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Adult Vesicoureteral Reflux

Vesicoureteral reflux (VUR) in an adult most often represents persistence of primary (congenital) reflux that was never corrected or that recurred after childhood repair, or reflux that is secondary to bladder outlet obstruction, neurogenic voiding dysfunction, prior pelvic or anti-reflux surgery, or a transplanted kidney.[1] The adult urologist's concerns differ from the pediatric framework: the driving questions are recurrent febrile infection, reflux nephropathy and its long-term renal and obstetric consequences, and whether correction is still worthwhile once scarring is already established. For pediatric VUR management and reimplantation technique, see Ureteral Reimplantation.

Primary Versus Secondary Reflux in the Adult​

  • Primary VUR reflects a congenitally short or abnormally positioned intramural ureteral segment. Most cases are diagnosed and either resolve or are corrected in childhood; some persist asymptomatically into adulthood and are discovered on imaging obtained for another reason, or after a febrile urinary tract infection or pregnancy-related workup.[1]
  • Secondary VUR in an adult follows bladder outlet obstruction, neurogenic lower urinary tract dysfunction, prior bladder or anti-reflux surgery, or a ureteral reimplantation into a bowel-based urinary reservoir or renal allograft. The underlying bladder or outlet process is assessed and treated alongside the reflux itself; reflux into a low-pressure, well-emptying adult bladder is managed differently from reflux maintained by ongoing elevated storage or voiding pressure.

Evaluation​

  • Voiding cystourethrogram (VCUG) remains the standard study to confirm and grade reflux in an adult, as in a child.[1]
  • Urodynamics is added when secondary reflux from outlet obstruction or a neurogenic process is suspected, to characterize bladder pressure, compliance, and emptying rather than treating the reflux in isolation.
  • Renal imaging and function testing (ultrasound, nuclear renography, serum creatinine/eGFR, and urinalysis for proteinuria) assess for reflux nephropathy, differential renal function, and hypertension, which drive most of the long-term morbidity attributed to VUR.[2][3]

Reflux Nephropathy​

Reflux nephropathy is focal renal scarring attributed to reflux, usually in the setting of recurrent childhood pyelonephritis, and is a recognized cause of hypertension, proteinuria, and progressive chronic kidney disease in adults who carry a VUR diagnosis.[2] Acquired (post-infectious) scarring is more common in girls, while congenital scarring detected without a preceding infection is more common in boys; this distinction has been proposed to explain a difference in adult presentation, with men more often presenting with hypertension, proteinuria, and progressive renal impairment and women more often presenting with recurrent urinary tract infection and a more favorable renal course.[2] Reported risk factors for reflux nephropathy include higher reflux grade, recurrent urinary tract infection, bladder-bowel dysfunction, younger age at infection, and delay in treating infection; no evidence-based guideline defines the optimal long-term follow-up interval for an adult with established reflux nephropathy.[2]

Pregnancy​

Renal scarring, rather than the presence or absence of reflux itself, is the main determinant of pregnancy-related morbidity in women with a history of VUR. Women with VUR and normal, unscarred kidneys have not been shown to have an increased rate of gestational hypertension, pre-eclampsia, or fetal morbidity regardless of whether the VUR was diagnosed in childhood or adulthood, though they do have a higher rate of urinary tract infection during pregnancy that is not reduced by prior ureteral reimplantation.[4] A 2018 systematic review and meta-analysis of case series reporting on 434 women and 879 pregnancies with reflux nephropathy, published from 2000 onward, found an increased risk of pregnancy-induced hypertension (odds ratio 5.55, 95% CI 3.56-8.66), pre-eclampsia (odds ratio 6.04, 95% CI 2.41-15.13), and hypertensive disorders overall (odds ratio 10.43, 95% CI 6.90-15.75) compared with a low-risk pregnancy reference population, with no significant difference in preterm delivery or cesarean section; no study in the review had its own internal control group, and a higher stillbirth rate in one series requires further study.[3] Taken together, these findings support counseling women with reflux nephropathy about a higher risk of hypertensive pregnancy complications, especially late in pregnancy, while making clear that correcting low-grade reflux in an unscarred kidney has not been shown to reduce that risk.[3][4]

