Primary VUR presenting in Adulthood

• 30 Apr 2021 05:51:03 PM
• |Pediatic Urology

Clinical Details:

·        30 Y, M

·        LUTS: since 2-3 months: Urine stream is weak, intermittency, straining, post void dribbling, sense of incomplete void, frequency D: 3-4, N: 01

·        AUA score is 16/35

·        Right abdominal pain sometime since 2 months

·        H/o fever 15 days back, no nausea, no vomiting, no haematuria

·        Appetite good, no constipation.

·        H/O Ayurvedic medicine for stone disease, doubtful h/o passing stone .

·        Past History: No h/s/o recurrent fever in childhood, On repeated asking no h/s/o recurrent UTI Asked the senior members of his family, He was hospitalized twice in childhood. Of which once was for jaundice and the other time no details

·        BP 155/91, P75

·        PA: soft, no lump ,no tenderness, bladder is not palpable, penis: NAD, no renal angle tenderness.

·        PR: Prostate is flat tone good, no tenderness, perianal sensation are normal

Lab and Imaging

·        HB: 13.7, TLC: 6,800, N: 56, L: 41, PL: 2,49,000,

·        Urea: 38, SrCr: 1.94, SrCr 2.58

·        Urine r/m 1-2 PC,

·        Urine c/s: No growth (he had received antibiotics before)

·        Ultrasound: Both kidneys are normal in size with raised renal CMD, RK PCS fullness, dilated upper ureter on right side, on bladder plate both the lower ureters are seen dilated, Prevoid 289, Postvoid Nil

·        Plain CT KUB: Bilateral renal cortical scarring, LK: 9.1x5.2 RK: 9.9x 4.8, Mild to mod HN RK, Mild prominence of lower ureters on both side, mild dilatation of bilateral distal ureter is noted

What next?

·        The bladder is smooth

·        The picture is s/o Primary reflux

·        He has bilateral dilating reflux

·        Creat is deranged

·        Hypertension

·        Do we reimplant? Will it help?

 

Comments(5)

• 

  HEMANT RANGNATH PATHAK

  04 May 2021 06:09:06 PM

  He has presented with voiding symptoms. No residual urine

  Any bowel symptoms?

  Should do his Uroflowmetry

• 

  Amilal Bhat

  04 May 2021 06:36:31 PM

  Voiding time 

  Uroflow

  Pandoscopy site n size of ureteric orifice

  Lower ureter dilated with distal narrowing rule out megaureter?

  Then decide

• 

  Amilal Bhat

  04 May 2021 06:36:36 PM

  Voiding time 

  Uroflow

  Pandoscopy site n size of ureteric orifice

  Lower ureter dilated with distal narrowing rule out megaureter?

  Then decide

• 

  Amilal Bhat

  04 May 2021 06:39:55 PM

  Need be UDS

• 

  Venugopal P

  07 May 2021 12:05:55 PM

  Dear All,

  Prashant Mulawkar post in Uroacademy on ‘Primary VUR in Adult’ is indeed thought provoking. It is uncommon to see VUR in Adults in the modern era as against in the past we used to see such situations in Adults more frequently. I personally have managed such Adult VUR’s in more than a dozen cases.

  These situations are often seen in adult women than in adult men and in women, they present often with symptoms of Pyelonephritis in Pregnancy.

  Though our experts have opined that various investigations need be done prior to decision of management, how useful will those informations help in the decision of management are controversial.

  Will the Scars present improve with surgical management? In our understanding of Reflux Nephropathy, it is said that scars do not have any bearing with the Grade of Reflux and are independent in its development. Very often surgical interventions do not have any merit in the control of hypertension due to reflux Nephropathy and such patients need to be placed on drugs for control of hypertension. But there is a different take on Adult VUR with Persistent Infection. In them, though it may not improve the Renal Functional Status, Surgical Correction could improve the infective status and thereby delay the progress of Renal Insufficiency.

  I am providing the link for a book on ‘Transition and Lifelong Care in Congenital Urology’ Editors: Hadley M Wood and Dan Wood (2015) wherein Ariella A Friedman* and Moneer K Hanna has written a chapter on ‘Vesico Ureteric Reflux in Adults’ Chapter 16 (Page 173). The chapter is well worth reading and understanding.

  https://link.springer.com/content/pdf/10.1007%2F978-3-319-14042-1.pdf

  Those interested can download the book and use it as areference book as and when occasions demand.

  With warm regards,

  Venu