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Chronic Lower Quadrant Abdominal Pain Due To Vesicoureteral Reflux
0022-534 7/83/1291-0135$02.00/0 Vol. 129, January
THE JOURNAL OF UROLOGY
Copyright© 1983'by The Williams & Wilkins Co.
Printed in U.S.A.
CHRONIC LOWER QUADRANT ABDOMINAL PAIN DUE TO VESICOURETERAL REFLUX ABDO J. FADDOUL
AND
JOHN A. BELIS
From the Departments of Urology, Clarksburg Veterans Hospital, Clarksburg and West Virginia University Medical Center, Morgantown, West Virginia
ABSTRACT
Chronic lower abdominal pain or flank pain in adults may be associated with vesicoureteral reflux. Although it is well known that renal scarring may occur in adults with vesicoureteral reflux associated with urinary tract infection, renal function may vary significantly when these patients are found to have sterile vesicoureteral reflux. We report 2 cases of lifelong intermittent lower abdominal pain associated with vesicoureteral reflux without damage to the upper urinary tracts. A voiding cystourethrogram should be included in the evaluation of adults with chronic lower quadrant pain or flank pain even if excretory urography and cystoscopy are normal and the urine is sterile. Vesicoureteral reflux has been considered to be uncommon in men. The reported incidence in all adults varies from 4 to 25 per cent, while the incidence in men varies from 1 to 6 per cent. 1• 2 An apparent increase in the diagnosis of reflux in adults may be due to the more frequent use of voiding cystourethrograms in the investigation of the adult urinary tract. The method of presentation of vesicoureteral reflux in adttl.ts often may be different from that noted in children. Abdominal or flank pain is a common complaint associated with vesicoureteral reflux in adults,3· 4while it is unusual in children. Herein we report 2 cases of apparent lifelong sterile primary vesicoureteral reflux and normal upper urinary tracts. Both patients complained only of chronic episodic lower abdominal or flank pain. CASE REPORTS
Case 1. A 59-year-old man complained of a lifelong history of intermittent right lower quadrant pain that at times radiated to the right flank and occasional episodic mild left flank pain. The pains were worse before voiding. The patient denied all other urinary symptoms and had no history of urinary tract infection. He had had an appendectomy in 1944 for the right lower quadrant pain and the appendix was normal. Gastrointestinal and orthopedic evaluations performed previously were normal. Physical examination showed mild right flank tenderness. Laboratory assessment was completely normal, including sterile urine cultures. Normal kidneys and mild dilatation of the right distal ureter were noted on excretory urography (IVP) (fig. 1, A). A voiding cystourethrogram showed grade III right and grade Ila left vesicoureteral reflux with a small right paraureteral diverticulum (fig. 1, B). At cystoscopy the patient had a laterally displaced golf hole right ureteral orifice and a patulous laterally displaced left ureteral orifice. Because the upper urinary tracts were normal and there had been no known urinary tract infection, the patient was instructed to perform scheduled voiding and double voiding. After 1 week of this regimen the pains disappeared. At followup 1½ years later he was free of pain and the urine had remained sterile. Case 2. A 60-year-old man complained of intermittent left lower quadrant and left flank pain that had been present at least since he was 20 years old. He had no other urinary symptoms and no known urinary tract infections. Since 1950 he had had 10 normal IVPs and 3 reportedly normal cystoscopic examinations. Previous gastrointestinal studies and a psychiAccepted for publication April 30, 1982.
