A 33-year-old female patient presented with bilateral VUR diagnosed 5 years earlier.
Background
The reason for diagnosis was recurrent pyelonephritis from 28 years of age.
Six months later a urological study with ultrasound, intravenous urography, Serial voiding cystourethrography (MSCU) and renal scintigraphy showed:
No history of VUR or previous pyelonephritis.
Patient's clinic was:
Pain characteristics were:
Antibiotic prophylaxis (AP) was established and the patient was studied as "fever of unknown origin".
Other diagnoses were ruled out including gynecological, cardiological, neoplasic, for aplastic, all tropical diseases were considered as a resumable clinical condition, etc. in various departments, because the VUR was initially considered not responsible for the disease.
There was no urinary incontinence or clinical bladder or sphincter dysfunction.
Establishment
Abnormal data: affectation of the general state, weight of 47 Kg. for a height of 1.73 m, temperature 37.5o, positive right renal percussion wrist.
Blood pressure, cardiac pulmonary auscultation, abdominal and pelvic palpation were normal.
There were no edemas of the upper limbs or of the lower limbs.
Clinical Judgment
Duplicity of right pyeloureteral junction with right VUR grade III in 2 ureters and left grade II, right reflux nephropathy, chronic pyelonephritis with progressive general deterioration, fever syndrome, severe reureter 5
Chi-square Indication
Endoscopic treatment (ET) of VUR was decided, based on the long evolution, chronic pyelonephritis, fever and pain symptoms, age and right reflux nephropathy.
Endoscopic Treatment
Cystourethroscopy with sedation was performed, with normal urethra and bladder neck.
One ortotopic meatus was found on each side, with scarce submucosal tunnel and positive hydrodischarge.
With the hydrodialysis of the right meatus, a single 2 mm pathway is established.
A metallic needle was used to inject Dextranomer/Non-animal stabilized Hyaluronic Acid (DX/NASHA), 0.5 CC on each side.
3rd generation intravenous Cephalosporin was administered at the beginning of ET.
Outcome measures
- BP is maintained for 3 months postoperatively.
- Renoureteral pain disappeared from the first postoperative days.
- Progressive fever disappearance, completely within one month of the ET.
- 1-month ultrasound without evidence of ureteral-pylo-jejunal dilation.
- VCUG at 3 months normal without VUR or post-void residual disease.
- 3-year follow-up without urinary tract infections or pyelonephritis or renoureteral pain.
Progressive weight gain up to 61 Kg., incorporation to working life, normal pregnancy and delivery.
1.
Establishment plan
The following is a description of the patient's own clinical situation from the beginning of her symptomatology to its disappearance, which she wrote at the request of the authors, to reflect with her words the subjective and objective reality.
I was diagnosed with right pyeloureteral duplication with bilateral vesicoureteral reflux: right upper and lower grade III in both ureters and left grade II, which was not corrected by a long term follow-up
"Everything started when I was 28, which was the first time I felt a kidney pain that turned out to be the first pyelonephritis, which was treated with antibiotics.
At 6 months after the first pyelonephritis, I suffered another pyelonephritis, with severe pain in the right kidney accompanied by a high fever that I don't want anyone.
She was treated with more antibiotics that then left me a week off.
After several urine tests and positive cultures, treated with antibiotics, I was referred to the Urology Department of a Hospital for multiple urinary infections that are intensified.
Then I got more tests:
At the end, what is decided in a clinical session is to give me a daily antibiotic therapy for 6 months, which makes me tiresome, and postpone surgery to correct reflux because "this is a complex intervention in adults".
During the first months I often had a fever of 37o, but after a while, the fever becomes a fever of between 37'7o and 38'5o, which stayed daily and did not start to lose 1 kilo73o
I had to stop working, because I couldn't do a normal life.
So my husband, who is, decides to take me to the internists of a hospital, to whom I am very much attached, that we have a lot of analysis and tests on the weights, vecultive reflux, tiredness, PET, etc.
A cardiologist also made me a full study.
But I still have my "fever of unknown origin" feeling increasingly sick, losing weight to 47 kilos.
During this period you suffer more and more often when you go to the end of your kidney because I feel pain when you close my kidney as if you pinch me from the lower part of your belly, you walk around intensely.
This is happening more and more frequently, regardless of whether or not you had a urinary infection, to the extent that when you felt the need for guidance, I had to go through it again.
The discomfort in both kidneys became continuous, and of course the fever, which remained around 38o, with what at the end and after almost 5 years from the start of the first urologist symptom deciding.
At the hospital, they proposed open surgery to me, without any guarantee to solve my problem.
For this reason I decided to request a second opinion, which was provided by Dr. who explained to me the existence of a minimally invasive technique that corrects V-ureteral reflux, but in which I live only urology performed it.
I was 33 years old, but Dr. Grey came to see me and treat me.
Median cystoscopy put me a few injections into my bladder.
It all lasts half an hour and I went home the same day.
A few days later the fever began to subside, I no longer felt any renal pain, and gradually I found myself much better.
A few months later I had a new VCUG, which showed that the operation had corrected the reflux.
I never had any more kidney pains or fever.
I was regaining my weight.
I went back to my job.
I even got pregnant.
Now I'm 37 years old, I weigh 60 kilos, I have two wonderful children and I don't know where my 3 ureters go through because I don't totally sleep.
After 4 years, I have not suffered any type of urinary tract infection again, nor have I re-remembered my bilateral vestibular reflux.
Thank you, Dr.... for having made my quality of life sick".
