Paeds · nephrology-urology-fluids-and-electrolytes
Vesicoureteric reflux
Also known as Vesicoureteral reflux · VUR · Reflux nephropathy · Ureterovesical reflux · Primary vesicoureteric reflux
Fellowship guide to vesicoureteric reflux, the retrograde flow of urine from the bladder into the upper urinary tract that is the most common urological abnormality in children. Covers the International Reflux Study grading system from grade I to grade V, the pathophysiology of an incompetent ureterovesical junction with a short intramural tunnel, the role of the micturating cystourethrogram in diagnosis, the natural history of spontaneous resolution skewed toward low-grade reflux, the RIVUR trial evidence on antimicrobial prophylaxis, the management ladder from observation through continuous antibiotic prophylaxis to endoscopic injection and ureteric reimplantation, the critical modifier of bladder and bowel dysfunction, and the long-term risk of reflux nephropathy with renal scarring, hypertension, and chronic kidney disease.
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- Breakthrough febrile urinary tract infection despite continuous antibiotic prophylaxis in a child with high-grade reflux
- Progressive renal scarring on serial DMSA scanning in a child with persistent high-grade vesicoureteric reflux
- Bilateral high-grade reflux with new or worsening hypertension signalling reflux nephropathy and hyperfiltration injury
- A febrile infant with a duplex collecting system and an ectopic upper-pole ureter causing obstruction and reflux simultaneously
- Recurrent pyelonephritis in a child with undiagnosed bladder and bowel dysfunction that is driving the reflux and preventing resolution
- Antenatally detected high-grade bilateral hydronephrosis that proves to be high-grade bilateral reflux on postnatal micturating cystourethrogram
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- Defines vesicoureteric reflux as the retrograde flow of urine from the bladder into the ureter and renal pelvis from an incompetent ureterovesical junction
- Recognises that reflux predisposes to recurrent urinary tract infection and renal scarring, and grades it using the International Reflux Study system from grade I to grade V
- Initiates prophylactic antibiotics and refers for specialist evaluation when reflux is suspected or confirmed after a febrile urinary tract infection
- Classifies reflux by grade I through V on the micturiting cystourethrogram and relates each grade to the likelihood of spontaneous resolution and the risk of renal scarring
- Interprets the RIVUR trial evidence on antimicrobial prophylaxis, balancing the halved recurrence rate against the absent reduction in new renal scarring and the rise in resistant organisms
- Constructs the management ladder from observation and prophylaxis through endoscopic injection to ureteric reimplantation, modified by bladder and bowel dysfunction
- International Reflux Study grading I to V and the natural history of spontaneous resolution by grade
- The RIVUR trial design, primary outcome, and the paradox of reduced recurrence without reduced scarring
- Management ladder of observation, continuous antibiotic prophylaxis, endoscopic Deflux injection, and open ureteric reimplantation
- Assesses a child with recurrent febrile urinary tract infection and constructs a structured investigation plan using ultrasound, micturating cystourethrogram, and DMSA
- Communicates the diagnosis, the prognosis, and the surveillance plan to a family whose child has vesicoureteric reflux
- Recognises the child with progressive reflux nephropathy and coordinates multidisciplinary nephrology and urology care
- Level 1: Recognition of vesicoureteric reflux as a cause of recurrent childhood urinary tract infection
- Level 2: Initiation of imaging and prophylaxis after febrile urinary tract infection and grading on micturating cystourethrogram
- Level 3: Coordination of surgical decision-making and long-term surveillance for reflux nephropathy
- International Reflux Study grading system from grade I to grade V and the radiological features of each grade
- The RIVUR trial evidence on antimicrobial prophylaxis and the role of endoscopic and surgical correction
- Bladder and bowel dysfunction as a modifier of resolution and treatment success, and the long-term risk of reflux nephropathy
- Assessment of a child with recurrent urinary tract infection and interpretation of the micturating cystourethrogram and DMSA scan
- Structured explanation of the management ladder and the rationale for each step
- Communication of the prognosis and the long-term surveillance plan for hypertension and chronic kidney disease
