Vesicoureteral Reflux — MCQs

10 questions

An otherwise asymptomatic child was found to have hypertension. On further evaluation, his urine analysis revealed 2-3 pus cells/HPF and 2-4 RBCs. Which of the following would be the most likely diagnosis?

What is the first-line intervention for acute symptomatic hydroureter with ureteral obstruction requiring urgent decompression?

A 2-year-old boy presents with a history of recurrent urinary tract infections, poor urinary stream, and failure to thrive. A voiding cystourethrogram (VCUG) is performed, and the images provided show dilated posterior urethra and a thickened bladder wall with a keyhole appearance. Based on these findings, the diagnosis of posterior urethral valves (PUV) is made. What is the management for this condition?

A one-year-old male child presented with a poor urinary stream since birth. The initial investigation of choice for evaluation is:

A 6-year-old boy came with a history of recurrent urinary tract infections. Imaging was done and showed retrograde flow of urine from the bladder into the ureters. What is the most likely diagnosis based on the imaging findings?

The most common underlying anomaly in a child with recurrent urinary tract infections is:

A 4-year-old girl presented with urinary infection caused by E. coli, pus cells in the urine, dilation of the left ureter with hydroureter, and a micturating cystourethrogram showing a filling defect in the bladder. What is the likely diagnosis?

A 10-year-old boy presents with hypertension. There is no history of urinary tract infections, abdominal pain, or family history of renal disease. Urine analysis reveals microscopic hematuria, proteinuria, and red blood cell casts. What is the most likely diagnosis?

Not true about chronic pyelonephritis in children –

Q10

A 5 year old child presented with periorbital swelling and oliguria. Nephrotic syndrome is suspected. Which of the following is the commonest type of nephrotic syndrome in this child?

Vesicoureteral Reflux Indian Medical PG Practice Questions and MCQs

Question 1: An otherwise asymptomatic child was found to have hypertension. On further evaluation, his urine analysis revealed 2-3 pus cells/HPF and 2-4 RBCs. Which of the following would be the most likely diagnosis?

A. Idiopathic RPGN
B. Post-Streptococal GN
C. IgA nephropathy
D. Chronic Reflux-Associated Pyelonephritis (Reflux Nephropathy) (Correct Answer)

Explanation: ***Chronic Reflux-Associated Pyelonephritis (Reflux Nephropathy)*** - **Hypertension** in an otherwise asymptomatic child, coupled with **mild pyuria (2-3 pus cells/HPF)** and **hematuria (2-4 RBCs)**, strongly suggests renal scarring from chronic pyelonephritis due to **vesicoureteral reflux**. - **Reflux nephropathy** leads to focal areas of scarring, impairing renal function and activating the **renin-angiotensin-aldosterone system**, causing hypertension. *Idiopathic RPGN* - **Rapidly progressive glomerulonephritis (RPGN)** typically presents with a rapid decline in renal function, significant proteinuria, and often more pronounced hematuria with red blood cell casts. - The mild and non-specific urine findings (2-3 pus cells, 2-4 RBCs) and the asymptomatic nature of the child do not fit the acute and severe presentation of RPGN. *Post-Streptococcal GN* - **Post-streptococcal glomerulonephritis** usually occurs 1-3 weeks after a strep infection and presents with acute nephritic syndrome, including periorbital edema, dark urine (gross hematuria), and significant hypertension. - The child in this case is described as "otherwise asymptomatic" without a history of recent infection, and the urine findings are not typical for acute glomerulonephritis. *IgA nephropathy* - **IgA nephropathy** often presents with recurrent episodes of gross hematuria, typically coinciding with or following an upper respiratory or gastrointestinal infection. - While it can cause hypertension, the presence of pus cells is not a characteristic feature, and the asymptomatic presentation with subtle urinary findings makes it less likely.

Question 2: What is the first-line intervention for acute symptomatic hydroureter with ureteral obstruction requiring urgent decompression?

A. Antibiotic prophylaxis alone
B. Immediate ureterolithotomy
C. Endoscopic ureteral stenting (Correct Answer)
D. Urinary alkalization

