Intervention
Intervention for VUR remains a controversial topic. Guidelines for medical and surgical management are constantly being reassessed. For many years, the emphasis on the investigation of the child with UTI has centered on diagnosis of VUR. More recently, some authors have suggested that the focus should be whether the child has renal scarring or is at risk for renal scarring. The natural tendency for VUR to resolve spontaneously during childhood warrants initial medical management of most patients with low-grade reflux. Image 31 shows the usual treatment algorithm of one well-known children's medical center.
Vesicoureteral reflux assessment and treatment algorithm.
The primary goals in the management of vesicoureteral reflux (VUR) are the prevention of pyelonephritis and renal scarring. Antibiotic prophylaxis should be instituted from the first day of life in all infants in whom VUR figures in the differential diagnosis. In children with VUR, prophylaxis is usually continued until the reflux spontaneously resolves or is surgically corrected. Some advocate stopping prophylaxis in children older than 7 or 8 years who have mild or moderate (grade I-III) VUR, particularly when no evidence of prior renal scarring is present. Randomized prospective studies have shown no significant difference between medical treatment and surgical treatment with respect to development of new scars or progression of preexisting scars. However, only surgical treatment may help those with high-grade reflux.
The requirement for early postnatal surgical intervention is virtually confined to relieving outflow obstruction (usually boys with posterior urethral valves) and relieving gross hydronephrosis.
Surgical correction of reflux and ureteral reimplantations involve the development of an adequate length of submucosal ureter as it courses into the bladder (see Image 30). It may take several months for inflammatory changes to resolve and the antireflux 1-way mechanism to become competent. The incidence of persistent VUR requiring repeat surgery is between 1% and 3%, usually the result of a short submucosal tunnel or unrecognized neuropathic bladder.
Excretory urogram demonstrates the position of surgically reimplanted ureters after correction of vesicoureteral reflux.
Other surgical techniques include endoscopic submucosal injection of materials to effect bulking of either the subureteric space or proximal ureter resulting in coaptation. Teflon has been the most widely used and studied agent, though reports of granulomas, particle migration, and embolization have curtailed its use in the United States. Other materials include biodegradable glutaraldehyde cross-linked bovine collagen (GAX-collagen), Macroplastique particles, polyvinyl alcohol, and autologous materials such as fat.
Bladder training and techniques to avoid constipation may also be considered to lessen VUR.
Medicolegal Pitfalls
- Voiding dysfunction should be excluded.
Special Concerns
- The results of sonographic evaluation for hydronephrosis or pelvicaliceal dilatation may vary greatly between the second and third trimesters.
- Abnormalities may not be detectable until the third trimester, later than the common second trimester screening examination.
- In the prenatal period, VUR is detected more frequently in boys than in girls, with a male-to-female of 5:1.
- Low-grade reflux is often associated with other prenatal urologic abnormalities.
- Mild pelviectasis is seen in 0.5-1% of all pregnancies.
- The widespread use of prenatal sonography has produced a marked increase in the early detection of urinary tract pathology in infants.
- The most common conditions identified are hydronephrosis and hydroureteronephrosis. Hydronephrosis is most often transient, but primary VUR is found in 10-40% of prenatally detected cases of hydronephrosis.
- With the advent of prenatal sonographic screening, the evaluation for hydronephrosis, and subsequently VUR, is being performed in the neonatal period.
- The neonate with sonographic signs of renal pathology and possible reflux should be given prophylactic antibiotics and undergo VCUG.
- The risk of renal scarring from neonatal and infant reflux of infected urine is too great to ignore.
More on Vesicoureteral Reflux |
| Overview: Vesicoureteral Reflux |
| Imaging: Vesicoureteral Reflux |
 Follow-up: Vesicoureteral Reflux |
| Multimedia: Vesicoureteral Reflux |
| References |
| Further Reading |
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References
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Further Reading
Related eMedicine topics
Vesicoureteral Reflux (Pediatrics: surgery)
Vesicoureteral Reflux (Urology)
Reflux Nephropathy
Pyelonephritis, Chronic
Radiographic Evaluation of the Pediatric Urinary Tract
Clinical guidelines
Vesicoureteric reflux (VUR). In: Guidelines on paediatric urology.
European Association of Urology - Medical Specialty Society
European Society for Paediatric Urology - Medical Specialty Society. 2008 Mar. 6 pages. NGC:006510
Urinary tract infections in children. In: Guidelines on the management of urinary and male genital tract infections.
European Association of Urology - Medical Specialty Society. 2008 Mar. 13 pages. NGC:006488
ACR Appropriateness Criteria® urinary tract infection—child.
American College of Radiology - Medical Specialty Society. 1999 (revised 2006). 7 pages. NGC:005552
Clinical trials
Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR)
Determination of Voiding Patterns of Children With Vesicoureteral Reflux
Evaluation of the Efficiency of Autologous Adipocytes Graft in Endoscopic Treatment in Vesico-Renal Reflux in Children
Keywords
vesicoureteral reflux, VUR, reflux nephropathy, posterior urethral valves, urinary tract infection, UTI
