New clinical evidence shifts approach to vesicoureteral reflux (VUR) care

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.”

Dr. Heidi Stephany, pediatric urologist at CHOC

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.”

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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.

Learn how CHOC’s urology care, ongoing treatment and surgical interventions preserve childhood for children in Orange County, Calif., and beyond.

CHOC-UCI Pediatric Urology study illustrates how COVID-19 delayed emergency care

CHOC’s pediatric urology team, in a partnership with UCI Health, has published the largest study of its kind on an emergency condition that afflicts young males, adding to the emerging body of data on how the COVID-19 pandemic has caused patients to delay seeking emergency treatment.

The CHOC/UCI-led study, recently published in the Journal of Pediatric Urology, also marks a first for the Western Pediatric Urology Consortium (WPUC), a group of several leading pediatric healthcare centers that CHOC was instrumental in founding in 2020.

“This study is a good example of CHOC leading the way and bringing together institutions to answer questions that haven’t been answered before,” says Carol Davis-Dao, PhD, a clinical epidemiologist in CHOC’s Department of Pediatric Urology who has a joint appointment in the UC Irvine Department of Urology.

Dr. Davis-Dao leads urology research efforts at CHOC to provide patients and their families with the most current, evidence-based diagnoses and treatments.

The lead author of “A Multicenter Study of Acute Testicular Torsion in the Time of COVID-10,” Dr. Sarah Holzman, a research fellow at UCI-CHOC, says the research paper is the only multicenter urology study and the largest one related to torsion and COVID-19. Most importantly, she adds, it’s the only study that shows patients were delaying presenting to the Emergency Department for testicular torsion.  

The study’s key finding: Patients significantly delayed seeking treatment in the Emergency Department following the onset of symptoms of a testicular torsion during the early months of the pandemic, and, as a result, more of them had to have a testicle removed compared to patients with the same condition who sought care before the pandemic.

“This is the largest study of testicular torsion during COVID-19 and the first to show a significantly longer time from symptom onset to presentation (in the Emergency Department),” the paper states.

“Low baseline awareness of torsion may contribute to delays in care that were present even before the pandemic, making patients and their families less likely to present for emergency care during the pandemic when there is concern for exposure to COVID-19.”

Also participating as authors of the study were CHOC pediatric urologists Dr. Heidi Stephany, Dr. Kai-wen Chuang, Dr. Elias Wehbi, and Dr. Antoine Khoury, chief of pediatric urology at both CHOC and UC Irvine Medical Center. 

Testicular torsion occurs when the spermatic cord that supplies blood to the testicle twists, cutting off the testicle’s blood supply. It presents as acute and severe scrotal pain that quickly worsens, as well as nausea and vomiting.

Testicular torsion occurs when the spermatic cord that supplies blood to the testicle twists, cutting off the blood supply.

It’s a relatively rare surgical emergency, with an incidence rate of around 4 per 100,000 males per year in the United States. It most frequently occurs in males between the ages of 10 and 19, with one peak in the neonatal period and the second peak around puberty.

Surgery is required for all patients with testicular torsion.

When torsion is caught early — typically within the first six hours — a detorsion orchiopexy can be performed. In the detorsion surgery, the spermatic cord is untwisted and the blood flow returns to the testicle. The surgeon then secures the testis to the inner scrotum so it can never twist again. However, if patients delay coming to the hospital and the testicle does not have blood supply for several hours, the testicle may have to be removed in a procedure called an orchiectomy.

The CHOC-UCI led study involved a total of 221 patients enrolled at one of seven hospitals in the WPUC (CHOC, Children’s Hospital Los Angeles, Seattle Children’s, UC San Francisco, UCLA, UC San Diego and Western University in Ontario, Canada).

A total of 84 patients with testicular torsion, ages 2 months to 18 years, made up the first cohort. They were studied from March 2020 through July 2020.

The second cohort totaled 137 patients who were treated from January 2019 through February 2020.

The median time it took patients in the COVID-19 cohort to show up at the Emergency Department from the onset of symptoms was 17.9 hours, the study found. This compares to 7.5 hours for patients in the pre-pandemic cohort.

A total of 42 percent of patients in the COVID-19 cohort underwent an orchiectomy (removal of the twisted testicle), compared to 29 percent in the pre-pandemic population.

Distribution of patterns in acute testicular torsion presentation by month of the COVID-19 pandemic. Blue bars represent rate of orchiectomy by month, while the navy-blue line represents median time from onset of symptoms to presentation by month.

Other studies have shown that COVID-19 has caused people to delay Emergency Department treatment, including one that examined acute appendicitis from the New York metropolitan region and another similar study in Virginia.

During the last week of June 2020, 41 percent of U.S. adults admitted to avoiding medical care because of COVID-19 exposure concerns and 12 percent avoided urgent or emergent care, according to the Morbidity and Mortality Weekly Report, an epidemiological digest for the United States published by the Centers for Disease Control and Prevention.

Drs. Holzman and Davis-Dao say they plan to continue the study as the pandemic progresses.

Read more about CHOC’s Department of Urology.