135
atric evaluation were not helpful. Physical examination showed mild left flank tenderness. Laboratory evaluation was normal, including a sterile urine culture. An IVP was normal (fig. 2, A). A voiding cystourethrogram demonstrated grade Ilb left vesicoureteral reflux (fig. 2, B). At cystoscopy the left ureteral orifice was laterally displaced and had a golf hole appearance. Because the upper urinary tracts were normal and there was no history of urinary tract infection, this patient also was treated conservatively with a voiding schedule. The pain ceased and the urine remained sterile 1 year after the regimen was instituted. DISCUSSION
Vesicoureteral reflux in infancy and childhood is common. The natural history in children is that reflux may disappear as the child grows and urinary infections are controlled. Therefore, reflux should be less common in adults. The disappearance of reflux is believed to be due to lengthening of the intravesical ureter and development of the musculature of the ureterovesical junction. 5 The significance of reflux in adults as related to pathological changes in the upper urinary tract has not been established. Vesicoureteral reflux may be an etiologic factor in hydronephrosis associated with neurogenic bladder6 as well as in chronic pyelonephritis. 7- 9 Chronic renal failure is a potential terminal event in the natural history of vesicoureteral reflux associated with recurrent urinary tract infection. However, the effect of sterile vesicoureteral reflux on renal function in adults is controversial. As noted in our 2 cases a lifelong history of sterile vesicoureteral reflux may have no significant effect on renal function. It has been noted that sterile vesicoureteral reflux did not lead to progressive renal scarring in children 10 and that reflux alone did not appear to harm normal kidneys. 11 Similar findings have been reported occasionally in adults. 12 Conversely, patients with reflux and sterile urine at the time of diagnosis may have renal scarring or hypertension. A possible "water hammer" effect of severe reflux on the kidneys has been suggested to be the origin of renal deterioration in patients with sterile urine 13 or the patient may have had an undiagnosed urinary infection in the past. 10• 14 The relationship between chronic lower abdominal or flank pain in adults and the diagnosis of sterile vesicoureteral reflux has not been investigated carefully. Flank pain associated with reflux has been reported to vary from 45 3 to 75 per cent. 4 These reports did not differentiate between those patients with urinary infection and those with sterile urine.
136
FADDOUL AND BELIS
FIG. 1. Case 1. A, IVP shows mild dilatation of right distal ureter. B, voiding cystourethrogram reveals grade III right and grade Ila left vesicoureteral reflux.
FIG. 2. A, normal IVP. B, voiding cystourethrogram shows grade IIb left vesicoureteral reflux
A voiding cystourethrogram should be included in the evaluation of adults with unexplained flank pain and sterile urine. Even cystoscopy in these patients may demonstrate normal ureteral orifices while the voiding cystourethrogram shows reflux. Indeed, normal-appearing ureteral orifices were found in 30 per cent of adults or children with vesicoureteral reflux. 15 Because the proportion of abnormal appearance of the ureteral orifices is the same in adults and children, it has been suggested that primary vesicoureteral reflux in adults has existed since childhood. 15 Although the role of antireflux surgery in adults has been debated many recent reports have supported it. 2 • 4 • 9• 16 Antireflux surgery may be beneficial in the presence of recurrent urinary tract infections. Surgery does not appear to be necessary when the upper urinary tract is normal and the urine is sterile. Urologic evaluation of adults with a history of chronic lower abdominal pain or flank pain should include a urine culture, IVP, voiding cystourethrography and cystoscopy. Despite a normal IVP and cystoscopy, the diagnosis of vesicoureteral reflux may be made on voiding cystourethrography, and appropriate therapy may be instituted. REFERENCES
1. Estes, R. C. and Brooks, R. T.: Vesicoureteral reflux in adults. J. Urol., 103: 603, 1970. 2. Erichsen, C. and Genster, H. G.: Vesico-ureteral reflux in nonpaediatric patients. Scand. J. Urol. Nephrol., 14: 233, 1980. 3. Lipsky, H. and Chisholm, G. D.: Primary vesicoureteric reflux in adults. Brit. J. UroL, 43: 277, 1971.
4. Kontturi, M. J. and Koskela, E. A.: Active surgical management of
5.
6.
7. 8. 9.
10.
11.
12. 13. 14.
15.
