Review of published literature on urinary reflu

Cockett, A. T. K.

English

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URINARY REFLUX - THE PHYSICIAN'S DILEMW 
A.  T. K. Cocket t ,  i4. D. 
From t h e  Department of  Surgery/Urology, Harbor General H o s p i t a l  e 
T o r r a n c e ,  C a l i f o r n i a ,  and the UCLA School o f  btedlcine, Los Angeles,  
Ca3 i f o r n i a  90024, 
This i n v e s t i g a t i o n  was suppor ted  by t h e  Nat iona l  A e r o n a h i c s  and 
Space A d m i n i s t r a t i o n  under  Grant Ro. NsG 237-62. 
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Urlnary Reflux - Cocktt 6 4 
Urlnary reflux - more specifically vsicoureteral regurgitation cf 
urtne into the renal pelvis and calyces, i s  still a controversial subject. 
C:arlty is undoubtedly hampered by the fact that obstruction at the bladder 
outlet 1s not always demonstrable ever! though vesicoureteral reflux is 
present, Cfoud?ng the issue still further i s  the occurrence of reGiux 
when bladder infection i s  present, When infertion i s  cleared, reflux dls- 
appars, 
ahnore21 occurrence. 
Nmetheless, f o r  purpcses of thls review, urinary reflux is an 
- HlstorScal Revfew 
A valve-like actlon of the ureter at the ureterovesical junction was 
z 2 suggested by Disse , Lucas arid others In the i9th century, The intra- 
mural, obiique zourse of the ureter strongly supported the concept of  a 
ope-way valvular action. 
3 In 1812 Chsries Bell described several anatomic structures at the 
ureterovesical junctlon, Stcdfes had liidfceted that the embryologtcal 
o r j g l n  of the trigone was separate from the rest of the bladder, and the 
proposed dynamics seemed to support thls concept. 
nechanical structures descended from the ureteral orifices toward the bladder 
neck where they united and ran toward the prostatic gland. 
the use of specific musc!es In this region to assist l a  bladder contraction, 
while at the same time closing and supporting the lower aspects of the 
ureterowsical junction, seemed to be important. 
Sell stated that these 
He stated that 
4 The recent contribution of Paquin is worth rnentiontng, He emphasized 
that ureterovesical valve length alone did not determine whether refiux 
would occur. 
of  this junctlonal valve to i t s  width. 
Paquin stated that reflux depended on the ratio of the length 
Included in the measurement 26 length 
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e Urinary Reflux - Cockett 
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of the ureterovesical valve and intramural ureter. The noma1 ratio in 
humans is approximately 6:1, and if this ratio i s  reduced below 3:1, reflux 
i s  more likely to occur. 
in contributing to reflux; they include decreased elasticity of the intra- 
mural ureter, fixation of the ureter to the trigone, and a disturbance in 
ureteral peristalsis. 
However, additional factors probably are important 
5 The anatomic dissections of Hutch provide a clearer understanding 
of the ureterovesical junction. 
layer encasing the h e r  3 cm of ureter blen!s w!th the middle mcscular 
layer of the trigone. Apparently, its function i s  to increase the obliquity 
of the intrmural u:eter. Hutch has also suggested a lengthening of the 
intravesical ureter from 0.5 cm at birth to 1.3 cm in aduithood. Reflcrx 
varies inverseiy with increasing length, perhaps -raining the more CC),WA~ 
occurrence of reflux in the pediatric age group. 
Waldeyer's sheath, a longitudinal musculer 
General Considerations 
The presence of urinary regurgitation is important to the clinlcian 
First, reflux is the means by which infected urine can i n  several ways. 
reach the pelvis and medulla; this is undoubtedly the major cause of 
ascending pyelonephritls. Seccnd, the presence of reflux should set in 
motlon an organized search for the presence of some type of bladder outlet 
obstruction. 
bladder neck obstruction; one's efforts, however, should not be discontinued 
until a mechanical cause is carefully ruled out. Third, it i s  a fact that 
both bladder and ureters decompensate with time. 
detrusor tone for micturition decreases. Ultimately, the classical signs 
In the majority of instances one can suspect a concentric 
When decompensation occur:., 
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Urinary Reflux - Cockett 
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of cellule formation with diverticuli further disrupt bladder efficiency. 
After a hypertrophic phase, the b!adder decompensates by becoming thln- 
walled and atonic. The ureters decompensate by dilation. Finally the 
ureters become tortuous and kink becwse lengthening is the only pathologic 
response available to the ureter. Increased urinary pressure is ultimately 
