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Vesicoureteric Reflux

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Overview

Vesicoureteric reflux (VUR) describes the abnormal backflow of urine from the bladder into the ureters and kidneys. This predisposes children to develop recurrent urinary tract infections (UTIs) which can lead to kidney scarring.

Around 30% of infants presenting with their first UTI may have underlying VUR.

Presentation

Children present with recurrent or atypical urinary tract infections:

  • UTIs are atypical if any of the following apply:
    • Poor urine flow
    • Abdominal or bladder mass
    • Serious illness
    • Sepsis
    • Raised creatinine
    • Failure to respond to antibiotics within 48 hours
    • Infection with organisms that are not E. coli
  • UTIs are classified as recurrent if any of the following apply:
    • ≥2 episodes of upper UTI
    • 1 episode of upper UTI plus ≥1 episode of lower UTI
    • ≥3 episodes of lower UTI

Investigations

Overview

Investigating recurrent UTIs involves the use of ultrasound scans, dimercaptosuccinic acid (DMSA) scans, and micturating cystourethrograms. NICE has set out guidelines on which patients should have what investigation.

VUR is diagnosed using a micturating cystourethrogram (MCUG) and renal scarring is assessed using a dimercaptosuccinic acid (DMSA) scan.

Ultrasound scans

Offer an ultrasound scan if any of the following apply:

  • All babies <6 months with their first UTI:
    • If the UTI responds well to treatment within 48 hours, this is within 6 weeks
    • If the UTI is atypical or recurrent, this is done during the infection
  • Children with recurrent UTIs within 6 weeks
  • Children with atypical UTIs during the infection

Micturating cystourethrogram (MCUG)

Offer a micturating cystourethrogram (MCUG) if any of the following apply:

  • Babies <6 months with any of the following:
    • Atypical UTI
    • Recurrent UTIs

Dimercaptosuccinic acid (DMSA) scan

Offer a dimercaptosuccinic acid (DMSA) scan within 4-6 months to assess for renal tract damage if any of the following apply:

  • Babies at any age up to 3 years with any of the following:
    • An atypical UTI
    • Recurrent UTIs
  • Children aged 3 years or older with recurrent UTIs

Management

Overview

The main goal of managing VUR is to reduce infections and subsequent scarring. In patients with recurrent UTIs, antibiotic prophylaxis is considered. Surgery is not routinely used for the management of VUR.

Complications

If untreated, the main complication of VUR is renal scarring which can lead to renal hypertension and chronic kidney disease.

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