16.
primary vesicoureteral reflux in adults. Scand. ,T. Urol. Nephrol., 11: 239, 1977. Hutch, J. A.: Theory of maturation of the intravesical ureter. J. Urol., 86: 534, 1961. Talbot, H. S. and Bunts, R. C.: Late renal changes in paraplegia: hydronephrosis due to vesico-ureteral reflux. J. Urol., 61: 870, 1949. Hodson, C. J. and Edwards, D.: Chronic pyelonephritis and vesicoureteric reflux. Clin. Rad., 11: 219, 1960. McGovern, J.M. and Marshall, V. F.: Reflux and pyelonephritis in 35 adults. J. Urol., 101: 668, 1969. De Sy, W., Oosterlinck, W. and Wyndaele, J. J .: A plea for antireflux operations in adults: review of 50 cases. J. Urol., 120: 549, 1979. King, L. R., Kazmi, S. 0. and Belman, A. B.: Natural history of vesicoureteral reflux. Outcome of a trial of nonoperative therapy. Urol. Clin. N. Amer., 1: 441, 1974. Stephens, F. D.: Preliminary follow-up study of 101 children with reflux treated conservatively. In: Renal Infection and Renal Scarring. Edited by P. Kincaid-Smith and K. F. Fairly. Melbourne: Mercedes Publishing Services, p. 283, 1971. Sargent, J. W .: Bilateral ureteral reflux observed in a patient over a 23 year period: case report. J. Urol., 91: 650, 1964. Salvatierra, 0. J. and Tanagho, E. A.: Reflux as a cause of end stage kidney disease: report of 32 cases. J. Urol., 117: 441, 1977. Lewy, P.R. and Belman, A. B.: Familial occurrence of nonobstructive, noninfectious vesicoureteral reflux with renal scarring. J. Ped., 86: 851, 1975. Senoh, K., Iwatsubo, E., Momose, S., Goto, M. and Kodama, H.: Non-obstructive vesicoureteral reflux in adults: value of conservative treatment. J. Urol., 117: 566, 1977. Dounis, A., Dunn, M. and Smith, P. J.B.: Ureteric reimplantation for vesicoureteric reflux in the adult. Brit. J. Urol., 50: 233, 1978.
THE JOURNAL OF UROLOGY
Copyright© 1983'by The Williams & Wilkins Co.
Printed in U.S.A.
CHRONIC LOWER QUADRANT ABDOMINAL PAIN DUE TO VESICOURETERAL REFLUX ABDO J. FADDOUL
AND
JOHN A. BELIS
From the Departments of Urology, Clarksburg Veterans Hospital, Clarksburg and West Virginia University Medical Center, Morgantown, West Virginia
ABSTRACT
Chronic lower abdominal pain or flank pain in adults may be associated with vesicoureteral reflux. Although it is well known that renal scarring may occur in adults with vesicoureteral reflux associated with urinary tract infection, renal function may vary significantly when these patients are found to have sterile vesicoureteral reflux. We report 2 cases of lifelong intermittent lower abdominal pain associated with vesicoureteral reflux without damage to the upper urinary tracts. A voiding cystourethrogram should be included in the evaluation of adults with chronic lower quadrant pain or flank pain even if excretory urography and cystoscopy are normal and the urine is sterile. Vesicoureteral reflux has been considered to be uncommon in men. The reported incidence in all adults varies from 4 to 25 per cent, while the incidence in men varies from 1 to 6 per cent. 1• 2 An apparent increase in the diagnosis of reflux in adults may be due to the more frequent use of voiding cystourethrograms in the investigation of the adult urinary tract. The method of presentation of vesicoureteral reflux in adttl.ts often may be different from that noted in children. Abdominal or flank pain is a common complaint associated with vesicoureteral reflux in adults,3· 4while it is unusual in children. Herein we report 2 cases of apparent lifelong sterile primary vesicoureteral reflux and normal upper urinary tracts. Both patients complained only of chronic episodic lower abdominal or flank pain. CASE REPORTS
