Hydronephrosis in Children

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Hydronephrosis is a condition where urine overfills, or backs up, into the kidney, which causes
the kidney to swell. Infants with hydronephrosis may be diagnosed before (prenatal) or after
(postnatal) birth. Learn more about how Boston Children's Hospital treats prenatal and postnatal
hydronephrosis.
If your baby is diagnosed with hydronephrosis, here are a few helpful things to know:

In many of the children who are diagnosed prenatally, the condition disappears
spontaneously by the time of birth or soon after.

In children who have mild or, sometimes, moderate hydronephrosis, kidney function is
commonly unaffected and the condition may resolve over a period of time after delivery.

We are here to help. At Boston Childrens, our physicians and nurses are trained in
pediatric urology and have extensive experience with hydronephrosis. We are ranked #1
in the nation and have the largest pediatric urology service in the world.

Key facts

Hydronephrosis affects the drainage of urine from the urinary systemthe kidneys,
ureters, bladder and urethra. When the urinary system is impaired, this can cause the
urine to back up and the kidney to swell.

Hydronephrosis affects about 1 in 100 babies.

Hydronephrosis is typically caused by either something blocking urine flow or by urine

leaking backward through the urinary system (reflux). Identifying the cause of your
childs hydronephrosis will help determine how we recommend treating it.

Your doctor will describe your childs hydronephrosis as mild, moderate or severe. This
description is based on how much the kidney is stretched and how much the urinary flow
is impaired. Your doctor will tell you whether your childs hydronephrosis affects one
kidney (unilateral) or both kidneys (bilateral).

Hydronephrosis can be detected via ultrasound. More than half of the cases resolve by the
time the baby is born or soon after.

In children who have mild or, sometimes, moderate hydronephrosis, kidney function is
frequently unharmed.

The likelihood of surgery depends on the cause and severity of your childs
hydronephrosis. Surgery for mild cases is unlikely. For moderate cases, surgery occurs 25
percent of the time. Children with severe hydronephrosis will need surgery 75 percent of
the time.

If surgery is required, our success rate is 95 percent successful and unsurpassed.

Hydronephrosis is not always congenital. It can develop as a result of injury or other

illness, such as kidney stones.

Hydronephrosis In Children Or Infants

Phone: (310) 794-7700

What is Hydronephrosis In Children Or Infants?

Overview. Antenatal hydronephrosis, the most common

urological problem found during prenatal ultrasound screening,
refers to the fluid-filled enlargement of the kidney as a result of obstruction in its output of urine.
It is usually detected in the fetus in the first trimester of pregnancy, though it can also be
discovered later in the pregnancy or after birth.

It is most commonly caused by

narrowing of the ureter (the tube that
carries urine from the kidney to the
bladder) close to the kidney; blockage in
the kidney or bladder; or vesicouretal
reflux, in which a faulty valve between
the bladder and the ureter causes the
urine to back up into the kidney when the
bladder fills or empties. In more rare
cases, antenatal hydronephrosis can result
from a duplication anomaly (two ureters
leading from the kidney, one of which
may be obstructed) or a multicystic
dysplastic (nonfunctional) kidney.
Diagnosis and Management. The initial
approach to most cases of antenatal
hydronephrosis is to perform regular
ultrasound testing to carefully monitor
kidney growth and function during the
pregnancy, infancy and childhood.
Usually, this is all that is necessary.
Obstetrical care is generally unchanged,
although low-dose antibiotics are
sometimes given to prevent infection.
After birth, the condition will usually
resolve itself with no damage to the
kidney; in some instances, the kidney that
appears enlarged in the ultrasound is
Kidney Disorders in Children (Health Library)
found to function normally after delivery.
Within the first few days after birth, the newborns kidneys are evaluated with an ultrasound. If
hydronephrosis is still found, other tests are performed. A voiding cystourethrogram, in which a
catheter is placed in the bladder, is used to rule out vesicouretal reflux, which is responsible for
25-30 percent of antenatal hydronephrosis cases. If reflux is confirmed as the cause, it can be
treated with antibiotics and regular monitoring with ultrasound and voiding cystograms. Most
children outgrow the reflux, but in some cases surgery is required. A diuretic renal scan,
requiring an IV and a catheter, further evaluates kidney function.
In cases in which obstruction or blockage threatens to severely damage the developing kidney
and other organ systems affected by kidney function, a surgical procedure known as a

pyeloplasty may prove necessary to correct the blockage. In rare cases, this is done in utero,
though the procedure remains experimental.
When the hydronephrosis is found not to be associated with reflux or obstruction, continued
monitoring with periodic ultrasounds is generally all that is needed.

