Janie, a 19-month-old toddler, has been in excellent health. She had her 18th month well-check a few weeks ago, and I remember commenting to Mom how Janie has not really been sick. Her chart listed well-checks with the exception of one ear infection at eight months.
Today the baby was in the office due to two days of high fever, up to 102.5 degrees. She did not have any specific symptoms such as a cough, runny nose, vomiting or diarrhea. The examination was normal and did not reveal any source for the fever. "Is it just a virus?" her Mom asked quite appropriately.
I thought for a moment before I answered. "It most definitely could be viral, but we have to be certain that we are not dealing with a urinary tract infection, UTI," I told her. If this was a urinary tract infection with such a fever it would mean that it was a kidney infection, not just a bladder infection.
I had the nurse collect a urine specimen from Janie. Sure enough , it was not normal and very indicative of a UTI. I sent the urine to be cultured so that the bacteria could be identified. The urine culture is the gold standard to document a UTI. We started Janie on antibiotics.
Within 24 hours the baby responded. The fever resolved and she was back to her playful and active self. At her re-check, I told Mom that we would need to do some tests to study the anatomy of Janie's urinary tract. This was to ascertain that there was not an anatomical abnormality that had predisposed her for getting an infection. Mom met this news with some anxiety, but I reassured her that this was the standard of care for all young children who get their first UTI. There was nothing different about Janie that alerted me to do these tests. This procedure would be recommended for any young child with a documented UTI.
Mom agreed. We scheduled Janie for an ultrasound of the kidneys and a special X-ray called a voiding cystourethrogram. The ultrasound is done to visualize that the kidneys are two of normal size and in their proper place. Some people are born with anatomical variants such as horse-shoe shaped, or are missing a kidney altogether. These conditions may alter the normal flow of urine from the kidneys. They can cause some stasis of the urine, thus setting one up for an infection.
The voiding cystourethrogram (VCUG) is an X-ray whereby the radiologist inserts a catheter into the bladder. It is filled with a dye that can be seen on X-ray. When the catheter is pulled and the patient voids, the dye and urine should stay within the bladder before being eliminated. If a person has vesicoureteral reflux, VUR, the urine and dye will flow instead backwards toward the kidneys. One may have significant VUR and have absolutely no symptoms. Over time, however, VUR can cause scarring of the kidneys which can lead to high blood pressure and even end-stage renal failure.
When Janie came in for the follow-up appointment we discussed the results of her tests. The ultrasound showed two normal-sized kidneys. Her VCUG, on the other hand, was NOT normal. It showed that she had grade II reflux of the left ureter and kidney. Again, her mother was quite concerned. I explained that VUR was not an uncommon condition. The urine is made by the kidneys and flows down a long narrow tube, the ureter, to the bladder. The lower part of the ureter is "tunneled" through the muscular wall of the bladder creating a valve-like pressure gradient . This, in turn, prevents the backflow of urine toward the kidney; hence, VUR. If the tunneled portion of the ureter is too short or off to one side, this may allow for VUR. Other conditions that have been associated with VUR are chronic constipation or incomplete emptying of the bladder upon voiding.
Based on VCUG studies there is a grading system to classify the severity of the reflux. It goes from grade I which is the mildest form to grade IV, the most severe. When one identifies VUR, three options are available to prevent recurrent infections or kidney damage. The first of these options is prophylactic antibiotics whereby a patient would take a low dose antibiotic daily for 6-12 months. As the milder forms of VUR can resolve on their own with time, the antibiotics are used to keep the urinary tract from becoming re-infected. This is safe and requires periodic urine cultures to be sure that the urine has not once again become infected. After six months, another VCUG is performed to see if the VUR has resolved. This is quite successful in treating grades I and II.
In grades III and IV there is usually structural changes of the kidneys as a result of the VUR. Many surgeons will recommend surgery. This would entail "re-implanting", or re-tunneling the distal end of the ureter into the bladder wall to re-establish the integrity of the unit to prevent reflux. Significant surgery is required which may mean a day or two in the hospital. But in competent hands, it is very successful.
The third option involves an endoscopic procedure usually performed in an out patient setting. Using an endoscope, a small tube with a camera at the end, the surgeon inserts the scope to the area where the ureter joins the bladder wall. He injects an inert gel at the spot where the ureter connects with the bladder. This creates a wall that will allow the urine to flow into the bladder but not flow back toward the kidney. Over time, new tissue forms in the area where the gel has been deposited. This has been very successful in providing long term results in preventing recurrence of VUR.
Going over all of the options, Janie's Mom preferred giving the antibiotics a try as it did not involve any invasive procedure. We agreed that this was perfectly acceptable.
After six months of preventive antibiotics we repeated the VCUG. It showed that the VUR had improved from a grade II to a grade I. Janie's mom was not too disappointed. The antibiotics had become very routine for both Janie and mom. She was willing to give it another six months. This decision seemed very reasonable. If this did not work, we should consider having Janie evaluated for the endoscopic procedure.
At the end of the second antibiotic trial the repeat VCUG was completely normal and we stopped the medication completely.