Vesicoureteral Reflux

Depending on different issues that your child may have, your pediatrician or urologist may talk to you about VUR or vesicoureteral reflux. What is it and why is it important?

What is vesicoureteral reflux (VUR)?

It may be helpful to familiarize oneself with the basics of the urinary tract.

The kidney makes urine, which is then passed into a funnel-shaped area in each kidney (the renal pelvis) and down into thin tubes called ureters. The ureters carry urine into the bladder.

Normally, urine flows in one direction only. The blue lines below show the normal flow of pee.

In vesicoureteral reflux, urine abnormally flows back into the ureters or, in worse cases, the kidney. The red lines below show how urine can flow upwards.

More “severe” reflux means that urine doesn’t just go up into the ureters but into the kidneys also.

What causes VUR?

This guide will talk more about “primary” reflux.

“Primary” reflux happens because of an abnormality of development of the ureter. Instead of serving as a valve that keeps urine flowing in one way, the ureter allows urine to flow back in both directions.

Why is VUR important in children?

Unfortunately, in some children, reflux can cause urinary tract infections.

This is likely because bacteria in the bladder can travel up to the kidneys through the refluxing urine.

However, it is important to remember that most children with urinary tract infections do not have VUR, and many children with VUR will not have urinary tract infections.

It can be useful to think of VUR as one of many possible risk factors that can cause a child to have kidney infections.

Please read our short guide on repeated urinary tract infections to learn more about other factors that your doctors may investigate to try to narrow down the cause of infections.

How do kids usually get evaluated for VUR?

Some kids start really young. An ultrasound that is done on the mother before birth can show a “dilation” of the urinary tract, which shows one or many parts of the urinary tract being extra filled with urine.

One possible cause of this “dilation” can be reflux.

Other kids get checked for reflux after birth. This especially happens when babies or young children develop febrile UTIs (urinary tract infections with fever). It is very important to figure out the cause of these febrile UTIs, because repeated kidney infections can cause damage to kidneys in the long run.

Depending on how your child presents, your doctor may advise a test called a VCUG or a voiding cysto urethrogram. If you and your child have been asked to undertake a VCUG, please read our guide to know what to expect.

Why does my doctor keep asking if my child is constipated?

For some kids, especially those at toilet training age, constipation can compound the problem of reflux and cause infections. This means that your doctor will check for constipation and likely treat it first before considering any invasive treatment options for VUR.

Please read our guide on bladder bowel dysfunction (BBD) to find out how children with constipation—whether they have or do not have reflux—can get urinary tract infections.

How is VUR treated?

Most children who have reflux might not need any treatment. Many children who do not have any symptoms do not need any treatment and will just outgrow it.

By itself, primary reflux (without any infections) has not been proven to cause kidney damage.

Unfortunately, some children develop bad infections with more severe reflux. It is those children who need to be treated. Treatment options will include:

Constipation treatment
Prophylactic antibiotics
Circumcision for male babies
Endoscopic injection
Surgery

Prophylactic antibiotics

In very young children with UTIs that occur frequently and severely, sometimes it helps to place them temporarily on continuous antimicrobial prophylaxis (CAP).

This means that a small dose of a safe oral antibiotic is given to the child every day.

This often allows the child to have fewer infections while their other risk factors or causes are being corrected.

CAP is like a seatbelt—it can protect from many infections, but not all.

Like with all medicine CAP has its own benefits and side effects. Please make sure to discuss with your doctor!

Circumcision for male babies

As we say in many different pages on this website, circumcision is not absolutely required for all children.

However, some boys benefit from circumcision. Boys with infections that are caused by reflux have been showed to get fewer infections after a circumcision, specially if the circumcision is done in the first year of life.

Circumcision will not cure the reflux, but will lessen the chances that an infection can happen in a child with reflux.

If you have more questions about circumcision, please feel free to explore our short guide on this common procedure.

Endoscopic options

In the last few decades, more and more options for treating reflux have developed, and some of these techniques are “minimally invasive.” This means that they do not involve cutting open into any part of the body.

A technique that has gained popularity in many parts of the world is endoscopic injection of agents like Deflux ™ or other gels.

This means that while the child is asleep, a small, thin telescope is placed into the urethra (or the pee-hole). Then, a very thin needle is used to inject a small amount of substance into the area where the ureter goes into the bladder.

This keeps urine from easily flowing up the ureter.

Your doctor has to be extra careful to avoid injecting too much, because injecting too much will cause the urine flow to be blocked completely.

Many doctors are beginning to prefer injectables, because there are no wounds created and the patient is usually able to go home on the same day. There is also a high success rate.

Surgery

There are different ways to perform surgery on the ureter to prevent reflux.

“Reimplantation” is considered the gold standard for repairing reflux. While there are many possible techniques, what they all have in common is that they modify the tube of the ureter so that it becomes tighter or is more supported where it enters the bladder. This stops pee flowing back into the ureters and kidneys.

Reimplantation surgery is done either through an “open” approach, where a cut is made on the lower abdomen below the bellybutton, or through “minimally invasive” approaches, where either laparoscopy or robotics can be used to do the surgery through much smaller cuts for faster recovery.

Depending on the approach, a child who has had a reimplantation typically spends a few days in the hospital.

Reimplantation also has a very high success rate.

Take Home Messages

Not all children with reflux will have infections, and not all children with infections have them because of reflux.

Not all children with reflux will need treatment. However, those children with infections and with reflux will need treatment.

Each child is different, and your pediatrician and pediatric urologist have the special role of narrowing down your child's risk factors in the hopes of lessening the chances of infection.

Your urologist may talk to you about some or all of the treatment options we have described, depending on your child’s presentation.

The goal of treating VUR is to preserve your child’s safety as well as their future kidney function, by preventing infections from happening as much as possible.

The information in this infographic is for general information purposes only.

We encourage you to seek an individualized consult for the most appropriate management. You may book an appointment with us or with your preferred pediatric urologist or pediatric surgeon.

Please feel free to send us a message for questions on pediatric urologic health!