Vesicoureteral reflux (VUR) occurs when urine flows backward from the bladder into the kidneys. It is most common in infants and children. This can create urinary tract infections (UTIs), which can lead to further complications if not treated right away. Thankfully, the condition is not known to be painful and effective treatment options are available.
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What Is Vesicoureteral Reflux?
Vesicoureteral reflux (VUR), or reflux of urine, is one of the more common reasons that children are referred to pediatric urologists. Reflux simply means that urine goes backwards in the ureter during urination.
The ureter is the tube that connects the kidney to the bladder.
Urine is supposed to go in one direction — from the kidneys to the bladder. When urine goes up from the bladder to the kidneys, it can result in health problems for the child.
Reflux may have been discovered in your child in one of two common ways.
First, the kidney is sometimes seen to be dilated, or "ballooned," on a prenatal sonogram (ultrasound). At the time of birth, testing may have revealed that this ballooning was due to reflux of urine.
The other common symptom of reflux is an unexpected urinary tract infection. Evaluation with x-rays after urinary infection may reveal reflux as an underlying cause or associated problem.
Sometimes, a child is screened for reflux because a brother or sister has the problem. Reflux is often discovered in this way, and many doctors feel that all brothers or sisters of children with reflux should have at least some screening tests performed.
What are the types and stages of vesicoureteral reflux?
VUR is typically graded on a scale from 1 (mild) to 5 (severe). The grade is determined by how far the urine back-travels and if the condition has widened the ureter. Stage I and II are milder and do not dilate the ureter, while stages III to V mean the urine has backed all the way into the kidneys and dilated, or widened, the ureter with urine.
When VUR only affects one kidney and ureter, it is referred to as unilateral reflux. If both kidneys and ureters are involved, it is referred to as bilateral reflux.
The two types of VUR depend on the origin of the condition:
- Primary VUR — Occurs when a child is born with a ureter that isn’t connecting to their bladder correctly. This poor connection results in urine flowing back from the bladder into the ureter and kidney. Primary VUR is most commonly unilateral reflux.
- Secondary VUR — Occurs when a blockage of some kind is causing pressure in the urinary tract, which is pushing urine back toward the kidneys. Secondary VUR is most commonly bilateral reflux.
How common is vesicoureteral reflux?
VUR is a relatively rare condition that affects up to 3% of infants and children in the United States. It affects more females than males.
What causes vesicoureteral reflux?
In primary VUR, children are born with a faulty flap valve between the bladder and ureter, which doesn’t close properly, so urine can flow back toward the kidneys.
In secondary VUR, some kind of blockage causes the issue. Either from tissue or bladder nerves that aren’t working properly, urine is pushed back where it came from.
Experts know that most children with primary or secondary VUR are born with some abnormality that causes it, but they have yet to determine exactly how or why it happens.
Although rare, adults can have VUR, too. Research shows that a recent surgery near the ureters, or other bladder or prostate-related conditions, can cause vesicoureteral reflex.
Vesicoureteral reflux risk factors
Children are more likely to be diagnosed with VUR if:
- It runs in their immediate family, such as a parent or sibling.
- They are a white female.
- They are born with kidney or urinary tract abnormalities.
- They have bladder and bowel dysfunction (BBD), a muscle or nerve condition that makes urinating and bowel movements difficult.
Complications of vesicoureteral reflux
Those with VUR may also struggle with:
- Bladder issues.
- Chronic UTIs.
- High blood pressure.
- Kidney damage, scarring, or failure.
How can I prevent vesicoureteral reflux?
While there isn’t one way to permanently remove the threat of VUR from your child’s life, there are certain habits you can maintain to ensure good kidney and urinary tract health.
These include:
- Drinking water every day.
- For infants and babies, change diapers immediately after they urinate or defecate.
- Receiving treatment for any bowel or bladder conditions right away.
- Urinating when the bladder is full and avoiding long periods of "holding it."
- Wiping fully from front to back after using the bathroom.
What Are the Signs and Symptoms of Vesicoureteral Reflux?
For many children, VUR has no symptoms. Symptoms only begin once the child has contracted a urinary tract infection, or UTI. UTIs can occur in the bladder or the kidneys.
