Management of Vesicoureteral Reflux in the Child - Research Paper Example

Management of Vesicoureteral Reflux in the Child over One Year of Age Introduction Vesicoureteral reflux (VUR) is a well known heterogeneous disease. It can be described as a disease process coupled with an anatomical abnormality at the ureterovesical junction. It can also be described as an abnormal urinal flow from the bladder to the upper urinary tract. VUR is usually categorized into either primary or secondary reflux. Of the two, primary reflux is the most common. It is as a result of an incompetent ureterovesical tunnel. Under normal circumstances, the ureter passes through the detrusor muscle and ends at the ureteral hiatus thus the intramural ureter (Aappublications.org., 2011). A short intramural ureter results into failure of the flap-valve mechanism. Secondary VUR is associated with abnormal high pressure build up in the bladder. It follows that a flap-valve mechanism failure at the intramural ureter is due to this high pressure. Posterior urethral valves and neurogenic bladder are normally associated with clinical conditions that lead to secondary reflux. The retrograde flow of urine is checked as the intramural ureter is passively compressed while the bladder fills. The disorder has been subjected to great scrutiny especially in relation to the general importance of the disorder as a clinical entity in renal development and function. Statistics reveal that 1% of normal children are usually affected by this disorder. Approximately 30-50% of children with urinary tract infections are also affected (Aappublications.org., 2011). It should also be noted that 10% of the children with prenatally diagnosed hydronephrosis have been reported to have the disorder. However, its treatment has since remained to be clouded with a lot of controversies in pediatric urology in addition to the fact that it represents one of the most significant risk factors for acute pyelonephritis in children. Common knowledge has it that pediatric nephrologists, pediatric urologists and pediatrics in general, have frequently encountered VUR. This has led to the conclusion that VUR is a prevalent disorder. According to Moyer and Elliot (2004) the above mentioned specialists’ groups will only work to help patients with VUR on condition that a synergistic relationship exists between them. It will then be realistic to guarantee special care for the respective patients. Surgical correction of VUR is highly dependent on the availability of renal scars; in relation to current indications. Anti-reflux surgery is only indicated in high-grade bilateral VUR in the absence of scars. The last 50 years have witnessed significant progress in relation to diagnosis, treatment and management of the disease (Moyer and Elliot, 2004). A clearer understanding of the disorder has since been enhanced through the discovery that VUR is a component of a generalized dysfunction of the urinary tract; lower urinary tract to be specific. The case of the four year old patient should be noted. This patient had VUR without any clinical evidence of bowel dysfunction. However, the patient had initially been reported to have a febrile urinary tract infection in addition to being diagnosed with VUR. Moyer and Elliot (2004) reveal that in 1997, the AUA Guideline for Pediatric Vesicoureteral Reflux established the relationship between UTI and VUR. The association was based on the significant high incidences of febrile UTI with ongoing VUR as compared to those children with treated cases of VUR. Chances of renal damage especially in children over one year of age can be reduced through management and identification of VUR. When a child has UTI in close proximity with VUR prevalence then he or she is likely to contract pyelonephritis and UTI. Renal scarring is a clear indicator of pyelonephritis. A child is more disadvantaged when he or she has both pyelonephritis and VUR as compared to when he or she only has pyelonephritis. The risk of permanent renal injury and morbidity of acute pyelonephritis can be lowered by administering VUR treatment. Three most common methods of treating VUR include curative interventions, continuous antibiotic prophylaxis and observation (Medicaltalking.com, 2011). Hypothesis Being Examined The incidence of recurrent UTI in children with grade II - III VUR does differ significantly between antibiotic prophylaxis and endoscopic subureteral injection. The relationship between the numbers of urinary tract infections is directly proportional to incidences of renal scarring. The presence of UTI for infants aged between two months and two years is associated with the occurrence of unexplained fever. Young children have a higher the risk of contracting UTI as compared to the older ones. Independent and Dependent Variables This study encompasses various variables. They are either dependent or independent. The dependent variables include: Events of renal scarring, incidence of recurrent UTI, type of treatment administered, cost of medical care and the type of disorder in question. Renal scaring has a particular close relationship with urinary tract infections. The study reveals how a patient can have more than one disorder. This view is dependent on quite a number of other factors or rather variables. The independent variables include: number of urinary tract infections, prevalence rate of infection in circumcised children, VUR grade and the ages of children/patients. The occurrence of UTI is closely associated with the chances of contracting VUR. It is also importance to note that the issue of circumcision plays a very important role in the chances of infections. The age of a child is very important since different ages are associated with different characteristics in relation to the general effect and occurrence of a certain disorder. Methods A thorough literature review should be conducted to facilitate generation of evidence tables. Apart from literature search, other methods that can be used include evidence combination and data extraction. The tables would be instrumental in relation to a proper decision making process. It is advisable to suggest several titles so that one has many options to pick from. This will ensure that the process of narrowing down to relevant titles is manageable. A member of an already formed panel is expected to use customized extraction forms to collect information independently. Information about the incidences of recurrence of UTI will be obtained through questionnaires, interviews