Urinary tract infection (UTI) is a common problem in infants and young children affecting about 2–5% of all small children. Almost a third to half of infants who are inflicted with urinary infection are likely to have an abnormal urinary tract, commonest of which is vesicoureteric reflux (VUR). Around 10–20% of children with VUR end with hypertension or end stage renal disease stressing the need to diagnose and manage these children early. This article reviews current status of clinical manifestations, diagnosis, and management of children with VUR.

1. Vesicoureteric Reflux in Children—Current Concepts

2. Apollo Medicine 2011 December
Review Article
Volume 8, Number 4; pp. 276–280
© 2011, Indraprastha Medical Corporation Ltd
Vesicoureteric reflux in children—current concepts
Anand Alladi*, Deepti Vepakomma**
*Senior Consultant, Paediatric Surgery and Urology, **Consultant, Paediatric Surgery, Apollo Hospitals, Bengaluru, Karnataka, India.
ABSTRACT
Urinary tract infection (UTI) is a common problem in infants and young children affecting about 2–5% of all small
children. Almost a third to half of infants who are inflicted with urinary infection are likely to have an abnormal urinary
tract, commonest of which is vesicoureteric reflux (VUR). Around 10–20% of children with VUR end with hyperten-
sion or end stage renal disease stressing the need to diagnose and manage these children early.This article reviews
current status of clinical manifestations, diagnosis, and management of children with VUR.
Keywords: Children, urinary tract infection, vesicoureteric reflux
Correspondence: Dr. Anand Alladi, E-mail: alladianand@gmail.com
doi: 10.1016/S0976-0016(11)60005-7
Urinary tract infection (UTI) is a common problem in
infants and young children affecting about 2–5% of all small
children. Boys are affected more in the neonatal period, and
girls beyond 6 months of age. The chances of recurrent
infection range from 1% to 3%, and this is more so in girls.1
Almost a third to half of infants who are inflicted with
urinary infection are likely to have an abnormal urinary
tract, predisposing them to infections. Vesicoureteric reflux
(VUR) is the commonest pathology predisposing children
to UTI.2
Such children need to be evaluated to protect fur-
ther infections and damage to their kidneys.
Vesicoureteric reflux is the abnormal retrograde pas-
sage of urine from the bladder into the ureter. The incidence
is around 1% of all children.3
Vesicoureteric reflux is reported to increase the risk of
febrile UTI in children and be associated with impaired
renal function in the long-term.
Widespread use of obstetric ultrasonography has helped
detect antenatal hydronephrosis accounting for 17–37%.4
The importance of diagnosing and treating VUR early can-
not be but stressed as 10–20% of children with reflux neph-
ropathy5
have hypertension or end-stage renal disease.6
Reflux can be primary or secondary to some bladder
or its outlet pathology or dysfunction causing high-pressure
systems. About 10–40% have primary VUR. There is a
definite genetic basis for the development of primary
reflux, which is borne out by the fact that nearly 30% of
siblings and 70% of offsprings of children with VUR have
the disease occurring in them.7
Those children who are not picked up antenatally may
present with recurrent febrile UTI. In secondary VUR, they
may present with symptoms of the primary diseases such as
voiding difficulties and urodynamic symptoms. Occasionally,
they may be present due to the sequelae of VUR such as
hypertension, failure to thrive, and renal failure.
Voiding cystourethrography (VCUG) is the gold standard
for the diagnosis of VUR (Figures 1–6). The International
Reflux Study Committee based on the degree of backflow
and dilatation of the upper tract classifies VUR into five
grades on VCUG9
:
Grade 1 – Reflux only in ureter does not reach the pelvis.
Grade 2 – Reflux up to pelvis with no dilation and normal
fornices.
Grade 3 – Mild to moderate dilatation of ureter with or
without tortuosity, moderate dilation of collect-
ing system with normal or blunting of fornices.
Grade 4 – Moderate dilation of ureter with or without tortu-
osity, moderate dilatation of collecting system
with blunting of fornices but maintained papil-
lary impressions.
Grade 5 – Severe dilation with tortuosity of ureter and severe
dilation of collecting system, clubbing of calyces,
loss of papillary impressions and/or presence of
intra-renal reflux.

3. Vesicoureteric reflux in children—current concepts Review Article 277
© 2011, Indraprastha Medical Corporation Ltd
Figure 1 International Reflux Grading classification scheme
for vesicoureteral reflux.8
I II III IV V
Figure 3 Voiding cystourethrography showing posterior ure-
thral valves with unilateral grade 5 vesicoureteric reflux, which
spontaneously resolved 1 year after fulguration of valve. Mild
prominence of the posterior urethra persists.
Figure 4 Voiding cystourethrography showing right vesicouret-
eric reflux and paraureteric diverticulum.
Figure 5 Dimercaptosuccinic acid showing bilateral normal
kidneys with no scars.
Voiding cystourethrography is followed by a dimercap-
tosuccinic acid cortical renogram to detect scarring and to
document split renal function.
Occasionally, additional investigations are required for
diagnosing the primary pathology in secondary VUR. These
include intravenous urography (IVU), CT, urodynamics, and
cystoscopy.
MANAGEMENT
The main principles of management of VUR include early
detection, monitoring, preventing infections, and allowing
normal renal growth and preventing long-term sequelae.
This is based on the natural history which shows spontane-
ous resolution in nearly 90% for low-grade reflux and up to
A B
Figure 2 (A) Voiding cystourethrography showing left grade 3
and right grade 1 vesicoureteric reflux. (B) Voiding cystoure-
thrography showing bilateral grade 5 vesicoureteric reflux with
intra-renal reflux.

