Vesicoureteral Reflux

Vesicoureteral reflux (VUR) is the abnormal backwards flow of urine from the bladder into the upper urinary tracts (ureters and kidney).  The incidence of reflux in children without any urologic symptoms is likely less than 1%. In children with history of a symptomatic urinary tract infection (UTI) the incidence of VUR has been estimated to be between 20-50%.

Patients can be seen by Texas Children's experts in Urology.

Causes & Risk Factors

VUR is caused by abnormal formation of the valve between the kidney and bladder.   Children are generally born with reflux, although they may not have any symptoms or infection for years.   Siblings of children with VUR have a 33% chance of also having vesicoureteral reflux.

Symptoms & Types

VUR alone does not cause any symptoms, and most cases of reflux are not found unless the child develops a urinary tract infection. Infections occur because VUR allows bacteria present in the bladder urine to reach the kidneys. This can lead to kidney infection, fever and kidney damage.  Symptoms of a UTI include burning sensation while urinating;  urinary urgency and  frequency; and abdominal pain.  Many children who have both a UTI and VUR experience a high fever, especially in very young children.

Grading the degree of VUR is an important step in the management of the condition. There are 5 grades of VUR: higher grades are associated with lower rates of spontaneous resolution and a higher incidence of renal scarring.

Diagnosis & Tests

Vesicoureteral reflux is diagnosed by performing a radiologic test called a voiding cystourethrogram (VCUG). This diagnostic test involves placing a catheter in your child’s urethra (the tube that connects the urinary bladder to the outside for the removal of fluids from the body) and filling his bladder with contrast dye.  A series of x-rays are then taken to evaluate if your child has VUR. 

If so,  the doctor will determine the grade and severity of the reflux.   Commonly a renal and bladder ultrasound is also done to evaluate your child’s kidney size and monitor for any dilation of the kidneys.   In some children a special imaging test will be used to look for any kidney damage.

Treatment & Care

VUR can be managed both medically and surgically.  The goal of both is to prevent recurrent episodes of urinary tract infection and especially renal scarring. The mainstay of medical management is prophylactic antibiotics. This is a low-dose daily antibiotic your child will take to sterilize his urine and prevent episodes of urinary tract infections.

Lower grades of reflux, especially in young children, commonly resolve on their own, and your child will be checked yearly with a cystogram (a special imaging scan that checks how well the bladder and urinary tract work) to evaluate if the reflux is becoming a lower grade or has resolved.

Although many patients with VUR can be managed with preventive antibiotics, surgical correction may be indicated when medical therapy is unsuccessful or renal scarring is present. Higher grades of reflux (4-5) less likely to get better its own and may require surgery.

Surgical management of VUR is done in 2 ways, but both are performed under general anesthesia.

  1. Ureteral reimplantation involves making an incision on the child’s abdomen and reimplanting the affected ureter(s) into the bladder to prevent reflux. This surgery has a 99% success rate, but requires an overnight to stay in the hospital.
  2. The second procedure, called Deflux®, involves the surgeon placing a cystoscope (a tube-shaped instrument) into the child’s urethra and injecting a substance (Deflux) at the point where the ureter meets the bladder. While Deflux is a less invasive method of surgery, the success rate is less than the reimplant surgery and some children require multiple Deflux injections.

Living & Managing

As described earlier the mainstay of therapy for most children with VUR is preventive antibiotics. It is important if your child is showing symptoms of a urinary tract infection (fever in an infant, urinary symptoms such as burning, frequency, urgency, or wetting in an older child) that you have his urine tested promptly for infection. A younger child will require a catheterized urine specimen while a toilet-trained child can perform a clean-catch voided specimen (where the middile portion of the urine is collected). If the urine culture is positive it is important to treat it appropriately and promptly and to notify your urologist.

References & Sources

Baskin, Laurence and Barry Kogan, John Duckett. Handbook of Pediatric Urology. Philadelphia: Lippincott-Raven; 1997.

Pediatric Urology for the Primary Care Provider. Zderic, S. and Kirk, J. Slack Incorporated, 2009.