and review of past medical records. The same will apply for the grade of VUR and the respective treatment measures that have been administered over time. There is a lot of literature about the earlier mentioned disorders. Proper research is therefore required in order to come up with a proper understanding of the disorders. Past medical records will be helpful when it comes to finding a history of infections across different ages. Aspects of occurrences, recurrence and prevalence will then be obtained from this kind of information. The major sources of these titles can be bibliographies, MEDLINE and files from selected authors. The information is usually in the form of the characteristics of the study, type and management of the disorder, the population of patients and the study characteristics. Additional information in relation to the circumcision status of patients; presence of duplex cases; number of children with specified dysfunctions; index cases’ relationships and events of prenatal and post-natal disorders (Medicaltalking.com, 2011). Medicaltalking.com (2011) reveals that a common outcome is that just a few of the articles provide original and reliable data. The articles should then be organized and arranged in order bearing in mind their significance. All this initiatives will definitely result into development of a model that is based on evidence. The major elements are quantitative outcomes obtained from the relevant literature. The existing literature should be subjected to a meta-analysis process. The literature usually describes the results of the surgical and nonoperative management of VUR. The analysis based on the selected methods should also describe certain specific questions upon which clinical decisions will be made. These particular questions should be categorized into three groups. The first group is concerned with evaluation of the association between renal injuries, pyelonephritis and VUR (Moyer & Elliot, 2004). This design helps to easily establish a casual relationship among the mentioned disorders. The second group comprises of questions through which one can determine results to various treatments administered. Finally, the third group of questions relates to the results of curative therapies that will be prescribed to the patient. There are so many literature resources available. Only the relevant ones should be selected for the study. It is expected that the final recommendation will be obtained by the evidence gathered. It is for this reason that the methodologist will rate the evidence as good, fair, strong or opinion/consensus. A comprehensive description of all the methods that should be used is generated. This should be recorded in a technical final report. Outline of Analysis Plan The preferred method of analysis is Decision analysis. It is used to analyze risks and cost-effectiveness in relation to diagnosis, management, and evaluation of UTI. The generated probability of undesirable outcome is an estimate due to the approximations that are expected. Various strategies were examined in relation to their cost-effectiveness. The break-even costs responsible for preventing chronic conditions should also be determined. A typical illustration of this could be estimation of an amount that could cover renal diseases and hypertension (Aappublications.org, 2011). This amount greatly relies on someone’s lifespan productivity. The person should be healthy and young. Such figures are necessary when it comes to general decision making. A common approach that can be applied here is the threshold approach which involves changing of variables during a decision analysis process. In the event that a resultant value exceeds the expected one, then an alternative variable is picked. Consensus should be applied whenever it is deemed necessary. It is advisable to develop an algorithm to represent the strategies. The algorithm should exhibit characteristics of both risk and benefits. In most cases, a sub-analysis is usually conducted to reveal the relationship between these disorders. A common occurrence is when the chances of developing renal injuries are compared to episodes of acute pyelonephritis in children living with VUR. There are so many articles dealing with children with acute pyelonephritis that can be of great help. It is advisable to select articles that have analyzed patients who have been analyzed for more than six months (Medscape.com, 2010). It should be noted that the study should not be limited to children with VUR but others with similar conditions should also be accommodated. This assists to come up with a comprehensive; one that is reliable and therefore credible. The methodology should be able to clearly describe how best to select the articles. The study is therefore expected to meet strict criteria. Plan for Reporting of Results As mentioned earlier, a final technical report that has detailed entries should be generated. The report should capture everything in the study. According to Medscape.com (2010) a good report gives a clear impression of the conducted study. The report should therefore be organized to enhance easy retrieval of vital information. The results of the study will be brought to the attention of the public through the media (newspapers, national radio and television) and a dedicated website. Various presentations should also be done during conferences and annual meetings in addition to the various publications about the study. Conclusion In conclusion, UTI and VUR are disorders that should be taken seriously especially now that ways to manage them are increasingly being developed. To enhance preparedness of both doctors, therapists and event relatives to the patients, proper awareness by relevant authorities and organizations, should be effected. References Aappublications.org. (2011). Practice Parameter: The Diagnosis, Treatment, and Evaluation of the Initial Urinary Tract Infection in Febrile Infants and Young Children. Retrieved 6th Oct. 2011 from http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/4/843#SEC1. Medicaltalking.com. (2011). Management of vesicoureteral reflux in the child over one year of age. Retrieved 5th Oct. 2011 from http://www.medicaltalking.com/vesicoureteral-reflux/21025-management-vesicoureteral-reflux-child-over-one-year-age.html. Medscape.com. (2010). Vesicoureteral Reflux. Retrieved 6th Oct. 2011 from http://emedicine.medscape.com/article/439403-overview. Moyer, V. & Elliot, E. (2004). Evidence based Pediatrics and Child Health. London: BMJ Books. Read More