Explanation: ***Endoscopic ureteral stenting*** - **Endoscopic ureteral stenting** is the primary intervention for **acute symptomatic ureteral obstruction** requiring urgent decompression when the obstruction causes **hydroureter**. - This minimally invasive procedure provides immediate drainage from the kidney to the bladder, preventing further renal damage, managing pain, and relieving obstruction. - **Indications for urgent stenting** include: infected hydronephrosis, impaired renal function, intractable pain, solitary kidney with obstruction, or bilateral obstruction. - Alternative to stenting is **percutaneous nephrostomy**, particularly when retrograde stent placement fails or in infected systems. *Antibiotic prophylaxis alone* - While antibiotics are essential when infection complicates obstruction (pyonephrosis), **antibiotics alone cannot relieve the mechanical obstruction**. - The physical blockage must be addressed to prevent progressive renal damage and sepsis. *Immediate ureterolithotomy* - **Open ureterolithotomy** is a definitive surgical treatment but is **not first-line** for acute obstruction. - It is more invasive and typically reserved for failed endoscopic management, large impacted stones, or anatomical abnormalities preventing endoscopic access. - Modern approach favors initial decompression followed by definitive treatment (ureteroscopy, ESWL, or surgery). *Urinary alkalization* - **Urinary alkalization** may help dissolve **uric acid stones** over time but does not provide immediate relief of acute obstruction. - This is an adjunctive measure for specific stone types, not an emergency intervention for symptomatic hydroureter.

Question 3: A 2-year-old boy presents with a history of recurrent urinary tract infections, poor urinary stream, and failure to thrive. A voiding cystourethrogram (VCUG) is performed, and the images provided show dilated posterior urethra and a thickened bladder wall with a keyhole appearance. Based on these findings, the diagnosis of posterior urethral valves (PUV) is made. What is the management for this condition?

A. Antibiotic prophylaxis and monitoring
B. Endoscopic valve ablation (Correct Answer)
C. Suprapubic cystostomy
D. Observation with follow-up imaging
E. Urinary diversion with vesicostomy

Explanation: ***Endoscopic valve ablation*** - This is the **definitive treatment** for posterior urethral valves (PUV) as it directly addresses the anatomical obstruction. - Ablating the valves with a **cystoscope** relieves the outflow obstruction, preventing further damage to the bladder and kidneys. *Antibiotic prophylaxis and monitoring* - While important for managing recurrent UTIs and preventing future infections in children with PUV, it does **not address the underlying anatomical obstruction**. - Without surgical intervention, the obstruction would persist, leading to progressive urinary tract damage despite antibiotic use. *Suprapubic cystostomy* - This procedure involves placing a catheter directly into the bladder via the abdominal wall to **divert urine**. - It is typically a **temporary measure** used for initial decompression in severely ill patients or those with complete obstruction, not the definitive management. *Urinary diversion with vesicostomy* - Vesicostomy creates an opening between the bladder and abdominal wall for temporary urinary diversion. - This may be used in **very young infants** or critically ill patients as a temporizing measure, but **endoscopic ablation remains the definitive treatment**. *Observation with follow-up imaging* - **Observation is not appropriate** for symptomatic PUV due to the risk of progressive and irreversible renal damage. - The condition requires **prompt intervention** to relieve the obstruction and prevent long-term complications like renal failure.

Question 4: A one-year-old male child presented with a poor urinary stream since birth. The initial investigation of choice for evaluation is:

A. USG bladder
B. Voiding cystourethrography (VCUG) (Correct Answer)
C. Uroflowmetry
D. Intravenous urography

Explanation: ***Voiding cystourethrography (VCUG)*** - A **one-year-old male child with poor urinary stream since birth** is highly suggestive of **posterior urethral valves (PUV)**, the most common cause of bladder outlet obstruction in male infants. - **VCUG is the investigation of choice** for diagnosing PUV as it directly visualizes the posterior urethra during voiding and can demonstrate the characteristic findings: dilated posterior urethra, valve leaflets, bladder trabeculation, and vesicoureteral reflux. - While it involves catheterization and radiation, in this classic presentation, VCUG provides definitive diagnosis and is essential for surgical planning. *USG bladder* - Ultrasound is a useful **non-invasive screening tool** that can detect secondary findings such as hydronephrosis, bladder wall thickening, and increased post-void residual. - However, **USG cannot visualize the urethral valves** themselves and cannot definitively diagnose PUV. - In practice, many centers may perform ultrasound first, but it must be followed by VCUG for definitive diagnosis in this clinical scenario. *Uroflowmetry* - This test measures the **rate of urine flow** and requires patient cooperation with voiding. - A **one-year-old child cannot reliably follow instructions** to perform uroflowmetry. - It is more useful in older, cooperative children and adults. *Intravenous urography* - **Intravenous urography (IVU)** involves contrast administration and multiple X-rays to visualize the urinary tract. - It has been largely **replaced by ultrasound and CT urography** due to better imaging quality and safety profile. - IVU does not adequately visualize the urethra or diagnose urethral pathology like PUV.

Question 5: A 6-year-old boy came with a history of recurrent urinary tract infections. Imaging was done and showed retrograde flow of urine from the bladder into the ureters. What is the most likely diagnosis based on the imaging findings?

