The British Journal of Radiology, 80 (2007), 392400

REVIEW ARTICLE

Vesicoureteric reflux in the adult

O BUCKLEY, MB, BCh, BAO, MRCPI, T GEOGHEGAN, MB, BCh, BAO, FRCR, J OBRIEN, MB, BCh, BAO, MRCPI and W C TORREGGIANI, MB, BCh, BAO, MRCPI, FRCR
Department of Radiology, Adelaide and Meath Hospitals incorporating the National Childrens Hospital (AMNCH), Tallaght, Dublin 24, Ireland

ABSTRACT. Vesicoureteric reflux (VUR) is a well-recognized entity in the paediatric population, but is not well described or understood in the adult population. This is partly explained by the fact that its incidence declines with advancing age. Its diagnosis is, however, still important, with VUR accounting for at least 10% of adult patients with end-stage renal disease. With early detection and careful management, the secondary complications of VUR such as renal failure can be prevented. Imaging plays a major role in the detection and evaluation of VUR in the adult patient. Conventional techniques such as micturating cystourethrograms have now been supplemented by cross-sectional imaging with CT and MRI. In this review article, we comprehensively review the up to date status of imaging the adult patient with VUR and discuss important subgroups of patients such as pregnant and transplant patients.

Received 7 July 2006 Revised 24 September 2006 Accepted 20 November 2006 DOI: 10.1259/bjr/60682848
2007 The British Institute of Radiology

Vesicoureteric reflux (VUR) is a well-recognized condition in the paediatric population, but is less well described in the adult population. The incidence of VUR declines with advancing age and is 49% under 1 year, 26% under 12 years and only 4.4% in the adult population [1, 2]. Despite this relatively low incidence, it still accounts for at least 10% of adult patients developing end-stage renal disease [3]. As well as renal failure, VUR may also result in other secondary complications such as hypertension, proteinuria, urinary tract infections and renal calculi. Certain subgroups of adults are particularly prone to VUR. These include patients who have undergone cystectomy with ileal conduit formation, transplant patients and patients with a neuropathic bladder from spina bifida, for example. It is also more common in pregnancy and more than half of pregnant females with VUR experience complications during pregnancy [4]. VUR is more common in the female patient due to both the association of VUR with pregnancy and the female urethra being predisposed to infections. Females generally present with signs and symptoms of urinary tract infection (UTI), whereas males present with hypertension and signs of renal impairment, such as proteinuria or hypertension. Adults do not benefit from the childhood tendency for VUR to improve with time and therefore secondary complications will ensue over time if VUR remains untreated [5]. With early detection and careful management, the secondary complications of VUR, such as renal failure, can be prevented. In this review, we describe the presentation and diagnosis of VUR in adults, with
Address correspondence to: Dr William C Torreggiani, Department of Radiology, Adelaide and Meath Hospital, Tallaght, Dublin 24, Ireland. E-mail: william.torreggiani@amnch.ie or williammart@ hotmail.com

specific reference to subgroups of adult patients prone to VUR such as pregnant females and transplant patients. In addition, the role of the various imaging modalities utilized in evaluating this disease will be comprehensively reviewed.

Definition and incidence

VUR is defined as the retrograde flow of urine from the bladder to the kidneys. It may be divided into primary and secondary types, with primary VUR being the predominant process. Primary VUR occurs in the absence of any underlying pathology, while secondary VUR in the adult occurs due to conditions such as obstruction, previous surgical procedures or a neurological disorder (Figure 1). It may also occur following surgical procedures such as renal transplantation or cystectomy with ileal conduit formation (Figure 2). VUR is thought to occur in 12% of the general population, with increased risk in siblings and children of affected patients [6]. In most patients with congenital VUR, the condition resolves before adolescence. The differentiation between adult-onset and paediatric-onset VUR can be difficult. However, many adults with VUR deny any history of childhood UTI and report recent onset of symptoms [7]. There is an estimated female:male ratio in adults of up to 5:1 [8]. In the 6070 year old age group, there is a rise in the incidence of males with VUR, likely to be due to the increased number of men under investigation for bladder outlet obstruction [9, 10]. Renal transplant recipients can suffer from primary and/or secondary reflux. VUR can occur into the native kidneys and, if associated with persistent UTI, the patient may have to undergo nephroureterectomy to prevent an increased rate of infection post transplant
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Figure 1. Micturating cystourethrogram in an adult patient

with known spina bifida and deteriorating renal function. The bladder is irregular, in keeping with a neurogenic bladder. There is free reflux seen in the left ureter (arrow).

