Our Health Topics

Vesicoureteral Reflux (VUR)

  • In normal kidney-bladder function, urine flows from the kidneys to the bladder. In children with vesicoureteral reflux (VUR), however, the urine also flows backwards, from the bladder up toward the kidneys. As a result, children with VUR are at risk for kidney infections and may develop kidney damage.

    • VUR affects about 1 percent of children.

    • Many children will grow out of their VUR as they get older.

    • Urine is normally sterile. When bacteria get into the bladder, a urinary tract infection (UTI) may result. In children with VUR, those bacteria can get to the kidneys more easily, resulting in a kidney infection.

    • A kidney infection can be a serious illness, with high fever, nausea, vomiting or pain. Kidney infections can also lead to damage (scarring) of the kidney.

    • The goal of treatment in children with VUR is to prevent kidney infections and kidney damage.

    • To prevent infections in children with VUR, most children take low-dose antibiotics once a day to keep their urine sterile.

    • Some children with VUR need surgery to correct the VUR, prevent infection and protect the kidneys.

    How Boston Children’s Hospital approaches VUR

    We take a conservative approach to VUR here at Children’s. Most children will outgrow their VUR on their own, so we give them a chance to do that. It’s very important that children with VUR be protected from infection, so preventive antibiotics are an essential component of our treatment.

    The most common reasons we recommend surgery to correct VUR are:

    • continued kidney infections despite preventive antibiotics
    • VUR that does not resolve on its own

    In the event that surgery is recommended, doctors at Children’s use surgical procedures that we pioneered. Our surgeons have also developed minimally invasive surgical techniques for use with patients with VUR, and procedures such as laparoscopic and endoscopic surgeries may be options.

    Children’s researchers have studied the wide variation in how VUR is treated throughout the country. We have found that how your child’s VUR is managed heavily depends on where you live and what hospital you are treated at. Our goal is to treat your child’s VUR based on the best available scientific evidence—not based on tradition or local customs. To help with this, we have developed the VUR Resolution Rate Calculator—unique to Children’s—which can help predict if a child’s reflux will resolve.

    Reviewed by Caleb P. Nelson, MD, MPH
    © Boston Children’s Hospital , 2010

  • Causes

    What causes vesicoureteral reflux?

    VUR is the result of abnormal formation of the normal valve between the kidney and bladder. This valve is supposed to ensure that urine only goes one way, from the kidney to the bladder. In children with VUR this valve does not work correctly. The cause of this abnormality is not known. However, many children with VUR have certain characteristics incommon:

    • VUR is common among children and siblings of people with VUR. There is a strong genetic component to VUR, although no specific genes have been identified.
    • Children with abnormal bladder function due to nerve or spinal cord problems, such as spina bifida, may have VUR.
    • VUR can occur in children with other urinary tract abnormalities such as posterior urethral valves, bladder exstrophy, ureterocele or ureter duplication.
    • Children with dysfunctional voiding (bladder and bowel problems, including accidents, frequent urination or constipation) may be more likely to have VUR.
    • During infancy, the disease is more commonly seen in boys. In older children, VUR is more commonly diagnosed in girls.
    • VUR is more common in Caucasian children than in African-American children.

    Symptoms

    What are the symptoms of vesicoureteral reflux?

    Children who have VUR may not feel sick, and VUR itself usually has no symptoms. VUR is most often diagnosed after a child has a urinary tract infection (UTI). Some children are also diagnosed shortly after birth if they had hydronephrosis (fluid on the kidneys) seen on their prenatal (before birth) ultrasounds. Common symptoms of UTI in children include:

    • fever
    • pain or burning with urination
    • strong or foul odor to the urine
    • sudden onset of frequent urination or wetting accidents
    • abdominal or flank pain

    FAQ

    Q: Can vesicoureteral reflux (VUR) be prevented?
    A:
    No. However, the urinary tract infections that are often associated with VUR can be prevented, with changes to toileting behaviors, management of constipation and preventive antibiotics.

    Q: Is VUR inherited?
    A:
    Yes, VUR is more common in family members of people with VUR. For this reason, you should discuss with your doctor whether siblings or other family members should be tested for VUR.

    Q: Is surgery mandatory?
    A:
    Many children with VUR will outgrow their VUR on their own. Therefore, we do not perform surgery as initial treatment in most children. However, some children will require surgery to correct VUR eventually. The most common reasons for surgical correction of VUR are repeated UTI with kidney involvement, failure of VUR to resolve on its own over time, or severe VUR that is very unlikely to resolve.

    Q: Are antibiotics safe to take for long time?
    A:
    Yes. The preventive antibiotics used are given once-a-day and are very low dose. There are some risks associated with any medication, but we believe that the benefits of preventing UTI (and kidney scarring) in children with VUR outweigh any small risks from taking the antibiotics for long periods. We have treated thousands of children with preventive antibiotics for many years with very few severe side effects.

