THE JOURNAL OF UROLOGY
Vol. 80, No. 2, August 1958 Printed in U.S.A.
VESICOURETERAL REFLUX IN CHILDREN B. W. JONES
JAMES W. HEADSTREAM
From the Department of Surgery, Division of Urology, University of Arkansas Medical Center, Little Rock, Ark.
The subject of vesicoureteral reflux has been one of intense speculation for many years, with conflicting opinions as to whether it occurs in a normal child. Textbooks differ in their opinions. Lowsley and Kirwin1 and Keyes and Ferguson2 state that reflux does occur in normal individuals. Campbell3 and Hinman4 deny this occurrence. Current literature reveals an expression by Gibson 5 and Innacone and Panzuioni 6 that reflux does occur in the normal; however, Stewart/ Bunge8 and St. Martin9 do not share this opinion. The mechanism of vesicoureteral reflux in obstruction is best stated in the words of Graves and Davidoff10 that "reflux depends primarily on sustained tonus of bladder musculature as it actively resists distention." Due to these divergent opinions, this investigation was initiated with the desire to determine if reflux occurred in children without history or findings suggestive of urinary tract disease. One hundred routine admissions, 70 males and 30 females, to the pediatric service were subjected to voiding cystography. These were Read at annual meeting of South Central Section of American Urological Association, Inc., Oklahoma City, Okla., October 21-24, 1957. 1 Lowsley, 0. and Kirwin, T.: Clinical Urology. Baltimore: Williams & Wilkins Co., 1940, vol. 2, p. 1158. 2 Keyes, E. and Ferguson, R.: Urology, 6th ed. New York: Appleton-Century Co., 1938, p. 134. 3 Campbell, M. S.: Urology. Philadelphia and London: W. B. Saunders Co., 1954, vol. 2, p. 1459. 4 Hinman, Frank: The Principles and Practice of Urology. Philadelphia: W. B. Saunders Co., 1935, p. 232. 5 Gibson, H. M.: Ureteral reflux in normal child. J. Urol., 62: 40, 1949. 6 Innacone, G. and Panzuioni, P. E.: Ureteral reflux in normal infants. Acta Radiol., 44: 451, 1955. 7 Stewart, C. M.: Delayed cystography and voiding cystourethrography. J. Urol., 74: 749, 1955. 8 Bunge, R. G.: Delayed cystograms in children. J. Urol., 70: 729, 1953. 9 St. Martin, E. C., Campbell, J. H. and Pesquier, C. M.: Cystography in children. J. Urol., 75: 151, 1956. 10 Graves, R. C. and Davidoff, L. M.: Studies on the bladder and ureters with special reference to regurgitation of vesical contents. J. Urol., 14: 1, 1925. 114
patients who had a non-urological admission with a negative urinalysis. The examination was, performed following recovery from their disease,. when ready for discharge from the hospital. The children ranged in age from 14 days to 14 years, averaging 3.5 years. The diagnoses were those usually seen on a general pediatric service. MATERIAL AND METHODS
No anesthesia, local or general, was used. Ten per cent sodium iodide was introduced through. an appropriate sized urethral catheter by gravity until the flow stopped. Then by means of a bulb syringe, H to 2 ounces, depending on size of patient, were instilled. An immediate film exposure was made. Following this, the catheter was removed and a voiding cystogram was obtained with the patient in the supine position (fig. 1). Of the 100 children examined by voiding cystography, only one exhibited vesicoureteral reflux. None of these had fever or other evidence of urinary tract infection after the examination. The one patient demonstrating bilateral reflux was a four-month-old male admitted to the hospital for malnutrition. He had a negative urinalysis and a normal nonprotein nitrogen. Excretory pyelography showed no evidence of obstructive uropathy. Cystoscopy revealed 180 cc residual urine, a bladder neck contracture, and moderate trabeculation of the bladder musculature (fig. 2, A, B). A transurethral resection of the bladder neck was performed with an uneventful postoperative course. Followup studies 6 months later demonstrated bilateral reflux on voiding cystography, no residual urine, and negative urinalysis (fig. 2, C). DISCUSSION
This investigation supports the findings of those who claim that vesicoureteral reflux occurs only in the presence of demonstrable uropathy. The ordinary cystogram does not always demonstrate reflux when it might be exhibited by voiding or delayed cystograms. The informa-
VESICOURETERAL REFLUX IN CHILDREN
Fm. 1. Normal voiding cystograms
Fm. 2. A, voiding cystogram demonstrates reflux in 4-month-old male. B, same case; excretory pyelogram. No dilatation. C, 6 months later. Voiding cystogram still demonstrates reflux.
tion gained by delayed cystography as described by Stewart11 and Bunge 12 is well recognized. This series did not include delayed cystograms, as this technique does not seem as practical as voiding cystography for the usual urological practice. Delayed cystography, because of the obvious waiting period and its handicaps in a small child, is a more difficult technique than voiding cystography. Our experience in known cases of vesicoureteral 11 Stewart, C. M.: Delayed cystograms. J. Urol., 70: 588, 1953. 12 Bunge, R. G.: Further observations with delayed cystograms. J. Urol., 71: 427, 1954.
reflux reveals equally satisfactory demonstration of reflux in voiding cystograms as compared with delayed cystograms. SUMMARY
One hundred voiding cystograms were performed in children without findings or history of urinary tract disease. Only one of these showed vesicoureteral reflux. Subsequent examination revealed bladder neck contracture and a transurethral resection was performed. It is our belief that children with normal urinary tracts will not exhibit vesicoureteral reflux.