The Diagnosis and Medical Management of Vesicoureteral Reflux: An Update and Current Controversies

Abstract

Primary vesicoureteral reflux (VUR) is most often diagnosed in children after a urinary tract infection (UTI), in infants with a prenatal ultrasound showing hydronephrosis, or in asymptomatic siblings of probands with VUR. While other diagnostic modalities have been advocated, the voiding cystourethrogram (VCUG) remains the most accurate. In particular, renal ultrasound (USG) will miss many children with all grades of reflux. Renal scarring, either due to renal dysplasia at birth or after pyelonephritis, is the most consequential of the sequelae of undiagnosed and untreated VUR. Recurrent urinary infection without pyelonephritic scarring, while of less significance, also contributes to VUR-related morbidity. Long-term, continuous low-dose antibiotic prophylaxis has been the mainstay of medical management. The majority of those with low-grade VUR (grades I, II, and III) outgrow their reflux with somatic growth, and they constitute 90% of all children identified with VUR. Continuous prophylaxis has been shown to prevent recurrent UTIs during the years of observation. More recently, the rationale for continuous prophylaxis has been challenged. Conflicting studies have produced contradictory outcomes, arguing for and against the benefit of prophylaxis. These studies and their shortcomings are discussed at length. Most recently, the results of the NIH-sponsored RIVUR (Randomized Intervention for children with Vesicoureteral Reflux) Trial were published, showing that continuous prophylaxis halved the number of UTIs over a 2-year observation period. Renal scarring was not decreased, however. The presence of bowel and bladder dysfunction (BBD) was a significant contributing factor to recurrent UTI. While it is known that many children might not require medical management, it is not possible to segregate those at risk for recurrent UTI, with or without renal involvement. The identification of those at greatest risk who would benefit from treatment remains a challenge for future research.