Vesicoureteral Reflux (VUR)

  • In normal kidney-bladder function, urine flows from the kidneys to the bladder. In children with vesicoureteral reflux (VUR), the urine 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. If your child has been diagnosed with vesicoureteral reflux, we are here to help. Our Department of Urology is staffed with caring and experienced pediatric physicians dedicated to providing your child with personalized and state-of-the-art urologic care.

    VUR Facts:

    • VUR affects about 1 percent of children.
    • Many children will grow out of their VUR.
    • Urine is normally sterile. When bacteria get into the bladder, a urinary tract infection, or (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.
    • To prevent infections in children with VUR, most children take low-dose antibiotics once a day to keep their urine sterile.
    • The goal of treatment in children with VUR is to prevent kidney infections and kidney damage.
    • Some children with VUR need surgery to correct the condition, prevent infection and protect the kidneys.

    Our approach

    Boston Children’s team of urology physicians takes a conservative approach to VUR. Most children will outgrow their VUR on their own, and we give them a chance to do just that. To protect children with VUR from infection, we prescribe preventive antibiotics as an essential component of our treatment.
    Surgery is recommended to correct VUR when:

    • urinary tract or kidney infections continue despite preventive antibiotics.
    • VUR does not resolve on its own.
    • VUR is severe and unlikely to resolve.

    If surgery is necessary, your child will have access to the latest procedures. Families from across the world come to Boston Children’s Department of Urology for their child’s care. Our doctors pioneered the use of minimally invasive surgical techniques including robotic, laparoscopic and endoscopic surgeries, for use with patients with VUR. Your doctor will recommend the surgical option that is right for your child.

    Learn more about the Boston Children’s Vesicoureteral Reflux Program.

  • What is vesicoureteral reflux (VUR)?

    VUR is the result of abnormal formation of the normal valve between the kidney and bladder. This valve ensures that urine travels one way from the kidney to the bladder. In children with VUR, this valve does not work correctly.

    What causes vesicoureteral reflux?

    The cause is unknown. However, many children with VUR have certain characteristics in common:

    • 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.

    What are the symptoms of vesicoureteral reflux?
    Children who have VUR may not feel sick because VUR typically does not present symptoms. VUR is most often diagnosed after a child has had multiple urinary tract infections (UTI) accompanied with a fever. Some children are also diagnosed shortly after birth if they had hydronephrosis (fluid in the kidneys) and the condition was 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 (between the hip and rib)

    Commonly asked questions about VUR:

    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. Some children, however, 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 a 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 associated with 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. Children can still fight off infections normally. However, the bacteria (germs) living on and inside of human beings can become resistant to certain antibiotics through chronic, or ongoing exposure.
    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 health care and is being studied carefully.

    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. 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 through the urethra into the bladder, and the bladder is filled with fluid. This procedure allows your doctors to see the reverse flow of urine toward the kidney. There are 2 types of cystogram:

    • voiding cystourethrogram (VCUG): an x-ray test that examines your child’s urinary tract. The bladder is filled with contrast using a catheter, and x-ray pictures are taken. The images will show if there is any reverse flow of urine into the ureters and kidneys.
    • radionuclide cystogram (RNC): an RNC is similar to a VCUG except a different fluid is used to highlight your child’s urinary tract.

    A cystogram is most commonly done in a child who has had a UTI but may also be performed in infants who have hydronephrosis (fluid in the kidneys)—a condition 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.

    Other test that are sometimes done in children with VUR include:

    • 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 scan: a test that provides very detailed information about the shape and condition of the kidneys, including scars and how well or poorly the kidneys are functioning.
    • 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: These tests determine how well your child’s kidneys are working.
    • urinalysis and urine culture: These laboratory tests examine urine and identify 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.
  • As a parent or caregiver, you are naturally concerned about your child's health and potential treatment options. Boston Children’s Urology Department is here to help. Our caring and experienced physicians and staff are dedicated to providing your child with state-of-the-art urologic care and surgical expertise when needed.

    How will my child's VUR be treated?

    We take a conservative approach to VUR at Boston Children's. Most children will outgrow their VUR on their own, so we allow for that to occur. During this time, it’s important that children with VUR be protected from infection. Most of our patients take a low-dose 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. Surgery is typically recommended when a child has persistent kidney infections despite preventive antibiotics, or when VUR does not resolve on its own.

    VUR occurs in varying degrees of severity. It may be mild, with only a small amount of urine backing up a short distance and not even reaching the kidneys, 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 diagnostic VUR testing, your child's physician 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, or score, the more severe the VUR.

    Mild VUR

    Mild VUR will likely improve on its own, and children with mild VUR are less likely to need surgery. Once VUR resolves itself, it is important for parents to know that a child can still get UTIs. However, 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 severe VUR are much more likely to require surgery.

    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 with persistent VUR, we recommend VUR testing 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.

    If surgery is recommended, what should we expect?

    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 backwards 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 traditional open surgery. Boston Children's is evaluating this possibility carefully, because the current success rate for open surgery is about 98 percent with few complications. Continued technical improvements in laparoscopic treatment 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 Boston 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. Although there are some advantages to endoscopic treatment, it is not always the best option. Talk to your Boston Children’s urology physician to discuss the best surgical option for your child.

    Support services

    We understand that VUR can be disruptive and of concern 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 providing your child with exceptional care and support.

    We have a variety of resources at Boston Children's to assist 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.

    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.

    Social work: As part of Boston 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.

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

    • getting to Boston Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family

    Child life specialists

    Caring for your child goes beyond a medical diagnosis and treatment. Here at Boston Children’s, our child life specialists are dedicated to easing the fear and anxiety associated with the hospital experience and giving special consideration to each child's family, culture and stage of development.  

  • 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.

    Innovative solutions

    Managing pain and discomfort from VUR surgery:

    Boston 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.

    Thanks to 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 the 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.

    Determining the role of genetics in VUR:

    A Boston 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 identify which genetic factors put children at risk of recurrent UTIs or kidney scarring.

    Q: What is the RIVUR study?
    : This is a large research study funded by the National Institutes of Health. The Urology Department at Boston Children's Hospital participated in the RIVUR study. This study found that children with VUR who took daily antibiotics were much less likely to have UTI’s than children who took a placebo (sugar liquid without medicine). The study tells us that antibiotics are useful in helping to prevent UTI in children with VUR.

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