Pyelectasis/hydronephrosis

What is pyelectasis/hydronephrosis?
To understand this condition, it is helpful to understand how the urinary tract works. In simple
terms, the kidneys filter the blood and remove waste products that are then taken out of the body
in the urine. The urine collects in the pelvis, which empties into a tube (the ureter) and then
drains into the bladder. From the bladder, the urine drains out of the body through the urethra.
During pregnancy, the placenta does most of this work for the baby. The babys kidneys produce
urine starting as early as the fifth week of gestation. While the baby is inside the womb, the urine
produced by the baby's kidneys adds to the amount of amniotic fluid (fluid surrounding the baby
in the uterus). The fluid is important to help the lungs develop. It also gives the baby a "cushion"
and provides him or her space to move.
Twenty to 30 percent of birth defects found before babies are born involve the urinary tract. Fifty
percent of these babies have a condition called hydronephrosis.
Hydronephrosis occurs when the pelvis becomes enlarged because urine is collecting in the area
of the kidneys. Doctors can diagnose hydronephrosis when the enlargement exceeds 10 mms at
20 to 24 weeks of pregnancy.

What causes hydronephrosis?

Hydronephrosis can be the result of:

A blockage, which can occur in a variety of places along the urinary tract

Reflux or backward flow of the urine

Immaturity, which allows more stretching of the pelvis than normal

An extra ureter (the tube that carries urine from the kidneys to the bladder)

Multicystic kidney (a birth defect in which the kidney does not function)

Pyelectasis
When the pelvis is stretched or enlarged, but not enlarged enough for doctors to diagnose
hydronephrosis, it is considered pyelectasis. Pyelectasis also is known as renal pelvic dilatation.
(Dilatation means stretching or enlargement). The amount of stretching of the renal pelvis with
pyelectasis is typically defined as greater than 4 mm but less than 10 mm in a baby younger than
24 weeks of gestation. Enlargement of 4 to 10 mm also may be called mild hydronephrosis.
In 90 percent of cases, this condition will improve by itself and never become hydronephrosis.
However, in 10 percent of cases, the dilatation will increase and hydronephrosis will be
diagnosed.

Testing for pyelectasis

If your baby has evidence of pyelectasis or mild hydronephrosis, your doctor will want to
perform another ultrasound as your pregnancy progresses. This is to examine your babys urinary
tract.
This ultrasound will look at:

The amount of dilatation in the pelvis

The appearance of each kidney

How many kidneys are affected

Your babys overall growth

Your babys gender

The amniotic fluid index (the amount of amniotic fluid present)

Bladder size and thickness

How well your baby is emptying his or her bladder

Prenatal diagnosis of hydronephrosis

Doctors usually diagnose hydronephrosis on a routine ultrasound. If your baby is diagnosed with
hydronephrosis, you will need to have follow-up ultrasounds to track the condition. About 85
percent of infants who are diagnosed with mild hydronephrosis before birth have an abnormal
urinary tract. The other 15 percent of these infants will get better on their own and have no
problems after birth.

Of the 85 percent of babies with a defect, only 15 to 25 percent require surgery to correct it.
Amniotic fluid volume is the single most important factor that shows the well-being of the
unborn baby. Another finding that causes concern is an enlarged bladder.

Specialists youll have to see during pregnancy

Your doctor likely will refer you to a maternal-fetal medicine specialist (a doctor who handles
high-risk pregnancies).
Other specialists you may see during pregnancy include a pediatric urologist (a doctor who
specializes in the urinary system) or nephrologist (a doctor who specializes in the kidneys) and a
neonatologist (a doctor who specializes in treating newborns). They will make recommendations
for follow-up care during your pregnancy as well as follow-up care for your baby once he or she
is born.

How does hydronephrosis affect my baby?

Pyelectasis or mild hydronephrosis will likely have little or no effect on your baby. Most babies
with this condition do very well. Very rarely, a baby will have severe bilateral hydronephrosis or
an extremely distended or filled bladder and insufficient amniotic fluid. These babies will have a
more guarded prognosis (see the chapter on bladder outlet obstruction for more information).
How hydronephrosis affects your baby will depend upon its cause. Two of the more common
causes for mild hydronephrosis and their effects are:

Ureteropelvic junction obstruction, also referred to as UPJ obstruction, is

the most common cause of hydronephrosis. With UPJ obstruction, the flow of
urine from the kidney to the ureter is blocked. This can affect one or both
kidneys. Complete obstruction, very early in the pregnancy (8 to 10 weeks)
will result in severe dysplastic changes. If the UPJ obstruction is on one side
only and has little effect on kidney function, we recommend testing after your
baby is born. Your doctor will perform an ultrasound of the kidneys and
bladder when your baby is about 4 weeks of age to determine if the
hydronephrosis is still present. If your doctor suspects UPJ, he or she may
perform a renal scan to confirm the diagnosis. This scan measures the
kidneys' ability to make and drain urine.
If the initial ultrasound shows severe hydronephrosis and/or other changes,
such as thickening of the cortex (the part of the kidney that produces urine),
your doctor may perform a voiding cystourethrography (VCUG) test. This is
done to see if urine is backing up.
Some babies with prenatally diagnosed hydronephrosis may be prescribed
antibiotics after birth to prevent a urinary tract infection. When the baby is
diagnosed with hydronephrosis before birth, follow-up is done soon after the
baby is born.

