The Relationship between Urinary Tract Infection and Vesicourethral Reflux in Children

Background: The incidence of vesicoureteral (VUR) in the general population is less than 1%. Reflux
carries an increased risk of pyelonephritis and renal failure. The purpose of the current study was to
check whether the voiding cystourethrography (VCUG) test is necessary in most cases of upper
urinary tract infection (UTI) in children, and to investigate if there is a correlation between the
presence of VUR and urinary tract infection, or the reflux is a random finding that does not require
monitoring. In the same time we studied the correlation with various markers of inflammation, renal
ultrasound findings (US), 99m technetium (Tc)-dimercapto-succinic acid (DMSA) nuclear renal scans
findings, and the clinical presentation.
Methods: The current study is retrospective, based on tests taken at the Poriya medical center in
Tiberius (Eastern Galilee population), between 2009-2013. The study includes 88 children up to 2
years that were asked for VCUG. All the children had symptoms of UTI. Prior to performing the
imaging tests, the children had laboratory tests (blood, urine, culture), then renal US. VCU was
performed within two weeks to one month from the beginning of the complaints, for children up to sixmonth-
old. Older children did the voiding test after doing DMSA. DMSA was done 3-5 months after
the acute UTI.
Results: Approximately 40% (37.5%) of patients suffered from reflux: 66.7% with incorrect DMSA
(filling defect / scar) had reflux. Only 18.2% of children with normal DMSA results had reflux. Renal
US test was not correlated with VCU results. High inflammation factors levels (CRP, ESR) were found
in all subjects with reflux, and only 52.6% of cases with positive reflux had low lymphocytes levels
compared with only 14.3% in patients without reflux.
Conclusions: VCUG is not required in most cases of upper UTI. Suitable replacement test can be
done by renal DMSA, which has also an added value of detecting a potential renal damage (scars).
High levels of inflammation factors, erythrocyte sedimentation rate (ESR), and C-reactive protein
(CRP) strongly suggest a possible existence of reflux. In contrast, lower levels deny the existence of
reflux in children with upper UTI.