Guidelines Summary

The 2010 American Urological Association (AUA) guidelines for management and screening of primary vesicoureteral reflux (VUR) in children were reconfirmed in 2017. Key recommendations for initial management of children less than 12 months old include the following^[4]:

Voiding cystourethrogram for neonates with high-grade (Society of Fetal Urology grade 3 and 4) hydronephrosis, hydroureter, or an abnormal bladder on ultrasound (late-term prenatal or postnatal), or who develop a urinary tract infection (UTI) on observation.
Continuous antibiotic prophylaxis (CAP) for VUR in patients with a history of a febrile UTI
CAP for VUR grades III–V in patients with no history of febrile UTI identified through screening
CAP may be offered for VUR grades I-II in patients with no history of UTI identified through screening

For children over one year old, several factors influence clinical outcome, including a greater likelihood of bowel and/or bladder dysfunction (BBD), lower probability of spontaneous resolution of VUR, lower risk of acute morbidity from febrile UTI, and a greater ability of the child to communicate complaint of symptoms of acute infection. Thus, the AUA notes that management decisions must take into account recognition of the clinical context (ie, age, VUR grade, presence of scarring, and parental preferences). The guidelines make the following treatment recommendations^[4]:

In the absence of BBD, recurrent febrile UTI, or renal cortical abnormaties, CAP is optional. Observational management without continuous antibiotic prophylaxis, with prompt initiation of antibiotic therapy for UTIs, may be also be considered.
CAP should be initiated in any child with VUR and BBD, recurrent febrile UTI, or renal cortical abnormaties.
Surgical intervention, including both open and endoscopic methods, may be considered.
Following endoscopic injection of bulking agents, a postoperative voiding cystography should be performed
With the occurrence of a febrile UTI following resolution or surgical treatment of VUR, evaluation for BBD or recurrent VUR is required.

Medication

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Author

James W Lohr, MD Professor, Department of Internal Medicine, Division of Nephrology, Fellowship Program Director, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

James W Lohr, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Nephrology, Central Society for Clinical and Translational Research

Disclosure: Received research grant from: GSK<br/>Partner received salary from Alexion for employment.

Coauthor(s)

Anupama Gowda, MBBS, MD Consulting Staff, Peachtree Nephrology, PC

Disclosure: Nothing to disclose.

Chike Magnus Nzerue, MD, FACP Professor of Medicine, Associate Dean for Clinical Affairs, Meharry Medical College

Chike Magnus Nzerue, MD, FACP is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Society of Nephrology, National Kidney Foundation

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FASN Professor of Medicine, Section of Nephrology-Hypertension, Deming Department of Medicine, Tulane University School of Medicine

Vecihi Batuman, MD, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Acknowledgements

Richard A Santucci, MD, FACS Specialist-in-Chief, Department of Urology, Detroit Medical Center; Chief of Urology, Detroit Receiving Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State University College of Medicine

Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, and Société Internationale d'Urologie (International Society of Urology)

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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