One of the most common conditions managed by pediatric urologists is vesicoureteral reflux (VUR), which occurs when urine in the bladder flows back into the ureters and/or kidneys. For years, the accepted practice involved diagnosing and treating the condition in all patients, regardless of symptoms, which also included routine follow-up testing. Recently, this approach has been questioned, and CHOC urologists have determined that repeated follow-up testing for some patient groups is often unnecessary.
“There is a wide spectrum of severity with VUR, from asymptomatic disease that is incidentally found to severe disease leading to subsequent kidney infections, renal scarring and deterioration of renal function,” says Dr. Heidi Stephany, a pediatric urologist at CHOC. “Our goal is to stratify patients by risk factors and severity to diagnose and treat at the appropriate level.”
Evaluating patient data from 2014 to present day, CHOC urologists have prospectively reviewed the diagnosis, treatment and outcome data to stratify VUR patients into three risk categories, including:
- Low Risk: Female, VUR grade 1–3, without bladder and bowel dysfunction (BBD); circumcised males, any VUR grade, without BBD; and uncircumcised males, over 1 year of age, any VUR grade, no BBD
- Intermediate Risk: Female, VUR grade 1–3, with BBD; female, VUR grade 4–5, presents without UTI, any BBD status; circumcised male, any grade VUR, with BBD; uncircumcised male, over 1 year of age, any grade VUR, with BBD; uncircumcised male, under 1 year of age, any VUR grade, any BBD status
- High Risk: Female, VUR grade 4 or 5, present with UTI, any BBD status
These classifications now drive patient care at CHOC. Historically, many children with low-risk VUR presented no symptoms and often over time, those with asymptomatic VUR and lower grades outgrew the condition, typically by age 5. Despite this, when VUR was diagnosed, even asymptomatic VUR often entailed annual testing. At CHOC, repeat testing is reserved for those with persistent symptoms such as urinary tract infections with fever or those in the high-risk category.
A variety of tests help diagnose VUR, including abdominal ultrasound and the gold standard, voiding cystourethrogram (VCUG). While diagnosing patients with high-risk disease is important, it’s equally as important to minimize over-diagnosis of patients with low-risk disease who will likely remain asymptomatic with no long-term sequelae. “VCUG is not pleasant for kids, so we limit its use,” Dr. Stephany says. “We want to focus on finding the patients at the highest risk for long-term sequelae who truly require treatment to prevent further upper tract damage.”
Stratified treatment for VUR begins with the least-invasive option: expectant management with behavioral modifications to ensure healthy bowel and bladder habits. Often, lower grades of VUR resolve as the child grows. In children at intermediate or high risk, a low-dose daily antibiotic may be prescribed along with an intent focus on bowel and bladder management in the toilet-trained child. Surgical intervention, such as an open ureteral reimplant or endoscopic treatment with injection of Deflux® (a bulking agent to prevent urinary reflux) is also available. In general, surgical intervention is offered to those with high-grade VUR who have recurrent kidney infections and potential for further kidney damage.
Regardless of the grade or risk group, CHOC urologists have a singular purpose. “Our goal is to protect the kidneys and bladder,” Dr. Stephany says. “There are many ways to approach VUR, and there is no standardized treatment. By constantly evaluating our diagnostic and treatment best practices, we force ourselves to consider whether a change in care would mean better outcomes for our patients. When supported by clinical evidence, we make the appropriate modification and VUR patients reap the benefit.”
CHOC Children’s Hospital was named one of the nation’s best children’s hospitals by U.S. News & World Report in its 2020-21 Best Children’s Hospitals rankings and ranked in the urology specialty.