Vesicoureteral Reflux Treatment in India

Overview of Vesicoureteral Reflux

Vesicoureteral Reflux (VUR) is a condition in which urine flows backwards instead of moving normally from the kidneys through the ureters to the bladder. In VUR, urine refluxes from the bladder into one or both ureters and in some cases, reaches the kidneys. This usually occurs when the valve that normally prevents backward urine flow does not function properly.

VUR is most common in newborns, infants and children younger than 2 years of age, although it can also occur in older children and, rarely, in adults.

VUR is most common in newborns, infants and children younger than 2 years of age, although it can also occur in older children and, rarely, in adults.

Types of Vesicoureteral Reflux (VUR)

VUR affecting one ureter and one kidney is known as unilateral reflux, while involvement of both ureters and kidneys is called bilateral reflux.

There are two main types of VUR:

Primary VUR: This is the most common type and usually affects only one ureter and kidney. It is present at birth and occurs when the ureter does not join the bladder properly. As a result, the valve between the ureter and bladder does not close completely, allowing urine to flow backwards into the ureter and sometimes the kidney.
Secondary VUR: This type develops when a blockage or problem in the urinary tract increases pressure, causing urine to flow backwards from the bladder into the ureters or kidneys. Blockages may result from abnormal tissue in the urethra or nerve problems that prevent the bladder from emptying normally. Secondary VUR often affects both ureters and kidneys (bilateral reflux).

Stages of Vesicoureteral Reflux (VUR)

VUR is classified into five grades based on how far urine flows backwards into the urinary tract and the degree of enlargement of the ureters and kidneys. Grade I is the mildest, while Grade V is the most severe.

Grade I: Urine flows back into the ureter only, and the ureter remains normal in size
Grade II: Urine reaches the ureter and the kidney pelvis without causing enlargement
Grade III: Mild to moderate enlargement of the ureter, kidney pelvis and calyces occurs due to urine reflux
Grade IV: The ureter becomes curved and moderately enlarged, with moderate widening of the kidney pelvis and calyces
Grade V: Severe urine reflux causes marked enlargement and distortion of the ureter, along with significant dilation of the kidney pelvis and calyces

Causes Vesicoureteral Reflux (VUR)

There are two main types of Vesicoureteral Reflux (VUR), each with a different cause:

Primary VUR: The most common type, present at birth. It occurs when the valve between the bladder and the ureter does not close properly, allowing urine to flow backwards. It may improve as the child grows and it can run in families
Secondary VUR: Caused by incomplete bladder emptying due to urinary tract blockage, narrowing of the urethra, or nerve damage affecting bladder function

Signs and Symptoms of Vesicoureteral Reflux (VUR)

VUR often does not cause symptoms unless it leads to a UTI. Symptoms of a UTI may include:

Frequent or urgent need to urinate
Burning or pain during urination
Passing small amounts of urine frequently
Cloudy urine
Fever
Pain in the side, groin or abdomen

In infants and young children, symptoms may include:

Unexplained fever
Poor feeding
Irritability or fussiness

If left untreated, VUR in older children may lead to:

Bedwetting
Constipation or bowel incontinence
High blood pressure
Protein in the urine
Frequent or urgent urination
Urinary incontinence (accidental urine leakage)

VUR can also cause hydronephrosis (swelling of one or both kidneys due to urine backup), which is often detected during prenatal ultrasound.

Risk factors of Vesicoureteral Reflux (VUR)

Bladder and bowel dysfunction (BBD): Children who hold urine or stool and experience repeated UTIs have a higher risk of VUR
Sex assigned at birth: VUR is more common in girls, except for cases present at birth, which occur more often in boys
Age: Infants and children under 2 years of age are more likely to develop VUR
Family history: Primary VUR can run in families. Children with affected parents or siblings have a higher risk and may need screening

Diagnosis of Vesicoureteral Reflux (VUR)

A paediatrician may refer your child to one or both specialists for evaluation and treatment.

Tests used to diagnose VUR may include:

Voiding cystourethrogram (VCUG): An X-ray test that captures images of the bladder and urethra before, during, and after urination. A catheter is used to fill the bladder with contrast dye to check if urine flows backwards into the ureters.
Ultrasound: A safe, painless test that uses sound waves to create images of the kidneys, bladder and urinary tract. It can detect abnormalities such as kidney swelling and may be performed before other tests to avoid radiation exposure
Dimercaptosuccinic acid (DMSA) scan: An imaging test used to check for kidney scarring caused by UTIs
Radionuclide cystogram (RNC): A nuclear imaging test that uses a small amount of radioactive material in the bladder to detect urine reflux. It is more sensitive than VCUG but provides less detail about bladder structure.

Treatment

Treatment depends on the severity of VUR. Mild cases of primary VUR may improve as the child grows, so healthcare providers may recommend monitoring with a wait-and-see approach.

For more severe VUR, treatment options include:

Medications: UTIs should be treated promptly with antibiotics to prevent infection from spreading to the kidneys. Low-dose antibiotics may be prescribed to help prevent recurring UTIs. Children on medication require regular checkups, urine tests and occasional imaging to monitor infections and determine if VUR has improved.

Surgery: Surgery may be recommended if VUR does not improve with medication or if the child continues to have fever-related UTIs. The goal of surgery is to repair the faulty valve between the bladder and ureter to prevent urine from flowing backwards.

Surgical options include:

Open surgery: Repairs the valve through a cut in the lower abdomen. A short hospital stay and catheter use may be needed after the procedure.
Robot-assisted laparoscopic surgery: It uses small cuts and robotic instruments to repair the valve. It may result in smaller scars but can have a lower success rate and more complications than open surgery.
Endoscopic surgery: A cystoscope is passed through the urethra, and a gel-like material is injected near the ureter opening to improve valve function. It is slightly invasive and usually allows same-day discharge but may be less effective than open surgery.
Nephrectomy: In rare cases, removal of part or all of a damaged kidney may be needed if the kidney is severely infected and no longer functions well.

Lifestyle recommendations

Lifestyle measures can help relieve discomfort from UTIs, which are common in children with VUR. These steps can help until antibiotics treat the infection:

Encourage your child to drink plenty of fluids, especially water, to dilute urine and help flush bacteria from the urinary tract
Use a warm heating pad, blanket, or towel on the abdomen to help reduce pressure and pain. Ensure it is warm, not hot

If bladder and bowel dysfunction (BBD) contributes to VUR, promote healthy bathroom habits:

Encourage regular toilet use, such as emptying the bladder every 2–3 hours while awake
Help prevent constipation by providing enough water and a high-fibre diet
If constipation continues, consult a doctor about treatment options, including laxatives if needed

Prevention

There is no known way to prevent VUR through diet, lifestyle changes, or medications. However, you can support your child’s urinary health by encouraging them to:

Drink enough water
Have diapers changed promptly after urination or bowel movements
Urinate regularly and avoid holding urine for long periods
Receive early treatment for constipation and urinary or bowel control problems
Encourage overall health through regular physical activity and a balanced, nutritious diet

Complications

The main concern with VUR is kidney damage. The risk and severity of complications increase with more severe reflux.

Kidney scarring: Untreated UTIs can damage kidney tissue and cause scarring. Severe scarring may lead to high blood pressure or kidney failure.
High blood pressure: Kidney damage can reduce the kidneys’ ability to filter waste from the blood, which may result in increased blood pressure.
Kidney problems: Scarring can affect kidney function and may lead to kidney failure, where the kidneys lose their ability to filter blood. This can occur suddenly (acute kidney injury) or develop gradually over time (chronic kidney disease).