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Vesicoureteral Reflux

Vesicoureteral reflux (VUR) is a relatively common condition in which urine backs up from the bladder into the kidneys. Many people, both children and adults, unknowingly have reflux because they have no symptoms. In a small number of children, VUR can cause permanent kidney damage if left untreated.

The combination of VUR and urinary tract infections (UTIs) is what concerns us.

When a child has frequent UTIs and symptoms like pain and problems with urination, doctors will:

  • Control the UTIs
  • Determine whether reflux may be involved
  • Investigate possible kidney damage.

Fortunately, only about 2-3% of children have the combination of reflux and UTIs that concerns us. If your child has not had multiple UTIs, you don’t need to be concerned about reflux.

According to Earl Y. Cheng, MD, attending physician, Division of Urology, physicians have significantly changed how they treat reflux in recent years. “Urologists are operating on children with reflux much, much less often than we were 10 years ago,” he says. “We now believe that most children with reflux will not require surgery. They will either outgrow their reflux or it will reach a point where it is no longer of clinical concern.”

Reflux is graded on a scale from 1 (mildest) to 5 (most severe). This grading system lets us estimate the chances of a child needing surgery. Most children with mild-moderate reflux (grades 1-3) have a good chance of outgrowing their reflux without needing surgery. However, it may take many years. The higher grades of reflux (4 and 5) are much more likely to require surgery. 

Causes

Urine is produced by the kidneys, then travels down small tubes called ureters into the bladder where it is stored prior to voiding (urinating). Normally, a one-way valve prevents urine from backing up, or refluxing, into the ureter and kidney. Reflux can occur when this valve doesn’t work properly.

VUR is more common in girls than boys and is most often found when the child is approximately two to three years of age. Caucasian children are more likely to have reflux than Latino or African American children, though it’s not understood why.

Reflux tends to run in families. Siblings of children with reflux are more likely to have it than most people. When a parent has a history of reflux, their children have a 66% chance of also having reflux.

Urinary reflux is usually congenital, which means the child was born with the condition, though it can be present before birth. If an ultrasound shows that your unborn child may have reflux, expect close monitoring throughout the rest of your pregnancy. Our multidisciplinary team of experts at the Institute for Fetal Health manages fetal urinary reflux.

Diagnosis & Treatment

Symptoms

Reflux alone does not cause symptoms, so it is usually only diagnosed after a child develops one or more urinary tract infections (UTIs). There are two main types of UTIs: bladder infections (cystitis) and kidney infections (pyelonephritis). Parents should watch for and understand the symptoms and possible effects of both types of UTIs.

Urine is normally sterile until it leaves the body. However, if bacteria enter the urinary tract from the skin around the urethra, the tube through which urine leaves the body, they can cause a bladder infection.

If a child does not have reflux, the infection will stay in the bladder. If a child has reflux, however, the infected urine in the bladder may travel to the kidneys and cause a kidney infection.

Kidney infections are much more serious than bladder infections, and children may become much more ill. Left untreated, kidney infections can cause permanent damage.

“We really want to emphasize that reflux does not cause UTIs, and UTIs do not cause reflux,” explains Dr. Cheng. “But the combination of a less-serious bladder infection and reflux allows for the development of a more-serious kidney infection.”

These symptoms indicate that your child may have a bladder infection:

  •  Irritability
  • Abdominal or genital pain, especially during urination
  • Frequent urinary accidents or trips to the bathroom
  • Strong-smelling or cloudy urine
  • Blood in the urine

 All of these symptoms also occur with kidney infections. Additionally, a child with a kidney infection is more likely to have a fever and feel generally ill.

Diagnosis

Children who have a history of UTIs, especially kidney infections, are generally evaluated for reflux using a test called a cystogram. This is the standard tool we use to learn whether your child has reflux.

We offer two types of cystograms—voiding cystourethrogram (VCUG) and nuclear cystogram (NVCUG)—and we will choose the appropriate type for your child.

Both types of cystograms require a skilled nurse or technician to place a catheter into your child’s urethra and then add dye. The dye’s movement through your child’s urinary tract will reveal whether your child has reflux. Your child will be asked to urinate during this study because reflux sometimes occurs only during voiding.

