年輕成人低度膀胱輸尿管逆流合併反覆腎盂腎炎：病例報告

吳昊勳¹、陳生文^1,2、張彰琦^1,2、程威銘^1,2、邱逸淳^2,3

¹臺北市立聯合醫院忠孝院區外科部泌尿科

²國立陽明交通大學醫學院

³臺北市立聯合醫院陽明院區外科部泌尿科

Low-Grade Vesicoureteral Reflux in a Young Adult Presenting with Recurrent Pyelonephritis: A Case Report

Hao-Hsun Wu ¹, Sheng-Wen Chen ^1,2, Chang-Chi Chang ^1,2, Wei-Ming Chen ^1,2, Yi-Chun Chiu ^2,3

¹ Division of Urology, Department of Surgery, Zhongxiao Branch, Taipei City Hospital

² National Yang Ming Chiao Tung University, School of Medicine, Taipei, Taiwan

³ Division of Urology, Department of Surgery, Yangming Branch, Taipei City Hospital

Introduction:

Recurrent urinary tract infections (UTIs) in young adults warrant thorough evaluation to identify potential underlying anatomical or functional abnormalities. Vesicoureteral reflux (VUR), although more commonly diagnosed in pediatric populations, may persist into adulthood or remain undiagnosed until recurrent infections occur. Adult patients with VUR may present with acute pyelonephritis, which can lead to renal parenchymal damage if not appropriately recognized and managed. The role of imaging studies, including contrast-enhanced computed tomography (CT) and voiding cystourethrography (VCUG), is essential in both diagnosing acute infection and identifying predisposing conditions. However, the management of low-grade VUR in adults remains controversial, with conservative treatment often favored in the absence of renal impairment or recurrent severe infections. Hence, we present a young female with recurrent pyelonephritis in whom low-grade VUR was identified during follow-up evaluation.

Case presentation:

A 26-year-old female with a history of thalassemia and recurrent UTIs, including prior episodes of right-sided acute pyelonephritis, presented to our institution with fever, dysuria, and right flank pain. Contrast-enhanced abdominal CT revealed right renal perinephric fat stranding, along with focal wedge-shaped areas of renal parenchyma that appeared swollen and demonstrated decreased enhancement compared to the normal renal tissue. These findings were consistent with a diagnosis of acute pyelonephritis. The patient was treated with intravenous antibiotics, resulting in clinical improvement and complete resolution of symptoms. She was subsequently discharged in stable condition. Given her young age and history of recurrent UTIs, a VCUG was performed during outpatient follow-up. The study demonstrated grade I VUR. As the reflux was mild, and renal ultrasonography showed no evidence of renal parenchymal damage or hydronephrosis, surgical intervention was not indicated. The patient was managed conservatively with regular outpatient follow-up, including periodic renal ultrasonography. In addition, patient education was provided regarding lifestyle modifications to reduce the risk of recurrent infections.

Discussion:

This case highlights several important clinical considerations in the evaluation and management of recurrent UTIs in young adults. First, although VUR is primarily regarded as a pediatric condition, it should not be overlooked in adult patients with recurrent pyelonephritis. In such cases, delayed diagnosis may increase the risk of recurrent infections and potential renal scarring. Contrast-enhanced CT plays a crucial role in diagnosing acute pyelonephritis, with characteristic findings including wedge-shaped areas of decreased enhancement and perinephric fat stranding. These imaging features help differentiate pyelonephritis from other renal pathologies and guide appropriate antibiotic treatment. The decision to perform VCUG in adults is not routine but should be considered in selected patients, particularly those with recurrent infections or atypical clinical courses. In this patient, the identification of grade I VUR provided an explanation for recurrent infections, although the clinical significance of low-grade reflux in adults remains debated.

Management strategies for VUR depend on the severity of reflux, presence of renal damage, and frequency of infections. Current evidence suggests that low-grade VUR (grade I–II) without renal scarring or hydronephrosis can be managed conservatively. Surgical intervention is generally reserved for patients with high-grade reflux, recurrent febrile UTIs despite prophylaxis, or progressive renal impairment. In addition to surveillance imaging, patient education plays a key role in reducing recurrence. Lifestyle modifications, including adequate hydration, proper voiding habits, and infection prevention strategies, are essential components of long-term management.

Conclusion:

In young adults presenting with recurrent pyelonephritis, underlying anatomical abnormalities such as vesicoureteral reflux should be considered. Selective use of VCUG can aid in diagnosis, particularly in patients with recurrent or atypical infections. Low-grade VUR without evidence of renal damage can be managed conservatively with close follow-up and patient education. Early recognition and appropriate management are crucial to prevent recurrent infections and preserve long-term renal function.

Reference:

1.      Shay Reinke, Zairha Snider. Vesicoureteral Reflux Diagnosis After Hospitalization for Acute Cystitis and Pyelonephritis. Cureus 2023 Apr 27;15(4):e38216.

2.      Ted Lee, John M Park. Vesicoureteral reflux and continuous prophylactic antibiotics. Investig Clin Urol. 2017 Jun;58(Suppl 1):S32-S37.