may be caused by underlying conditions, such as an enlarged prostate (men) or a ureter blocked by a ureter stone. In the case of an enlarged prostate, which surrounds the urethra (which transports urine from the bladder out of the body), pressure from the swollen gland can narrow or obstruct flow, forcing fluid from the bladder back up into the ureter. Likewise, a blocked ureter can also cause reflux as urine backs up into the urinary tract. Treating these underlying conditions should alleviate the symptoms of vesicoureteral reflux.
Treatment for an Enlarged Prostate
Treatment options for an enlarged prostate include medications, catheterization, holmium laser enucleation of the prostate (HoLEP). and surgery to remove the prostate (prostatectomy). A doctor's approach should depend on the severity of the condition and the patient's needs.
- Medications: Alpha-blockers, such as tamsulosin (Flomax), alfuzosin (Uroxatral), terazosin (Hytrin) and doxazosin (Cardura); alpha-reductase inhibitors, such as finasteride (Proscar) and dutasteride (Avodart); or herbal therapies, such as saw palmetto, can all be used to treat an enlarged prostate. These medications reduce the size of the gland and alleviate pressure on the bladder, thus restoring normal urine flow.
- Catheterization: Patients with an enlarged prostate can also use catheters to overcome an obstruction. A patient can be taught to self-catheterize, and can then guide his own catheter from the urethra to the bladder and drain the urine himself.
- Holmium laser enucleation of the prostate (HoLEP): In this procedure, a holmium-based laser is used to reduce the size of the prostate gland, burning away the tissue that's placing extra pressure on the ureter and relieving the constriction.
- Prostatectomy: In this surgical procedure, an incision is made into the abdomen to remove all or part of the prostate.
Treatment for a Ureter Stone
Stones can form anywhere along the urinary tract. Ureter stones begin their formation in the kidney before moving down to the ureter. When materials found in the urine (such as calcium and uric acid) become concentrated, they bind together to form crystals that, over time, amass into a solid stone. Treatment options depend on the stone's size and composition, as well as the impact it has had on urinary function.
- Watchful waiting: This is the most conservative treatment option for a ureter stone. Rather than actively treating it, a physician will monitor the patient using periodic x-rays or ultrasounds to ensure the stone is not growing or transforming. This approach is most effective when a stone is less than 7 mm in diameter. Stones larger than 8mm in diameter tend to require intervention.
- Extracorporeal shock wave lithotripsy or ESWL: ESWL is used to treat ureter stones that cannot pass on their own. This minimally invasive approach uses shock waves—applied outside of the body—to shatter the ureter stone into smaller pieces. Once the ureter stone has been broken down, the pieces may be more capable of passing through the ureter, bladder, and urethra. This procedure is most effective for stones smaller than 2 cm in diameter. It is less successful for stones larger than that, as well as those composed of cystine or calcium oxalate monohydrate; these tend to be too dense for shock waves to break up.
- Ureteroscopy: Ureteroscopy is a more invasive procedure than ESWL, and involves the placement of a slender microscope, or ureteroscope, into the ureter. Once the stone is within view, the surgeon can insert a flexible basket into the ureter to capture and remove it. If the stone is smaller than 10 mm in diameter, it can be extracted whole. If it's larger, a urologist can use various lithotripsy tools to fragment it into smaller, extractable pieces.
Additional Treatment Options
In some instances, vesicoureteral reflux is caused by anatomical problems that can't heal or self-correct, including those resulting from surgery or injury. If the nerves of the bladder are damaged, or scar tissue impedes the urinary tract, urine can flow back into the ureters and kidneys. Injury to the valves—where the ureter attaches to the bladder—can also cause reflux. When these and other more permanent issues are the underlying cause of vesicoureteral reflux, patients have two treatment options:
- Endoscopic injection into the ureter: This is a minimally invasive procedure in which an endoscope (a small, wand-like instrument with a camera at the tip) is used to inject a specialized gel into the ureter where it connects to the bladder. The gel creates a valve at the ureteral opening that prevents urine from flowing backwards up the ureter. This procedure, which can be performed under general anesthesia, is effective for patients who have mild forms of vesicoureteral reflux that is caused by problems with the ureter valve.
- Open surgery: If the cause of vesicoureteral reflux is more complicated or cannot be addressed through endoscopic injection into the ureter, open surgery must be done to correct the problem. Patients who undergo this invasive procedure need to spend several days in the hospital.
Prognosis
A patient's prognosis depends on the severity of the damage caused by vesicoureteral reflux. If the condition is identified and treated before the kidney suffers long-term damage, the patient should do well.
References
American Urological Association guideline: Management of benign prostatic hyperplasia (BPH). (2010). American Urological Association.
Management of ureteral calculi: Diagnosis and treatment recommendations. (2007). American Urological Association.
Vesicoureteral reflux. (2012). National Kidney and Urologic Disease Information Clearinghouse.
Albala D.M., Morey A.F., Gomella L.G., & Stein J.P. (2011). Stone fragmentation techniques: extracorporeal lithotripsy. Oxford American handbook of urology. Oxford University Press. Chpt. 8; p 372.
