7.7.1 Secondary reflux

Predecessor of a secondary reflux is not an inborn primary disturbance of the terminal ureter, but rather an anatomically or functionally obstructive or inflammatory illness of the bladder, or direct damage to a previously intact orifice. It seems that many refluxes, especially of lower grade l-lll, are secondary refluxes and may disappear with the maturation of the bladder function.

7.2 Classification

The International Reflux Study Committee introduced a uniform system for the description of reflux, based on the earlier classification by Heikel and Parkkulainen, in 1985. Furthermore, a standardized performance of a voiding cystourethrogram was described to allow comparative studies.

Table 8: Grading system for reflux

Grade I Reflux does not reach the renal pelvis; varying degrees of ureteral dilatation

Grade II Reflux reaches the renal pelvis; no dilatation of the collecting system; normal fornices

Grade III Mild or moderate dilatation of the ureter, with or without kinking; moderate dilatation of the

collecting system; normal or minimally deformed fornices Grade IV Moderate dilatation of the ureter with or without kinking; moderate dilatation of the collecting

system; blunt fornices, but impressions of the papillae still visible Grade V Gross dilatation and kinking of the ureter, marked dilatation of the collecting system; papillary

impressions no longer visible; intraparenchymal reflux

Apart from reflux grading, a description of the position and morphology of the ureteral orifices (normal, stadium, horseshoe or golf-hole orifice) are helpful for planning treatment. The position of an orifice should becategorised as A (trigonal), В, С or D (markedly lateral).

7.3 Diagnosis

All patients awaiting clarification of a reflux should undergo a basic diagnostic work up, comprising laboratory tests (kidney function), urine status and urine cultures, together with a detailed medical history and physical examination. Direct evidence of a reflux or its exclusion, obtained by VCUG or sonography supplements the initial diagnosis. An optional IVU is performed before surgery and in any case with an inconclusive sonography. During the examination, a catheter should be in place.

Without exposure to radiation, sonography can provide detailed information on the size of the kidney,

any possible duplicate formations, the shape and size of the collecting system, and also permits assessment of the renal parenchyma. Detection of reflux itself is only possible by using special contrast media and in case of gross reflux.

If VCUG or sonography is negative, but clinical evidence of a suspected reflux persists, the examination should be repeated after an interval; the grade of the reflux is not constant under different conditions of examination.

If residual urine is apparent after micturition, without presence of an infravesical obstruction, a urodynamic examination should be performed in order to exclude bladder/sphincter dysfunction and thus secondary reflux.

Evidence of or exclusion of a reflux can also be provided by nuclear medicinal methods. Due to the much lower exposure to radiation, a radionuclide cystography to verify or to exclude reflux can also be used, especially for follow-up examinations.

Endoscopic examination is helpful in case of planned operative treatment and can provide evidence of a pathological configuration of the ureteral orifices and position, as well as the exclusion of infravesical obstruction. The examination is carried out under anaesthesia and preparation made for subsequent reflux correction. For any reflux therapy to be performed endoscopically, the configuration of the ureteral orifices is of greater importance than the reflux grading; in case of a golf-hole orifice, the prospects of success are markedly lower.

Table 9: Algorithm for the stepwise diagnosis of a primary reflux

Basis diagnostic history
	physical examination
	blood pressure
	laboratory tests
	urinalysis and culture
Sonography	dilatation
	renal parenchyma
	duplication of the kidney	optional --■►	IVU	dilatation/obstruction
	bladder configuration
	voiding	optional --■►	MAG-3	dilatation/obstruction
			DMSA	split renal function
Uroflow	in children over 3 years	optional	Cystometry
VCUG	grade of reflux
	reflux in a single or	optional	Endoscopy	infravesical obstruction
	duplicated kidney			orifices
	bladder configuration
	ureteral configuration

surgical treatment

Decision making on treatment strategy

medical treatment

IVU = intravenous urogram; DMSA = di-mercaptosuccinic acid; VCUG = voiding cystourethrography.