Case 1. A 59-year-old man complained of a lifelong history of intermittent right lower quadrant pain that at times radiated to the right flank and occasional episodic mild left flank pain. The pains were worse before voiding. The patient denied all other urinary symptoms and had no history of urinary tract infection. He had had an appendectomy in 1944 for the right lower quadrant pain and the appendix was normal. Gastrointestinal and orthopedic evaluations performed previously were normal. Physical examination showed mild right flank tenderness. Laboratory assessment was completely normal, including sterile urine cultures. Normal kidneys and mild dilatation of the right distal ureter were noted on excretory urography (IVP) (fig. 1, A). A voiding cystourethrogram showed grade III right and grade Ila left vesicoureteral reflux with a small right paraureteral diverticulum (fig. 1, B). At cystoscopy the patient had a laterally displaced golf hole right ureteral orifice and a patulous laterally displaced left ureteral orifice. Because the upper urinary tracts were normal and there had been no known urinary tract infection, the patient was instructed to perform scheduled voiding and double voiding. After 1 week of this regimen the pains disappeared. At followup 1½ years later he was free of pain and the urine had remained sterile. Case 2. A 60-year-old man complained of intermittent left lower quadrant and left flank pain that had been present at least since he was 20 years old. He had no other urinary symptoms and no known urinary tract infections. Since 1950 he had had 10 normal IVPs and 3 reportedly normal cystoscopic examinations. Previous gastrointestinal studies and a psychiAccepted for publication April 30, 1982.
135
atric evaluation were not helpful. Physical examination showed mild left flank tenderness. Laboratory evaluation was normal, including a sterile urine culture. An IVP was normal (fig. 2, A). A voiding cystourethrogram demonstrated grade Ilb left vesicoureteral reflux (fig. 2, B). At cystoscopy the left ureteral orifice was laterally displaced and had a golf hole appearance. Because the upper urinary tracts were normal and there was no history of urinary tract infection, this patient also was treated conservatively with a voiding schedule. The pain ceased and the urine remained sterile 1 year after the regimen was instituted. DISCUSSION
Vesicoureteral reflux in infancy and childhood is common. The natural history in children is that reflux may disappear as the child grows and urinary infections are controlled. Therefore, reflux should be less common in adults. The disappearance of reflux is believed to be due to lengthening of the intravesical ureter and development of the musculature of the ureterovesical junction. 5 The significance of reflux in adults as related to pathological changes in the upper urinary tract has not been established. Vesicoureteral reflux may be an etiologic factor in hydronephrosis associated with neurogenic bladder6 as well as in chronic pyelonephritis. 7- 9 Chronic renal failure is a potential terminal event in the natural history of vesicoureteral reflux associated with recurrent urinary tract infection. However, the effect of sterile vesicoureteral reflux on renal function in adults is controversial. As noted in our 2 cases a lifelong history of sterile vesicoureteral reflux may have no significant effect on renal function. It has been noted that sterile vesicoureteral reflux did not lead to progressive renal scarring in children 10 and that reflux alone did not appear to harm normal kidneys. 11 Similar findings have been reported occasionally in adults. 12 Conversely, patients with reflux and sterile urine at the time of diagnosis may have renal scarring or hypertension. A possible "water hammer" effect of severe reflux on the kidneys has been suggested to be the origin of renal deterioration in patients with sterile urine 13 or the patient may have had an undiagnosed urinary infection in the past. 10• 14 The relationship between chronic lower abdominal or flank pain in adults and the diagnosis of sterile vesicoureteral reflux has not been investigated carefully. Flank pain associated with reflux has been reported to vary from 45 3 to 75 per cent. 4 These reports did not differentiate between those patients with urinary infection and those with sterile urine.
136
FADDOUL AND BELIS
FIG. 1. Case 1. A, IVP shows mild dilatation of right distal ureter. B, voiding cystourethrogram reveals grade III right and grade Ila left vesicoureteral reflux.
