Vesicoureteral Reflux’s Role in Children with Febrile Urinary Tract Infections
As pediatric urologists, one of the most common patients we encounter is children with recurrent urinary tract infections (UTIs), and an important consideration in children with a UTI is whether a fever is present. A high fever suggests a kidney infection, also called pyelonephritis, and one of the most common underlying causes of pyelonephritis in children is vesicoureteral reflux (VUR). In this blog post, I’ll provide an overview of VUR, its febrile UTIs, their impact on children, and available treatment options, including watchful waiting with antibiotic prophylaxis and surgical correction.
What is vesicoureteral reflux?
Vesicoureteral reflux occurs when urine backflows from the bladder up the ureter and into the kidney. Normally, urine travels in only one direction: down from the kidney into the ureter and then the bladder. In children with VUR, the valve mechanism that prevents backflow doesn’t work correctly, allowing urine to flow from the bladder up to the kidneys. This can lead to kidney infections in some kids.
How is vesicoureteral reflux related to febrile urinary infections?
Statistically, 40% of children who develop a urinary infection with a fever have underlying VUR. The backward flow of urine from the bladder to the kidneys allows bacteria-laden urine to travel to an area where bacteria are not normally located, specifically in the kidney. These infections are clearly uncomfortable for the child but can also result in kidney scarring, and this becomes more likely after the first infection.
How is VUR diagnosed?
Several tests are ordered for kids who develop a febrile UTI. First, a kidney and bladder ultrasound is obtained in all kids. Ultrasound does not diagnose VUR but helps outline urinary tract anatomy. Vesicoureteral reflux is diagnosed with a test that mimics bladder filling called a voiding cystourethrogram (VCUG) and can confirm the backward flow of urine up to the kidneys. A catheter is placed in the bladder, and a contrast liquid is used to fill it. X-rays are taken as the bladder fills. Sometimes a study is done looking for kidney scarring called a DMSA scan. The studies needed are ultimately up to your doctor.
How do we treat vesicoureteral reflux?
VUR treatment aims to prevent additional kidney infections and protect the kidney from damage. The approach can vary based on many factors, including the parent’s preference after counseling.
Watchful Waiting and Antibiotics
Continuous antibiotic prophylaxis involves giving a daily, low-dose antibiotic to prevent additional UTIs. This can be used as a temporary measure or as a longer-term treatment while awaiting resolution of reflux. Watchful waiting while on antibiotic prophylaxis is an excellent option for children where spontaneous resolution is likely over a 1-2 year period. Our practice has developed a validated risk stratification tool called the VUR index that is used across the country to help counsel families on the likelihood of spontaneous resolution and UTI recurrence. One of the downsides of long-term continuous antibiotic prophylaxis is that this increases the risk of any subsequent infection being more resistant to antibiotics.
The Surgical Option
Surgical correction of VUR provides a durable solution to correct the underlying anatomic problem, reducing the risk of UTIs and subsequent kidney damage. The types of surgery available are ureteral reimplantation and endoscopic injection. Ureteral reimplantation is the traditional treatment that involves tucking the ureter into the bladder wall to re-create the natural flap valve mechanism. This approach is performed through either a pfannensteil incision hidden below the underwear line or laparoscopically with the help of a robot. It is often used, especially if there are other underlying anatomic abnormalities in addition to VUR. It requires a hospital stay, and there is some recovery from the surgical incision.
Endoscopic injection is performed with a substance called Deflux, the only FDA-approved substance for correcting VUR, injected at the ureter’s opening. This outpatient procedure takes 30 minutes and is ideal for kids with grades I-IV reflux and no other anatomic abnormalities. All approaches are similarly successful at correcting VUR and stopping future UTIs.
The Bottom Line
Understanding the relationship between UTIs and kidney scarring is important for managing vesicoureteral reflux correctly. If your child has been diagnosed with VUR or kidney infections, it is recommended that you work with a pediatric urologist to choose the best treatment approach that protects your child’s kidneys. Remember, early diagnosis and appropriate treatment can reduce the risk of kidney scarring and improve your child’s long-term quality of life.
