What is Normal?
Your child has two kidneys that make urine. The urine travels down the ureters into the bladder where it is stored until he urinates out the urethra. This urine flow should only be one way: from kidney to ureter to bladder to urethra and out.
What is Reflux?
In patients who have reflux, urine washes back up from the bladder to the kidney. The usual cause is a weakness or deficiency of muscle at the point where the ureter connects to the bladder. This muscle normally acts to close the ureter and prevent backwash of urine up to the kidneys. The reflux of clean urine poses no problem to the child and no threat of damage to the kidneys. However, if the urine becomes infected, the infection can travel back up to the kidneys and cause a kidney infection-pyelonephritis. Kidney infections can cause damage or scarring to the kidney. Reflux can occur on one side (unilateral) or both sides (bilateral). Reflux also occurs in different degrees or grades from mild (grade 1) to severe (grade 5).
How is Reflux Diagnosed?
A VCUG – X-ray of the bladder is used to diagnose reflux. A thin tube, catheter, is inserted into the urethra- the opening where the urine comes out. Fluid containing dye is injected through the tube until the bladder is full. The child urinates and pictures are taken to see if the dye goes backward up to one or both kidneys.
Mild to moderate reflux is treated with long-term, low-dose antibiotic therapy to prevent infections. In many cases, as the child grows and the bladder muscles develop, the reflux cures itself. Your child will need to have an X-ray study to determine the amount of reflux still present. One sign that these muscles may be maturing is the development of urine control in a child who was previously a day or night wetter.
In more severe forms of reflux or if antibiotic therapy does not control the infections, surgery may be needed. Traditional techniques move the ureter to a place on the bladder where there is more muscular support.
Endoscopic treatment means that a cystoscope- a miniature viewing device- is inserted into the bladder through the urethra. A material is then injected into the bladder at the locations where the ureters enter the bladder. A little bulge is formed which makes it harder for the urine to flow backwards. The bulge also makes the openings from the ureters into the bladder smaller, which again makes it harder for the urine to flow back. The openings are still large enough for the urine to flow down into the bladder without any problem.
1. Any time your child has a fever of 101 degrees F or more, he will need to have his urine checked, not just his ears and throat. (Your family doctor can do this.)
2. Since reflux tends to run in families, it is a good idea to have your other children evaluated by a urologist. (The office staff can set that up for you.)
Be sure to keep the appointments with the doctor as scheduled.
It is important to give antibiotics once a day, usually at bedtime, to prevent infection.
When to call the office
1. If your child has a urinary tract infection
2. If your child has any unexplained fever or belly pain
Why is Surgery Necessary for Children with Reflux
Reflux is the backward flow of urine from the bladder to the kidney. Surgery stops this backward flow. This backward flow poses a treat to the kidneys’ health when the urine is infected. The main reasons for performing surgery are:
1. Inability to control infection
2. Persistent reflux
3. Severe degree of reflux that has little chance of stopping on its own
What is Anti-reflux Surgery?
Anti-reflux surgery is done to stop the flow of urine up into the kidneys. There are two possible types of surgery your child may have if diagnosed with reflux.
The surgery consists of moving (“reimplanting”) the ureter (tube which carries urine from the kidneys to the bladder) to a place on the bladder where there is more muscular support so the urine can not wash back u the ureters to the kidney. The incision for the surgery will be in a curved line just above the pubic area, or a small incision in the groin.
Endoscopic treatment means that a cystoscope (a miniature viewing device) is inserted into the bladder through the urethra. A material is then injected into the mucosa of the bladder at the locations where the ureters enter the bladder. A little bulge is formed which keeps the urine from flowing backwards. The bulge also makes the openings from the ureters into the bladder smaller, which again keeps urine from flowing back. The openings are still large enough for the urine to flow down into the bladder without any problem.
After your child is taken into surgery, you can wait in the Outpatient Surgery Lobby at Children’s Hospital. The “reimplantation” surgery takes 2-3 hours, and the endoscopic surgery takes 30 minutes. Your doctor will talk to you as soon as he is finished. Your child will then be in the Post Anesthesia Care Unit (Recovery Room) for 1-2 hours before you can see him in his room. The staff will call you when you can see your child.
What to Expect after “Reimplant” Surgery
When you see your child after surgery, he will have:
- IV- A plastic tube into his arm for the first day following surgery. This will be removed as your child eats and drinks without problems
- Foley Catheter- a tube that drains the bladder of urine. This tube is connected to a urine bag. While the bladder is draining, the urine may look dark red or pink and may contain some blood clots. This is normal. Your child may go home with the catheter in place for several days from the day of surgery. He may pass some clots in his urine and may feel burning when urinating for several days after the catheter is removed. This is also normal. Be sure your child drinks plenty of fluids.
- Dressing- A small gauze dressing or “Steri-Strips” will cover the incision.
- Medication- Your child will be given pain medication as needed. It will be given in the IV until he/she is eating and then can be given in oral form. Your child will also receive antibiotics through the IV and then by mouth. He/She will continue on the antibiotics at home.
- Pain- Some children may have bladder spasms which give them an intense feeling of having to urinate even though their bladder is empty. These spasms happen because the bladder has been opened for surgery. Constipation may make bladder spasms worse, so you must ensure that your child has at least one soft bowel movement per day. You may use an over the counter stool softener if necessary (milk of magnesia,, etc.).
- Activity- Early activity should be encouraged. Hen he is out of bed, a special leg bag may be used for the catheter so it is easier for him to move around.
Home going Instructions for “Reimplant” Surgery
1. No heavy physical activities (such as gym, bike riding, swimming) for 3 weeks.
2. Continue giving the antibiotics and other medications as directed.
3. You may begin giving baths the day after hospital discharge.
4. Your child may return to school 10 days after surgery.
Follow-up Care for “Reimplant” Surgery
Your child will need to be followed up for at least a year. At the first appointment after surgery (1 month), your child will be scheduled for an ultrasound exam of the kidneys and bladder. The ultrasound is then repeated at 4 months and 12 months after the operation.
What to Expect after Endoscopic Surgery
- Medication- Your child will need to continue taking a daily antibiotic until a bladder X-ray shows reflux is no longer present.
- Pain- There may be some pain after your child has endoscopic surgery, including pain with urination. Your child may use Tylenol for this pain.
- Activity- Your child will go home the next day of surgery. He will be able to go to school the in 2-3 days, and to participate in activities as he can tolerate.
Home going Instructions for Endoscopic Surgery
1. Continue giving the antibiotics and other medications as directed.
2. You can begin giving baths the day that you go home.
Follow-up Care for Endoscopic Surgery
Your child will need to be followed up for at least a year. At the first appointment after surgery (1 month), your child will be scheduled for an ultrasound exam of the kidneys and bladder. At 4 months as well as 12 months after the surgery, your child will have a voiding cystourethrogram (VCUG), as well as another ultrasound.
When to Call the Office
1. If your child has a fever of more than 101 degrees F
2. If your child is having severe pain
3. If your child has significant vomiting or is dehydrated