[11]. In secondary cases, reflux of urine may occur retrogradely up the newly implanted ureter (Figure 3) and the clinical significance of this is controversial [12].

Pathophysiology
A family history of VUR is common, with a prevalence of 4.751% in siblings of an affected child [13]. Advances in genetic mapping have led to the localization of the genetic abnormality to chromosome 1 [14]. The mechanism of primary VUR is thought to be secondary to weakness in the muscle of the trigone of the bladder, which leads to the ureteric orifice lying in an abnormally lateral position [15]. The ectopic location of the ureter leads to a shortened course within the detrusor muscle.
Figure 3. Single image from a micturating cystogram in a
patient post renal transplant. The transplant is located in the right iliac fossa and contrast is seen to reflux into the implanted ureter.

Figure 2. Adult patient with previous cystectomy and ileal

conduit formation. Contrast has been infused into the ileal conduit through a Foley catheter inserted into the proximal portion of the conduit. Contrast is seen to reflux freely into the right ureter and collecting system of the right kidney.

The valve becomes incompetent as a result when the intravesical pressure rises on filling and micturition and retrograde flow of urine ensues. It is not well understood whether the pathophysiology of primary VUR in the paediatric population is the same as that found in the adult population, or whether adults with VUR are simply congenital cases detected later in life. About 35% of adults found to have VUR give a history of previous UTI in childhood [14] and many report recent onset of symptoms at the time of presentation [7]. Adults do not benefit from the childhood tendency for VUR to improve with time [5]. In adults, complications may often occur despite treatment as the vesicoureteric junction does not develop as it does in children and, as a result, the mechanism for reflux persists [9]. The probability that the affected kidney will become scarred is highest in infants and reduces with age. The reason for this is not well understood. Theories include a possible maturation process in the kidney that protects from scarring, although this has not been proven. With regard to adults, the onset and duration of primary VUR is rarely known and secondary complications such as scarring and nephropathy only become apparent late in the disease process. Secondary VUR results from disruption of the normal valve at the ureteric orifice due to surgery or neurological problems. In the renal transplant recipient, the likelihood of VUR increases with time post transplant regardless of renal implantation technique [16].
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Clinical presentation
VUR may be asymptomatic. Overall, there are two categories of adult presentation of patients with primary VUR: (1) patients who have had VUR since childhood that has remained undetected and presents in adulthood with complications; and (2) patients who develop VUR in adulthood de novo with no prior history of UTI. There are differences in the way males and females present. The majority of females diagnosed with VUR initially present with a UTI [8]. Some females may be asymptomatic and have incidental bacteriuria noted on urinalysis. The incidence of bacteriuria is more common in females, probably due to the anatomy of the female urethra [17]. Males more commonly present with symptoms of complications of VUR and reflux nephropathy such as hypertension and proteinuria [18]. Males are often detected incidentally when they are being investigated for other urinary symptoms [19]. When the prevalence of VUR is assessed in patients undergoing dialysis, the strong female-to-male preponderance is less marked as many males present very late when already in renal failure, whereas females are detected earlier. In-a study of in-patients with hypertension and normal renal function, the incidence of VUR was as high as 19.1%, much higher than the incidence of VUR in the general population (2%) [20]. This is a significant finding and should be considered when patients with hypertension are being worked up as this is a potentially reversible condition. Pregnancy and reflux nephropathy have profound effects on each other. More than half of pregnant females with VUR experience complications during pregnancy [4]. Physiological dilatation of the urinary tract and increased glomerular filtration predispose the pregnant woman with VUR to UTI, eclampsia and progression of renal disease. Pre-conception renal function has a significant impact on pregnancy-related complications. The detection of VUR in pregnancy should also prompt the search for neonatal VUR in the subsequent offspring due to the genetic nature of the condition.

