CLINICAL COURSE OF VESICOURETERAL REFLUX

Abstract

The clinical course of 44 patients with vesicoureteral reflux was analysed. The patients were folowed for at least one year and on the average for 3 years and 10 months after diagnosis. Of these 44 patients, 29 had primary reflux and 15 had reflux secondary to neurogenic bladder, urinary tract tuberculosis, radical hysterectomy for cervical carcinoma, ureteral re-implantation or cystoplasty. The age and sex distribution are given in Table 1. The chief complaint, X-ray findings and urinalysis at diagnosis are presented in Table 2.
Nineteen patients who had recurrent attacks of acute pyelonephritis were treated by sulfonamides (sulfamethizole 2 to 3gm per day) for more than 6 months. Twelve patients with primary reflux responded well to the medication and experienced no fever and no urinary infection during the follow-up period (Table 3). All patients with successful long-term sulfa-therapy except one had normal upper urinary tract on urography.
Anti-reflux operations were performed in 15 patients. Though the reflux was stopped in all cases at the time of discharge, it recurred in 8 out of 10 patients who underwent cystographic check-up more than 6 months after the operation (Table 4). However, successful eradication of pyelonephritic attack and urinary infection was obtained in 7 out of 10 patients with primary reflux (Table 5).
Despite medication, 12 patients had presistent pyuria, 10 of which showed pyelonephritic or hydronephrotic changes on X-ray examination (Table 6). In 4 patients with persistent pyuria the reflux was completely asymptomatic without demonstrable progressive changes on pyelograms.
Progressive damage to the refluxed kidney during the follow-up period of an average of 5 years and 7 months was noted in one patient with primary reflux and 5 with secondary reflux (Table 7). Renal deterioration of these patients was due to hydronephrotic change.
The results of this study would suggest that presence of non-obstructive reflux, even with urinary infection, is not always noxious to the kidney and primary reflux does not damage the kidney in the majority of cases though it may cause recurrent acute pyelonephritis. It seems likely that the pyelonephritic contracted kidney due to reflux rarely develops.
Long-term sulfonamides medication will be the treatment of choice for the patients with primary reflux suffering from pyelonephritic attacks when the upper urinary tract is nearly intact. If the medication fails or progressive renal damage is demonstrated, surgical measures will be indicated. Patients with asymptomatic reflux and persistent urinary infection must be kept under close surveillance, since progressive damage to the kidney may occur occasionally.