Answer for BIR CoW 05 Jul 2026
Bilateral Grade V vesicoureteric reflux (VUR) with neurogenic bladder.
Findings
Plain X-ray Film: No evidence of radio-opacity noted within the renal parenchyma or bladder. Procedure: About 300 ml of normal saline + 30 ml of contrast (Iohexol) is instilled into the bladder via Foley's catheter and films are taken. Full Bladder Phase: Bladder appears normally distended with a characteristic pine tree appearance noted in the dome of the bladder.Evidence of contrast-filled tortuous and severe dilatation of ureter and pelvicalyceal system, with loss of fornices and papillary impressions on the left side. Foley's catheter is removed and the patient is asked to void. Voiding Phase: Evidence of contrast opacification of both ureters with severe dilatation and tortuosity of ureters and pelvicalyceal system, with loss of fornices and papillary impressions on both right and left sides. Post-Voiding Phase: No evidence of residual urine after voiding in the bladder.
Discussion
Vesicoureteric reflux (VUR) is the term for the abnormal flow of urine from the bladder into the upper urinary tract and is typically encountered in young children. Epidemiology:The incidence of urinary tract infection is 8% in females and 2% in males 2. Among children with urinary tract infections, the incidence of vesicoureteric reflux rises to ~ 25-40% Clinical presentation:Reflux from the bladder into the upper urinary tract predisposes to pyelonephritis by allowing entry of bacteria to the usually sterile upper tract. As such the diagnosis is first suspected after urinary tract infection in a young child. Vesicoureteric reflux may be an isolated abnormality or associated with other congenital anomalies including: 1)Congenital obstructive posterior urethral membrane (COPUM) 2)Bulbar urethral obstruction (Cobb collar)3)ureteral partial obstruction4)duplex collecting system Pathology:Vesicoureteric reflux is, in the majority of cases, the result of a primary maturation abnormality of the vesicoureteral junction resulting in a short distal ureteric submucosal tunnel. As a result, the normal pinch-cock action of the vesicoureteric junction when bladder pressure increases during micturition is impaired, allowing urine to pass retrogradely up the ureter.Radiographic featuresThe primary diagnostic procedure for evaluating vesicoureteric reflux is a voiding cystourethrogram (VCUG), which requires bladder catheterization and distention of the bladder. Patients unsuitable for the catheterization may need to undergo cystoscopy as an alternative. Voiding cystourethrogram (also known as micturating cystourethrogram) should be performed after the first well-documented urinary tract infection up to the age of 6 years. Points to be noted in VUR during MCU study: 1)Confirm the presence of reflux with grading 2)The occurrence of reflux during micturition or during bladder filling 3)Presence of associated anatomical anomalies 4)Length of the ureteric tunnel 5)The width of the lower ureterVesicoureteric reflux (VUR) grading divides vesicoureteric reflux (VUR) according to the height of reflux up the ureters and degree of dilatation of the ureters: Grade 1: reflux limited to the ureter Grade 2: reflux up to the renal pelvis Grade 3: mild dilatation of ureter and pelvicalyceal system Grade 4 :tortuous ureter with moderate dilatation,blunting of fornices but preserved papillary impressions Grade 5:tortuous ureter with severe dilatation of ureter and pelvicalyceal system ,loss of fornices and papillary impressions Routine ultrasound is usually also performed (in addition to voiding cystourethrogram) to assess the renal parenchyma for evidence of scarring or anatomic anomalies. Treatment and prognosis: Significant vesicoureteral reflux, if untreated, may lead to recurrent urinary tract infections, renal scarring, and eventually renal failure (reflux nephropathy). Low-grade reflux may be treated by prophylactic antibiotic treatment. Surgical reimplantation to treat higher grades of reflux is aimed at reducing the incidence of reflux nephropathy. Endoscopic treatment, performed by injection of a bulking agent (e.g. Deflux) at the ureterovesical junction, may be used and is variably effective in preventing sequelae of reflux.