    Q: Don’t children become “immune” to the antibiotics?
    A:
    Children do not become immune to antibiotics. Their immune systems (the germ-fighting and infection-fighting systems) remain fully functional and aren’t altered by being on these medications. The children can still fight off infections normally. However, the bacteria (germs) that live on and inside of human beings can become resistant to certain antibiotics through chronic exposure. Since most UTIs are caused by the germs that live on us, this can be a problem.

    This problem is minimized by properly selecting the best antibiotic medicines for UTI prevention, using a very low dose, and giving it only once a day. Resistance to antibiotics is a major concern in healthcare and is being studied carefully.

    Q: What is the RIVUR study?
    A:
    This is a large research study funded by the National Institutes of Health. The Urology Department at Boston Children's Hospital is participating in the RIVUR study. The purpose of this study is to determine if preventive antibiotics are effective in preventing urinary tract infections in children with VUR. For more information about RIVUR, you can visit the study web page.

    Q: If my child has VUR, what type of follow-up is needed?
    A:
    Children with VUR are usually followed until their reflux goes away or is surgically corrected. Most children are seen every six to 12 months. Your doctor will often use ultrasound to follow your child’s kidney growth and health. We perform special tests to check for VUR every one to two years. Although VUR may resolve, in some cases, VUR can result in scarring in the kidney, which can lead to high blood pressure. Children with scars in their kidneys should have their blood pressure and urine checked every six months, even if their VUR has gone away.

  • Vesicoureteral reflux (VUR) can only be diagnosed by a test called a cystogram, in which a catheter is placed in the bladder and the bladder filled with fluid. This allows your doctors to see the reverse flow of urine toward the kidney.

    This type of test is most commonly done in a child who has had a UTI, but may also be performed in infants who have hydronephrosis (fluid on the kidneys) detected by ultrasound before birth.

    If you have a family history of VUR, but your child has no symptoms, your child's physician may elect to perform a diagnostic test to rule out VUR. Some of the tests that are used in children with VUR may include:

    • Voiding cystourethrogram (VCUG): A specific x-ray test that examines your child’s urinary tract. The bladder is filled with contrast using a catheter, and x-ray picture are taken. The images will show if there is any reverse flow of urine into the ureters and kidneys (VUR).
    • Renal ultrasound: The test is used to determine the size and shape of your child’s kidneys, and to detect scars, kidney stones, cysts or other obstruction or abnormalities.
    • DMSA renal scanA test that provides very detailed information about the shape and condition of the kidneys, including scars and function.
    • Urodynamics: Some children with VUR will have their bladder function tested by measuring bladder volume, pressure and emptying. It is performed to determine how a child’s bladder function may be contributing to her VUR.
    • Blood tests: To see how well your child’s kidneys are working.
    • Urinalysis and urine culture:  Laboratory tests that examine the urine. These tests can indicate microscopic blood or protein in the urine, other chemicals, or evidence of a UTI. In young children who are not toilet trained, the urine may sometimes be collected with a catheter to ensure that the sample is clean and pure.
    • VUR Resolution rate calculator: Unique to Children’s Hospital Boston, this is an online tool that can help predict your child’s chance of resolving VUR. By entering in your child’s characteristics, the calculator will provide a probability that your child’s VUR will resolve on its own, without surgery. 
  • It's entirely natural that you might be concerned, right now, about your child's health; a diagnosis of vesicoureteral reflux (VUR) can be frightening. But you can rest assured that at Boston Children's Hospital, your child is in good hands.

    How will my child's VUR be treated?

    We take a conservative approach to VUR at Children's. Most children will outgrow their VUR on their own, so we give them a chance to do that. It's very important that children with VUR be protected from infection, so we prescribe preventive antibiotics. Most of our patients take an antibiotic once a day for a year or more while we wait for them to outgrow their VUR.

    Some children will eventually require surgery, but not all. The most common reasons we recommend surgery to correct VUR are continued kidney infections despite preventive antibiotics, or VUR that does not resolve on its own.

    VUR occurs in varying degrees of severity. It may be very mild, with only a small amount of urine only backing up a short distance and not even reaching the kidney, or it may be severe, with large volumes of urine causing the kidneys to be dilated (blown up like a balloon). The more severe the VUR, the higher the chances of UTI and kidney scarring, and the lower the chance that the VUR will go away on its own.

    Based on the results of the testing that diagnoses your child's VUR, Your child's physician may will usually assign a number score for the VUR. Scores range from 1 to 5 or 1 to 3, depending on the type of test that was performed. The higher the number, the more severe the VUR.

    Mild VUR

    Mild VUR will resolve on its own, and children with this form are less likely to need surgery. They can still get UTIs, however, so we prescribe preventive antibiotics, especially if the child has had UTIs in the past. If your child gets frequent kidney infections, despite the antibiotics, she may need surgery to correct the VUR.

