Vesicoureteral Reflux (VUR) in Children: A Complete Guide

A] What Is Vesicoureteral Reflux in Children?

VUR is a common urinary tract condition in infants and young children. Normally, urine flows from the kidneys down through the ureters into the bladder. However, in children with VUR, some urine flows backward, or refluxes, from the bladder up through one or both ureters and sometimes reaches the kidneys.

This abnormal flow increases the risk of urinary tract infections (UTIs). If left untreated, it can potentially cause kidney damage.

B] Types of Vesicoureteral Reflux

1. Primary VUR

Primary VUR is a congenital defect in the valve between the ureter and bladder. This defect causes improper closing of the valve, allowing urine to reflux backward from the bladder to the kidney. In mild cases, this condition resolves on its own as the child grows.

2. Secondary VUR

Secondary VUR can result from an underlying issue that increases pressure within the bladder or obstructs urine flow. Its causes may include UTIs, bladder dysfunction, or anatomical abnormalities, like posterior urethral valves.

This form of VUR requires intensive treatment, as it is often persistent. You can also read more about related conditions, such as bladder outlet obstruction in children.

C] Causes of Vesicoureteral Reflux in a Child

Several structural or functional issues within the urinary tract can lead to VUR in children. One of the leading causes is congenital abnormalities, such as improperly developed valves. Other contributing factors include bladder dysfunction and UTIs. Inflammation, scarring, and even genetic factors can play a role, as VUR often runs in families.

D] Symptoms of Vesicoureteral Reflux in a Child

The symptoms of VUR may vary depending on the severity of the condition. A common sign in children, especially when VUR is associated with a UTI, is a pain or burning sensation during urination. The child may also feel an urgent need to urinate and have cloudy or foul-smelling urine. Other symptoms can include abdominal pain, lower back pain, or fever, which may also be associated with a UTI.

In some cases, a child may experience poor weight gain, especially if the condition is chronic or leads to recurrent kidney infections. VUR may also be asymptomatic and is sometimes detected only after recurrent UTIs or during tests related to kidney problems.

E] Diagnosis of Vesicoureteral Reflux in Children

• Renal Ultrasound: VUR is generally detected by ultrasound after a UTI, especially when the infection is recurrent and accompanied by fever. A renal ultrasound is usually the first imaging test that a healthcare provider uses to detect kidney abnormalities. The results appear as real-time images on a monitor, which helps identify any signs that may suggest VUR.
• Voiding cystourethrogram (VCUG):  A voiding cystourethrogram (VCUG), a type of X-ray, provides the most accurate diagnosis of VUR. The procedure involves inserting a contrast agent (a fluid that appears bright on imaging tests) into the bladder through a catheter. Then, the X-ray machine takes a real-time video, during which the fluid highlights the urinary tract and helps doctors determine whether there is any backflow of urine into the ureters and kidneys.

F] Treatment Options for Vesicoureteral Reflux in Children

The treatment options for VUR may range from conservative management to paediatric urology surgery, depending on the severity of the condition. The aim is to prevent recurrent UTIs and preserve the normal function of the kidneys.

Medically Supervised Observation and Follow-Up

For children with no history of recurrent UTIs and low-grade VUR (grades I and II), the condition often resolves on its own as the child grows. In such cases, regular monitoring, periodic urine tests, ultrasounds, and repeat VCUGs may be recommended to evaluate changes in the reflux. These approaches are considered appropriate without the immediate need for medical or surgical intervention. Parents are advised to watch for signs of UTIs, such as fever, irritability, or difficulty with urination.

Antibiotic Prophylaxis

Children with moderate to high-grade VUR (grades III to V), or those at a greater risk of kidney damage, are generally recommended to receive antibiotic prophylaxis. In this approach, a child is given a low dose of antibiotics over a long period to prevent infections. Although this method does not cure VUR, it helps manage the condition and allows time for spontaneous resolution of the reflux. Regular follow-ups and assessments are essential in this process, as prolonged antibiotic use may result in the development of antibiotic resistance.

Surgical Intervention

If conservative treatment fails, a paediatric surgeon may recommend surgical options tailored to your child’s specific needs. The following are two commonly used surgical methods:

1. Ureteral Reimplantation Surgery

For high-grade VUR, this is the traditional and most effective surgical option when other treatments fail. This open surgical procedure involves repositioning the ureters within the bladder wall to create a longer intramural tunnel that prevents the reverse flow of urine. The recovery for this condition involves only a short hospital stay.

While open surgery for ureteral reimplantation is a widely followed practice, minimally invasive techniques such as laparoscopic robotic surgery are also excellent alternatives. These may be preferred based on the patient’s condition, the surgeon’s expertise, and other individual factors.

2. Endoscopic Injection (Deflux Procedure)

This is a comparatively less invasive technique than open surgery, in which a bulking agent (usually dextranomer/hyaluronic acid) is injected near the ureteral opening inside the bladder. The injected material creates a bulge that acts as a valve mechanism to reduce reflux. The procedure is normally performed on an outpatient basis and requires less recovery time than open surgery.