Editing Pediatrics: Vesicoureteral Reflux (section)

== Associated Anomalies and Conditions ==

* '''<span style="color:#ff0000">Ureteropelvic Junction Obstruction'''
** '''<span style="color:#ff0000">VUR and UPJO are two of the most common pathologic conditions in pediatric urology'''
** '''The incidence of VUR associated with UPJO ranges from 9-18%'''
** '''Radiologic signs that suggest the existence of UPJO in the setting of reflux (3):'''
**# '''Pelvis shows little or no filling while the ureter is dilated by contrast'''; this may indicate a point of kinking secondary to reflux or from a primary UPJO
**# '''Poorly visualized contrast in the pelvis''' because of dilution in a large pelvic volume and exhibits a markedly reduced radiodensity compared with the ureter or bladder
**# '''Large pelvis that fails to exhibit prompt drainage but retains contrast'''
** Radiographic studies of UPJO associated with VUR may indicate true anatomic obstruction or simply dilation associated with pelvicureteral dilation from higher grades of reflux.
** '''If scintigraphy (with catheter drainage) confirms obstruction, pyeloplasty should be performed.'''
*** '''If both the UPJ and UVJ meet criteria for operative repair of obstruction and reflux, respectively, the UPJ should be repaired first to avoid the incipient obstruction that may ensue if resistance is added to the UVJ when reflux is corrected.'''
*** '''With care, both processes may be repaired simultaneously when it is clear that they are independent significant problems'''
**** The simultaneous open correction of UPJO and reflux has always raised a concern over surgical manipulation of both the upper and lower ureter at the same time, as well as its potential negative impact on ureteral vascularity. However, the advent of endoscopic injection raises the possibility of correcting reflux at the time of pyeloplasty for secondary or primary UPJO.
* '''Ureteral Duplication'''
** '''See Ectopic Ureter, Ureterocele, and Ureter Anomalies Notes'''
* '''Bladder Diverticula'''
** '''Reflux associated with a paraureteral diverticulum'''
*** '''Mechanisms'''
**** '''More common: a paraureteral diverticulum, which shares an anatomic point of origin at or near the UVJ, compromises the anti-reflux configuration of the UVJ to cause reflux'''
**** Rarely: a large paraureteral diverticulum expands within the Waldeyer fascia to cause ureteral obstruction or project forward into the bladder to obstruct the bladder outlet, much as a ureterocele, and incite secondary reflux
*** '''Resolves at rates similar to primary reflux and should be managed according to the prevailing indications for the reflux itself, irrespective of the diverticulum'''
** '''Reflux associated with a ureter entering a diverticulum'''
*** When a refluxing ureter enters a diverticulum, the diverticulum is no longer paraureteral
*** '''With no muscular support to the UVJ, reflux is not expected to resolve'''
*** '''Indications for repair requires the combined consideration of both the reflux and the diverticulum'''
* '''Renal Anomalies associated with VUR'''
** '''Multicystic dysplastic kidney (MCDK)'''
** '''Renal agenesis'''
*** '''Presence of either condition mandates a VCUG (CUA MCDK Guidelines do not mandate VCUG)'''
* '''Megacystis-Megaureter'''
** '''Definiton of megacystis-megaureter: a non-obstructive condition by regurgitation from incompetent valves'''
** The persistent large residual urine volume is a significant risk factor for recurrent UTI
** '''Diagnosis and Evaluation'''
*** '''Normal posterior urethra on voiding studies'''
**** '''Posterior valves or prune-belly syndrome will demonstrate an open posterior urethra'''
** '''Management'''
*** '''Surgical correction for the reflux is indicated''' given the propensity for VUR to exacerbate the effects of bacteriuria and the fact that UVJ dysfunction is the primary factor perpetuating the syndrome
*** '''Vesicostomy can temporize by eliminating the residual urine volume and establishing safe drainage of the upper tracts until ureteral reimplantation can be performed'''
*** A period of bladder rehabilitation by strict attention to emptying in the post-operative period usually will result in a return to normal bladder volume and contractile behavior
* '''Other Anomalies'''
** '''Congenital conditions and syndromes associated with VUR:'''
*** '''VACTERL association''' (''V''ertebral, ''A''nal, ''C''ardiac, ''T''racheo''E''sophageal, ''R''enal, and ''L''imb anomalies)
*** '''CHARGE''' '''syndrome''' (''C''oloboma, ''H''eart disease, ''A''tresia choanae, ''R''etarded development, ''G''enital hypoplasia, and ''E''ar anomalies)
*** '''Imperforate anus'''
** In cases in which VUR is anticipated, a VCUG is the initial study of choice to disclose both dysfunction at the UVJ and overall bladder and bladder outlet anatomy.