What is the initial management for Vesicoureteral Reflux (VUR)?

Initial Management of Vesicoureteral Reflux (VUR)

The initial management of vesicoureteral reflux should be tailored to the patient's risk category, with continuous antibiotic prophylaxis (CAP) being the primary initial treatment for most children with symptomatic VUR, particularly those with high-grade reflux or abnormal kidneys. 1

Risk Stratification Approach

The management of VUR depends on several key factors that determine the risk category:

High Risk Patients

• Symptomatic patients after toilet training with high-grade reflux (grade IV-V) and abnormal kidneys:
  • With LUTD: Initial treatment is LUTD management with CAP 1
  • Without LUTD: Surgical intervention should be considered 1
  • Note: Reimplantation has better results than endoscopic surgery for high-grade reflux 1

Moderate Risk Patients

• Symptomatic patients before toilet training with high-grade reflux and abnormal kidneys:

  • CAP is the initial treatment 1
  • Intervention may be considered for breakthrough infections or persistent VUR 1
  • Spontaneous resolution is higher in males 1

• Asymptomatic patients with high-grade reflux and abnormal kidneys:

  • CAP is the initial treatment 1
  • Intervention may be considered for breakthrough infections or persistent VUR 1

• Symptomatic patients after toilet training with high-grade reflux, normal kidneys, and LUTD:

  • Initial treatment is LUTD management with CAP 1
  • Consider intervention for breakthrough infections or persistent VUR 1

• Symptomatic patients with low-grade reflux and abnormal kidneys:

  • Treatment choice is controversial 1
  • Endoscopic treatment may be an option 1
  • LUTD treatment should be given if needed 1

Low Risk Patients

• Symptomatic patients with normal kidneys, low-grade reflux, and no LUTD:

  • No treatment or CAP 1
  • Parents should be informed about infection risk 1

• Asymptomatic patients with normal kidneys and low-grade reflux:

  • No treatment or CAP in infants 1
  • Parents should be informed about infection risk 1

Management of Bladder and Bowel Dysfunction (BBD)

BBD significantly impacts VUR outcomes and must be addressed:

• Standard: Symptoms of BBD should be evaluated during initial assessment 1

  • Look for urinary frequency, urgency, prolonged voiding intervals, daytime wetting, perineal/penile pain, holding maneuvers, and constipation/encopresis 1

• When BBD is present with VUR:

  • Initial treatment should always address the BBD 1
  • CAP should be continued until BBD resolves 1
  • The presence of both BBD and VUR doubles the risk of recurrent febrile UTI 1

Antibiotic Prophylaxis Considerations

• CAP typically consists of daily antibiotics at one-quarter to one-half of the regular therapeutic dose 1
• For breakthrough febrile infections, immediate parenteral antibiotic treatment is strongly recommended 1
• The RIVUR trial showed CAP provided a small but significant benefit for infants with grade III-V VUR in preventing first UTI 1, 2

Surgical Management Indications

Consider surgical correction in:

• Patients with persistent high-grade reflux (grades IV/V) 1
• Patients with frequent breakthrough infections 1
• Children above age 1 year with high-grade reflux and abnormal renal parenchyma 1

Important Caveats and Pitfalls

1. Don't overlook BBD: Failure to identify and treat BBD can lead to treatment failure and increased risk of recurrent UTIs 1

2. Avoid unnecessary imaging: In infants with minimal renal pelvic dilation and absent postnatal calicectasis, VCUG is not recommended as VUR is rare and likely low-grade 1

3. Beware of antibiotic resistance: Long-term CAP can lead to increased non-E. coli organisms and antibiotic resistance 1

4. Don't delay treatment of breakthrough infections: Immediate parenteral antibiotic treatment for febrile breakthrough infections is essential to prevent renal scarring 1

5. Consider family preferences: Family education and involvement in decision-making is considered a standard of care, as parental preferences may influence adherence to the treatment plan 1

The management of VUR has evolved to recognize that not all children require the same approach, and treatment decisions should be based on the individual risk factors for renal damage while minimizing treatment morbidity.