Treatment for Vesicoureteral Reflux (VUR)
Treatment for grades I III VUR includes daily low-dose antibiotics (e.g., trimethoprim-sulphamethoxazole, amoxicillin) until the reflux resolves or until the child is at least 5 years old. These cases require regular monitoring by a pediatric urologist to diagnose urinary tract infection (UTI) and prevent the condition from worsening.
Secondary reflux that does not resolve with antibiotic treatment, or that results in UTI despite antibiotic therapy (called breakthrough infections), and primary reflux that is severe (grades IV and V) require surgery to prevent permanent kidney damage.
Nonoperative Management of VUR
When reflux is related to an underlying problemsuch as constipation, infrequent voiding, abnormal bladder activity, or blockages like strictures or valvesthe predisposing factor should be corrected first and the reflux then re-evaluated.
Mild-to-moderate degrees of reflux (grades I to III) have a good chance of spontaneous resolution with age in over 80 percent of cases. This typically occurs over the span of few years. Unfortunately, there is no way to know exactly when the reflux will go away for a particular child. The chance of spontaneous resolution of high grade reflux (IV to V) is much lower.
The key to the nonoperative management of reflux is to give the child time to outgrow the reflux without developing infection problems. Since most children with mild-to-moderate reflux will outgrow the condition, low doses of preventive antibiotics are used to reduce the risk of UTI during this time.
After a 1 to 2year interval of treatment with antibiotics, reflux is re-evaluated with VCUG. At the same time, doctors check the kidneys with ultrasonography to be certain they are growing properly and that no interval damage has occurred.
No antibiotic is risk-free, and no antibiotic will destroy all types of bacteria. However, amoxicillin, cephalosporin, trimethoprim-sulfamethoxazole, and nitrofurantoin have proven the most useful and effective preventive antibiotic agents with minimal side effects.
During the course of nonoperative management, any fever, unexplained illness, or urinary tract symptoms (burning, frequency, urgency, foul odor, bloody urine, or unusual urinary accidents) must be aggressively evaluated with urine analysis and urine culture to make certain there is no urinary infection. A breakthrough urinary infection, in spite of preventive antibiotics, is a dangerous situation indicating that there is not enough time to wait for spontaneous resolution and the next step should be surgical correction of reflux.
Surgical Correction for VUR
Correction of reflux (called ureteral reimplantation or ureteroneocystostomy) is recommended for high grades of reflux (because they are unlikely to resolve by themselves), for reflux that fails to resolve on its own despite monitoring over several years, and for patients with breakthrough infections.
The traditional surgical approaches have high degrees of success and usually involve opening the bladder and creating a new, longer tunnel for the ureter to pass through the bladder wall. If the ureter is very wide due to high grade reflux, it may need to be narrowed to make a successful flap valve with at least a 4:1 ratio of tunnel length to ureter width.
Potential complications include bleeding, infection, urinary leakage, and bladder spasms shortly after the surgery (usually resolve in 2 to 3 weeks), and ureteral obstruction or persistent reflux later. The latter two complications are managed differently if they occur.
Sometimes complications improve on their own with time and other times, additional surgery is necessary. The child remains on preventive antibiotics for several months until postoperative VCUG proves that the reflux has been corrected.
Other surgical methods that may be performed include laparoscopic correction and using an endoscope to inject a bulking agent (e.g., Deflux) at the ureteral opening. Bulking agents are used to create a bulge in the tissue, making it more difficult for urine to flow back up the ureter. This outpatient procedure usually is performed under general anesthesia and takes about 15 minutes. If VUR does not resolve, this treatment can be repeated. Side effects include urinary tract infections and widening of the ureter.
Overall experience with these treatment methods is limited compared to traditional surgical approaches and, in general, they are considered less effective in correcting VUR.