Vesicoureteral reflux: Role in pyelonephritis

Abstract

Vesicoureteral reflux is being demonstrated increasingly, not only in children who have intermittent bouts of acute pyelonephritis, but also in adults with chronic non-obstructive pyelonephritis. We present twenty-two of our own patients, all adults with recurring or chronic non-obstructive pyelonephritis, in each of whom reflux has been demonstrated. Reflux may be intermittent, hence, a negative cystogram does not rule it out. Normal intravenous pyelograms frequently are found in patients with ureteral reflux. Residual urine may represent return of refluxed urine to the bladder rather than vesical neck obstruction. Reflux may be the cause of atrophic pyelonephritis; it may be a factor in obstruction of the ureteropelvic junction and may explain abdominal pain after voiding. The ease with which reflux occurs in the human ureterovesical valve changes with the sex and age of the patient and closely parallels the natural history of pyelonephritis. Animal experiments demonstrate the valvular mechanisms involved in the prevention of reflux. Reflux perpetuates infection by overloading the intrinsic bladder defense mechanism immediately after evacuation of the bladder, by the return of the infected urine to the bladder. Surgical correction of reflux stops the clinical attacks of pyelonephritis and sterilizes the urine. Since asymptomatic infection of the bladder urine has been shown to be more common than previously believed, and since reflux is being demonstrated with increasing frequency, the detection and treatment of reflux may lead to a better understanding of the pathogenesis and treatment of chronic nonobstructive pyelonephritis.