We pride ourselves on creating a kid-friendly environment thanks to our specially trained staff and state-of-the-art equipment. Cystograms are invasive, but most of our patients experience only minimal discomfort and do not require sedation.

If your child has reflux, we will need to repeat the cystogram every 12-18 months for the next several years to be certain no kidney damage is occurring.

We may also order other tests, such as an ultrasound. An ultrasound cannot tell us whether your child has reflux, but we may use it to help determine how severe your child’s reflux is. This noninvasive imaging helps us monitor your child’s kidney size and growth, and it allows us to check for kidney swelling.

Your child may also benefit from having a nuclear renal scan, or renogram. This test helps monitor kidney function and checks to see if your child’s kidneys show signs of scarring. The clinician will insert a small intravenous (IV) catheter into your child’s arm. They will add dye through the IV and take images over several hours.

If your child has urinary reflux, we will also need to evaluate him or her for constipation and dysfunctional voiding. This is an abnormal urinating pattern that puts children at more risk for developing bladder infections.

The most common kind of dysfunctional voiding occurs in girls when the bladder becomes overstretched and enlarged from a pattern of "holding" and waiting until the last second to urinate. Left untreated, dysfunctional voiding can increase the risk of bladder infection and reduce the chances that reflux will resolve without treatment.

Treatment

In the past decade, treatment trends have veered away from surgery whenever possible. We now know that most cases of low- and medium-grade reflux will eventually resolve without surgery. Children with high-grade reflux may need surgery, but we will most likely recommend trying medical therapy first.

Reflux is only harmful in the presence of a bladder infection — when the infection can spread from the bladder to the kidney — so our top priority in medical management is to prevent bladder infections. We will prescribe a low-dose antibiotic, which is usually given once a day, to prevent UTIs.

Even if your child remains infection-free, they will need to continue taking the antibiotics for months or even years. Additionally, we will order a routine cystogram and ultrasound every year or two to monitor kidney growth and evaluate for persistent reflux.

Many parents want to avoid overusing antibiotics, and rightly so. “That is a legitimate concern, but the antibiotics we use to manage reflux become concentrated in the child’s urine and so are less likely to cause resistance than other kinds of antibiotics,” Dr. Cheng says. “These have all been used for many years and are proven to be safe. Plus, we use them at much lower doses for preventing infections rather than treating them.”

Some children will ultimately need surgery to correct their urinary reflux. We may recommend surgery if your child has:

  • High-grade or worsening reflux
  • Multiple UTIs despite taking preventive antibiotics
  • Persistent reflux over several years
  • Delayed kidney growth
  • Kidney scarring

There are several different ways to surgically correct reflux.

Open Surgery – This is the traditional and extremely effective surgery for urinary reflux. We make a two to three inch incision crosswise just above the child’s pubic bone. We detach the ureters from the bladder, then reattach them to a stronger section of bladder wall. This surgery is more than 95% successful in eliminating reflux. Expect your child to stay in the hospital for one to two days after surgery. He or she may need a mild prescription pain reliever and can return to full activities in about one week.

Endoscopic Injections – This newer, less-invasive surgical option allows us to correct your child’s reflux using an endoscope. We will inject Deflux, an FDA-approved blend of hyaluronic acid and a polymer, into the area where the ureter meets the bladder to strengthen the valve. This procedure is approximately 70-80% successful in stopping reflux.

The advantages of the endoscopic approach are that it is a short, outpatient procedure. Another plus to endoscopic injections: we can still correct your child’s reflux with surgery if needed in the future. This is important because, as with other new therapies, we are still gathering data on long-term success rates.

Robot-Assisted Laparoscopic Surgery – Lurie Children’s is one of only a few medical centers to offer robot-assisted laparascopic surgery as an option for correcting urinary reflux. Our experienced urology surgeons and treatment teams use the da Vinci robot-assisted laparoscopic surgery to provide minimally invasive, state-of-the-art care. 

Current data are very promising and show that the success rate of robot-assissted laparoscopic surgery to correct VUR is more than 95%. As a leading research institution, we are continuing to track and publish our results in this area.

If your child requires surgery to correct reflux, we will recommend a specific operation based on surgeon preference and your child’s circumstances.