What is the treatment for Vesicoureteral Reflux (VUR) in children?

Treatment of Vesicoureteral Reflux (VUR) in Children

The primary goal of VUR treatment is preservation of renal function, with initial management stratified by risk category: low-risk patients (low-grade VUR, normal kidneys, no symptoms) can be observed without antibiotics; moderate-risk patients require continuous antibiotic prophylaxis (CAP) with or without bladder/bowel dysfunction (BBD) treatment; and high-risk patients (high-grade VUR with abnormal kidneys) need CAP plus early consideration of surgical intervention, particularly if breakthrough infections occur. 1

Risk Stratification Framework

Treatment decisions must be based on multiple factors rather than VUR grade alone 1:

• Grade of reflux (I-V using International Reflux Study Committee classification) 1
• Renal parenchymal status (presence of cortical scarring on DMSA scan) 1
• Age and toilet-training status 1
• Presence of bladder and bowel dysfunction (BBD/LUTD) 1
• History of febrile UTIs 1
• Bilaterality of reflux 1

Treatment Approach by Risk Category

High-Risk Patients

Post-toilet training with grade IV-V VUR, abnormal kidneys, and LUTD:

• Initial treatment must always address LUTD first with urotherapy plus CAP 1
• Surgical intervention should be considered early if breakthrough infections occur or LUTD persists despite urotherapy 1
• Greater possibility of earlier intervention compared to other groups 1

Post-toilet training with grade IV-V VUR, abnormal kidneys, without LUTD:

• Surgical intervention should be considered as primary treatment 1
• Ureteral reimplantation has superior outcomes compared to endoscopic correction for high-grade reflux 1

Moderate-Risk Patients

Pre-toilet training infants with high-grade VUR and abnormal kidneys:

• CAP is the initial treatment regardless of reflux grade 1
• Spontaneous resolution rates are higher in males 1
• Surgical intervention considered only for breakthrough infections or persistent VUR 1
• Full re-evaluation after 12-24 months 1

Post-toilet training with high-grade VUR, normal kidneys, and LUTD:

• LUTD treatment is mandatory as first-line therapy with CAP 1
• If LUTD persists despite urotherapy, surgical intervention should be considered 1
• Follow-up focuses on UTI, LUTD, and kidney status with re-evaluation after successful urotherapy 1

Post-toilet training with low-grade VUR and abnormal kidneys:

• Treatment choice is controversial 1
• Endoscopic treatment may be an option (80-90% success rates for lower grades) 2
• LUTD treatment should be provided if present 1

Low-Risk Patients

Symptomatic patients with normal kidneys, low-grade VUR, no LUTD:

• Close surveillance without antibiotic prophylaxis is appropriate 1
• Alternative: CAP can be offered 1
• Parents must be informed about infection risk if no treatment is given 1

Asymptomatic patients (prenatal hydronephrosis or siblings) with low-grade VUR:

• No treatment or CAP in infants 1
• Parental education about infection risk is essential 1

Continuous Antibiotic Prophylaxis (CAP) Details

Indications and dosing:

• Daily antibiotics at one-quarter to one-half the therapeutic dose 1
• Not needed in every VUR patient 1
• Particularly beneficial for infants with grade III-V VUR without previous UTIs 1

Evidence from PREDICT trial:

• CAP provided small but significant benefit in preventing first UTI in infants with grade III-V VUR 1
• Trade-off: increased non-E. coli organisms and antibiotic resistance 1

Practical approach:

• Continue CAP until BBD resolution 1
• More aggressive follow-up needed with re-evaluation after 6 months in high-risk patients 1

Surgical Management

Indications for Surgery

Strong indications:

• Frequent breakthrough febrile infections despite CAP 1, 3
• Persistent high-grade reflux (grades IV-V) with abnormal renal parenchyma 1
• Failure of conservative management in children >1 year with high-grade VUR and abnormal kidneys 1
• Parental preference for definitive therapy over conservative management 1

Surgical Options

Ureteral reimplantation (open or minimally invasive):

• Superior outcomes for high-grade reflux (grades IV-V) 1
• Success rates approaching 98% 4
• Reserved for persistent high-grade reflux 1

Endoscopic injection of bulking agents:

• Satisfactory results for lower-grade reflux 1
• Success rates 50-92% depending on grade 4
• Less invasive option 2

Critical Management of BBD/LUTD

All toilet-trained children must be carefully evaluated for BBD:

• Presence of both BBD and VUR doubles the risk of recurrent febrile UTI 1
• BBD treatment must always precede or accompany VUR treatment 1
• More intensive follow-up required until BBD resolves 3

Common Pitfalls to Avoid

Do not:

• Treat VUR without first addressing BBD in toilet-trained children 1
• Use the same approach for all VUR grades—treatment must be risk-stratified 1
• Continue conservative management if breakthrough febrile infections occur 3
• Perform routine postoperative VCUG—only on indication 1

Do:

• Inform parents that siblings have high VUR prevalence and may need screening 1, 3
• Provide immediate parenteral antibiotics for febrile breakthrough infections 1
• Monitor height, weight, blood pressure, and possibly serum creatinine during follow-up 1, 3
• Continue follow-up of kidney status until after puberty in high-risk cases 1