A. Vesicoureteric reflux (VUR) (Correct Answer)
B. Urinary bladder diverticulum (UBD)
C. Vesicocolic fistula (VCF)
D. Urinary bladder hernia (UBH)

Explanation: ***Vesicoureteric reflux (VUR)*** - VUR is defined by the **retrograde flow of urine from the bladder into the ureters**, which directly matches the imaging finding described - This is the **most common cause of recurrent UTIs in children**, as reflux allows bacteria to ascend from the bladder to the kidneys - Diagnosed by **voiding cystourethrogram (VCUG)**, which shows contrast refluxing into ureters during micturition - Graded from I to V based on severity; can lead to **reflux nephropathy** and renal scarring if untreated *Urinary bladder diverticulum* - An **outpouching of the bladder wall** through weakened muscle layers - May predispose to UTIs due to urinary stasis within the diverticulum, but does **not cause retrograde flow into ureters** - Imaging would show a **saccular projection** from the bladder, not ureteral filling *Vesicocolic fistula* - An **abnormal communication between bladder and colon**, typically from inflammatory bowel disease, malignancy, or trauma in adults (rare in children) - Presents with **pneumaturia (air in urine)**, fecaluria, and recurrent UTIs - Would not demonstrate **retrograde ureteral flow** on imaging *Urinary bladder hernia* - Protrusion of bladder through a **hernial defect** (inguinal, femoral, or abdominal wall) - Presents as a **reducible mass** that may increase with Valsalva - Does not cause **ureteral reflux** and has a distinct clinical and radiological presentation

Question 6: The most common underlying anomaly in a child with recurrent urinary tract infections is:

A. Posterior urethral valves
B. Vesicoureteric reflux (Correct Answer)
C. Neurogenic bladder
D. Renal calculi

Explanation: ***Vesicoureteric reflux*** - **Vesicoureteric reflux (VUR)** is the most common anatomic anomaly contributing to recurrent UTIs in children, allowing urine to flow backward from the bladder to the kidneys. - This retrograde flow can carry bacteria from the bladder to the upper urinary tract, leading to **pyelonephritis** and kidney damage. *Posterior urethral valves* - **Posterior urethral valves (PUV)** are a cause of severe urinary obstruction almost exclusively in newborn males, leading to bladder and kidney damage, but are less common than VUR for recurrent UTIs in childhood generally. - While PUV can cause recurrent UTIs due to stasis and obstruction, its incidence is lower than VUR, and it typically presents with more severe obstructive symptoms early in life. *Neurogenic bladder* - **Neurogenic bladder** results from nerve damage (e.g., spina bifida) affecting bladder control, leading to incomplete emptying, stasis, and recurrent UTIs. - While a significant cause of UTIs in affected children, it is a specific neurological condition and not the *most common underlying anomaly* overall for recurrent UTIs. *Renal calculi* - **Renal calculi (kidney stones)** can cause urinary obstruction and provide a nidus for bacterial growth, leading to recurrent UTIs. - However, kidney stones are less common in children than adults and are not the primary underlying anatomical anomaly; they are often secondary to other metabolic or structural issues.

Question 7: A 4-year-old girl presented with urinary infection caused by E. coli, pus cells in the urine, dilation of the left ureter with hydroureter, and a micturating cystourethrogram showing a filling defect in the bladder. What is the likely diagnosis?

A. Sacrococcygeal teratoma (a congenital tumor)
B. Ureterocele (a cystic lesion in the ureter) (Correct Answer)
C. Posterior urethral valves (a condition in males)
D. Vesicoureteral reflux (urine backflow into the ureters)

Explanation: ***Ureterocele (a cystic lesion in the ureter)*** - A **ureterocele** is a congenital malformation where the **distal ureter balloons into the bladder**, creating a filling defect on a micturating cystourethrogram (MCUG). - Its presence can lead to **obstruction** and **stasis**, causing recurrent **urinary tract infections (UTIs)**, **hydroureter**, and **hydronephrosis**. *Sacrococcygeal teratoma (a congenital tumor)* - A **sacrococcygeal teratoma** is a tumor typically found at the base of the spine and is usually **palpable externally** or identified prenatally. - While it can cause urinary symptoms due to compression, it would not directly present as a **filling defect within the bladder** on an MCUG. *Posterior urethral valves (a condition in males)* - **Posterior urethral valves** are obstructive membranes found in the **male urethra**, almost exclusively affecting boys. - This condition is unlikely in a 4-year-old girl and typically causes global bladder and upper tract dilation rather than a discrete filling defect from a ureteral anomaly. *Vesicoureteral reflux (urine backflow into the ureters)* - **Vesicoureteral reflux (VUR)** is the **abnormal backflow of urine from the bladder into the ureters** and often presents with UTIs and hydroureter. - However, VUR itself does not create a **filling defect in the bladder** on an MCUG; rather, the contrast would be seen flowing up the ureter.

