Vesicoureteric reflux: Case

This child has grade IV left vesicoureteric reflux with an established upper-pole renal scar, recurrent febrile infection, and a clear picture of bladder and bowel dysfunction. The grade IV is defined by the moderate dilatation and tortuosity of the ureter, the obliteration of the calyceal fornices, and the preservation of the papillary impressions on the micturating cystourethrogram. The cortical defect on the DMSA scan confirms reflux nephropathy, and the split function of 42 percent on the left reflects the functional loss from the scar. The three febrile infections in 10 months, despite intermittent treatment, signal that the conservative approach has failed and that a structured management plan is needed. ^[1]

Clinical findings

The key clinical findings are the recurrent febrile infections, the grade IV reflux on the left, the upper-pole cortical scar, the blood pressure on the 90th centile, and the bladder and bowel dysfunction. The three febrile infections in 10 months place this child in the highest risk category for progressive scarring, and the existing scar is evidence that the damage has already begun. The split function of 42 percent on the left is modestly reduced, which indicates that the scar has affected the function of the left kidney, and the blood pressure on the 90th centile is a warning sign that the reflux nephropathy may already be driving an early hypertension. ^[8]

The bladder and bowel dysfunction is a critical finding. The daytime urgency, the infrequent voiding of three times a day, and the chronic constipation are the classic triad, and Elder and Diaz showed that this constellation is present in over 40 percent of children with reflux. The dysfunctional bladder generates high storage and voiding pressures that drive the reflux and the recurrent infection, and the loaded rectum compresses the bladder and worsens the voiding pattern. The bladder and bowel dysfunction is the strongest predictor of conservative management failure, and its treatment is the first priority. ^[5]