Figure 4. Single image from a micturating cystogram in an adult female patient who presented with recurrent urinary tract infection (UTI) demonstrated unilateral reflux with dilatation of the right ureter.

according to a designated grading system. There are several classification systems of VUR. The International Reflux Grading system is probably the best recognized. Depending on the degree of retrograde filling and dilation of the renal collecting system as seen at micturating cystogram, the International Reflux Grading system classifies VUR into five grades (Figure 5) [23]. The severity of VUR is directly related to the severity of scarring and the likelihood of complications. The limitations of this technique include the fact that VUR is transient and the conditions that simulate it may not be reproduced at the time of MCUG.

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Imaging
The best protocol for radiological investigation of VUR has been heavily debated over the years. Most of the guidelines that do exist have been devised with reference to the screening for VUR in the paediatric population. With advances in radiology in non-ionizing modalities such as ultrasound and MRI, the current guidelines may gradually move to minimize the risk from ionizing radiation [21]. Radiological techniques used to investigate VUR include micturating cystourethrogram, radionuclide cystography, intravenous pyelography, ultrasound, CT and MRI.

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Grade I: Urine refluxes into the ureter only, with normal renal pelvis and calyces Grade II: Urine refluxes into the ureter, renal pelvis and calyces, but they appear normal Grade III: Urine refluxes into the ureter and collecting system. The ureter appears mildly dilated and there is evidence of some blunting of the calyces

Micturating cystourethrogram (MCUG)

MCUG is increasingly being used to investigate adults with recurrent urinary tract infections to test for the presence of reflux [9, 22]. Reflux can be unilateral (Figure 4) or bilateral and the severity is classified
394 Figure 5. Diagrammatic representation of the International
Reflux Grading system. Vesicoureteric reflux (VUR) is classified into five grades. (Illustration courtesy of Tony Geoghegan.)

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Figure 6. Spot film from a micturating cystogram in an adult male who present with hypertension and renal impairment. Urine refluxed freely into the ureters and collecting system, and in this image the pelvis appears severely dilated and calyces are severely blunted. The ureters appear very dilated with a tortuous course.

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Grade IV: Urine refluxes into the ureter and collecting system. Evidence of moderate dilatation of the ureter and moderate blunting of the calyces Grade V: Urine refluxes into the ureter and collecting system. The pelvis appears severely dilated and the calyces are severely blunted. The ureter appears very dilated with a tortuous course (Figure 6)

Figure 7. Loopogram in a patient with an ileal conduit

performed following cystectomy for bladder cancer. There is bilateral reflux into the ureters with evidence of ureteric dilatation and calyceal clubbing secondary to the vesicoureteric reflux (VUR).

In cases of secondary VUR due to surgery such as ileal conduit formation, contrast can be injected via the stoma into the conduit, a procedure known as a loopogram. The ureters can be affected by VUR with varying degrees of severity, similar to that of primary VUR depending on the calibre of the ureteric re-anastomosis (Figure 7).

Nuclear medicine
Nuclear medicine techniques permit direct and indirect evaluation of VUR as well as assessment of renal scarring secondary to VUR. With direct radionuclide cystography, the bladder is infused with 500 ml of saline mixed with 99mTechnetium-labelled sulphur colloid via a catheter. The bladder is filled and the patient subsequently micturates under direct visualization of the gamma camera. Any nuclide appearing in the ureters and kidney is abnormal and diagnostic of reflux. Nuclear medicine cystography is felt to be more sensitive than conventional micturating cystography and has the advantage of continuous imaging, unlike intermittent fluoroscopy at MCUG [24]. With indirect radionuclide cystography, a standard renogram is initially performed. 20 min following this, when the patient feels the need to micturate, they are asked to do so in front of the gamma camera. The radiolabelled urine in the bladder is monitored and any amount of refilling at the end of micturition is suggestive of VUR. This technique requires the patient to have control of their bladder. Indirect radionuclide cystography has been shown to be an effective way of detecting VUR in young women who
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present with acute pyelonephritis [25]. With radionuclide cystography, the severity can be assessed by the levels of activities in the bladder, ureters and renal pelvis. It is not easy, however, to transfer the grading system used for assessing the severity of VUR on MCUG. Technetium-labelled dimercaptosuccinic acid (DMSA) is used to illustrate the size, shape and position of the kidneys and also to identify scarring or thinning of the cortex. DMSA scanning has a sensitivity of 7986% in detecting changes in the renal parenchyma of patients with VUR and is more sensitive than ultrasound in this regard [26, 27]. The changes seen at DMSA may be transient in patients with acute pyelonephritis. DMSA imaging also plays a complementary role to ultrasound in the follow up of renal transplants. VUR is relatively common in transplanted kidneys. Although it is controversial as to whether VUR damages transplant kidneys, both DMSA imaging for scarring and dynamic renal scintigraphy scans using radiolabelled diethylenetriamine pentaaceticacid (DTPA) or MAG-3 for renal function are useful modalities to assess the transplanted kidney.

