Vesicoureteral Reflux (VUR): Causes, Grades, and Treatment Options

Vesicoureteral reflux (VUR) happens when the urine goes in the wrong direction, backing up the ureters (the tubes that carry urine from the kidney to the bladder). It is a common urinary tract condition in newborns, toddlers and children.

A child with VUR may not have symptoms; however, when symptoms appear (such as Burning or pain when peeing, only peeing a few drops at a time, etc.), high-grade fever or flank pain, they most commonly indicate a urinary tract infection (UTI).

Read Also: Winter Dehydration: The Hidden Reason Behind UTI Spikes

What is Vesicoureteral Reflux (VUR)?

Normally, urine is transported from the kidneys to the bladder via the tubes called the ureters. However, in some children, there is a retrograde flow of urine from the bladder into the upper urinary tract, which is called vesicoureteral reflux.

Why Does VUR Happen?

It stems from two main types:

• Primary: Intrinsic failure of the valve mechanism at the ureterovesical junction. It is often congenital.
• Secondary: It occurs when high pressure on the bladder affects the valve mechanism

Common causes:

• Bladder outflow obstruction, such as posterior urethral valves
• Functional abnormalities, such as a neurogenic bladder
• Severe dysfunctional voiding

How Common is VUR?

Here are the key statistics:

• The calculated general child population incidence: 1– 3%
• Incidence of VUR in children diagnosed with urinary tract infection (UTI): 8% - 40%
• VUR in girls with UTI ranges from 17% - 34% and in boys from 18% - 45%.

Read Also: Urinary Incontinence in Women: Bladder Control and More

VUR Grades: Understanding the Severity

The International Reflux Study Committee grades VUR based on micturating cystourethrogram (MCUG) imaging, from mild to severe:

Goals of VUR Management

The management of VUR mainly focuses on three main goals:

• To prevent recurring febrile UTIs.
• Avoid kidney damage or renal scarring.
• To minimize the morbidity of treatment and follow-up.

Risk Factors for New Renal (Kidney) Scars

The following factors may increase the risk of kidney damage in children with VUR.

• Febrile UTI
• High-grade reflux
• Bilateral reflux (affecting both kidneys)
• Cortical abnormalities in the kidneys
• Lower urinary tract dysfunction (LUTD) is an additional risk factor for new scars.

How Do We Manage VUR?

When a child is diagnosed with vesicoureteral reflux, paediatric urologists and nephrologists at Surya Hospitals perform a comprehensive initial evaluation to assess kidney health and infection risk. Management and follow-up should be guided by risk stratification.

Management Strategies

The strategy depends on the child’s risk profile based on the following points

• Presence of renal scars
• Clinical course
• Reflux grade
• Ipsilateral renal function
• Bilaterality
• Bladder function
• Associated anomalies of the urinary tract
• Age
• Compliance
• Parental preference

Initial evaluation of a child with VUR usually includes:

1. Careful general medical evaluation, including measurement of height, weight, and blood pressure (BP).
2. Blood test for creatinine if bilateral renal abnormalities are found.
3. Urinalysis for proteinuria and bacteriuria. If the urinalysis indicates infection, a urine culture and sensitivity is performed.
4. Renal ultrasound because VUR and UTI may affect renal structure and function

Initial management should aim to manage lower urinary tract dysfunction (LUTD) and bowel dysfunction. Educating the patient and family must remain the key part of the strategy at all stages of management.

Continuous Antibiotics Prophylaxis (CAP)

CAP is a small dose of antibiotics usually given at bedtime to prevent recurrent UTIs in children with VUR. 

Here are the recommended situations based on the review of the literature for the management of VUR:

Children younger than 1 year

• CAP is recommended for
• Dilating VUR (Grade III–V)
• Regardless of age, if symptoms or renal scars exist

Children aged 1–5 years

• CAP for Grade I–II reflux if there are:
  • Recurrent Febrile UTIs
  • Renal abnormalities
  • Bladder or bowel dysfunction

Children older than 1 year with Grade III–V reflux

• CAP recommended

CAP is usually stopped after successful toilet training if the child remains stable.

