Management of Primary Vesicoureteral Reflux in Children

Publication Date: September 1, 2010
Last Updated: March 14, 2022

Recommendations

Initial Evaluation of the Child with VUR

General Evaluation

VUR and UTI may detrimentally affect the overall health and renal function in affected children. Therefore, on initial presentation the child with VUR should undergo a careful general medical evaluation including measurement of height, weight and blood pressure, as well as serum creatinine if bilateral renal cortical abnormalities are found. (Standard, )
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Urinalysis for proteinuria and bacteriuria is recommended. If the urinalysis indicates infection, urine culture and sensitivity are recommended. (Recommendation, )
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A baseline serum creatinine may be obtained to establish an estimate of glomerular filtration rate (GFR) for future reference. (, )
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Imaging Procedures

Because VUR and UTI may affect renal structure and function, performing renal ultrasound to assess the upper urinary tract is recommended. (Recommendation, )
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DMSA renal imaging can be obtained to assess the status of the kidneys for scarring and function. (Option, )
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Assessment of Voiding Patterns

Symptoms indicative of BBD should be sought in the initial evaluation (including urinary frequency and urgency, prolonged voiding intervals, daytime wetting, perineal/penile pain, holding maneuvers [posturing to prevent wetting] and constipation/encopresis). (Standard, )
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Family and Patient Education

Family and patient education regarding VUR should include a discussion of the rationale for treating VUR, potential consequences of untreated VUR, the equivalency of certain treatment approaches, assessment of likely adherence with the care plan, determination of parental concerns and accommodation of parental preferences when treatment choices offer a similar risk-benefit balance. (Standard, )
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Initial Management of the Child with VUR

The Child Younger Than 1 Year With VUR

CAP is recommended for the child less than one year of age with VUR with a history of a febrile UTI. This approach is based on the greater morbidity from recurrent UTI found in this population. (Recommendation, )
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In the absence of a history of febrile UTI, CAP is recommended for the child less than one year of age with VUR grades III–V who is identified through screening. (Recommendation, )
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In the absence of a history of febrile UTI, the child less than one year of age with VUR grades I–II who is identified through screening may be offered CAP. (Option, )
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Circumcision of the male infant with VUR may be considered based on an increased risk of UTI in boys who are not circumcised. Although there are insufficient data to evaluate the degree of this increased risk and its duration, parents need to be made aware of this association to permit informed decision-making. (Option, )
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The Child Older Than 1 Year With UTI and VUR

Influence of BBD in VUR Management
If clinical evidence of BBD is present, treatment of BBD is indicated, preferably before any surgical intervention for VUR is undertaken. There are insufficient data to recommend a specific treatment regimen for BBD, but possible treatment options include behavioral therapy (see Glossary for description), biofeedback (appropriate for children more than age five), anticholinergic medications, alpha blockers and treatment of constipation. Monitoring the response to BBD treatment is recommended to determine whether treatment should be maintained or modified. (Recommendation, )
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CAP is recommended for the child with BBD and VUR due to the increased risk of UTI while BBD is present and being treated. (Recommendation, )
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CAP may be considered for the child over one year of age with a history of UTI and VUR in the absence of BBD. (Option, )
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Observational management without CAP, with prompt initiation of antibiotic therapy for UTI, may be considered for the child over one year of age with VUR in the absence of BBD, recurrent febrile UTIs, or renal cortical abnormalities. (Option, )
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Surgical intervention for VUR, including both open and endoscopic methods, may be used. (Option, )
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Followup Management of the Child with VUR

General evaluation, including monitoring of blood pressure, height and weight is recommended annually. (Recommendation, )
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Urinalysis for proteinuria and bacteriuria is indicated annually, including a urine culture and sensitivity if the urinalysis is suggestive of infection. (Recommendation, )
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Cystography and Ultrasonography

Ultrasonography is recommended every 12 months to monitor renal growth and any parenchymal scarring. Voiding cystography (radionuclide cystogram or low-dose fluoroscopy, when available) is recommended every 12 to 24 months with longer intervals between follow-up studies in patients in whom evidence supports lower rates of spontaneous resolution (i.e. those with higher grades of VUR [grades III–V], BBD and older age). This is to limit the overall number of imaging studies performed. If an observational approach is being used, follow-up cystography becomes an option. (Recommendation, )
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Follow-up cystography may be done after one year of age in patients with VUR grade I–II; these patients tend to have a high rate of spontaneous resolution and boys have a low risk of recurrent UTI. (Option, )
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A single normal voiding cystogram (i.e., no evidence of VUR) may serve to establish resolution. The clinical significance of grade I VUR and the need for ongoing evaluation is undefined. (Option, )
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Dimercaptosuccinic Acid