FIG. 2. A, normal IVP. B, voiding cystourethrogram shows grade IIb left vesicoureteral reflux
A voiding cystourethrogram should be included in the evaluation of adults with unexplained flank pain and sterile urine. Even cystoscopy in these patients may demonstrate normal ureteral orifices while the voiding cystourethrogram shows reflux. Indeed, normal-appearing ureteral orifices were found in 30 per cent of adults or children with vesicoureteral reflux. 15 Because the proportion of abnormal appearance of the ureteral orifices is the same in adults and children, it has been suggested that primary vesicoureteral reflux in adults has existed since childhood. 15 Although the role of antireflux surgery in adults has been debated many recent reports have supported it. 2 • 4 • 9• 16 Antireflux surgery may be beneficial in the presence of recurrent urinary tract infections. Surgery does not appear to be necessary when the upper urinary tract is normal and the urine is sterile. Urologic evaluation of adults with a history of chronic lower abdominal pain or flank pain should include a urine culture, IVP, voiding cystourethrography and cystoscopy. Despite a normal IVP and cystoscopy, the diagnosis of vesicoureteral reflux may be made on voiding cystourethrography, and appropriate therapy may be instituted. REFERENCES
1. Estes, R. C. and Brooks, R. T.: Vesicoureteral reflux in adults. J. Urol., 103: 603, 1970. 2. Erichsen, C. and Genster, H. G.: Vesico-ureteral reflux in nonpaediatric patients. Scand. J. Urol. Nephrol., 14: 233, 1980. 3. Lipsky, H. and Chisholm, G. D.: Primary vesicoureteric reflux in adults. Brit. J. UroL, 43: 277, 1971.
4. Kontturi, M. J. and Koskela, E. A.: Active surgical management of
5.
6.
7. 8. 9.
10.
11.
12. 13. 14.
15.
16.
primary vesicoureteral reflux in adults. Scand. ,T. Urol. Nephrol., 11: 239, 1977. Hutch, J. A.: Theory of maturation of the intravesical ureter. J. Urol., 86: 534, 1961. Talbot, H. S. and Bunts, R. C.: Late renal changes in paraplegia: hydronephrosis due to vesico-ureteral reflux. J. Urol., 61: 870, 1949. Hodson, C. J. and Edwards, D.: Chronic pyelonephritis and vesicoureteric reflux. Clin. Rad., 11: 219, 1960. McGovern, J.M. and Marshall, V. F.: Reflux and pyelonephritis in 35 adults. J. Urol., 101: 668, 1969. De Sy, W., Oosterlinck, W. and Wyndaele, J. J .: A plea for antireflux operations in adults: review of 50 cases. J. Urol., 120: 549, 1979. King, L. R., Kazmi, S. 0. and Belman, A. B.: Natural history of vesicoureteral reflux. Outcome of a trial of nonoperative therapy. Urol. Clin. N. Amer., 1: 441, 1974. Stephens, F. D.: Preliminary follow-up study of 101 children with reflux treated conservatively. In: Renal Infection and Renal Scarring. Edited by P. Kincaid-Smith and K. F. Fairly. Melbourne: Mercedes Publishing Services, p. 283, 1971. Sargent, J. W .: Bilateral ureteral reflux observed in a patient over a 23 year period: case report. J. Urol., 91: 650, 1964. Salvatierra, 0. J. and Tanagho, E. A.: Reflux as a cause of end stage kidney disease: report of 32 cases. J. Urol., 117: 441, 1977. Lewy, P.R. and Belman, A. B.: Familial occurrence of nonobstructive, noninfectious vesicoureteral reflux with renal scarring. J. Ped., 86: 851, 1975. Senoh, K., Iwatsubo, E., Momose, S., Goto, M. and Kodama, H.: Non-obstructive vesicoureteral reflux in adults: value of conservative treatment. J. Urol., 117: 566, 1977. Dounis, A., Dunn, M. and Smith, P. J.B.: Ureteric reimplantation for vesicoureteric reflux in the adult. Brit. J. Urol., 50: 233, 1978.