VUR

Question 1

Initial EVALUATION of child with VUR

Answer 1

General medical evaluation in all patients:

• Measurement of height, weight, and blood pressure, and serum creatinine if bilateral renal abnormalities are found.
• Urinalysis for proteinuria and bacteriuria; if urinalysis indicates infection, a urine culture and sensitivity is recommended.
• A baseline serum creatinine may be obtained to establish an estimate of glomerular filtration rate.

Imaging procedures:

• Renal ultrasound to assess the upper urinary tract is recommended.
• DMSA (technetium-99m-labeled dimercaptosuccinic acid) renal imaging can be obtained to assess the kidney for scarring and function.

Assessment of voiding patterns:

• Symptoms indicative of bladder/bowel dysfunction (BBD) should be sought including: urinary frequency and urgency, prolonged voiding intervals, daytime wetting, perineal/penile pain, holding maneuvers (posturing to prevent wetting), and constipation/encopresis.

Family and patient education:

• Discussion should include rationale for treating VUR, potential consequences of untreated VUR, equivalency of certain treatment approaches, assessment of likely adherence with the care plan.
• Determination of parental concerns and accommodation of parental preferences when treatment choices offer a similar risk-benefit balance.

Question 2

Initial MANAGEMENT of child with VUR

Answer 2

The goals of management are to 1) prevent recurring febrile urinary tract infection (UTI) 2) prevent renal injury; and 3) minimize morbidity of treatment and follow-up.

• The child with VUR <1 year of age:
• CAP is recommended for children <1 year of age with VUR and a history of a febrile UTI.
• In the absence of a history of febrile UTI, CAP is recommended for the child 1 year of age with VUR grades lll-V identified through screening.
• In the absence of a history of febrile UTI, the child <1 year of age with VUR grades l-ll who is identified through screening may be offered CAP.
• Circumcision of the male infant with VUR may be considered based on an increased risk of UTI in boys who are not circumcised.
• Parents need to be made aware of this association to permit informed decision-making.
• The child with UTI and VUR >1 year of age (Table 1):
• If clinical evidence of BBD is present, treatment is indicated, preferably before any surgical intervention for VUR is undertaken.
• Treatment options include behavioral therapy, biofeedback (for children >5 years of age), anticholinergic medications, alpha blockers, and treatment of constipation.
• CAP is recommended for the child with BBD and VUR due to the increased risk of UTI while BBD is present and being treated.
• CAP may be considered for the child >1 year of age with a history of UTI and VUR in the absence of BBD.
• Observational management without CAP, with prompt initiation of antibiotic therapy for UTI, may be considered for the child >1 year of age with VUR in the absence of BBD, recurrent febrile UTIs, or renal cortical abnormalities.
• Surgical intervention for VUR including both open and endoscopic methods, may be used.

Question 3

Followup management of child with VUR

Answer 3

General follow-up in all patients:

• General evaluation, including monitoring of blood pressure, height, and weight is recommended annually.
• Urinalysis for proteinuria and bacteriuria is indicated annually, including a urine culture and sensitivity if the urinalysis is suggestive of infection.
• Imaging – ultrasonography and cystography:
• Ultrasonography is recommended every 12 months to monitor renal growth and any parenchymal scarring.
• Voiding cystography (radionuclide cystogram or low-dose fluoroscopy, when available) is recommended between 12 and 24 months.
• Longer intervals between follow-up studies are suggested in patients who may have lower rates of spontaneous resolution (i.e. those with VUR grades lll-V, BBD, and older age).
• If an observational approach without CAP is being used, follow-up cystography is an option.
• Follow-up cystography may be performed after 1 year of age in patients with VUR grades l-ll; these patients have high rates of spontaneous resolution and boys also have a low risk of recurrent UTI.
• A single normal voiding cystogram may serve to establish resolution.
• The clinical significance of grade I VUR, and the need for ongoing evaluation is undefined.
• Imaging – DMSA:
• Recommended when renal ultrasound is abnormal, when there is a greater concern for scarring (i.e. breakthrough UTI [BT-UTI]; grade lll-V VUR), or if serum creatinine is elevated.
• May be considered for follow-up of children with VUR to detect new renal scarring, especially after a febrile UTI.

Question 4

Intervention for the child with breakthrough UTI

Answer 4

• If symptomatic BT-UTI occurs, a change in therapy is recommended.
• 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 (BBD) that might contribute to UTI, as well as parental preferences.
• Patients receiving CAP with a febrile BT-UTI should be considered for open surgical ureteral reimplantation or endoscopic injection of bulking agents for intervention with curative intent.
• In patients receiving CAP with a single febrile BT-UTI and no evidence of pre-existing or new renal cortical abnormalities, changing to an alternative antibiotic agent is an option prior to intervention with curative intent.
• In patients not receiving CAP who develop a febrile UTI, initiation of CAP is recommended.
• In patients not receiving CAP who develop a non-febrile UTI, CAP is an option; not all cases of pyelonephritis are associated with fever.

Question 5

Surgical treatment of VUR

Answer 5

• Surgical treatment of VUR, including both open and endoscopic methods, is an option.
• Following open surgical or endoscopic procedures for VUR, a renal ultrasound should be obtained to assess for obstruction.
• Postoperative voiding cystography following endoscopic injection of bulking agents is recommended.
• Postoperative cystography may be performed following open ureteral reimplantation.

Question 6

Management following resolution of VUR

Answer 6

• Either spontaneously or by surgical intervention, monitoring of blood pressure, height, and weight, and urinalysis for protein and UTI is recommended annually through adolescence.
• If both kidneys are normal by ultrasound or DMSA scanning, such follow-up is an option
• With the occurrence of a febrile UTI following resolution or surgical treatment of VUR, evaluation for BBD or recurrent VUR is recommended.
• Discussion is recommended of the long-term concerns of hypertension (particularly during pregnancy), renal functional loss, recurrent UTI, and familial VUR in the child’s siblings and offspring with the family and child at an appropriate age.

Question 7

Screening for VUR in siblings

Answer 7

The incidence of VUR in siblings of children with VUR is 27% overall and decreases with age. The incidence of VUR in offspring of a parent with reflux is 37%.
For siblings of children with VUR:

• A voiding cystourethrogram (VCUG) or radionuclide cystogram is recommended on evidence of renal cortical abnormalities or renal size asymmetry on ultrasound or a history of UTI in the sibling who has not been tested.
• Given that the value of identifying and treating VUR is unproven:
• Ultrasound screening of the kidneys may be performed to identify significant renal scarring and to focus attention on the presence and potential further risk of VUR.
• Screening offspring of patients with VUR can be considered as similar to screening of siblings

Question 8

Neonates with prenatal hydronephrosis

Answer 8

The incidence of VUR in children who have had hydronephrosis detected prenatally is 16% overall. The likelihood of VUR is not predicted by the severity of the hydronephrosis either prenatally or postnatally.

• VCUG is recommended for children with high-grade (Society for Fetal Urology [SFU] grade 3 and 4) hydronephrosis, hydroureter or an abnormal bladder on ultrasound (late-term prenatal or postnatal), or who develop a UTI on observation.
• Screening for VUR in children with a history of prenatally detected hydronephrosis with low grade hydronephrosis (SFU grade 1 or 2) is an option.
• An observational approach without screening for VUR, with prompt treatment of any UTI, may be taken for children with prenatally detected hydronephrosis (SFU grade 1 or 2).