Pediatric Vesicoureteral Reflux

There are many different reasons why a child may develop vesicoureteral reflux. Some of the more common causes include:

• Having parents or siblings with VUR
• Severe abnormal urinating patters such as excessive holding of urine
• Being born with neural tube defects such as spina bifida
• Having other urinary tract abnormalities, such as posterior urethral valves, ureterocele, or ureter duplication

During infancy, the disease is more common among boys because as they urinate, there is more pressure in their entire urinary tract. In early childhood, the irregularity is more common in girls. VUR is more common in Caucasian children than in African-American children.

The following are the most common symptoms of vesicoureteral reflux, however, each child may experience symptoms differently. Symptoms may include:

• Urinary tract infection (urinary tract infections are most common in children younger than age 5 and unlikely in boys at any age, unless VUR is present)
• Trouble with urination including:
  • Urgency
  • Dribbling
  • Wetting pants
• An abdominal mass from a swollen kidney
• Poor weight gain
• High blood pressure

The symptoms of VUR may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis.

VUR can often be suspected by ultrasound before a child is born if there is stretching of the kidney (hydronephrosis), but this does not prove that reflux is present. If there is a family history of VUR, but your child has no symptoms, your child's physician may elect to perform a diagnostic test to rule out VUR.

Diagnostic procedures for VUR include:

• Renal ultrasound. This is a noninvasive test in which a probe is passed over the kidney producing sound waves which bounce off the kidney, transmitting a picture of the organ on a video screen. The test is used to determine the size and shape of the kidney, and to detect a mass, kidney stone, cyst, or other obstruction or abnormalities. This cannot prove that reflux is present, but can see the stretch of the kidneys that reflux can produce, or scarring caused by reflux.
• Voiding cystourethrogram (VCUG). A VCUG is an X-ray test that examines the urinary tract. A small catheter (hollow tube) is placed in the urethra (tube that drains urine from the bladder to the outside of the body) and the bladder is filled with a liquid dye. X-ray images will be taken as the bladder fills and empties. The images will show if there is any reverse flow of urine into the ureters and kidneys.
• Voiding urosonogram. This is a test that combines both features of an ultrasound and a VCUG. The urosonogram requires that a small catheter is inserted into the urethra to fill the bladder with a dye that can be seen by ultrasound. Ultrasound images will be taken as the bladder fills and empties, like in a VCUG but without radiation.
• Blood tests. These are used to measure kidney function.

VUR can occur in varying degrees of severity. It can be very mild, when urine backs up only a short distance in the ureters. Or, it can be severe and lead to kidney infections and permanent kidney damage (scarring). A Children’s National, specific treatment for VUR will be determined by your child's doctor based on:

• Your child's age, overall health, and medical history
• The severity or grade of reflux
• Your child's ability to take specific medications, procedures, or therapies
• Possibility of the reflux going away on its own
• Your opinion or preference

Your child's doctor may assign a grading system (ranging from 1-5) to indicate the degree of reflux. The higher the grade, the more severe the reflux.

VUR Grade 1-3

Most children who have grade 1 through 3 VUR do not need any type of intense therapy. The reflux resolves on its own over time, usually within five years. Children who develop frequent fevers or infections may require ongoing preventive antibiotic therapy and periodic urine tests.

Preventive antibiotics have been shown to stop urinary infection s in some cases and pose little risk of problems. They do not make your child less immune to disease or infection. The doses used are very low, just enough to prevent a urinary infection from starting. While you are waiting for the reflux to go away, it is sometime best to keep your child on a preventive antibiotic so that they do not have more infections.

Surgical treatment is also available.

VUR Grade 4-5

Children who have grade 4 and 5 reflux may require surgery. During the procedure, the surgeon will create a flap-valve apparatus for the ureter that will keep the urine from flowing into the kidney. In more severe cases, the scarred kidney and ureter may need to be surgically removed.

The procedure can be performed through endoscopic surgery, open surgery or robot-assisted laparoscopic surgery.

• Endoscopic surgery is offered for simple, low-grade VUR and consists of inserting a cystoscope through the urethra into the bladder. A paste called Deflux^® is injected under the ureter to correct the VUR.
• Open surgery is done through a lower abdominal incision (bikini incision), the bladder is opened and the ureters are repaired in such a way to prevent more reflux. The success rate is very high (95 – 97%).
• Laparoscopic surgery with robotic assistance (DaVinci) can now be performed at selected hospitals and offers a generally shorter hospital stay and more rapid recovery with three small incisions.

Children’s National Hospital offers all surgical options for correcting VUR, including robotic surgery and minimally invasive procedures. The pediatric specialists will develop a care plan that best meets the needs of each individual child.

Learn about preparing your child for surgery.