Treatment​

Antireflux surgery versus continued medical management​

Older long-term adult comparisons report lower rates of pyelonephritis after surgical correction than with continuous antibiotic prophylaxis, with similar overall urinary tract infection rates between strategies; a frequently cited 16-year adult follow-up reported pyelonephritis in 33% of patients after reimplantation versus 72% managed with continuous prophylaxis, though overall infection rates were not significantly different and the original report does not give the cohort denominator.[5] Surgical correction has not been shown to reverse established proteinuria or halt progressive renal decline once baseline renal dysfunction is present, so correction is directed at recurrent symptomatic infection and reflux-associated flank pain rather than at reversing already-established nephropathy.[5] This evidence predates contemporary antibiotic stewardship practice and should not be read as a current guideline recommendation for or against surgery.

Endoscopic injection in adult women​

Endoscopic subureteral injection of dextranomer/hyaluronic acid copolymer has been reported as an office- or day-surgery-level option for adult women with VUR, most of whom present after childhood VUR, a family history of VUR, or prior open anti-reflux surgery. In a retrospective series of 19 women (mean age 22 years) treated for VUR diagnosed by cystourethrogram after pyelonephritis or recurrent infection with renal scarring, the success rate (strictly defined as complete resolution of reflux) was 79% after one injection, 92% after a second treatment in five patients, and 96% after a third treatment in two patients, with no reported perioperative complications.[6] This is a single-center series without a comparison group.

Reflux after renal transplantation​

Vesicoureteral reflux into a transplanted kidney is common and is usually asymptomatic. Surgical treatment is reserved for recipients with recurrent graft pyelonephritis despite antimicrobial prophylaxis; endoscopic bulking injection has been described for low-grade disease, while higher-grade (IV-V) reflux is generally managed with open ureteroneocystostomy revision.[7]

See Also​

References​

1. Friedman AA, Hanna MK. Vesicoureteral Reflux and the Adult. In: Wood HM, Wood D, eds. Transition and Lifelong Care in Congenital Urology. Springer; 2015:173-191.

2. Mattoo TK. "Vesicoureteral Reflux and Reflux Nephropathy." Adv Chronic Kidney Dis. 2011;18(5):348-54. doi:10.1053/j.ackd.2011.07.006

3. Attini R, Kooij I, Montersino B, Fassio F, Gerbino M, Biolcati M, Versino E, Todros T, Piccoli GB. "Reflux Nephropathy and the Risk of Preeclampsia and of Other Adverse Pregnancy-Related Outcomes: A Systematic Review and Meta-Analysis of Case Series and Reports in the New Millennium." J Nephrol. 2018;31(6):833-46. doi:10.1007/s40620-018-0515-1

4. Hollowell JG. "Outcome of Pregnancy in Women With a History of Vesico-Ureteric Reflux." BJU Int. 2008;102(7):780-4. doi:10.1111/j.1464-410X.2008.07671.x

5. Köhler J, Thysell H, Tencer J, et al. "Conservative Treatment and Anti-Reflux Surgery in Adults With Vesico-Ureteral Reflux: Effect on Urinary-Tract Infections, Renal Function and Loin Pain in a Long-Term Follow-Up Study." Nephrol Dial Transplant. 2001;16(1):52-60. doi:10.1093/ndt/16.1.52

6. Murphy AM, Ritch CR, Reiley EA, Hensle TW. "Endoscopic Management of Vesicoureteral Reflux in Adult Women." BJU Int. 2011;108(2):252-4. doi:10.1111/j.1464-410X.2010.09824.x

7. Duty BD, Barry JM. "Diagnosis and Management of Ureteral Complications Following Renal Transplantation." Asian J Urol. 2015;2(4):202-7. doi:10.1016/j.ajur.2015.08.002