Ultrasound
Ultrasound is an inexpensive, widely available technique that can be used to screen for reflux. Ultrasound permits assessment of renal size, shape and cortical abnormalities, as well as ureteric abnormalities
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Figure 8. Sagittal ultrasound image in the pelvis demonstrating dilated duplex ureters (arrow; left ureter) in a patient with vesicoureteric reflux (VUR). (Asterix on bladder).

(Figure 8). A dilated system and scarring in the appropriate clinical context are predictors of reflux and, if needed, patients may proceed to a formal MCUG. Sensitivities have been recorded as high as 93% in some studies [28]. In the 1970s, Tremewan et al initially reported the use of ultrasonography in adult patients with severe VUR [29]. Since then, there have been advances in ultrasound technology that make it a more sensitive means of detecting VUR, such as wide band harmonic imaging and echo enhanced cystosonography in the diagnosis of reflux [30, 31]. With this method, a galactose suspension of fluid is instilled into the bladder

Figure 10. Intravenous pyelogram (IVP) in a patient with a

horseshoe kidney shows evidence of chronic reflux nephropathy with scarring of the renal cortex, grossly dilated ureters and clubbed calyces bilaterally.

and the presence of reflux is detected by continuous scanning. Advantages of this technique include the absence of ionizing radiation as well as better anatomic resolution compared with radionuclide studies. This technique has been found to be as sensitive as MCUG in the detection of VUR [32]. This technique is of particular use in the adult population as there is better patient cooperation than in the paediatric age group [28].

Figure 9. Intravenous pyelogram (IVP) in a patient with

secondary vesicoureteric reflux (VUR) due to a neuropathic extrophic bladder demonstrates calyceal clubbing as a result of VUR.

Figure 11. Post-contrast image of an intravenous pyelogram

(IVP) in a patient with vesicoureteric reflux (VUR) and consequent reflux nephropathy demonstrates thinning of the upper poles bilaterally due to scarring.

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Figure 12. Transverse CT image following oral and intravenous contrast in a patient with a horseshoe kidney and vesicoureteric reflux (VUR). There is dilatation of the collecting systems and scarring bilaterally.

Limitations of voiding ultrasonography include poor sensitivity at detecting Grade 1 reflux as well as the length of time required for the procedure. As in radionuclide cystography, the grading system for contrastenhanced voiding ultrasonography is estimated by the degree of microbubbles found in the ureter and the pelvis, and if any dilatation is noted.
Figure 14. Coronal maximum intensity projection (MIP) in a
patient with a known horseshoe kidney image using a fluidsensitive half-Fourier single-shot turbo spin-echo (HASTE) magnetic resonance urography protocol demonstrates a Foley catheter in the bladder with dilatation of both ureters and the collecting system of the kidneys in keeping with reflux disease.

Intravenous pyelogram (IVP)

The role of intravenous pyelogram is rapidly decreasing in assessing the patient with VUR. It may detect secondary changes of VUR, but does not provide a dynamic assessment of the refluxing urine. Secondary changes include evidence of parenchymal scarring,

calyceal clubbing, ureteric dilatation and mucosal striations (Figures 911).