4. 278 Apollo Medicine 2011 December; Vol. 8, No. 4 Alladi and Vepakomma
© 2011, Indraprastha Medical Corporation Ltd
70% in the bilateral grade 310
and the fact that sterile reflux
is not harmful to the kidney.
The mainstay of management is conservative with
cyclical antibiotic prophylaxis, treatment of bladder dys-
function, bladder training, urinary surveillance, serial
assessment of blood pressure and renal functions, annual
renal ultrasound, and VCUG and DMSA renogram till the
resolution of reflux.
The prophylactic antibiotic used is generally amoxicil-
lin or cephalexin in neonates and young infants and tri-
methoprim and nitrofurantoin in older children. The dose
used is usually half to one-third of the therapeutic dose
administered at bedtime.
The International Reflux Study has found that children can
be managed nonsurgically with little risk of new or increased
renal scarring, provided they are maintained infection-free.
The chance of spontaneous resolution of reflux is high in
children <5 years with grades I–III reflux and in children
<1 year (especially boys). Even higher grades of reflux
(grades IV–V) may resolve spontaneously as long as they
remain infection-free.10
The philosophy of medical management is based on the
knowledge that low-grade reflux resolves spontaneously
and sterile reflux does not damage the kidney. This involves
administering long-term prophylactic antibiotics. Continuous
antibacterial prophylaxis is said to decrease the incidence of
pyelonephritis and subsequent renal scarring. Vesicoureteral
Reflux Guideline Update Committee was set up by the
AUA in 2005. They searched the MEDLINE®
database
from 1994 to 2008. The panel could not establish the effi-
cacy of continuous antibiotic prophylaxis with current data.
However, its purported lack of efficacy, as reported in the
selected prospective clinical trials, is also unproven owing
to significant limitations in these studies.
In a recent Cochrane Database Systematic Review of
20 randomized control trials (RCTs) including 2324 chil-
dren, it was found that long-term low-dose prophylactic
antibiotics did not significantly decrease the incidence of
recurrent symptomatic or febrile UTI, although there was
considerable heterogeneity in the analyzes and only one study
was adequately blinded. Antibiotic prophylaxis, however,
decreased the risk of progressive or new damage on DMSA.
There was also a 3-fold increase in the emergence of drug-
resistance on long-term prophylaxis. Long-term prophylaxis
in comparison to surgery or endoscopic correction with short-
term (0–24 months) did not significantly reduce the risk of
febrile infections.11
With more evidence now suggesting that patients with
primary VUR also have an element of bladder dysfunction,
the current focus is on managing this problem also. The
measures include behavior modification protocol to ensure
that the child empties his/her bladder completely at regular
intervals (every 3 h), adequate hydration and constipation
prevention. Anticholinergic medications are added where
detrusor instability is documented.12,13
The American Urology Association treatment algorithm
for the management of VUR is given in given in Figure 7.
Surgical intervention is indicated in children with
breakthrough infections despite prophylaxis or noncompli-
ance to medical treatment. Relative indications include per-
sistent high-grade reflux, associated congenital structural
anomalies, appearance of new scars and girls with dilating
reflux.There has been a wide spectrum of surgical techniques,
using intravesical, extravesical, or combined techniques.
However, the basic principle of all is to provide an anti-reflux
Figure 6 Intravenous urography and dimercaptosuccinic acid
showing right ureterocele in the bladder as filling defect and
right duplex with poorly functioning upper moiety on dimer-
captosuccinic acid.
Diagnosis
VUR grade I–II
Patients 0–10 years
(unilateral/bilateral)
VUR cured
or resolved
Antibiotic
prophylaxis
Endoscopic
implantation with
NASHA/Dxgel
VUR grade III–IV
Patients 0–10 years
(unilateral/bilateral)
VUR grade V
Patients <1 year
(unilateral/bilateral)
VUR grade V
Patients 1–10 years
(unilateral/bilateral)
Open surgery
Figure 7 American Urology Association treatment algorithm.
VUR: vesicoureteric reflux; NASHA/Dxgel: non-animal stabi-
lised hyaluronic acid/dextranomer gel.

5. Vesicoureteric reflux in children—current concepts Review Article 279
© 2011, Indraprastha Medical Corporation Ltd
mechanism by creating an adequate submucosal tunnel. With
advances in minimally invasive and robotic surgery, these
surgeries are being carried out with minimum morbidity,
faster recovery, and equally good results (Figure 8).
Figure 8 Intravesical Cohen’s transtrigonal re-implantation for
unilateral vesicoureteric reflux.
Figure 9 (A, B) Endoscopic injection for vesicoureteric reflux—
pre- and postinjection.
A
B
Endoscopic treatment involves submucosal injection
of a bulking agent into the bladder wall below the ureteral
orifice, or within the ureteral tunnel, to provide tissue
augmentation. The most commonly used substance nowa-
days is a dextranomer/hyaluronic acid copolymer. This
is technically easy and is a patient-friendly treatment
modality. Success rates are slightly lower than in open
surgery and a second or third injection of bulking agent
is often necessary (Figure 9). The reported success
range are 67.4% following single, 86.6% and 88.3%
following second and third injections, respectively.14
A
word of caution in analyzing these results—most of the
resolutions and good results are documented in low-grade
refluxes.
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