The Cinecystogram and Reflux during Childhood
Authors: Robertson Angus 
Published: March 2008

SUMMARY

On initiating micturition in urinary bladders associated with reflux, there appears to be a normal descent of the bladder neck and pelvic floor. Except in cases of neuro‐muscular incoordination and uncommon urethral lesions, the intravesical pressures and urethra appear normal. The ureters also show peristaltic activity. The primary fault appears to lie in the distal 2 cm. of the ureter, that is, where it passes obliquely through the bladder wall. Because of the variation in the time and quantity of reflux, there may be some secondary, as yet undefined, factor involved.
This review confirms previously held impressions that the cause of reflux in the vast majority of otherwise normal children is in the faulty insertion of the ureter into the bladder. The ureters associated with reflux pass straight through the bladder wall and the ureteric orifice “gapes” when seen on cystoscopy. There is no oblique passage of the ureter through the bladder wall. The mechanisms of micturition and the pressure relationships are perfectly normal in these children.
It is impossible to exclude even gross reflux on an excretory pyelogram. This fact is not yet fully appreciated. Reflux was also present in a much larger number of patients than is at present appreciated by the medical profession. Thirty‐seven per cent, of patients examined showed reflux on cinecystography. Ten per cent, of patients examined showed reflux on cinecystography, despite a normal

If intravenous pyelography is used as a screening test for reflux, 10% of cases will be missed. In other words, this review shows the indications for cinecystography to be clinical–not radiological. It would appear to be medical negligence to reserve cinecystography for those patients showing pathological changes on the intravenous pyelogram in the presence of infection.The total error of prediction of vesico‐ureteric reflux on the intravenous pyelogram is 20%. This emphasizes the errors made if one relies on static appearances for diagnosing dynamic phenomena.

There is no relationship between infection and the aetiology of reflux. Only 28% of cases with reflux showed infection at the time of the cinecystogram, and some of these were cases of unilateral reflux.
This review shows that it is infection and not reflux which causes destruction of renal cortex, i.e., chronic pyelonephritis. Cases of reflux in meningomyelocele with an ileal loop bladder did not show renal cortical destruction despite gross reflux. In fact, as the ileal loop bladder facilitated control of urinary infection, renal function improved post‐operatively in 50%, and renal deterioration was arrested in a further 40% of cases for periods of up to 36 months. These findings negate the views of Hodson and Edwards (1960) that reflux causes renal cortical destruction. In fact, renal function is improving despite reflux. It is seen that all the cases of renal cortical destruction showed vesico‐ureteric reflux into the associated ureter.

It is seen that all the cases of renal cortical destruction–23 or 6% of patients–had been subject to recurrent urinary tract infections with a variety of organisms. The correlation of these findings strongly points to infection as being the cause of the renal damage.

In those cases showing renal cortical destruction reflux was marked. In 88% of kidneys showing scars, the reflux reached the renal pelvis and calyces, and in 72% of kidneys showing scars the reflux occurred not only on micturition but also on filling the bladder.
This review shows that the intravenous pyelogram may demonstrate abnormalities previously considered sufficient cause for renal infection or cortical destruction, e.g., pelvi‐ureteric obstruction. However, reflux can occur into these ureters, with the result that curing the proximal pathology removes an “in‐built protection” against ascending infection. Thus no matter what the intravenous pyelogram findings all patients with a proven urinary tract infection must be fully investigated by an intravenous pyelogram and a cinecystogram.
Reflux must predispose to renal cortical destruction in some way. This is demonstrated by those cases showing renal cortical loss localized to that area drained by the half of a double‐collecting system into which reflux occurs. At the same time the area of renal cortex drained by that half of the double‐collecting system into which no reflux occurs is normal.
This review shows that bladder neck obstruction is a myth.
Double or triple micturition, assiduously applied, will empty the bladder even if there is a large post‐micturition residue on the intravenous pyelogram.
Urinary infection is commoner in female children, reflux is commoner in female children, and destruction of renal cortical tissue is commoner in female children. Destruction of renal cortex can be present from birth onwards. Reflux diagnosed under two years of age has a particularly bad prognosis.
Reflux tends to diminish in some patients as puberty approaches, but it may increase with age in others.
As a result of this review, the author feels the medical treatment of these children must be modified. For medical treatment to succeed, it must either

control infection, or
control the reflux, or
preferably control both.

ontrol of the infection can only be obtained with full parental co‐operation associated with three‐monthly analyses of fresh specimens of urine. Urine in patients with reflux can be kept sterile.
Control of the reflux. Double or triple micturition is, of course, not a control of the reflux, but it is an effort to negate the effects of the reflux.
Preferably control both. A combination of “laboratory‐controlled” long‐term chemotherapy and triple micturition.

Some intelligence is required of the parents for this treatment to be undertaken satisfactorily.

Recurrent infection.

This review shows that destruction of renal cortex may occur in less than twelve months. In order to prevent this, surgical correction of the anatomy of the lower ureter must be undertaken, but the main indications are considered by the author to be:

Marked reflux, i.e. reflux occurring as the bladder fills and reflux that reaches the calyces.

It is too late to wait until renal scars are present to perform surgery for correction of the reflux. Surgery will offer an 80–85% chance of complete cure of the reflux, and this cure rate may rise as more experience is obtained.

This review shows that with the equipment at present available the cinecystogram is the only adequate method of demonstrating vesico‐ureteric reflux. Contrary to some current opinions, the author firmly believes that in paediatrics all other methods of investigation will cause misdiagnosis and mismanagement, with regrettable and irreversible consequences.

Any additional radiation to the patient is insignificant when compared to the irretrievable damage that may be caused by allowing reflux to go undetected.In order to perform the examination competently, a dynamic recording is required. The cine camera is the only adequate means at present available.

Under no circumstances must vesico‐ureteric reflux be ignored, and no urinary infection should be left uninvestigated or, worse, half‐investigated. The cost in renal cortical destruction is too great to be considered.