8.7 Management

such patients before proceeding with operative correction of VUR.

–The cystometrography gives useful information about:

•Bladder capacity and leak point

•Pressures at various stages of filling

•The presence and frequency of uninhibited (involuntary) bladder contractions and compliance.

•Abdominal and pelvic CT-scan and MRU (Figs. 8.42, 8.43, 8.44, 8.45, 8.46, and 8.47):

–These are useful in delineating:

•The anatomy and cause as well as the degree of ureteric dilatation

•Hydronephrosis

•Renal parenchymal thickness

8.7Management

•VUR is known to be associated with morbidity and sometimes mortality.

•The management of VUR depends on several factors including:

–The grade of VUR

–The compliance of patients with medications and follow-up

–The presence or absence of urinary tract infections and the frequency of urinary tract infections.

–The presence of renal scarring

•The aims of treatment are:

–To prevent episodes of acute pyelonephritis

–To prevent scarring of the kidney associated with VUR (reflux nephropathy), which increases the risk of hypertension and renal failure

•Although medical conservative treatment of VUR is well established, controversy continues regarding the timing, surgical technique, and benefits.

•Three approaches are used to treat children with vesicoureteral reflux (VUR):

–Surveillance (observation)

–Medical treatment

–Surgical treatment

•The first goal of treatment is to prevent or minimize urinary tract infection.

•Medical management is recommended in children with Grade I-III VUR as most cases will resolve spontaneously.

•This is primarily done by prophylactic antibiotics

•An important aspect of conservative management is bowel and bladder management.

•Children who hold their bladder or who are constipated have a greater number of infections than children who void on a regular schedule.

•Failure of medical treatment to prevent recurrent urinary tract infections, or if the kidneys show progressive renal scarring are indications for surgical interventions.

•A trial of medical treatment is indicated in patients with Grade IV VUR especially younger patients or those with unilateral VUR.

•Patients with Grade V VUR are treated surgically except infants who are treated medically before surgery is indicated.

8.7.1Medical Treatment of VUR

•This is based on the fact that low-grade VUR resolve spontaneously and sterile reflux does not damage the kidney.

•Medical treatment with prophylactic antibiotics remains the mainstay of initial management of vesicoureteral reflux.

•Because vesicoureteral reflux spontaneously resolves in most children, medical management allows this natural history to take its course while providing some measure of protection against recurrent UTI and renal injury.

•The International Reflux Study has found that children can be managed nonsurgically with little risk of new or increased renal scarring, provided they are maintained infection free.

•The chance of spontaneous resolution of reflux is high in children younger than 5 years with grades I-III reflux and in children younger than 1 year (especially boys).

•Even higher grades of reflux (grades IV–V) may resolve spontaneously as long as the child remains infection free.

•Antibiotic prophylaxis:

–The recommendations for antibiotic prophylaxis vary according to the presence or

absence of renal scarring at diagnosis, and the age at diagnosis.

–For children without renal scarring at diagnosis, recommendations are as follows:

•Diagnosis made in infancy:

–All patients diagnosed at infancy (i.e. <1 year) with grades I–V reflux should be treated initially with continuous prophylactic antibiotics.

• Diagnosis made in children aged 1–5 years:

–When unilateral and/or bilateral grades I–IV reflux or unilateral grades III–V reflux are diagnosed in children aged 1–5 years, they should be treated initially with continuous prophylactic antibiotics.

• Diagnosis made in children aged 6–10 years:

–Children diagnosed at age 6–10 years with unilateral and/or bilateral grades I–II reflux and unilateral grades III–IV reflux should be treated initially with continuous antibiotic prophylaxis.

–However, some experts advocate withholding treatment in patients with grade I or II VUR, as most of these patients are at low risk for UTIs and pyelonephritis provided they have no voiding dysfunction or constipation.

–For children with renal scarring at diagnosis, recommendations are as follows:

•Diagnosis made in infancy:

–Infants (i.e. <1 year) with grades I–V reflux should be treated initially with continuous antibiotic prophylaxis.

• Diagnosis made in children aged 1–5 years:

–Antibiotic prophylaxis is the preferred option for preschool-aged children (i.e., 1–5 years) with renal scarring at diagnosis, unilateral and/ or bilateral grades I–II reflux, unilateral grades III–IV reflux, and bilateral grades III–IV reflux.

6–10 years with renal scarring and unilateral and/or bilateral grades I–II reflux or unilateral grades III–IV reflux, antibiotic therapy is the preferred treatment option.

•The initial treatment of the child with a UTI involves:

–Supportive care

–Prompt administration of appropriate antibiotics

–Timely institution of antibiotic therapy has been shown to be critical in preventing scar formation in kidneys with pyelonephritis. A high index of suspicion for UTI in children is important.

•Since a substantial number of children experience spontaneous resolution of VUR, medical treatment spares this group the morbidity of surgery while protecting the kidneys from further damage.

•Prophylaxis should be started once a child has completed treatment of the initial UTI and continues at least until imaging reveals vesicoureteral reflux.

–If no vesicoureteral is seen, prophylaxis is discontinued.

–If vesicoureteral reflux is present, prophylactic antibiotics are continued until:

•Vesicoureteral reflux resolves

•Vesicoureteral reflux is surgically corrected

•The child grows old enough that prophylaxis is deemed no longer necessary.

•Virtually all children with a new diagnosis of grade I–IV reflux, and some with grade V, are given a trial of medical treatment.

•This consists of:

–Antibiotics given at one fourth of the therapeutic dosage

–Regular follow-up care and imaging.

–Regular follow-up consists of renal ultrasonography and VCUG or nuclear cystography every 12–18 months.

–Regular follow-up and compliance with prophylactic antibiotics are important to avoid the complications of VUR.

–Once follow-up imaging demonstrates resolution of vesicoureteral reflux, antibiotics are discontinued.

–Incomplete bladder emptying and constipation are important etiological factors.

–The importance of aggressive bladder and bowel management for dysfunctional elimination cannot be overemphasized.

–These patients benefit from bladder training and sometimes the use of anticholinergic medications.

–Constipation should be avoided and children with primary bowel elimination problem should be treated with enemas, dietary changes, and stool bulking agents.

•In 2014, the results of the Randomized Intervention for children with Vesicoureteral Reflux (RIVUR) study showed that antibiotic prophylaxis with trimethoprim-sulfame- thoxazole was associated with a decrease of approximately 50 % in the incidence of recurrent UTI among children with VUR, in comparison with placebo.

•Children on medical management of vesicoureteral reflux are regularly seen on an outpatient basis.

•Routine evaluation includes:

–Urinalysis and urine culture

–Appropriate imaging, and blood pressure measurement.

–Parents can be taught how to perform urinalysis at home and report positive home urinalysis.

–Parents should be aware of UTI and seek medical care.

•Spontaneous resolution rates decrease as patient age increases and with higher grades of reflux.

•Surgical intervention is recommended for children with reflux that has persisted for more than 3 years with no improvement in the grade of reflux if it is grade II or greater.