    Severe VUR

    The severe form of VUR is less likely to resolve on its own, and children with this it require surgery more often.

    How often do children with VUR need to be seen?

    We usually see patients with VUR every six to 12 months. Infants may be seen more often. For children whose VUR has not yet gone away, tests for VUR are usually performed every year to two years, depending on the child's age.

    What do parents of a child with VUR need to look out for?

    The most important issue for children with VUR is a urinary tract infection (UTI). Kidney infections can cause kidney damage, so parents need to watch for signs of UTI. In young children, this usually means a fever. Other signs of UTI include foul-smelling urine, pain with urination, blood in the urine, increased frequency of urination or wetting accidents, or flank and abdominal pain.

    What happens during surgery for VUR?

    During the procedure, the surgeon makes an incision in the lower abdomen and exposes the bladder. The junction of the bladder and the ureter (the tube connecting the bladder to the kidney) is reconstructed to prevent urine from flowing backward up into the kidney. A catheter is left in the bladder to drain the urine for the first one to two days after surgery.

    Laparoscopic treatment

    Laparoscopic surgery (inserting small instruments through several tiny incisions in the abdomen) for vesicoureteral reflux is being explored as a new alternative to the usual open surgery. Children's is evaluating this possibility carefully, because the current success rate for open surgery is about 98 percent, with very few complications. Continued technical improvements in this method will likely provide good alternatives to open surgery in the future. We have made great progress with robotic-assisted laparoscopic surgery for VUR, and some patients may be candidates for this technique.

    For more information on laparoscopy, learn about Children's approach to Minimally Invasive Surgery.

    Endoscopic treatment

    Endoscopic treatment is an option for some children who have lower grades of VUR.

    • The procedure is performed on an outpatient basis under general anesthesia.
    • The doctor inserts a small scope into the bladder through the urethra (the tube connects the bladder to the outside) and injects a small amount of gel-like material under the opening of the ureter.
    • The injected material partially closes the opening and prevents the urine from going backwards toward the kidney.

    The success rate of this procedure is about 75 percent, and there are very few complications. However, we do not know how long the results will last, since some children can have recurrence of their VUR months or years later. Therefore, although there are some advantages to endoscopic treatment, it is not always the best option.

    Coping & Support

    We understand that VUR be disruptive and frightening—not only for your child, but for your whole family. From your first visit, you'll work with a team of professionals who are committed to supporting you.

    We have a variety of resources at Children's to help you and your family:

    Patient education: From office visits to inpatient testing or surgery, our nurses will be on hand to walk you through your child's treatment and help answer any questions you may have. They will also reach out to you by phone, continuing the care and support you receive while you're at Children's.

    Parent to parent: Want to talk with someone else whose child has VUR? We can put you in touch with other families who have been down a similar road and can share their experience.

    Faith-based support: If you and your family find yourself in need of spiritual support, we can connect you with the Children's chaplaincy. Our program includes nearly a dozen clergy representing Episcopal, Jewish, Lutheran, Muslim, Roman Catholic, Unitarian and United Church of Christ traditions who will listen to you, pray with you and help you observe your own faith practices during your treatment experience.

    Social work: As part of Children's broader social work program, our pediatric urology department has a dedicated professional who has helped many other families in your situation. Your social worker can offer counseling and assistance with issues such as coping with your child's diagnosis, dealing with financial difficulties and finding temporary housing near the hospital if your family is traveling to Boston from another area.

    On our For Patients and Families site, you can read all you need to know about:

    • getting to Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family
  • In addition to leading the way in the use of robotic surgery, Boston Children’s Hospital is continually working toward faster, more accurate diagnoses and more effective treatments for children with urologic disorders. Among the recent areas of research that our Department of Urology has conducted, several hold great promise for improving the lives of children with VUR:

    Problem: Pain and discomfort from surgery for VUR

    Innovative solution: Children’s has been a pioneer in anesthesia for children, and our urologists and anesthesia doctors have worked together to develop highly effective pain-management techniques for children who have surgery for VUR.

    Using these methods, most children recover quickly after surgery and their pain is kept to a minimum. Most children can go home within one or two days. In addition, we have been leaders in development of less invasive methods of correcting VUR. Our pioneering surgeons have used laparoscopic and robotic-assisted laparoscopic surgery to successfully correct VUR in many children. We also use endoscopic techniques (such as Deflux®) to perform injections to correct VUR in selected children.

    Problem: Determining the role of genetics in VUR

    Innovative solutions: A Children's study of VUR genetics is looking at families with multiple members with VUR. This will help us learn about the genetics of VUR to determine how it is inherited, as well as identifying which genetic factors put children at risk of recurrent UTIs or kidney scarring. We are also a major recruitment site for the RIVUR study, a study funded by the National Institutes of Health looking at the role of antibiotics in prevention of UTI in children with VUR.

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