Question 8: A 10-year-old boy presents with hypertension. There is no history of urinary tract infections, abdominal pain, or family history of renal disease. Urine analysis reveals microscopic hematuria, proteinuria, and red blood cell casts. What is the most likely diagnosis?

A. Reflux nephropathy
B. Polycystic kidney disease
C. Chronic glomerulonephritis (Correct Answer)
D. All of the options

Explanation: ***Chronic glomerulonephritis*** - The combination of **microscopic hematuria, proteinuria, and RBC casts** is pathognomonic for **glomerular disease**. - **RBC casts** specifically indicate glomerular bleeding and are highly specific for **glomerulonephritis**. - **Hypertension** in chronic glomerulonephritis results from sodium retention, fluid overload, and activation of the renin-angiotensin-aldosterone system. - The absence of acute features suggests a **chronic** process rather than acute post-streptococcal glomerulonephritis. *Reflux nephropathy* - While reflux nephropathy can cause hypertension and proteinuria, it typically presents with a history of **recurrent urinary tract infections**, which is explicitly absent in this case. - **RBC casts are NOT a feature** of reflux nephropathy; urinalysis may show proteinuria and occasionally WBCs/bacteria if infection is present. - Diagnosis requires imaging (VCUG, DMSA scan) showing vesicoureteral reflux and renal scarring. *Polycystic kidney disease* - **Autosomal dominant PKD** rarely presents with symptoms in childhood; it typically manifests in the 3rd-4th decade. - **Autosomal recessive PKD** presents in infancy/early childhood with enlarged kidneys and renal failure. - While PKD can cause hematuria (from cyst rupture), **RBC casts are not characteristic** as the pathology is cystic, not glomerular. - Diagnosis is made by ultrasound showing multiple bilateral renal cysts. *All of the options* - This is incorrect because the **specific urinalysis findings** (particularly **RBC casts**) point definitively to **glomerular pathology**. - RBC casts are the hallmark of glomerulonephritis and are not seen in reflux nephropathy or polycystic kidney disease. - The clinical presentation with specific laboratory findings allows differentiation between these conditions.

Question 9: Not true about chronic pyelonephritis in children –

A. Associated with renal scarring
B. Associated with Ureteric reflux
C. Males are more affected than females (Correct Answer)
D. Associated with Intrarenal reflux

Explanation: ***Males are more affected than female*** - This statement is **incorrect** because chronic pyelonephritis and urinary tract infections (UTIs) in childhood are **more common in females** due to shorter urethras and proximity to the anus. - While males can be affected, especially those with congenital anomalies, the overall incidence is higher in females. *Associated with renal scarring* - **Chronic pyelonephritis** is a major cause of **renal scarring** in children, which can lead to long-term complications like hypertension and chronic kidney disease. - The repeated inflammatory responses and infection in the kidney parenchyma contribute to the formation of scar tissue. *Associated with Ureteric reflux* - **Vesicoureteral reflux (VUR)**, where urine flows backward from the bladder into the ureters, is a strong predisposing factor for chronic pyelonephritis. - VUR allows bacteria to ascend to the kidneys, increasing the risk of infection and subsequent damage. *Associated with Intrarenal reflux* - **Intrarenal reflux** occurs when urine from the renal pelvis flows back into the collecting ducts and renal parenchyma, providing a pathway for bacteria to infect the kidney tissue. - This phenomenon is often seen in conjunction with vesicoureteral reflux and is a key mechanism leading to **renal damage and scarring** in chronic pyelonephritis.

Question 10: A 5 year old child presented with periorbital swelling and oliguria. Nephrotic syndrome is suspected. Which of the following is the commonest type of nephrotic syndrome in this child?

A. Focal segmental glomerulosclerosis (FSGS)
B. Chronic glomerulonephritis
C. Minimal change disease (Correct Answer)
D. Congenital nephrotic syndrome

Explanation: ***Minimal change disease*** - This is the **most common cause of nephrotic syndrome** in children, accounting for approximately 80% of cases. - It presents with sudden onset of **periorbital edema**, **generalized edema**, and often **oliguria** due to severe proteinuria. *Focal segmental glomerulosclerosis (FSGS)* - While a significant cause of nephrotic syndrome in children, it ranks second to minimal change disease in frequency. - FSGS tends to have a **poorer response to steroids** and a higher risk of progression to **end-stage renal disease**. *Chronic glomerulonephritis* - This is a broad category of glomerular diseases, typically having a **more insidious onset** and often associated with hematuria and hypertension, which are not mentioned in this acute presentation. - It usually presents with features that suggest **nephritic syndrome** (e.g., hematuria, hypertension) rather than primarily nephrotic syndrome features. *Congenital nephrotic syndrome* - This is a **rare genetic condition** that presents within the first 3 months of life, which is much earlier than the 5-year-old age of this patient. - It is characterized by severe proteinuria from birth and is typically part of inherited syndromes.

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