Bladder UTI symptoms include:
- Cloudy urine.
- Frequent urination.
- Pain in the abdomen.
- Pain or a burning sensation when urinating.
Kidney UTI symptoms include:
- Back pain.
- Chills.
- High fever.
- Reduced kidney function.
It can be difficult to notice UTI or VUR symptoms in an infant. Watch closely if they lose their appetite or seem fussier than normal.
When should I call a doctor about my child's vesicoureteral reflux symptoms?
If your infant or child is showing any symptoms of vesicoureteral reflux, it is important to get them an appointment with their pediatrician.
How Do You Diagnose Vesicoureteral Reflux?
First, your pediatrician will talk with you about your child’s health history and symptoms. They may refer you to a pediatric urologist or nephrologist for formal diagnostic tests.
Your child’s doctor or specialist may order:
- Ultrasound — This imaging test uses sound waves to look inside the body and can create images of the entire urinary tract system, including the bladder and kidneys. This test can show if the ureter has widened, showing stage III or higher VUR.
- Urinalysis — A urine sample may be collected and tested to look for signs of a UTI.
- Voiding cystourethrogram (VCUG) — This test takes x-ray images of the bladder and urethra to look for the backflow of urine. A catheter is used to fill the child’s bladder with a special dye that helps create images before, during, and after urination.
Vesicoureteral reflux prognosis
For many children, VUR resolves over time: Either they grow out of the condition or it is treated effectively.
How Do You Treat Vesicoureteral Reflux?
The treatment methods for VUR depend on many factors, including:
- Age.
- Grade of VUR (I to V).
- Symptoms.
Type of VUR (primary or secondary).
Treating primary VUR
In most cases, primary vesicoureteral reflux will go away on its own as children age.
Medication
If your child is dealing with UTIs, doctors can prescribe antibiotics to fight the bacteria. Your child’s doctor may also prescribe a long-term, low-dose antibiotic to prevent more UTIs, although this can sometimes make antibiotics less effective for the future.
Minimally invasive procedure
In some cases, bulking injections could be beneficial. A doctor injects gel-like liquid near the opening of the ureter to act as a working valve. This procedure can be done under general anesthesia and is treated as an outpatient surgery, meaning you can go home the same day.
Surgery
If your child is dealing with chronic UTIs, their doctor may recommend surgery to correct the reflux. During this procedure, a surgeon will either repair, reattach, or reconfigure the tissue flaps so they work correctly.
Surgery for reflux is highly successful and carries relatively little risk. The operation is usually done through a "bikini" incision. The bladder is opened, and the ureters are freed from the inside of the bladder. They are then tunneled under the bladder lining, so that the ureter acts as its own flap valve, restoring proper function. Alternatively, the ureters may be tunneled in the bladder wall from outside the bladder.
You can expect your child to be in the hospital for one to two days. The success of these operations in routine cases is more than 95%, and complications are rare.
Treating Secondary VUR
Depending on the cause of the blockage, treatment for secondary VUR may look like:
- Antibiotics for UTIs.
- Intermittent urinary catheterization (using a catheter to empty the bladder if it is not emptying properly).
- Surgery to correct the abnormal valve.
- Surgery to remove blockage from the ureter.
Preventing infections
Children with reflux need to prevent kidney infections.
This can be achieved in three ways:
- Improving the way that your child voids — Many children with reflux and infection have some form of voiding dysfunction, or what is now referred to as dysfunctional elimination syndrome (DES). This condition might involve urinary frequency or infrequent voiding.
- Prophylactic antibiotics — Most children are given prophylactic antibiotics to prevent — not treat — infection. Therefore, the doses used are low, and the antibiotic is usually given only once a day. Antibiotics given in this way are very safe and rarely cause any long-term problems. The risk of taking low-dose antibiotics is much less than the risk of recurrent kidney infections.
- Surgical correction of the reflux — In most cases, surgery is not necessary, but it can be highly successful when indicated.
Often, there are accidents or urgency when voiding occurs. Constipation is almost always present to some degree. Treating voiding dysfunction will often dramatically reduce the incidence of urinary infections.
