Vesicoureteral Reflux Guidelines

Updated: Sep 30, 2021
  • Author: Carlos Roberto Estrada, Jr, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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Guidelines Summary

Guidelines on management of vesicoureteral reflux (VUR) have been published by the following organizations:

  • American Urological Association(AUA) [10]
  • European Association of Urology (EAU) [5]

American Urological Association guidelines

In 2017, the  confirmed the validity of its 2010 guidelines for the management of VUR in children, which serve as a good resource for patients, parents, and physicians. [10] Recommendations for antibiotic prophylaxis vary according to age at diagnosis.

For initial management of VUR in children < 1 year, recommendations are as follows [10] :

  • Continuous antibiotic prophylaxis (CAP), if child has a history of a febrile urinary tract infection (UTI)
  • Offer CAP for VUR grades III–V, if child has no history of febrile UTI 
  • Consider CAP for VUR grades I-II, if child has no history of febrile UTI

For initial management of VUR in children > 1 year, recommendations are as follows [10] ​:

  • CAP for the child with bladder/bowel dysfunction and VUR due to the increased risk of UTI while bladder/bowel dysfunction (BBD) is present and being treated 
  • CAP may be considered for the child with a history of UTIs in the absence of BBD
  • Observational management without CAP, with prompt initiation of antibiotic therapy for UTIs, may be considered for the child with VUR in the absence of bladder/bowel dysfunction, recurrent febrile UTIs, or renal cortical abnormalities 
  • Surgical intervention for VUR, including both open and endoscopic methods, may be used. 

If symptomatic breakthrough UTI occurs (manifest by fever, dysuria, frequency, failure to thrive, or poor feeding), a change in therapy is recommended. If symptomatic breakthrough urinary tract infection occurs, 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 (bladder/bowel dysfunction) that might contribute to UTI, as well as parental preferences.

Patients receiving CAP with a febrile breakthrough UTI should be considered for open surgical ureteral reimplantation or endoscopic injection of bulking agents for intervention with curative intent. However, if there is no evidence of pre-existing or new renal cortical abnormalities, changing to an alternative antibiotic agent is an option prior to surgical intervention with curative intent.

Patients not receiving CAP who develop a febrile UTI should begin CAP. 

European Association of Urology guidelines

The EAU guidelines note that because of the lack of robust prospective randomized controlled trials of VUR, their recommendations are based on consensus. [5]


  • If routine prenatal ultrasound (US) detects dilatation of the upper urinary tract, the EAU recommends performing postnatal US (delayed until the first week after birth, to allow resolution of the oliguria that normally occurs in the first 48 hours or so postnatally) followed by a voiding cystourethrogram (VCUG) if the US shows dilatation. The guidelines note that that up to 25% of newborns with upper urinary tract dilatation have VUR.
  • In children who experience a proven febrile UTI in the first 2 years of life, the EAU recommends VCUG, followed by a nuclear renal scan with dimercaptosuccinic acid (DMSA) if the VCUG shows reflux. An alternative approach is to perform an initial DMSA scan close to the time of a febrile UTI, followed by VCUG if the DMSA scan reveals kidney involvement.
  • Children with VUR who have symptoms suggestive of lower urinary tract dysfunction (LUTD; eg, urgency, wetting, constipation or holding maneuvers) should undergo an extensive history and examination, including voiding charts, uroflowmetry and residual urine determination, to confirm the diagnosis of LUTD.


The EAU guidelines provide recommendations on conservative and surgical therapy for VUR. Conservative therapy has the objective of preventing febrile UTI, and comprises the following:

  • Watchful waiting
  • Intermittent or continuous antibiotic prophylaxis
  • Bladder rehabilitation in patients with LUTD
  • Consideration of circumcision during early infancy
  • Regular follow-up with imaging studies (eg, VCUG, nuclear cystography, or DMSA scan)

Surgical treatment of VUR consists of endoscopic injection of bulking agents or ureteral re-implantation.                   

EAU treatment recommendations are as follows:

  • Initially treat all patients diagnosed within the first year of life with CAP, regardless of the grade of reflux or presence of renal scars.
  • Offer immediate, parenteral antibiotic treatment for febrile breakthrough infections.
  • Offer definitive surgical or endoscopic correction to patients with frequent breakthrough infections.
  • Offer open surgical correction to patients with persistent high-grade reflux and endoscopic correction for lower grades of reflux.
  • Initially manage all children presenting at age one to five years conservatively.
  • Offer surgical repair to children above the age of one year who present with high-grade reflux and abnormal renal parenchyma.
  • Offer close surveillance without antibiotic prophylaxis to children presenting with lower grades of reflux and without symptoms.
  • Ensure that a detailed investigation for the presence of lower urinary tract dysfunction (LUTD) is done in all and especially in children after toilet-training. If LUTD is found, the initial treatment should always be for LUTD.
  • Offer surgical correction, if parents prefer definitive therapy to conservative management.

The guidelines suggest selecting the most appropriate management option based on the following:

  • Presence of renal scars
  • Clinical course
  • Grade of reflux
  • Ipsilateral kidney function
  • Bilaterality
  • Bladder function
  • Associated anomalies of the urinary tract
  • Age and gender
  • Compliance
  • Parental preference

The EAU guidelines also offer treatment and follow-up recommendations based on risk groups (ie, high, moderate, low). [5]