Management of children with moderate to severe (grades III to V) vesicoureteral reflux

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

* Antimicrobial agents most commonly used for prophylaxis are amoxicillin (infants <2 months old), trimethoprim-sulfamethoxazole, trimethoprim alone, or nitrofurantoin. Antibiotic prophylaxis is appropriate for most children in this category because it reduces the risk of febrile UTI, which can lead to kidney scarring, and because VUR often improves during the first 1 to 3 years of life. For families who prefer to avoid antibiotic prophylaxis, alternatives include surveillance (eg, for families who are able to observe closely for signs of UTI and adhere to follow-up and monitoring) and surgery (eg, for children with high-grade VUR).

¶ Occasionally, VUR is identified if a VCUG is performed in an asymptomatic infant or child, rather than after a UTI. For example, a VCUG might be performed for selected infants with prenatally detected hydronephrosis (although VCUG is not routinely recommended in this situation). In this case, more conservative management (eg, surveillance) may be appropriate if the VUR is not severe and there is no evidence of kidney scarring or CAKUT.

Δ Physiologic phimosis can be treated with topical corticosteroid therapy.

◊ We generally obtain a DMSA scan to assess for kidney scarring during the initial evaluation of children with VUR grades III to V if there are kidney parenchymal or size abnormalities on ultrasound or a history of multiple episodes of pyelonephritis. During follow-up, we repeat this test only if there is a concern for kidney scarring, based on ultrasound findings, VCUG, or clinical history.

§ 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.

¥ Monitoring of VUR is done by either contrast VCUG or RNC and is typically performed in our practice every 12 to 24 months. DMSA renal scan may be obtained; refer to UpToDate content on management of VUR for further details.

‡ Surgical correction is generally recommended for those patients with breakthrough febrile UTIs (despite adhering to antibiotic prophylaxis). In addition, for children with high-grade VUR that persists beyond 2 or 3 years of age, surgery is generally preferred for grades IV or V reflux, and is an option for grade III reflux. The alternative is ongoing medical therapy (antibiotic prophylaxis, surveillance including periodic imaging, and treatment of any BBD). The family's preferences 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 1 year).