THE RELATIONSHIP AMONG DYSFUNCTIONAL ELIMINATION SYNDROMES, PRIMARY VESICOURETERAL REFLUX AND URINARY TRACT INFECTIONS IN CHILDREN

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Abstract
We determine whether functional bladder and/or bowel disorders influence the natural history or treatment of children with primary vesicoureteral reflux. We assessed 143 children with primary vesicoureteral reflux that stopped spontaneously or was surgically corrected for functional bowel and/or bladder disorders, including bladder instability, constipation and infrequent voiding, termed the dysfunctional elimination syndromes. Dysfunctional elimination syndromes were present in 66 of 143 children (43%) thought to have primary vesicoureteral reflux. Of these 66 patients 54 (82%) had a breakthrough urinary tract infection and underwent reimplantation compared to only 18% without the syndromes. Of 70 children who had a breakthrough urinary tract infection dysfunctional elimination syndromes were present in 54 (77%) and absent in 16 (23%). Of the remaining 73 patients who did not have a breakthrough infection dysfunctional elimination syndromes were present in 12 (16%) and absent in 61 (84%). In children with dysfunctional elimination syndromes the resolution of reflux that was 1 grade less severe required an average of 1.6 years longer. After the disappearance of reflux, urinary tract infection developed in 18 children, including 14 (78%) with dysfunctional elimination syndromes. Unsuccessful surgical outcomes involving persistent, recurrent and contralateral reflux occurred only in children with dysfunctional elimination syndromes. Dysfunctional elimination syndromes are common and are often unrecognized in children with primary reflux. These syndromes are associated with delayed reflux resolution and an increased rate of breakthrough urinary tract infection, which leads to reimplantation surgery. Dysfunctional elimination syndromes also adversely affect the results of reimplantation and represent a risk for recurrent urinary tract infection after reflux resolves. The evaluation and management of dysfunctional elimination syndromes should be an integral part of the treatment of every child with vesicoureteral reflux. Effective evaluation and treatment may be made cost-effective by decreasing the followup, the number of breakthrough urinary tract infections and the number of children requiring reimplantation.