CT/MRI
CT with multiformat reconstructions can illustrate the renal tract and any secondary changes that have resulted from chronic VUR. Scarring is well seen (Figure 12) and areas of active pyelonephritis, which occurs secondary to VUR, may also be visualized. CT is superior to both ultrasound and IVP in detecting focal parenchymal abnormalities, defining the extent of disease and detecting perinephric fluid collections and abscesses [33, 34]. CT does, however, expose the patient to considerably more radiation than other techniques for the evaluation of this condition and it is not routinely used as a tool or investigation of VUR. MRI on the other hand is a radiation-free technique a particular advantage when the pregnant female requires evaluation. Magnetic resonance urography (MRU) is useful in defining any anatomical anomalies of the urinary tract that can contribute to VUR, as well as evaluating renal cortical scarring. In our experience, the addition of heavily T2 weighted single-shot turbo spin-echo (HASTE) sequences results in MR urographic images that are highly fluid
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Figure 13. Three-dimensional gadolinium-enhanced source image using a fast low-angled shot (FLASH) protocol in a patient with vesicoureteric reflux (VUR) demonstrates marked scarring of the lower pole of the right kidney. Non-enhancing simple cysts are incidentally noted in both kidneys. The British Journal of Radiology, June 2007

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(a)

(b)

Figure 15. (a) Coronal true FISP (fast imaging with steady-state precession) and (b) coronal maximum intensity projection (MIP) image of a patient with unilateral vesicoureteric reflux (VUR) that has resulted in a small, shrunken right kidney.

sensitive and allow evaluation of the collecting system of the urinary tract, particularly when the system is dilated (Figures 1316). Coronal and axial T1 and T2 weighted sequences with and without intravenous gadolinium and/ or intravesical contrast provide both anatomical and functional information. Voiding MR cystography is not as sensitive as other techniques for detecting VUR, but it can be useful where the risks of ionizing radiation must be considered [35].

surgical treatment has not been shown to provide any benefit [38, 39].

