Intravenous Pyelography in Children With Urinary Tract Infection and Vesicoureteral Reflux

¹ The Section of Pediatric Nephrology and the Departments of Pediatrics and Diagnostic Radiology, Rambam Medical Center, and the Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel

In a previous study of the radiologic evaluation of children with urinary tract infection it was recommended that IVP be performed in all patients with either abnormal ultrasonographic or voiding cystourethrographic findings. However, the benefit from IVP was believed to be questionable in children with normal ultrasonography findings and vesicoureteral reflux of only a low grade (I or II of V). To gain a better understanding of the need for IVP in the radiologic evaluation of such children, the database was expanded and the findings concerning ultrasonography and IVP were analyzed in 52 children with urinary tract infection and vesicoureteral reflux seen during the last 3 years. Of a total of 72 instances of reflux, 44 (61.1%) were of low grade (I or II), 14 of medium grade (III), and 14 of high grade (IV or V). Of the 44 urinary systems with low-grade reflux, results were as follows: renal ultrasonography appeared normal in 38 and in 34 of these, the IVP also appeared normal; in the other four, only minor and negligible changes were seen with IVP. Surgical intervention was not necessary in any of these 38 urinary systems. In six systems with low-grade vesicoureteral reflux but with abnormal ultrasonography findings, IVP results were also abnormal, and surgery was necessary in two instances. Of the 14 urinary systems with medium-grade reflux, ultrasonography appeared normal in ten but in six of these the IVP appeared abnormal. In all 14 urinary systems with highgrade reflux, both the ultrasonography and the IVP appeared abnormal. There was surgical correction of 11 instances of high-grade reflux and four of medium-grade reflux. It is concluded that IVP does not contribute to the treatment of children with urinary tract infection in whom renal ultrasonography appears normal and voiding cystourethrography results show only low-grade reflux; for such children, IVP can be excluded from the initial radiologic evaluation protocol. The following modification of the previously suggested algorithm is therefore proposed: For patients whose radiologic evaluation starts with normal appearing ultrasonography followed by voiding cystourethrography that appears normal or shows only low-grade reflux, no further radiologic workup is necessary. In those patients whose radiologic studies start with voiding cystourethrography and in whom low-grade reflux is found, the next procedure should be ultrasonography; IVP will follow only if ultrasonography appears abnormal. Children with high-grade reflux must have IVP. Application of this modified protocol to the present series could have spared 25 of the 34 children (73.5%) with low-grade reflux from having IVP, that is, approximately half of the total of 52 children who were studied.

Key Words: urinary tract infection • vesicoureteral reflux • intravenous pyelography • ultrasonography

Submitted on November 2, 1987
Accepted on April 1, 1988

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