The American Urlogical Association - OU Medicine

Introduction
Vesicoureteral reflux refers to the retrograde flow of urine from the bladder into the ureter and, usually,
into the collecting system of the kidney. In most individuals, reflux results from a congenital
anomaly of the ureterovesical junction, whereas in others it results from high-pressure voiding secondary
to posterior urethral valves, neuropathic bladder or voiding dysfunction. Between 3–5 percent
of girls and 1–2 percent of boys experience a urinary tract infection before puberty (Jodal and Winberg,
1987). Approximately 40 percent of children with a urinary tract infection have reflux (Bourchier,
Abbott and Maling, 1984; Drachman, Valevici and Vardy, 1984). Urinary tract infection is the most
common bacterial disease during the first 3 months of life (Krober, Bass, Powell, et al., 1985) and
accounts for approximately 6 percent of febrile illnesses in infants (Hoberman, Chao, Keller, et al.,
1993). Reflux is a predisposing factor for pyelonephritis, which can result in renal injury or scarring,
also termed reflux nephropathy. The most serious late consequence of reflux nephropathy is renal insufficiency
or end-stage renal disease. Between 3.1–25 percent of children and 10–15 percent of adults
with end-stage renal disease have reflux nephropathy (Arant, 1991; Avner, Chavers, Sullivan, et al.,
1995; Bailey, Maling and Swainson, 1993). In addition, reflux nephropathy may result in renin-mediated
hypertension and cause morbidity in pregnancy (Martinell, Jodal and Lidin-Jason, 1990).
The primary goals in the management of vesicoureteral reflux in children are to prevent
pyelonephritis, renal injury and other complications of reflux. Children with reflux may be managed
either medically or surgically. The rationale for medical management is prevention of urinary tract
infection with daily antimicrobial prophylaxis, regular timed voiding and, in some cases, anticholinergic
medication. These children also undergo periodic screening of the urine for infection and radiologic
reassessment of the urinary tract for reflux and renal injury. Many children show spontaneous
reflux resolution while receiving medical management. Surgical management of reflux consists of
repair of the ureterovesical junction abnormality.
Although vesicoureteral reflux is common, there is disagreement regarding the optimal management,
even among specialists caring for these children (Elder, Snyder, Peters, et al., 1992; International
Reflux Study Committee, 1981). Because of the lack of consensus regarding management of this
common condition, the American Urological Association (AUA) convened a panel of experts to
develop treatment guidelines for children with vesicoureteral reflux. The panel was charged with the
task of producing practice recommendations based primarily on outcomes evidence from the scientific
literature. This Report on the Management of Primary Vesicoureteral Reflux in Children is the result of
the panel’s efforts. The panel members represent various geographic areas, ages, professional activities
(academic medical centers, private practice, health maintenance organizations) and expertise (pediatric
urology, pediatric nephrology), allowing a broad perspective on the management of reflux.
The recommendations in this report are to assist physicians specifically in the treatment of vesicoureteral
reflux in children diagnosed following a urinary tract infection. The recommendations apply
to children aged 10 years and younger with unilateral or bilateral reflux with or without scarring. The
report therefore deals only peripherally with the diagnostic methods of identifying vesicoureteral
reflux, renal scarring and management of children with reflux identified incidentally or by screening of
asymptomatic siblings. In addition, the report does not pertain to reflux associated with neuropathic
bladder, posterior urethral valves, bladder exstrophy or fixed anatomic abnormalities, such as ectopic
ureterocele and ectopic ureter.
Because treatment recommendations are made jointly with the parents of the child, A Guide for
Parents, based on this report, is available to assist the physician in discussing treatment options with
the parents. A summary of this report has been published in the Journal of Urology, May 1997.
Copyright © 1997 American Urological Association, Inc.
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