QuestionPrescription
QuestionComment
haematuria but otherwise normal dip - is peel not a concern?
17492
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Prognosis Benign
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Is Trimethoprim actually wrong in this case?
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She's allergic to co-trimoxazole, which contains trimethoprim, so best to avoid it :)
61148
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FíonnMacCumhaill
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CT Complement
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# Summary

Vesicoureteral reflux (VUR) is a congenital condition where urine flows backwards from the bladder into the ureters and kidneys, increasing the risk of recurrent urinary tract infections (UTIs). Symptoms include recurrent UTIs, fevers, and abdominal pain, with severe cases leading to renal scarring and hypertension. Diagnosis can involve ultrasound, MCUG, MAG reflux test, and DMSA scan. Management includes prophylactic antibiotics, monitoring, and possibly surgery for severe cases. Complications include UTIs, pyelonephritis, and chronic kidney disease.

# Definition

Vesicoureteral reflux (VUR) is a condition where urine flows backwards from the bladder into the ureters and potentially the kidneys, rather than the usual one-way flow from the kidneys to the ureters and then to the bladder. This condition is typically present from birth and can lead to recurrent UTIs, as the backward flow of urine can carry bacteria up into the kidneys, causing an infection. It is a significant risk factor for atypical UTIs and recurrent infections.
 

# Epidemiology
 

VUR affects around 1-3% of all children and can occur in all age groups. It is more commonly diagnosed in children with UTIs, especially if these UTIs are recurrent or atypical. A familial predisposition is often present.
 

#  Pathophysiology

The abnormal flow of urine in VUR can occur due to a variety of reasons, including a shortened intravesical ureter (the part of the ureter that passes through the bladder wall), an improperly functioning valve where the ureter joins the bladder, or a neurological disorder affecting the bladder.
 

# Signs and Symptoms
 
VUR is often asymptomatic and may only be detected when investigating recurrent or atypical UTIs. 

Symptoms can include:

- Recurrent UTIs or persistent bacteriuria
- Unexplained fevers
- Abdominal or flank pain
- In severe cases, renal scarring can occur leading to hypertension and chronic kidney disease
 

# Investigations
 

In children with recurrent or atypical UTIs, investigations considering VUR include:
 
- Ultrasound of the kidneys and bladder is often performed initially 
    - Used to detect hydronephrosis, dilatation of renal pelvis or incomplete bladder voiding 
- Micturating Cystourethrogram (MCUG) 
    - Contrast is passed into the bladder, and the patient passes urine whilst x-rays are taken.
    - This enables the refluxing of urine to be visualised 
- MAG (mercapto acetyl triglycine 3) reflux test 
    - IV contrast recorded on x-ray whilst the child passes urine, to enable any reflux to be visualised 
- Dimercaptosuccinic acid (DMSA) scan
    - This can detect scarring or damage to the kidneys as a result of VUR
 

# Management
 

The management of VUR can be conservative or surgical, depending on the severity of the condition, the age of the patient, and the risk of kidney damage. 

- Conservative management:
    - Prophylactic antibiotics to prevent UTIs
    - Regular monitoring of kidney function and growth
    - Treatment of constipation if present
- Surgical treatment, such as ureteral reimplantation, may be considered in severe cases or when conservative management fails.
 

# Complications

Potential complications of VUR include:
 

 -  Recurrent UTIs
 -  Pyelonephritis
 -  Renal scarring and Chronic Kidney Disease (CKD)
 -  Hypertension
 
This highlights the importance of early detection and management of VUR, especially in children with recurrent or atypical UTIs.
 
#  NICE Guidelines 

[NICE Guideline Urinary tract infection in under 16s: diagnosis and management](https://www.nice.org.uk/guidance/ng224/chapter/Recommendations-for-research) 
 
# References

[Kidney Research UK Vesicoureteral reflux](https://www.kidneyresearchuk.org/conditions-symptoms/vesico-uretal-reflux/)
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Urinary tract infection in children
Topic
75
GP
# Drug choice feedback

This woman likely has a lower urinary tract infection with no overt complications. In cases whereby there is a low risk of resistance, the two possible first line agents for non-pregnant women include nitrofurantoin or trimethoprim. Given that she is allergic to co-trimoxazole which contains trimethoprim, only nitrofurantoin can be prescribed.

# Dose/Route/Frequency/Duration feedback

The recommended dose is either 50mg or 100mg, and the frequency is QDS or BD, depending on whether the immediate- or modified-release form is prescribed respectively. It should be prescribed for 3 days. Women who are pregnant and all men who have a lower urinary tract infection require a longer prescription of 7 days.
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50 mg
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nitrofurantoin 50 mg tablets
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3 days
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four times daily (QDS)
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oral (PO)
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50 mg
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nitrofurantoin 50 mg tablets
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3 days
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four times daily (QDS)
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oral (PO)
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100 mg
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nitrofurantoin 100 mg tablets
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3 days
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twice daily (BD)
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oral (PO)
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100 mg
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nitrofurantoin 100 mg m/r capsules
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3 days
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twice daily (BD)
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oral (PO)
Case Presentation: A 51-year-old woman attends the GP with urinary frequency, foul-smelling urine and dysuria. She mentions the symptoms are causing her distress. She does not report any loin-to-groin pain nor rigours.


## PH

Breast cyst diagnosed 23 years ago, surgically removed without recurrence or complications

## DH

NIL (Allergy to Co-trimoxazole)

## On examination

Alert and oriented. No loin tenderness.

Temperature 36.5°C, HR 75, RR 12, BP 125/79, O<sub>2</sub> 98% RA, GCS 15, Weight 68kg

## Investigations

Haematuria 1+ on dipstick, otherwise normal

Urinary MC&S not appropriate as of now as clinically low risk of resistance.

# Prescribing Request

Write a prescription for one antibiotic that is most appropriate for treating her condition.