The presence rate of VUR in adults is an uncommon occurrence, and the imperative for diagnostic assessments to detect VUR in this demographic has not yet been definitively established [6, 7]. Moreover, the natural history of vesicoureteral reflux first detected in adulthood has shown an association with strikingly high incidence of urinary tract infections, hypertension and nephrolithiasis [8]. In addition, the initial presentation of VUR in adults diverges significantly from its pediatric counterpart. In adults, manifestations often manifest as symptomatic episodes characterized by recurrent urinary tract infections or persistent pain [9].
Presently, no established guidelines provide recommendations for the VCUG or CEVUS in adults experiencing their initial episode of pyelonephritis, in contrast, to EUA pediatric guidelines, there it is recommended to rule out VUR in infants following their initial episode of febrile UTI with a non-E. Coli infection. Moreover, for children over one year old experiencing an E. Coli infection, the recommendations are to assess for VUR after the occurrence of the second febrile UTI. Furthermore, in cases where abnormal findings are detected in US examinations, evaluation of the upper tract and exclusion of VUR are deemed necessary [10].
Indeed, the literature contains several articles emphasizing the necessity of conducting a comprehensive investigation for VUR in adults. Notably, these studies consistently focus on cases characterized by recurrent infections or the presence of additional pathology in the urinary tract. For example, Pereira et al. elucidated a case involving a patient with repetitive urinary tract infections and recurrent pyelonephritis. It was only subsequent to completing a comprehensive urological investigation that the presence of VUR was unveiled [6]. Berquist et al. also underscored the need to entertain suspicions of reflux in individuals with a history of recurrent UTIs, particularly if accompanied by discernible indications such as renal parenchymal scarring, ureteral dilatation, or mucosal striations [11]. Another study indicates that urologists need to maintain an index of suspicion for VUR when evaluating adult patients with recurrent pyelonephritis or complicated UTIs [7]. Okeke et al. presented data from their study involving 13 women who experienced acute pyelonephritis. The participants were assessed for VUR', they found that 9 out of 13 participants (69%) had VUR. However, it's noteworthy that among these patients, 5 had undergone previous surgery for vesicoureteral reflux, and 2 had experienced reflux during childhood, which was subsequently documented to have resolved [12]
We have previously presented our data with endoscopic correction of |VUR in adult patients [13]. Although, the mail goal of this manuscript was to evaluate the efficacy of this surgical technique in adult population, we have mentioned the high incidence of the renal parenchymal damage in this group of patients and also a higher incidence of Rec UTI both febrile and afebrile following successful surgical correction. This data emphasize an importance of early detection of VUR and commencement of treatment.
Our study underscores the compelling proposition that in the inaugural episode of pyelonephritis, even in patients devoid of a documented urological history, it is both pragmatic and beneficial to explore the potential presence of VUR. These recommendations are substantiated by the dual considerations of the minimal risk associated with conducting such an investigation and the notable prevalence of identified VUR cases in our study (60%).
Contrary to the results of our study, Choi et al. conducted an extensive investigation into VUR in adult women experiencing uncomplicated acute pyelonephritis. Their study, involving 86 patients with uncomplicated acute pyelonephritis, revealed a mere 2.3% incidence of VUR [14]. According to their data, VUR does not appear to constitute a significant etiological factor in uncomplicated acute pyelonephritis among adults. Subsequent studies have reported a similar prevalence of VUR (up to 9%) in patients with recurrent pyelonephritis [15,16]. In contrast to these findings, our study identified a notably higher percentage of patients presenting with reflux following the initial episode. This observed disparity could be attributed to several factors: Firstly, Choi's study exclusively included patients with uncomplicated pyelonephritis, whereas our cohort, even in the context of a first pyelonephritis presentation, exhibited additional complexities. Specifically, among the 14 patients with identified reflux in our study, 2(14.3%) presented with a kidney abscess, 4(28.6%) with hydronephrosis and 4(28.6%) displayed renal scars or atrophy. Furthermore, our study incorporated both male and female participants, diverging from Choi's investigation, which exclusively focused on women.
In 10 patients (71.4%), it was determined that surgical intervention is necessary to address the VUR. Our initial preference is endoscopic repair, with 9 patients opting for this procedure. We firmly advocate for endoscopic repair as a durable and minimally invasive option, surpassing the test of time and offering a less intrusive alternative to open surgery. Of the patients that underwent endoscopic repair, only one had a febrile UTI since the procedure, and VCUG demonstrated reflux resolution
As for the study population it is known that the prevalence of adult VUR is higher in women [17]. Indeed, in our study, out of the 14 patients who suffered from VUR, 10(71.4%) were women. It's noteworthy that among the male population in the study, 4 out of 5 RRU (80%) experienced grade 4 reflux, whereas in women, only 2 out of 13 RRU (15.3%) were grade 4. Despite the high prevalence of VUR in women, these findings suggest a potential for greater severity in men.
Our study is subject to several limitations. Firstly, it is retrospective in nature, which inherently carries certain constraints. Secondly, the study is susceptible to various biases related to the patient population. For instance, it is conceivable that patients hospitalized for pyelonephritis in the urology department, rather than the internal medicine department, may have been in a more critical condition. Additionally, there is a potential bias in the selection of patients returning for clinic reviews with additional imaging, as they might be those who experienced more pronounced back pain, influencing the completeness of the investigation.