Breakthrough UTI

If a symptomatic breakthrough UTI occurs (manifested by fever, dysuria, frequency, failure to thrive, or poor feeding), a change in therapy (including a change of antibiotic prophylaxis/surgical management) is recommended.

Surgical Management

Surgery may be recommended in children when conservative methods fail to show an effect. Here are the two common surgical procedures

• Circumcision – reduces the risk of UTIs
• Endoscopic therapy (single bulking agent injection)
• Ureteric reimplantation

Surgery has a good outcome: The resolution rate per 100 children was 98.1 for open surgery (ureteric reimplantation) and 83.0 for endoscopic therapy after a single injection of bulking agent (into the ureteric orifice)

Indications for Ureteric Reimplantation:

• Symptomatic children with abnormality of the lower end of the ureter, like ureterocele, ectopic ureter and Hutch diverticulum
• Considered in patients with duplex kidneys
• Two failed attempts of Endoscopic treatment (STING) Surgery can be performed using:
  • Open surgery
  • Laparoscopic surgery
  • Robotic surgery
  • Vesicoscopic surgery

Follow Up After Treatment:

Even after VUR resolves, the doctor recommends ongoing monitoring

• Physical examination
• Blood pressure monitoring
• Urinalysis
• Kidney imaging if needed

Monitoring is recommended annually through adolescence (by the nephrology team) if either kidney is abnormal by ultrasound or DMSA scanning.

Screening for VUR

Vesicoureteral Reflux runs in the family; studies have shown the following data:

• The prevalence is approximately 27% in siblings of children with VUR
• The incidence of reflux in the offspring of a patient with VUR is 35.7%

Hence, siblings and offspring should be screened by renal ultrasonography if they present with symptomatic UTI.

However, for asymptomatic siblings and offspring, there is no need for screening.

A micturating cystourethrogram or radionuclide cystogram is recommended if there is evidence of renal cortical abnormalities or renal size asymmetry on ultrasound/history of UTI.

MCUG is recommended for children with high-grade (Society of Fetal Urology grade 3 and 4) hydronephrosis, hydroureter or an abnormal bladder on ultrasound (late-term prenatal or postnatal) or who develop a UTI on observation.

Conclusion

VUR itself isn’t life-threatening; mild cases may not need treatment, and some children outgrow VUR; however, regular monitoring is crucial to prevent kidney damage from infection.

Sometimes, doctors may recommend treatment (ranging from antibiotic prophylaxis to surgical correction) based on the severity of your child’s symptoms, age and other factors. All you need is to follow the doctor’s advice and go for regular follow-ups, even if VUR resolves, to prevent long-term complications.

Are you looking for the best treatment for vesicoureteral reflux?

Get expert care by contacting Surya Hospitals at +91-882882 8100; info@suryahospitals.com Surya Hospitals, 101-102, Mangal Ashirwad, S.V. Road, Santacruz West, Mumbai – 400054.

Surya Hospitals, Shrikant Chambers-II, Beside R.K. Studio, Chembur, Mumbai, Maharashtra, 400071

FAQs

Q1: Can VUR be prevented?
A: There isn’t a known way to prevent vesicoureteral reflux (VUR). However, the following habits can help reduce UTI risk:

• Drinks adequate water.
• Gets their diaper changed right away after they poop and pee.
• Pees regularly and avoids “holding it".
• Visit the child’s doctor for treatment for constipation and urinary or faecal incontinence as soon as possible.

Q2: What is the best treatment for VUR?
A: There is no single “best” treatment for VUR. The strategy depends on the child’s risk profile and the severity of reflux.

Q3: What are the symptoms of VUR in children?
A: Kids with VUR may not have symptoms. Those who are symptomatic usually present symptoms of a urinary tract infection:

• Needing to pee more often.
• Burning or pain when peeing.
• Only peeing a few drops at a time.
• Cloudy pee.
• Pee smells bad.
• Pain in their abdomen or lower back (flank pain)
• Fever
• Lethargy, irritability and poor feeding (in babies)