Vesicoureteral Reflux (VUR) in Children

What Causes Vesicoureteral Reflux?

In a properly functioning urinary tract, urine flows from the kidneys through the ureters to the bladder, where it is stored until a person urinates. From there, it flows down the urethra to exit the body. The ureters have a one-way valve system that normally stops urine from flowing back up to the kidneys. In a child with VUR, the mechanism doesn’t work properly. Urine can flow backward into the ureters and may enter the kidneys.

There are many potential reasons a child may develop VUR, which is most often diagnosed in infancy or childhood. Causes include neural tube defects such as spina bifida or the presence of other urinary tract problems, such posterior urethral valves or ureterocele.

Children with a parent or sibling with VUR are at a slightly greater risk of developing this condition. In infancy, it’s more common among boys. In early childhood, it’s more common among girls.

VUR Symptoms

Some children may not experience any symptoms of VUR. Others may experience symptoms of a urinary tract infection (UTI), which may include:

• Blood in the urine (hematuria)
• Burning feeling or pain with urination
• Chills
• Fatigue
• Fever
• Foul-smelling urine
• Frequent urination
• Nausea or vomiting
• Other urination symptoms such as increased urgency or accidents.
• Pain in the abdomen, side or ribs

Other symptoms of VUR may include:

• High blood pressure
• Poor weight gain
• Swollen kidney that feels like a mass in the belly

A child who has VUR is at risk for repeat kidney infections. Over time, this can cause damage and scarring to the kidneys. Diagnosing and treating severe VUR is important to help prevent future kidney damage and other complications.

VUR Diagnosis

VUR is often diagnosed before birth with a prenatal ultrasound as a megaureter. Diagnosis after birth is often prompted when an infant or child has symptoms of a urinary tract infection. If there is a family history of VUR, your child’s doctor may want to test for it, even if your child doesn’t have any symptoms.

In addition to conducting a physical exam and taking medical history, your child’s healthcare provider may perform additional diagnostic tests such as:

• Renal ultrasound: This imaging test uses sound waves to look at the kidneys and bladder.
• Voiding cystourethrogram (VCUG): A catheter is placed through your child’s urethra into the bladder, slowly filling the bladder with a contrast solution. A special machine called fluoroscopy takes pictures. The test can determine if any of the contrast is going back up the ureters toward the kidneys, which indicates the presence and degree of urine reflux.
• Urinalysis: A urine test can look for the presence of bacteria and other substances in the urine.

Vesicoureteral Reflux Treatment

VUR treatment depends on many factors, including the child’s age, general health and the severity of the condition. VUR can range from mild to severe. With mild VUR, the urine may only back up a short distance in the ureters. However, severe VUR may cause urine to collect in the kidneys, which can put a child at risk for infections and kidney damage.

When diagnosing VUR, your child’s doctor may classify their condition on a scale of 1 to 5, with one being the mildest form and 5 being the most severe. This will help inform the type of treatment recommended.

• Observation: Mild VUR (grades 1–3) usually goes away on its own. In these cases, treatment is often not required. Your child may require periodic follow-up exams and tests such as ultrasounds and urine tests to check for signs of infection or worsening reflux.
• Medications: Your child will be prescribed antibiotics if they develop a UTI. It’s important to take antibiotics as directed and complete the entire course, even if symptoms improve sooner. They will also need preventive antibiotics in the first year of life.
• Surgery: In children with more severe VUR (grades 4–5), surgery may be required to repair the valve between the bladder and ureters to prevent urine from flowing backwards. Surgical methods may include ureteral reimplant, during which your child’s surgeon creates a flap-valve that will help prevent reflux.

Another procedure is performed endoscopically (using a thin, flexible tube inserted through the urethra). With this procedure, your child’s doctor injects a small amount of gel-like material under the opening of the ureter. The injected material partially increases the resistance at the ureter opening and prevents the urine from flowing backward toward the kidney. This procedure is performed under general anesthesia, but children generally go home the same day and can resume normal activity the day after.

In more severe cases, the scarred kidney and ureter may need to be removed.