VUR is a condition where urine flows backward from the bladder up toward the kidneys. This abnormal flow results from a structural issue with the valve mechanism where the ureter enters the bladder. VUR significantly increases the risk of bacteria-laden urine reaching the kidneys. The primary goal of management is to prevent recurrent infections that can lead to kidney damage and permanent scarring.
Daily Management and Antibiotic Prophylaxis
Daily management involves maintaining a clean urinary tract and promoting optimal bladder function. Simple behavioral modifications are important for minimizing the bacterial load in the bladder. This includes encouraging regular and complete bladder emptying, often through timed voiding schedules, since residual urine can allow bacteria to multiply.
Maintaining soft stools is part of daily care, as chronic constipation can cause a distended rectum that presses on the bladder, interfering with its ability to empty fully and potentially worsening reflux. Proper hygiene is particularly important for girls, who should wipe from front to back to prevent bacteria from the bowel area from entering the urethra.
Continuous antibiotic prophylaxis (CAP) is a cornerstone of management, aimed at suppressing bacterial growth in the bladder. This involves administering a low-dose antibiotic once daily, often at bedtime, which is typically about one-quarter of the dose used for an active infection. The goal is to keep the urine sterile, preventing bacteria from traveling up to the kidneys during a reflux episode. Strict adherence to this nightly schedule is necessary until the VUR resolves spontaneously or another treatment is pursued.
Recognizing and Addressing Urinary Tract Infections
A urinary tract infection (UTI) poses the most immediate risk to the kidneys in a child with VUR, making prompt recognition and treatment essential. Symptoms of a UTI can vary significantly depending on the child’s age, which often complicates early detection. In infants and toddlers, signs are frequently non-specific, including unexplained fever, irritability, poor feeding, or vomiting.
Older children may be able to verbalize their symptoms, reporting pain or a burning sensation during urination, a sudden or frequent urge to void, or discomfort in the lower abdomen or flank area. Fever is a particularly concerning sign, as a high temperature often indicates that the infection has progressed beyond the bladder and has reached the kidneys, a condition called pyelonephritis. This type of kidney infection carries the highest risk of causing permanent renal scarring.
If a UTI is suspected, parents must contact the pediatrician immediately to obtain a clean urine sample for testing. This sample must be collected quickly to confirm the presence of an infection and to identify the specific bacteria causing it. Once the infection is confirmed, the child will be switched from the low-dose prophylactic medication to a full course of therapeutic antibiotics at a much higher dose. Starting this therapeutic treatment promptly is an urgent step to eradicate the bacteria and minimize the window of opportunity for kidney damage.
Monitoring Tests and Medical Progression
Long-term management of VUR requires consistent medical surveillance using specific imaging tests. The Voiding Cystourethrogram (VCUG) is the initial diagnostic test, where a catheter is used to fill the bladder with a liquid contrast agent visible on X-ray. This procedure is performed while the child is voiding to visualize the urinary tract and is used to assign a grade from I (mildest) to V (most severe) to the reflux.
A renal ultrasound is a non-invasive test used regularly to assess the structure of the kidneys, tracking their size, growth, and checking for fluid buildup known as hydronephrosis. To assess for kidney damage, a specialized nuclear scan called a DMSA (Dimercaptosuccinic Acid) scan may be performed. This scan involves injecting radioactive material absorbed by healthy kidney tissue, allowing physicians to detect areas of reduced function or scarring.
The treatment plan is determined by the VUR grade, the child’s age, and whether they experience breakthrough infections while on prophylaxis. For lower grades (I-III) in young children, a period of watchful waiting is common, as the condition frequently resolves spontaneously as the ureter matures and elongates. Grades I to III have an annual resolution rate of approximately 13% in the first few years, compared to around 5% yearly for the highest grades (IV-V).
If the reflux is severe, or if the child experiences recurrent febrile UTIs despite prophylaxis, intervention may be necessary. The least invasive option is endoscopic injection, which involves injecting a bulking agent near the ureteral opening to create a better functioning valve. Surgical ureteral reimplantation, which physically reconstructs the ureter’s entry into the bladder, is a more definitive treatment typically reserved for high-grade or persistent reflux, boasting success rates often exceeding 90%.