Under normal circumstances, urine flows from the kidneys to the bladder through tubes called ureters. Vesicoureteral reflux (VUR) is a condition that causes this flow to be reversed. VUR is most commonly diagnosed in infants and young children. It can be classified as either primary or secondary, with a grading system between 1 (mild) and 5 (severe). Children often outgrow primary VUR as they age, however, complications can arise if the condition is left untreated.

Vesicoureteral reflux screening and diagnosis

Age, sex, and family history are three of the most important factors used to determine a child’s risk of developing VUR. Children under 2 are much more likely to have VUR than those who are older. Boys most often have primary VUR, but secondary VUR is more common among girls. About 1 in 4 siblings of children with VUR also have the condition, along with about 1 in 3 who have a parent who’s had VUR.

To diagnose the condition, a voiding cystourethrogram (VCUG) is used to detect irregular urine flow. Currently, the American Academy of Pediatrics guidelines recommend VCUG after the second febrile urinary tract infection (UTI). There are some reasons why you would choose to defer VCUG until the second febrile UTI include:

• Most low-grade VUR resolves on its own.
• Most children with initial febrile UTI do not have a recurrent UTI.

Additionally, an infant or young child under 2 who has had two or more UTIs with fever should receive a VCUG.

As a general rule, patients should not receive a VCUG based solely on family history, but exceptions where you might opt to screen include:

• Infant screening:
  • Newborns with moderate to severe hydronephrosis (SFU grade 3 or 4, or UTD scale 2 or 3) should receive a VCUG. VUR risk is similar across all degrees of hydronephrosis, but infants with severe hydronephrosis are likely to have a degree of concurrent obstruction, which can cause more frequent or severe UTI episodes.
  • Children with hydroureteronephrosis, as they are at significantly increased risk of VUR, compared with infants with renal dilation but no ureteral dilation. These children should undergo VCUG even if their hydronephrosis is not severe.
• Sibling screening: screening siblings of children with VUR and renal disease or renal impairment (one or more family members with severe, high-grade VUR and renal scarring). It would also be reasonable to obtain an ultrasound, and if any abnormalities are identified, a VCUG would be appropriate at that time.

How to treat vesicoureteral reflux

Antibiotic prophylaxis is recommended for children with:

• Grade 3 VUR and higher (The AAP recommendation)
• Kidney injury or documented renal scarring history
• Severe or prolonged febrile UTI history
• Documented bowel and bladder dysfunction (which also should be treated)

Prophylaxis is not necessary for every child with VUR. Patients less likely to receive prophylaxis include children with:

• Low reflux grades 1 or 2
• No bowel or bladder dysfunction
• No UTI history but received diagnosis through sibling or familial screening
• No voiding dysfunction
• No renal scarring or damage

The treatment is continued until reflux risk is considered low.

Behavioral changes also can be effective in preventing UTIs. Drinking more fluids, regular emptying of the bladder, frequent changing of diapers to prevent spread of bacteria, and wiping from front to back are strategies that can help patients.

For children with grade 4 or 5 reflux or who have severe or repeated UTIs with chance of kidney scarring, surgery may be required. Procedures have the goal of strengthening the bladder’s ability to prevent urine from reentering the ureters and kidneys.

Deflux injections are another option for treatment. These injections reinforce the bladder wall to help prevent urine from traveling back up the ureters.

Ureteral reimplant surgery corrects the anatomical abnormality that allows urine to flow back into the ureter.

When to refer to a pediatric urologist

A child can benefit from seeing a pediatric urologist for VUR if the child has:

• Anatomic issues including hydronephrosis, kidney abnormalities, urinary function issues and recurrent UTI
• Grade 3 and higher VUR
• Persistent reflux