Vesicoureteral Reflux (VUR)

A common ureteral abnormality in children, causing retrograde urine flow from the bladder to the upper urinary tract.

Suspect VUR in children with recurrent UTIs, including urinary urgency and urge incontinence symptoms.

Risk factors and presentation

First-degree relatives with VUR, history of prenatal hydronephrosis. Suspect in a child with recurrent UTIs or pyelonephritis.

Ask about bladder and bowel dysfunction (BBD) — previously called dysfunctional elimination syndrome, and itself a risk factor for recurrent UTI (worsened further in the setting of VUR), commonly under-recognised and under-treated in primary care:

• Urgency and urge incontinence
• Daytime wetting
• Weak stream, hesitancy
• Urinary frequency, or infrequent voiding (<4 times/day)
• Prolonged voiding intervals
• Holding manoeuvres (posturing to prevent wetting)
• Perineal or penile pain
• Constipation and/or encopresis

Neurogenic disorders (e.g. spina bifida) can cause dysfunctional voiding falling within the BBD spectrum, from failure of urethral sphincter relaxation during voiding.

Examination

Height, weight, blood pressure. Abdominal exam for a large bladder or pelvic mass. Genital exam — rule out labial adhesions in girls; assess circumcision status and check for phimosis in boys.

Investigations

• Voiding cystourethrogram or radionuclide cystogram (unpleasant beyond infancy, may need sedation), or DMSA scan (requires toilet training)
• Renal USS KUB cannot diagnose VUR itself, but is a reasonable first-line investigation if a structural problem is suspected
• Serum creatinine if bilateral abnormalities are found

Management

Manage complications: hypertension, recurrent UTI/pyelonephritis, renal scarring, renal failure. Refer to a paediatrician — children with recurrent UTIs, or any child under 3 with a UTI.

5 grades — spontaneous resolution is common in grade I–II (good prognosis); more severe disease may need surgical intervention or antibiotic prophylaxis.

Continuous antibiotic prophylaxis (CAP) — a genuinely nuanced decision

Extensive study has found no evidence to support antibiotic prophylaxis from the index UTI — a paediatric specialist should be involved in the decision to start long-term prophylaxis, given the resistance risk. CAP causes adverse effects in 8–10% of cases (mostly non-serious — nausea, vomiting, skin reactions). The RIVUR and PRIVENT trials inform current practice; benefit depends on age, VUR severity, presence of BBD, toilet-training status, and circumcision status.

Circumcision — a specific consideration in uncircumcised boys <1 year

In uncircumcised boys under 1 year with recurrent UTI or grade III–V VUR, circumcision can be considered based on baseline risk and foreskin anatomy. This age group has the highest UTI/recurrent-UTI risk (compared with older children, girls of the same age, and circumcised infant boys), with a suggested increased complication and renal-scarring risk after UTI — circumcision is weighed against non-invasive measures, with the greatest benefit specifically in infants under 1. This decision should involve thorough discussion between parents, the primary care physician, and specialist services.