- Grading of vesicoureteric reflux and the relationship between grade, spontaneous resolution, and renal scarring risk
- RIVUR trial outcomes and the role of continuous antibiotic prophylaxis in children with reflux
- Surgical options including endoscopic dextranomer hyaluronic acid injection and ureteric reimplantation
- Recognition of vesicoureteric reflux as the most common urological abnormality in children and a cause of renal scarring
- Initiation of prophylaxis and timely referral for recurrent febrile infection or high-grade reflux
- Family communication around the management ladder, surgical options, and the long-term risk of reflux nephropathy
- Canadian approach to vesicoureteric reflux with selective imaging after febrile urinary tract infection
- RIVUR trial application to clinical practice and the role of continuous antibiotic prophylaxis
- Transition of care for young adults with reflux nephropathy and long-term hypertension and renal surveillance
Overview & Definition
A child who presents with a febrile urinary tract infection in infancy, or an infant found to have hydronephrosis on the antenatal scan, leads the clinician to the diagnosis of vesicoureteric reflux. The condition is the retrograde flow of urine from the bladder up into the ureter and the renal pelvis, and it is the most common urological abnormality in children, found in approximately 1 to 2 percent of all children and in up to 30 to 40 percent of those who present with a febrile urinary tract infection. The abnormality lies at the ureterovesical junction, where the ureter enters the bladder through a short or absent intramural tunnel that fails to act as a one-way valve. [8]
The clinical significance of reflux is twofold. First, it allows infected bladder urine to ascend to the kidney, which converts a lower urinary tract infection into pyelonephritis and causes renal scarring. Second, the refluxing urine creates a residual volume that predisposes to recurrent infection. The scarred kidney carries a life-long risk of hypertension, proteinuria, and chronic kidney disease, and in pregnancy it increases the risk of pre-eclampsia. This cascade from a febrile infection to permanent renal damage is the entire rationale for the investigation, grading, and management of reflux. [8]
Primary reflux is the congenital form, in which the ureterovesical junction is structurally abnormal from a short intramural tunnel, and it is the form that resolves spontaneously as the child grows. Secondary reflux arises from a high-pressure or abnormal bladder, such as posterior urethral valves, a neurogenic bladder, or bladder and bowel dysfunction, and it persists until the underlying cause is treated. The distinction is critical, because primary reflux is managed on the grade and the infection history, while secondary reflux is managed by treating the bladder. [3]
References12ShowHide
- [1]Lebowitz RL, Olbing H, Parkkulainen KV, et al. International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children. Pediatr Radiol, 1985.PMID 3975102
- [2]Hoberman A, Greenfield SP, Mattoo TK, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med, 2014.PMID 24795142
- [3]Peters CA, Skoog SJ, Arant BS Jr, et al Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children. J Urol, 2010.PMID 20650499
- [4]Mathews R, Mattoo TK The role of antimicrobial prophylaxis in the management of children with vesicoureteral reflux--the RIVUR study outcomes. Adv Chronic Kidney Dis, 2015.PMID 26088078
- [5]Elder JS, Diaz M Vesicoureteral reflux--the role of bladder and bowel dysfunction. Nat Rev Urol, 2013.PMID 24126731
- [6]Stein R, Dogan HS, Hoebeke P, et al Urinary tract infections in children: EAU/ESPU guidelines. Eur Urol, 2015.PMID 25477258
- [7]Kirsch AJ, Cooper CS, Läckgren G Non-Animal Stabilized Hyaluronic Acid/Dextranomer Gel (NASHA/Dx, Deflux) for Endoscopic Treatment of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years? Urology, 2021.PMID 34411597
- [8]Mattoo TK, Mohammad D Primary Vesicoureteral Reflux and Renal Scarring. Pediatr Clin North Am, 2022.PMID 36880925
- [9]Mattoo TK, Shaikh N, Nelson CP Contemporary Management of Urinary Tract Infection in Children. Pediatrics, 2021.PMID 33479164
- [10]Zhao B, Ivanova A, Shaikh N, et al Antimicrobial prophylaxis for vesicoureteral reflux: which subgroups of children benefit the most? Pediatr Nephrol, 2024.PMID 38244067
- [11]Farhat W, McLorie G, Geary D, et al The natural history of neonatal vesicoureteral reflux associated with antenatal hydronephrosis. J Urol, 2000.PMID 10958740
- [12]Connolly LP, Zurakowski D, Connolly SA, et al Natural history of vesicoureteral reflux in girls after age 5 years. J Urol, 2001.PMID 11696785