placed on the renal pelvis and calyces. Hydronephrosis is the final resuit 
culminating in renal insufficiency. 
Technics to Demonstrate Reflux 
6 Murphy and his co-workers emphasized the importance of intravesical 
pressure mon?torfng before and during micturition. Intravesical pressures 
greater than 30 cm. of water are seen in clinical cases Essociated with 
urinary reflux. H i s  group emphasized the importance of searching for lower 
urinary tract obstruction as the underlying cause of reflux. Physiological 
dats are obtained, during micturition, by placing special catheters into 
the bladder and connecting these outflow tubes to pressure recording 
systems . 
51 Improved radiographic technics are available to demonstrate reflux, 
7 In 1948 Stewart 
to demonstrate reflux. Stemrt stated that bladder distension is not neces- 
sary, beceuse volume Is not felt to be a critical factor. He later suggested 
the voiding cystourethrogram as the most important maneuver during radio- 
graphic study. 
described the delayed cystogram, one of the better techniques 
The voiding cystogram i s  now advocated by most urologists. 
The need for a standardized radiographic method is proposed by Lattimer 
and his group8; in their proposal the cystogram consists principally of 
filling the bladder at a given rate from some standard height above the 
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symphysis pubis, Pre-voiding and post-voiding f i lms  are obtained as wel? 
as the t rappi rg  f i l m  devised t o  demnstrate obstruction below the ureter, 
thus permit t ing re f  lux, 
!4!9ters9 recently suqgested the use of radioisotopes i n  the diagnosis 
of uretera l  reflux, i n  h i s  report he i n s t i l l s  a so lut ion containing radio- 
ac t i ve  lodine i n t o  the bladder. By placing gama s c i n t i l l a t i o n  counters 
over the region of  each kidney, z c t i v i t y  i s  obtsined i n  t h i s  locat ion whenever 
re f lux occurs, Winters believes that one s ign i f i can t  advantage af  t h i s  msthod 
i s  the minimal amount o f  radiat ion to  the patient. 
More recently, the cine-radrograph (movie f i lms  made a t  the t ime o f  
fluoroscopy during a voiding cystogram) has come i n t o  favor. 
overcome the disadvantages inherent i n  a single exposure, and these f i l m s  
Such methods 
are able t o  demonstrate the dynamics o f  voiding w i t h  a demonstration o f  
regurgi tat ion when i t  i s  present. I n  addition, these fl lms, when properly 
obtained, reduce the overa l l  exposure t o  radiation. 
The Probable Pathogenesis o f  Urinary Reflux 
,The m s t  frequent cause o f  urinary re f lux  i s  the presence o f  bladder 
o u t l e t  obstruction. From a review o f  several c l i n i c a l  series w i t h  ref lux,  
bladder neck obstruction accounts f o r  about 75 percent o f  cases i n  the 
pedfa t r i c  age group, 
ma jor i t y  o f  pat ients w i t h  r e f l ux  w i l l  be In the f i r s t  decade. 
This occurrence i s  congenital i n  or ig in,  and the 
Bladder 
o u t l e t  obstruction i n  the male i s  a concentric fibromuscular r i n g  which i s  
s tenot ic  and obstructs normal urine f low during mfctur i t ion.  In the female, 
a concentric fibromuscular r i n g  may also be present. 
Lyon and Smi th ”  has emphasized the Occurrence o f  d i s t a l  urethra l  stenosis 
A recent report by 
i n  the female child. Again the fibromuscular r i n g  i s  o f  importance a t  t h i s  
more d i s t a l  location, and t h i s  en i t5 ty  can best be treated i n  a manner 
s imi la r  t o  ear ly  bladder neck stenosis. 
Another less com~on mechanical defect is the poster ior  u re th ra l  valve. 
This may occur i n  the pros ta t i c  urethra i n  the male ch i ld ;  i n  the female a 
not uncommon defect i s  the fibromuscular, stenot ic mid-urethral r i n g  d i s t a l  
t o  the bladder neck sphincter. 
When bladder o u t l e t  obstruction i s  present, the bladder responds by 
attempting t o  empty i t s e l f  against t h i s  type o f  outf low resistance. Bladdsr 
muscle hypertrophies w i th  tlme to  overcome reslstance a t  the bladder out let .  
I f  prolonged, the intravesical  dynamics encourage the development o f  t ra-  
becutations (muscular hypertrophy) e Because weakened in te rs t i ces  between 
the bladder musculature, outpocketlngs of the bladder mucosa may resul t ;  
cel  l u l e  formation and d i v e r t i c u l l  herald the onset o f  progressive bladder 
decompensation. 
Patho-Physiological Grouping of  Patients w i t h  Reflux 
Class 1. High Intravesical  Pressure 
Patients in  t h i s  group re f lux  ur ine only a t  pressures greater than 
80-100 em o f  water. 
the uretera l  o r l f i c e  p r i o r  to  ur inat ion encourages development o f  a patulous 
