How does bilateral vesicoureteral reflux present in an adult?

Clinical Presentation of Bilateral Vesicoureteral Reflux in Adults

Bilateral VUR in adults most commonly presents with recurrent febrile urinary tract infections (pyelonephritis), often accompanied by characteristic "reflux pain" and constitutional symptoms including fever and weight loss. 1, 2

Primary Clinical Manifestations

Recurrent Pyelonephritis

• Recurrent uncomplicated pyelonephritis is the hallmark presentation of adult VUR, occurring in the vast majority of symptomatic cases 1, 3
• Patients experience multiple episodes of febrile UTIs despite appropriate antibiotic treatment 2
• Chronic low-grade fever (>37°C) with frequent spikes above 38°C may persist between acute episodes 2
• Constitutional symptoms include progressive weight loss (documented cases losing 8+ kg) and general malaise 2

Characteristic "Reflux Pain"

• A distinctive pain pattern occurs that is pathognomonic for VUR: acute, intense, excruciating pain that is ascending in nature, located along the ureters and kidneys 2
• The pain begins several minutes before urination and resolves several minutes after voiding 2
• This pain pattern is sufficiently characteristic that patients can clearly describe and identify it 2
• Lumbar/flank pain may be present between acute episodes 2

Important Clinical Context

Epidemiology in Adults

• VUR is uncommon in adults but accounts for at least 10% of adult patients with end-stage renal disease, making early detection critical 4
• The incidence of VUR declines with advancing age, which contributes to underdiagnosis in the adult population 4
• When VUR does present in adults, it represents either persistent congenital reflux or acquired pathology 1

Bilateral Disease Characteristics

• Bilateral reflux carries higher risk for recurrent febrile UTIs and renal damage compared to unilateral disease 5
• Bilaterality is recognized as a specific risk factor for possible renal damage in the European Association of Urology guidelines 5
• Management decisions must account for the presence of bilateral involvement 5

Diagnostic Considerations

When to Suspect VUR in Adults

• Consider VUR in any adult with multiple recurrent episodes of pyelonephritis, particularly when infections are "uncomplicated" (no structural abnormalities on routine imaging) 1, 6
• The diagnosis requires a high index of suspicion, as VUR is not routinely investigated in adult patients with pyelonephritis 1
• Unlike in children, where VUR workup is standard after febrile UTI, no formal guidelines exist for screening adults 1

Diagnostic Confirmation

• Voiding cystourethrography (VCUG) performed after resolution of acute symptoms is the gold standard for confirming VUR 5, 1
• VCUG should not be performed during acute pyelonephritis but rather after symptom resolution 5
• Adult women with predisposing factors suggesting risk of vesicoureteral reflux may benefit from VCUG evaluation 5

Associated Findings

• Renal scarring and cortical abnormalities may be present on imaging, indicating chronic damage from recurrent infections 1, 3
• Renal ultrasound may show evidence of chronic pyelonephritis including renal scarring, atrophy, cortical thinning, and renal asymmetry 5, 4
• Cross-sectional imaging with CT or MRI can supplement conventional VCUG for comprehensive evaluation 4

Key Clinical Pitfalls

Common Diagnostic Errors

• Do not assume VUR is only a pediatric condition—failure to consider VUR in adults with recurrent pyelonephritis leads to delayed diagnosis and progressive renal damage 1, 4
• Do not rely on the absence of VUR during acute infection—transient low-grade VUR during the acute infectious phase is uncommon in adults (unlike children), and VCUG should be performed after symptom resolution 6
• The overall prevalence of VUR in adult women with uncomplicated acute pyelonephritis is only 2.3%, but this increases substantially in those with recurrent episodes 6

Recognition of Atypical Presentations

• Patients may present with chronic "fever of unknown origin" that has been extensively worked up for other etiologies before VUR is considered 2
• The characteristic reflux pain may be misattributed to musculoskeletal causes or other urologic conditions if the temporal relationship to voiding is not elicited 2
• Progressive deterioration in quality of life, chronic symptoms, and breakthrough infections despite antibiotic prophylaxis should prompt investigation for VUR 2

Clinical Significance and Outcomes

Impact on Quality of Life

• Symptomatic VUR in adults causes significant impairment in quality of life through chronic pain, recurrent infections, constitutional symptoms, and progressive renal dysfunction 2
• Successful treatment (endoscopic or surgical) can eliminate reflux pain within days and normalize temperature within one month 2

Risk of Renal Damage

• Early detection and careful management can prevent secondary complications including renal failure 4
• The presence of bilateral reflux, high-grade reflux, and cortical abnormalities are recognized risk factors for progressive renal damage 5
• Chronic pyelonephritis from untreated VUR leads to progressive renal scarring and potential end-stage renal disease 4, 2