Management of children with mild (grades I to II) vesicoureteral reflux

BBD: bladder and bowel dysfunction; CAKUT: congenital anomalies of the kidney and urinary tract; DMSA: dimercaptosuccinic acid; RNC: radionuclide cystogram; UTI: urinary tract infection; VCUG: voiding cystourethrogram; VUR: vesicoureteral reflux.

* Monitoring for UTI consists of advising the parents to be alert for unexplained fever or other signs of possible UTI (dysuria, urgency) and to present promptly if any of these symptoms are present. If symptoms develop, the evaluation includes mandatory urinalysis and urine cultures.

¶ For details on antibiotic prophylaxis for VUR, refer to UpToDate content on management of VUR. Antimicrobial agents most commonly used for prophylaxis are amoxicillin (in infants <2 months old), trimethoprim-sulfamethoxazole, trimethoprim alone, or nitrofurantoin. The antibiotic may be changed if there are significant side effects or a breakthrough UTI (defined as a UTI that occurs despite adherence to prophylaxis regimen) or if antibiotic resistance develops.

Δ Symptoms and clinical findings of BBD include urinary symptoms, such as urinary incontinence, urinary urgency/frequency, infrequent voiding, recurrent UTI, and dysuria, as well as symptoms of abdominal pain, constipation, and fecal soiling. For details on the management of BBD, refer to UpToDate content on bladder dysfunction and chronic functional constipation.

◊ Practice varies regarding follow-up testing for VUR for children with mild VUR and no UTIs. In our practice, we routinely test for VUR by either contrast VCUG or RNC every 12 to 24 months. Other clinicians perform VCUG or RNC only if the patient has a febrile UTI.

§ Surgery is generally preferred for children with breakthrough UTI, if the patient has been adherent to the prophylaxis and the organism is sensitive to the regimen. The alternative is ongoing medical therapy (antibiotic prophylaxis, surveillance including periodic imaging, and treatment of any BBD). The family's preferences are are important components of this decision.

¥ For those with persistent VUR, a trial of discontinuing antibiotics is reasonable if the child is at least 3 years old; is toilet trained; and has no BBD, kidney scarring, or recent UTI (eg, within the past year).

‡ Occasionally, VUR is diagnosed when VCUG is performed in an asymptomatic infant or child, rather than after a UTI. As an example, VCUG might be performed for selected infants with prenatally detected hydronephrosis (although VCUG is not routinely recommended in this situation).