Clinical applications
No clinical guidelines exist for the evaluation of adult VUR. In children, the American Academy of Paediatrics advise MCUG and ultrasound for all young children with first UTI [40, 41]. The role of DMSA in the evaluation of first UTI in children remains controversial [40]. Traditionally imaging of UTI in the adult is reserved for those with complicated infections or immunocompromised patients [42]. The increased recognition of adult VUR as a clinical entity should lead to physicians investigating for the condition and the prevention of VUR-related complications. Adult females with acute pyelonephritis especially if of childbearing age represent a group that would benefit from investigation for VUR with ultrasound [43] and MCUG or direct radionuclide cystography (DRC). Detection of VUR pre-conception would enable treatment and/or careful management of potential pregnancy-related complications. MRI and ultrasound have an important role in the pregnant and young adult female, and also in in utero detection of VUR, as they have the advantage of lacking ionizing radiation. Adult males with uncomplicated UTI may benefit from investigation with ultrasound and MCUG as, if VUR is missed, these males tend to present with
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Treatment
Both surgical and medical options are available. Surgical treatment includes reimplantation of the ureter or injection of a synthetic polytetrafluoroethylene paste. Medical treatment consists of antimicrobial treatment or prophylaxis of UTI and treatment of hypertension. The choice of treatment largely depends on the severity of the nephropathy secondary to VUR and also the circumstances of the patient. Long-term antibiotic prophylaxis may not be the ideal option for a younger patient in whom more definitive treatment would be preferred. A young patient with symptomatic UTI despite antimicrobial treatment is a relatively strong indication for surgical intervention [36]. In a young female likely to become pregnant, surgery may be the preferred option to avoid potential pregnancy-related complications [37]. In cases where severe renal scarring has already taken place,
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related to age, gender, race and diagnosis. J Urol 2003;170:154850. Kincaid-Smith P, Becker G. Reflux nephropathy and chronic atrophic pyelonephritis: a review. J Infect Dis 1978;158:77480. Zhang Y, Bailey RR. A long term follow up of adults with reflux nephropathy. NZ Med J 1995;108:1424. El-Khatib M, Packham DK, Becker GJ, Kincaid-Smith P. Pregnancy-related complications in women with reflux nephropathy. Clin Nephrol 1994;41:505. Weston PM, Stone AR, Bary PR, Leopold D, Stephenson TP. The results of reflux prevention in adults with reflux nephropathy. Br J Urol 1982;54:67781. Mak RH, Kuo HJ. Primary ureteral reflux: emerging insights from molecular and genetic studies. Curr Opin Pediatr 2003;15:1815. McAninch J, Campbell P. Primary vesicoureteral reflux in adult patients. Urology 1973;11:3935. El-Khatib M, Becker GJ, Kincaid-Smith P. Reflux nephropathy and primary vesicoureteric reflux in adults. Q J Med 1990;77:124153. Berquist TH, Hattery RR, Hartman GW, Klalis PP, De Weerd J. Vesicoureteric reflux in adults. Am J Roentgenol Radium Ther Nucl Med 1975;125:31421. Bumpus HC. Urinary reflux. J Urol 1924;12:3416. Tripathi M, Chandrashekar N, Kumar R, Malhotra A. Reflux in native kidneys mimicking urine leak in the postrenal transplant. Clin Nucl Med 2005;30:3446. Vianello A, Pignata G, Caldato C, Di Falco G, Calconi G, Fadella A, et al. Vesicoureteric reflux after kidney transplantation: clinical significance in the medium to long term. Clin Nephrol 1997;47:35661. Ataei N, Madani A, Esfahani ST, Kejbafzadeh A, Ghaderi O, Jalili S, et al. Screening for vesicoureteral reflux and renal scars in siblings of children with known reflux. Pediatr Nephrol 2005;20:12012. Feather SA, Malcolm S, Woolf AS, Wright V, Blaydon D, Reid CJ, et al. Primary, nonsyndromic vesicoureteric reflux and its nephropathy is genetically heterogenous, with a locus on chromosome 1. Am J Hum Gene 2000;66:14205. Tanagho EM, Hutch JA. Primary reflux. J Urol 1965;93:15864. Reinberg Y, Bumgardner GL, Aliabadi H. Urological aspects of renal transplantation. J Urol 1990;143:108792. Cox CE, Lacey SS, Hinman F. The urethra and its relationship to urinary tract infection. II. The urethral flora of the female with recurrent urinary tract infection. J Urol 1968;99:6328. Becker GJ. Reflux nephropathy. Aust NZ J Med 1985;15: 66876. Nativ O, Hertz M, Hanani Y, Many M, Jonas P. Vesicoureteral reflux in adults: a review of 95 patients. Eur Urol 1987;13:22932. Barai S, Bandopadhayaya GP, Bhowmik D, Patel CD, Malhotra A, et al. Prevalence of vesicoureteric reflux in patients with incidentally diagnosed adult hypertension. Urology 2004;63:10459. Riccabona M, Fotter R. Modern imaging technology for childhood urinary tract infection. Radiologe 2005;45:107884. Leadbetter GW, Duxbury JH, Dreyfuss JR. Absence of vesicoureteral reflux in normal adult males. J Urol 1960;84:6970. Lebowitz RL, Olbing H, Parkkulainen KV, Smellie JM, Tamminen-Mobius TE. International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children. Pediatr Radiol 1985;15:1059. Pollet JE, Sharp PF, Smith FW, Davidson AI, Miller SS. Intravenous radionuclide cystography for the detection of vesicorenal reflux. J Urol 1981;125:758. Pinthus JH, Oksman Y, Leibovitch I, Goshen E, Dotan ZA, Schwartz A, et al. The role of indirect radionuclide

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Figure 16. Coronal true FISP (fast imaging with steady-state precession) image of a patient with spina bifida and vesicoureteric reflux (VUR) secondary to a neuropathic bladder, as evidenced by a dilated left ureter and clubbed calyceal system.

13.

significant delayed complications of VUR. Barai et al [20] suggest that routine DRC should be included in the evaluation of adults with hypertension as VUR is present in 19% of adults with hypertension and normal renal indices. Further studies on this subject are required to create clearer guidelines for all.

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Conclusion
Currently, there is great attention paid to both the detection of VUR and the prevention of its secondary complications in the paediatric population. It is generally felt that children then outgrow the risks of VUR and that this entity is not of major clinical importance in the adult population. When the incidence of VUR is assessed in adults with end-stage renal failure, it is found to be high at 10%. Many of these adults have no prior history of UTI or childhood VUR. Subgroups of the adult population that suffer VUR and its complications include pregnant females and renal transplant patients. Imaging plays a key role in making the diagnosis and, although traditional modalities such as nuclear medicine studies and micturating cystograms continue to play a key role in the evaluation of VUR, cross-sectional imaging and especially MRI will likely play a greater role in the future.
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