o r i f i ce .  
in fec t ion  may supervene. 
a lso  in tens i fy  ureterovesical ref  lux. 
If l e f t  untreated, constant stretching and pressure a t  
Since ur inary s tas is  i s  encouraged i n  t h i s  s i tuat ion,  bladder 
Edema and r i g i d i t y  of the intramural ureter  w l l j  
Unfortunately, t h i s  group of pat ients are not seen by the uro log is t  
unless a recurrent h is to ry  o f  urinary t r a c t  in fec t ion  i s  e l ic i ted.  In  
&.I Urlnary Reflux - Cockett 
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chi ldren, the presenting h i s to ry  i s  a f a i l u r e  t o  t h r i v e  o r  develop normally. 
Reflux, if l e f t  untreated, progresses t o  a more serious and near ly i r rever -  
s f b l e  stage. 
Class I t .  Patients w i th  Reflux a t  Low Int raves ica l  Pressures bu t  High 
Urinary Volumes. 
In t h i s  group the pat ients  r e f l u x  a t  In t raves ica l  pressure o f  5-25 cm 
of water (9-30 mm Hg), but  only a f r s r  large ur inary  volumes have ascumuiated. 
11 Stephens has suggested that these ureterovesical junct ions have 2 
p a r t i a l  muscular def ic lency i n  the in t raves ica l  ureter. Consequently, t h e  
Shf l f ty  t o  r e s i s t  ref:ux i s  only p a r t i a l l y  reta?nsd, 
tor tuos:ty and d i l a t a t i o n  o f  the af fected ure ter  i s  present. 
ves ica l  pressure becomes reduced as the ureters  d i l a t e  slnce bjadcier u r ine  
Is qulte easf ly  displaced into t h i s  re f l ux ing  ureter. 
I n  a chronic s ta te 
The in t ra -  
~ Class 1 1 1 ,  Patients wlth Reflux a t  Low Int raves ica l  Pressures and LON 
Vol umes Q 
The worst: prognosfs w i l l  be f o m d  i n  these patients, 
pabrlent the ureterovesical  junc t ion  i s  no longer ab le  t o  r e s i s t  ref lux.  
The ureters  are widely d i l a ted  and kink. Ureteral  p e r i s t a l s i s  i s  impaired, 
Consequently, u r i ne  see-saws from the bladder t o  the upper t r a c t s  i n  hap- 
hazard fashion. 
tracts because of  chronic i ty ,  Renal insu f f i c iency  i s  a more serious 
problem i n  these patients, 
In the t yp l ca i  
These pat ients  display severe?y deranged upper u r inary  
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Urinary Reflux - Cockett 
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SYNOPSIS 
Urinary ref lux needs careful evaluation and prompt treatment. Pre- 
senting complaints include failure to thrive; andjar recurrence of a ?~rln=lry 
tract infection. If  bladder outlet obstruction is present, then surgical 
Intervention is necessary. Bladder neck revision combined with an anti- 
reflux operation i s  a decision reserved for the urologist. 
of bladder inflammation affect the ureterovesical junction even though 
bladder neck obstruction cannot be demonstrated. Vigorous antibacterial 
treatment wlll abolish urinary reflux. A neurogenic bladder disorder i s  
present in 10 to 15 percent of all cases with reflux. One should separate 
Kechanical causes f rom physiological factors affecting bladder function 
since the neurogenic bladder i s  handled differently. 
Certain types 
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REFEREiXES 
1. DZsse, J,: Der Harnleiter, V. Bardeleben, Karl: Handbuch der 
Anatomie, Jena: Gustav Fischer, 1902, p. 139. 
2, Lucus, D, R.: Physiological and Pharmacological Studies of  the 
Ureter 1 1 - 1 .  Amer. J, Physlol 22: 245, 1908. - 
3, Bell, C.: Account of the Muscles of the Ureters and their Effects 
in the irritable States of the Bladder. 
171, 1812. 
Med, Chfr. Tr, Lond. 3: - -  
4, Paquin, A,: Ureterovesfcal Anastomosis; Description and Evaluation 
of a Technique, J. Urol 82: 573-583 (Nov) 1959, -- 
5, Hutch, J. A,: The Ureterovesical Jurxtion. The University of Cali- 
fornia Press, Berkeley, 1958. 
6. Murphy, J, J,, and Schoenberg, H, W,: 
Pressure Changes during Micturition. J, Urol 84: 106-1 10 (July) 
1960. 
Observations on Intravesical 
-- 
7. Steward, C. M.: Delayed Cystography and Voiding Cystourethrography, 
J, U r d  -- 2%: 749-759 (Dec) 1955. 
8 ,  Dean, A, Le, Lattlmer, J, K., and McCoy, C, B.: 
Columbia University Cystogram. J, Urol 78: 662-668 (Nov) 1957. 
The Standardized 
9. Winter, C. C.: A New Test fo r  Vesicoureteral Reflux: An External 
Technique Using Radioisotopes. J, Urol 83: 105-1 1 1  (Jan) 1959, -- 
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d+ Urinary Reflux - Cockett 
10, Lyon, R, Pc, and Smith, D. R.: Distal Urethral Stenosis, J, Ut01 
82: -- 414-421 (March) 1963, 
11. Stephens, F, D,, and Lenaghan, D,: The Anatomical Basis  and Dynamics 
of VesIcoureteral Reflux, J, Urol 87: -- 669480 (May) 1962, 


Urinary Reflux - the Physician's Dilemma

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