Thematic Area: Vesicoureteral Reflux
The following guidance document has been adopted based on standardized reviews:
J Urol 2010; 184: 1134-44
- On initial presentation the child with vesicoureteral reflux (VUR) should undergo a careful general medical evaluation including measurement of height, weight, blood pressure and serum creatinine if bilateral renal abnormalities are found. Urinalysis for proteinuria and bacteriuria as well as renal ultrasound to assess the upper urinary tract are recommended.
- Symptoms indicative of bladder/bowel dysfunction should be sought in the initial evaluation.
- Voiding cystourethrogram is recommended for children with high-grade hydronephrosis, hydroureter or an abnormal bladder on ultrasound (late-term prenatal or postnatal), or who develop a urinary tract infection (UTI) on oberservation.
- Continuous antibiotic prophylaxis (CAP) is recommended for the child <1 year of age with VUR with a history of a febrile UTI, or with VUR grades III–V identified through screening.
- If clinical evidence of bladder/bowl dysfunction is present treatment of bladder/bowel dysfunction is indicated for the child of >1 year of age, preferably before any surgical intervention for VUR.
CAP is recommended with bladder/bowel dysfunction and VUR while bladder/bowel dysfunction is present and being treated.
- It is recommended that patients receiving CAP with a febrile breakthrough UTI be considered for surgical intervention with curative intent. In patients not receiving CAP who develop a febrile UTI, initiation of CAP is recommended.
- General evaluation is recommended annually for follow-up of the child with VUR. Ultrasonography is recommended every 12 months to monitor renal growth and any parenchymal scarring.
- Surgical intervention for VUR, including both open and endoscopic methods, may be used. Prospective randomized controlled trials have shown a reduction in the occurrence of febrile UTIs in patients who have undergone open surgical correction of VUR as compared to those receiving CAP.
- Following open surgical or endoscopic procedures for VUR, a renal ultrasound should be obtained to assess for obstruction.
- Following the resolution of VUR, either spontaneously or by surgical intervention, general evaluation, is recommended annually through adolescence if either kidney is abnormal by ultrasound or DMSA scanning.
- It is recommended that the long-term concerns of hypertension (particularly during pregnancy), renal functional loss, recurrent UTIs, and familial VUR in the child's siblings and offspring be discussed with the family and communicated to the child at an appropriate age.
Comments by Evaluators:
- The document is primarily a pediatric urology guideline.
It seems that no specialists and stakeholders other than urologists were represented in the expert panel.