Vesicoureteral Reflux

Vesicoureteral Reflux (VUR) in Children

What is vesicoureteral reflux in children?

Vesicoureteral reflux (VUR) is a condition where urine in the bladder flows in the wrong direction. It goes up into the tubes (ureters) that lead to the kidneys. It often flows all the way back up to the kidneys.

Normally urine flows down from the kidneys through the ureters to the bladder. The bladder is the organ that stores urine before it leaves the body during peeing (urination). The bladder has 3 small openings. The 2 openings at the top connect the ureters to the bladder. The opening at the bottom leads from the bladder to a tube called the urethra. Urine exits the body through the urethra.

The ureters have a 1-way valve system that normally stops urine from flowing back up to the kidneys. When a child has VUR, this valve system doesn’t work. Urine can then flow backward (reflux) into the ureters and may enter the kidneys.

This condition is most often diagnosed in infancy and childhood.

What causes vesicoureteral reflux in a child?

There are many reasons why a child may develop VUR. Some of the more common causes include:

• Being born with a neural tube defect like spina bifida
• Having other urinary tract problems, such as posterior urethral valves, ureterocele, or ureter duplication

Which children are at risk for vesicoureteral reflux?

A child is more at risk for VUR if they have parents or siblings with VUR. In infancy, the disease is more common among boys. This is because when they pee (urinate) there is more pressure in their whole urinary tract. In early childhood, VUR is more common in girls. It is more common in white children than in African-American children.

What are the symptoms of vesicoureteral reflux in a child?

Symptoms may be different for each child. They can include:

• Urinary tract infection (UTI) symptoms, such as a burning feeling or pain when peeing, frequent peeing, fever, and back pain
• Trouble with peeing such as urgency, dribbling, or wetting pants
• A swollen kidney that can be felt as a mass in the belly
• Poor weight gain
• High blood pressure

These symptoms may be caused by other health conditions. Have your child see their healthcare provider for a diagnosis.

How is vesicoureteral reflux diagnosed in a child?

VUR can often be found by ultrasound before a child is born. Sometimes there may be a family history of VUR, but a child has no symptoms. In those cases, a healthcare provider may want to do a test to check for VUR. Tests for VUR include:

• Voiding cystourethrogram (VCUG). A VCUG is a type of X-ray that examines the urinary tract. The healthcare provider puts a thin, flexible tube (catheter) in the urethra. This tube drains urine from the bladder to the outside of the body. The provider fills the bladder with a liquid dye. X-ray images are taken as the bladder fills and empties. The images will show if there is any reverse flow of urine into the ureters and kidneys.
• Renal ultrasound (sonography). This is a painless test that uses sound waves and a computer to create images of body tissues. During the test, a healthcare provider moves a small device (transducer) over the belly in the kidney area. This sends a picture of the kidney to a video screen. The provider can see the size and shape of the kidney. They can also see a growth, kidney stone, cyst, or other problems.

How is vesicoureteral reflux treated in a child?

Treatment will depend on your child’s symptoms, age, and general health. It will also depend on how bad the condition is.                               

VUR can be mild or more serious. It can cause mild reflux, when urine backs up only a short distance in the ureters. Or it can cause severe reflux leading to kidney infections and lifelong (permanent) kidney damage. Your child's healthcare provider may assign a grade from 1 to 5 to show the degree of reflux. The higher the grade, the more severe the reflux.

Treatment depends on the grade of reflux:

• Grades 1 to 3. Most children with grade 1 to grade 3 VUR don’t need any type of intense therapy. The reflux goes away on its own over time, often within 5 years. Children who have fevers or infections often may need to take antibiotic medicine and have periodic urine tests. They may also need surgery.
• Grades 4 to 5. Children who have grade 4 or grade 5 reflux may need surgery. During the procedure, the surgeon will create a flap-valve device for the ureter. This will prevent reverse flow of urine into the kidney. In more severe cases, the scarred kidney and ureter may need to be removed.

New treatments are being introduced for VUR. Talk with your child's healthcare provider for more information.

Talk with your child’s healthcare providers about the risks, benefits, and possible side effects of all treatments.

What are possible complications of vesicoureteral reflux in a child?

A child who has VUR is at risk for repeat kidney infections. Over time, this can cause damage and scarring to the kidneys.

When should I call my child’s healthcare provider?

Call your child’s healthcare provider if your child has:

• Symptoms that don’t get better, or get worse
• New symptoms

Key points about vesicoureteral reflux in children

• Vesicoureteral reflux (VUR) is a condition where urine in the bladder flows in the wrong direction. It goes up into the tubes (ureters) that lead to the kidneys. It often flows all the way back up to the kidneys.
• The ureters have a one-way valve system that normally stops urine from flowing back up to the kidneys. When a child has VUR, this valve system doesn’t work.
• Some of the more common causes of VUR include a neural tube defect or other urinary tract problems.
• Symptoms can include urinary tract infections and trouble with urination.
• Your child's healthcare provider may assign a grade from 1 to 5 to show the degree of reflux. The higher the grade, the more severe the reflux.
• A child who has VUR is at risk for repeat kidney infections. Over time, this can cause damage and scarring to the kidneys.

Next steps

Tips to help you get the most from a visit to your child’s healthcare provider:

• Know the reason for the visit and what you want to happen.
• Before your visit, write down questions you want answered.
• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.
• Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.
• Ask if your child’s condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if your child does not take the medicine or have the test or procedure.
• If your child has a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your child’s provider after office hours, and on weekends and holidays. This is important if your child becomes ill and you have questions or need advice.