In a healthy urinary tract system, a child’s urine flows in one direction: downward from the kidneys, through the ureters and into the bladder. From there, urine leaves the body when we urinate. Vesicoureteral reflux (VUR) is a problem that causes urine to flow backwards from the bladder into the ureters and kidneys—the opposite direction of a normal flow.
Who gets vesicoureteral reflux?
- Although VUR may be present at birth, it may not be detected until later.
- Siblings of children diagnosed with vesicoureteral reflux are at a higher risk.
- According to the National Institute of Diabetes and Digestive and Kidney Diseases, an estimated 10 percent of children have VUR.
When a child with vesicoureteral reflux urinates, some urine goes back into their ureter(s) and/or kidneys. Primary VUR is a congenital condition (present at birth) caused by an abnormal connection of the ureters in the bladder. This abnormal anatomy allows urine to flow backwards.
The type of VUR and the severity of the condition determine how each child’s VUR is treated. Here is the grading system pediatric urologists use to describe VUR, from the mildest to the most severe condition:
- Grade I: Only the ureter is affected by reflux.
- Grade II: Both the ureter and the renal (kidney) pelvis are affected by reflux.
- Grade III: Reflux causes swelling in the ureter and inside the kidney.
- Grade IV: Reflux causes more swelling in the ureter and inside the kidney.
- Grade V: The ureter and renal pelvis are severely enlarged.
Vesicoureteral Reflux Symptoms
In otherwise healthy children, an isolated urinary tract infection (UTI) is not a significant cause for concern if the infection responds to prescribed medication and never returns.
If your child has vesicoureteral reflux, he or she may be prone to recurring urinary tract infections, despite medical treatment. In children with VUR, multiple urinary tract infections (especially if associated with a fever) are a bigger problem because infected urine can travel into the ureters and/or kidneys.
These UTIs can lead to more serious infections such as pyelonephritis—an acute infection of the kidneys accompanied by a high fever and possible damage to renal (kidney) function. The kidneys are important to health for many reasons—mainly because they remove waste from the body and balance fluids.
Children who have recurrent UTIs with a fever over 101.5°F warrant the most concern. Their UTIs may resemble an isolated urinary tract infection with urgent or frequent peeing, pain, incontinence and blood in the urine. Repetition of infection accompanied by a high fever suggests a more serious infection involving the kidneys.
Diagnosis of Vesicoureteral Reflux
Diagnosis of vesicoureteral reflux starts with urinalysis, a urine culture and possibly some blood tests. Based on these test results, pediatric urologists at Riley at IU Health may order a renal ultrasound to check for structural abnormalities in the urinary tract.
If the ultrasound is normal and your child is otherwise healthy, we may monitor your child to see if the problem resolves on its own. Unless another serious infection follows, no further tests may be needed.
If your child is very young, very sick or has an abnormal ultrasound, such as swelling in the kidneys or ureter (also called hydronephrosis), your physician may order a special test called a voiding cystourethrogram (VCUG). Typically, the VCUG is only needed for children who have had recurrent febrile urinary tract infections. (Febrile means the infections are accompanied by high fevers.)
VCUG is a test that requires a catheter. Your child’s bladder is filled with a special X-ray dye that allows radiologist to evaluate the bladder for reflux of urine.
Most children are awake and tolerate a VCUG well. Our child life specialists support your child with toys, games and other distractions to help them manage the procedure with minimal pain or discomfort. The presence of a parent or caregiver may make the test easier on your child. The test takes 30 - 45 minutes and is performed by a dedicated radiology team, including an experienced radiologist who reads the images.
Treatments
Treatments
Children may outgrow vesicoureteral reflux. Using treatment guidelines published by the American Urological Association, our physicians may prescribe a small dose of daily antibiotic to protect children against recurrent urinary tract infections while waiting to see how a child’s development affects the condition. During that phase, we closely monitor children and help them adopt healthy voiding habits, if necessary.
In more severe cases, children are less likely to outgrow the condition. If tests show renal scarring, or if children have recurring urinary tract infections while taking antibiotics, surgery may be necessary.
Here are three common surgeries used to correct VUR:
- The least invasive procedure is called Deflux® implant—an outpatient procedure done under general anesthesia. Surgeons inject a sterile, biodegradable gel into the bladder where the ureters enter. This forms a bulge at the opening. The bulge narrows the ureter(s) and prevents urine from flowing backwards. Eventually, the body forms tissue around the implant, keeping the bulge in place where it can do its job. The procedure lasts about 30 minutes, and children usually recover very quickly. It is an outpatient procedure, so your child goes home the same day. This procedure is used for lower and moderate grade reflux and may need to be repeated to achieve cure.
- A more invasive option for treating vesicoureteral reflux is open ureteral reimplantation. In this procedure the ureters (the tubes that connect the kidney to the bladder) are rerouted or lengthened to prevent reflux. An open ureteral reimplantation may take several hours. Children typically are in the hospital for one to two days after surgery.
- Riley at IU Health also offers robotic ureteral reimplantation, a minimally invasive approach that uses the da Vinci® robotic surgical system. Surgery is done using tiny incisions and advanced tools that let surgeons see clearly and operate with enhanced precision. This technique is similar to open ureteral reimplantation, except the operation is done inside the body. Robotic-assisted surgeries typically offer faster recovery, shorter hospitalization and less pain. This approach is favored in older, larger children.
Key Points to Remember
Key Points to Remember
- Most children will outgrow vesicoureteral reflux (VUR).
- Children who have recurrent UTIs with high fevers (febrile urinary tract infections) should be evaluated for possible urinary tract problems such as vesicoureteral reflux—usually with a renal bladder ultrasound and VCUG.
- Repeated UTIs with high fevers can lead to serious infections with potential to damage a child’s kidneys.
- Diet does not cause VUR and cannot prevent it.
- If your child shows signs of scarring on the kidneys or diminished kidney function, surgery may be necessary to correct VUR.
Support Services & Resources
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