References:
1. Ralph Weissleder. Primer of Diagnostic Imaging with CD-ROM. (2006) ISBN: 0323040683 2. Wolfgang Dähnert. Radiology Review Manual. (2011) ISBN: 9781609139438 3. Lebowitz R, Olbing H, Parkkulainen K, Smellie J, Tamminen-Möbius T. International System of Radiographic Grading of Vesicoureteric Reflux. Pediatr Radiol. 1985;15(2):105-9. doi:10.1007/bf02388714
Findings
Plain X-ray Film: No evidence of radio-opacity noted within the renal parenchyma or bladder. Procedure: About 300 ml of normal saline + 30 ml of contrast (Iohexol) is instilled into the bladder via Foley's catheter and films are taken. Full Bladder Phase: Bladder appears normally distended with a characteristic pine tree appearance noted in the dome of the bladder.Evidence of contrast-filled tortuous and severe dilatation of ureter and pelvicalyceal system, with loss of fornices and papillary impressions on the left side. Foley's catheter is removed and the patient is asked to void. Voiding Phase: Evidence of contrast opacification of both ureters with severe dilatation and tortuosity of ureters and pelvicalyceal system, with loss of fornices and papillary impressions on both right and left sides. Post-Voiding Phase: No evidence of residual urine after voiding in the bladder.
Discussion
Vesicoureteric reflux (VUR) is the term for the abnormal flow of urine from the bladder into the upper urinary tract and is typically encountered in young children. Epidemiology:The incidence of urinary tract infection is 8% in females and 2% in males 2. Among children with urinary tract infections, the incidence of vesicoureteric reflux rises to ~ 25-40% Clinical presentation:Reflux from the bladder into the upper urinary tract predisposes to pyelonephritis by allowing entry of bacteria to the usually sterile upper tract. As such the diagnosis is first suspected after urinary tract infection in a young child. Vesicoureteric reflux may be an isolated abnormality or associated with other congenital anomalies including: 1)Congenital obstructive posterior urethral membrane (COPUM) 2)Bulbar urethral obstruction (Cobb collar)3)ureteral partial obstruction4)duplex collecting system Pathology:Vesicoureteric reflux is, in the majority of cases, the result of a primary maturation abnormality of the vesicoureteral junction resulting in a short distal ureteric submucosal tunnel. As a result, the normal pinch-cock action of the vesicoureteric junction when bladder pressure increases during micturition is impaired, allowing urine to pass retrogradely up the ureter.Radiographic featuresThe primary diagnostic procedure for evaluating vesicoureteric reflux is a voiding cystourethrogram (VCUG), which requires bladder catheterization and distention of the bladder. Patients unsuitable for the catheterization may need to undergo cystoscopy as an alternative. Voiding cystourethrogram (also known as micturating cystourethrogram) should be performed after the first well-documented urinary tract infection up to the age of 6 years. Points to be noted in VUR during MCU study: 1)Confirm the presence of reflux with grading 2)The occurrence of reflux during micturition or during bladder filling 3)Presence of associated anatomical anomalies 4)Length of the ureteric tunnel 5)The width of the lower ureterVesicoureteric reflux (VUR) grading divides vesicoureteric reflux (VUR) according to the height of reflux up the ureters and degree of dilatation of the ureters: Grade 1: reflux limited to the ureter Grade 2: reflux up to the renal pelvis Grade 3: mild dilatation of ureter and pelvicalyceal system Grade 4 :tortuous ureter with moderate dilatation,blunting of fornices but preserved papillary impressions Grade 5:tortuous ureter with severe dilatation of ureter and pelvicalyceal system ,loss of fornices and papillary impressions Routine ultrasound is usually also performed (in addition to voiding cystourethrogram) to assess the renal parenchyma for evidence of scarring or anatomic anomalies. Treatment and prognosis: Significant vesicoureteral reflux, if untreated, may lead to recurrent urinary tract infections, renal scarring, and eventually renal failure (reflux nephropathy). Low-grade reflux may be treated by prophylactic antibiotic treatment. Surgical reimplantation to treat higher grades of reflux is aimed at reducing the incidence of reflux nephropathy. Endoscopic treatment, performed by injection of a bulking agent (e.g. Deflux) at the ureterovesical junction, may be used and is variably effective in preventing sequelae of reflux.
References:
1. Ralph Weissleder. Primer of Diagnostic Imaging with CD-ROM. (2006) ISBN: 0323040683 2. Wolfgang Dähnert. Radiology Review Manual. (2011) ISBN: 9781609139438 3. Lebowitz R, Olbing H, Parkkulainen K, Smellie J, Tamminen-Möbius T. International System of Radiographic Grading of Vesicoureteric Reflux. Pediatr Radiol. 1985;15(2):105-9. doi:10.1007/bf02388714
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!