In the past, without diagnosis before birth, these babies with no apparent
problems would go for years without a diagnosis, and kidney function could
be severely affected. Surgery may be required if kidney function is affected.
Pyeleoplasty (removal of the blocked area) is the surgery needed for UPJ
obstruction. However, many cases of UPJ obstruction will get better on their
own in the first 18 months of life.

Vesicoureteral reflux (VUR) is the abnormal flow of urine from the bladder
back toward the kidney(s). This can result from an abnormal flap valve. The
back flow of urine allows bacteria from the bladder to enter the kidney. This
makes these babies more prone to urinary tract infections of the bladder
and/or kidney(s) (pyelonephritis).
Pyelonephritis can seriously damage the kidney(s). This can put babies at risk
for hypertension and kidney failure.Vesicoureteral reflux is diagnosed through
a VCUG test or radionuclear cystourethrogram (RNC) test. If reflux is found,
your doctor may perform an isotope renal scan to evaluate kidney function
and assess for damage.
When the diagnosis of reflux is made early, treatment is aimed at preventing
urinary tract infections or UTI. Treatment may include:
o

Antibiotics

Physical exams

X-rays of the bladder and/or kidneys (to monitor the reflux)

Urine analysis (to check for infections)

Often, reflux will disappear as the child grows and the ureter lengthens and develops. This form
of treatment is most commonly used for reflux that causes only mild hydronephrosis and is less
severe.
Surgery is another possible treatment. It aims to fix the flap valve problem so that urine is not
able to flow backward. It also may fix a twisted ureter or dilated/distended ureter. Surgery is used
when reflux causes more severe hydronephrosis that is more likely to result in kidney damage.

How does hydronephrosis affect my pregnancy?

Doctors usually diagnose hydronephrosis during a routine ultrasound. If your doctor suspects
that your baby has hydronephrosis, he or she will refer you for a follow-up ultrasound that can
examine your babys anatomy in more detail.
The two most important factors for babies who have hydronephrosis are the volume of amniotic
fluid and the appearance of the kidneys. These factors can change for either better or worse as

the pregnancy progresses. For that reason, you may need to have multiple ultrasounds to watch
for changes in symptoms.
How hydronephrosis affects your pregnancy will depend upon the severity of the condition. Most
womens pregnancies progress normally.
Your doctor will use ultrasound to observe your baby's kidneys to ensure they continue to
function well. Your doctor also will monitor the amniotic fluid volume, which is the best clue
about how well your babys kidneys are functioning.

How do you treat hydronephrosis?

Most babies with hydronephrosis will be cared for in the newborn nursery. Some may have an
ultrasound of their kidneys and bladder before they go home. Most will have an ultrasound at
approximately 4 weeks of age. These babies usually go home when their mother is discharged,
and doctors will schedule the ultrasound for a later date.
Even if the first ultrasound after birth is normal, your baby will have to have another one later to
make sure that the hydronephrosis hasn't returned. That said, it is rare for mild enlargement to
progress. The majority of babies diagnosed with mild hydronephrosis before birth will require no
type of treatment except observation.
If the hydronephrosis continues to be seen after birth or if an ultrasound shows there are changes
in the kidney(s), your doctor will order tests to determine if your baby has reflux or an
obstruction. An X-ray may be taken to look more closely at the renal anatomy, and other tests
may be done to rule out reflux. If your baby has an obstruction or reflux and it is causing
problems with kidney function, he or she may need surgery.

What happens after surgery?

Rarely, surgery to fix an obstruction or reflux is required for mild hydronephrosis.
Surgery is almost never needed when the baby is first born. Instead, it is scheduled after the child
has grown and tests have been done to measure the extent of the problem.

Will I be able to help care for my baby?

Yes. Your baby will more than likely go to the newborn nursery and be treated there if
hydronephrosis is his or her only problem. The urologist/nephrologist may see him or her in the
hospital if you deliver at Froedtert & The Medical College of Wisconsin Froedtert Hospital
Campus. If you do not deliver at Froedtert or the urologist/nephrologist does not see your baby
before you go home, please call to set up a follow-up appointment soon after you take your baby
home.

After birth and before your appointment with a pediatric urologist, an ultrasound of the kidneys
will be done to look at the structures. This is also to compare the pictures taken before your baby
was born.

When can my baby go home?

Most babies that were diagnosed with hydronephrosis before birth will go home with their
mothers after delivery. Follow-up is done on an outpatient basis. If your baby does require
surgery, it will be done later in life.

What is my baby's long-term prognosis?

Long-term prognosis is excellent for most of babies with hydronephrosis. Even if your baby has
only one working kidney, he or she can live a full life with few limits on activity.
For more information, visit the Urology Care Foundation.