Pediatric Vesicoureteral Reflux Guidelines

Updated: Jul 09, 2020
  • Author: Caleb P Nelson, MD, MPH; Chief Editor: Marc Cendron, MD  more...
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Guidelines

AUA Guidelines for Management of Pediatric Vesicoureteral Reflux

The American Urological Association (AUA) has issued guideline statements regarding management of vesicoureteral reflux (VUR) in children. [6] Statements are classified as standards, recommendations, or options.

Initial management

Child with VUR aged < 1 year

Continuous antibiotic prophylaxis (CAP) is recommended for the child younger than 1 year of age with VUR and a history of a febrile urinary tract infection (UTI). (Recommendation)

In the absence of a history of febrile UTI, CAP is recommended for the child with VUR grade III-V identified through screening. (Recommendation)

In the absence of a history of febrile UTI, CAP may be offered to the child with VUR grade I-II identified through screening. (Option)

Circumcision of the infant male with VUR may be considered on the basis of the increased risk of UTI in uncircumcised boys. (Option)

Child with UTI and VUR aged >1 year

If clinical evidence of bladder/bowel dysfunction (BBD) is present, treatment of BBD is indicated, preferably before any surgical intervention for VUR is undertaken. (Recommendation)

CAP is recommended for the child with BBD and VUR because of the increased risk of UTI while BBD is present and being treated. (Recommendation)

CAP may be considered for the child with a history of UTI and VUR in the absence of BBD. (Option)

Observational management without CAP, with prompt initiation of antibiotic therapy for UTI, may be considered for the child with VUR in the absence of BBD, recurrent febrile UTI, or renal cortical abnormalities. (Option)

Surgical intervention for VUR, including both open and endoscopic methods, may be used. (Option)

Follow-up management 

General

General evaluation, including monitoring of blood pressure, height, and weight, is recommended annually. (Recommendation)

Urinalysis for proteinuria and bacteriuria is indicated annually, including a urine culture and sensitivity if the urinalysis is suggestive of infection. (Recommendation)

Imaging with cystography and ultrasonography

Ultrasonography (US) is recommended every 12 months to monitor renal growth and any parenchymal scarring. Voiding cystography (radionuclide cystography or low-dose fluoroscopy, when available) is recommended between 12 and 24 months, with longer intervals between follow-up studies in cases where evidence supports lower rates of spontaneous resolution (eg, grade III-V VUR, BBD, and older age). If an observational approach is being used, follow-up cystography becomes an option. (Recommendation)

Follow-up cystography may be done after the age of 1 year in patients with VUR grade I-II. (Option)

A single normal voiding cystogram (ie, no evidence of VUR) may serve to establish resolution. The clinical significance of grade I VUR and the need for ongoing evaluation are undefined. (Option)

Imaging with dimercaptosuccinic acid

Dimercaptosuccinic acid (DMSA) imaging is recommended when renal US is abnormal, when there is a greater concern for scarring (eg, breakthrough UTI [BT-UTI] or grade III-V VUR), or when serum creatinine is elevated. (Recommendation)

DMSA imaging may be considered for follow-up of children with VUR to detect new renal scarring, especially after a febrile UTI. (Option)

Interventions for breakthrough urinary tract infection

If symptomatic BT-UTI occurs (manifested by fever, dysuria, frequency, failure to thrive, or poor feeding), a change in therapy is recommended. The clinical scenario will guide the choice of treatment alternatives; this includes VUR grade, degree of renal scarring (if any), and evidence of abnormal voiding patterns (BBD) that might contribute to UTI, as well as parental preferences. (Recommendation)

It is recommended that patients receiving CAP with a febrile breakthrough UTI be considered for open surgical ureteral reimplantation or endoscopic injection of bulking agents for intervention with curative intent. (Recommendation)

In patients receiving CAP with a single febrile breakthrough UTI and no evidence of preexisting or new renal cortical abnormalities, changing to an alternative antibiotic agent is an option before intervention with curative intent. (Option)

In patients not receiving CAP who develop a febrile UTI, initiation of CAP is recommended. (Recommendation)

In patients not receiving CAP who develop a nonfebrile UTI, initiation of CAP is an option. (Option)

Surgical treatment 

Surgical intervention for VUR, including both open and endoscopic methods, may be used. (Option)

Postoperative imaging for patients receiving definitive interventions

After open surgical or endoscopic procedures for VUR, renal US should be obtained to assess for obstruction. (Standard)

Postoperative voiding cystography following endoscopic injection of bulking agents is recommended. (Recommendation)

Postoperative cystography may be performed after open ureteral reimplantation. (Option)

Follow-up management after resolution

After resolution of VUR, either spontaneously or through surgical intervention, and if both kidneys are normal on US or DMSA scanning, general evaluation (including monitoring of blood pressure, height, and weight) and urinalysis for protein and UTI annually through adolescence are an option. (Option)

After resolution of VUR, either spontaneously or through surgical intervention, general evaluation (including monitoring of blood pressure, height, and weight) and urinalysis for protein and UTI are recommended annually through adolescence if either kidney is abnormal on US or DMSA scanning. (Recommendation)

With the occurrence of a febrile UTI after resolution or surgical treatment of VUR, evaluation for BBD or recurrent VUR is recommended. (Recommendation)

It is recommended that the long-term concerns of hypertension (particularly during pregnancy), renal functional loss, recurrent UTI, and familial VUR in the child's siblings and offspring be discussed with the family and communicated to the child at an appropriate age. (Recommendation)