DMSA imaging is recommended when a renal ultrasound is abnormal, when there is greater concern for scarring due to breakthrough UTI or VUR grade III–V or if there is an elevated serum creatinine. (Recommendation, )
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DMSA may be considered for follow-up of children with VUR to detect new renal scarring, especially after a febrile urinary tract infection. (Option, )
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Interventions for the Child with Breakthrough UTI (BT-UTI)

If symptomatic BT-UTI occurs (manifest by fever, dysuria, frequency, failure to thrive or poor feeding), a change in therapy is recommended. If symptomatic BT-UTI occurs, the clinical scenario will guide the choice of treatment alternatives; this includes VUR grade, degree of renal scarring, if any, evidence of abnormal voiding patterns (BBD) that might contribute to UTI and parental preferences. (Recommendation, )
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It is recommended that patients receiving CAP with a febrile BT-UTI be considered for open surgical ureteral reimplantation or endoscopic injection of bulking agents for intervention with curative intent. (Recommendation, )
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In patients receiving CAP with a single febrile BT-UTI and no evidence of preexisting or new renal cortical abnormalities, changing to an alternative antibiotic agent is an option prior to intervention with curative intent. (Option, )
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In patients not receiving CAP who develop a febrile UTI, initiation of CAP is recommended. (Recommendation, )
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In patients not receiving CAP who develop a non-febrile UTI, initiation of CAP is an option in recognition of the fact that not all cases of pyelonephritis are associated with fever. (Option, )
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Surgical intervention for VUR, including both open and endoscopic methods, may be used. Prospective randomized controlled trials (RCTs) have shown a reduction in the occurrence of febrile UTIs in patients who have undergone open surgical correction of VUR as compared to those receiving CAP. (Option, )
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Postoperative Imaging for Patients Receiving Definitive Interventions

Following open surgical or endoscopic procedures for VUR, a renal ultrasound should be obtained to assess for obstruction. (Standard, )
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Postoperative voiding cystography following endoscopic injection of bulking agents is recommended. (Recommendation, )
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Postoperative cystography may be performed following open ureteral reimplantation. (Option, )
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Followup Management After Resolution of VUR

Following the resolution of VUR, either spontaneously or by surgical intervention and if both kidneys are normal by ultrasound or DMSA scanning, general evaluation, including monitoring of blood pressure, height and weight, and urinalysis for protein and UTI, annually through adolescence is an option. (Option, )
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Following the resolution of VUR, either spontaneously or by surgical intervention, general evaluation, including monitoring of blood pressure, height and weight, and urinalysis for protein and UTI, is recommended annually through adolescence if either kidney is abnormal by ultrasound or DMSA scanning. (Recommendation, )
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With the occurrence of a febrile UTI following resolution or surgical treatment of VUR, evaluation for BBD or recurrent VUR is recommended. (Recommendation, )
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It is recommended that the long-term concerns of hypertension (particularly during pregnancy), renal functional loss, recurrent UTI and familial VUR in the child's siblings and offspring be discussed with the family and communicated to the child at an appropriate age. (Recommendation, )
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APN, acute pyelonephritis; BBD, bladder and bowel dysfunction; BT-UTI, breakthrough UTI; CAP, continuous antibiotic prophylaxis; DMSA, dimercaptosuccinic acid; UTI, urinary tract infection; VCUG, voiding cystourethrogram; VUR, vesicoureteral reflux

Recommendation Grading

Overview

Title

Management of Primary Vesicoureteral Reflux in Children

Authoring Organization

Publication Month/Year

September 1, 2010

Last Updated Month/Year

January 5, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Child, Infant

Health Care Settings

Ambulatory, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D003556 - Cystitis, D014718 - Vesico-Ureteral Reflux

Keywords

vesico-ureteral reflux, Urinary diseases, VUR, bowel dysfunction