Figure 830

Proposed treatment of vesicoureteral reflux (VUR) in children. This algorithm provides an approach to evaluate and treat VUR in children. In VUR associated with other genitourinary anomalies, therapy for reflux should be part of a comprehensive treatment plan directed toward correcting the underlying urologic malformation. Children with mild VUR should be treated with prophylactic antibiotics, attention to perineal hygiene and regular bowel habits, surveillance urine cultures, and annual voiding cystourethrogram (VCUG). Children with recurrent urinary tract infection on this regimen should be considered for surgical correction. In children in whom VUR resolves spontaneously, a high index of suspicion for urinary tract infection should be maintained, and urine cultures should be obtained at times of febrile illness without ready clinical explanation.

In persons in whom mild VUR fails to resolve after 2 to 3 years of observation, consideration should be given to voiding pattern. A careful voiding history and an evaluation of urinary flow rate may reveal abnormalities in bladder function that impede resolution of reflux. Correction of dysfunctional voiding patterns may result in resolution of VUR. In the absence of dysfunctional voiding, it is controversial whether older women with persistent VUR are best served by surgical correction or close observation with uroprophylactic antibiotic therapy and surveillance urine cultures, especially during pregnancy. Males with persistent low-grade VUR may be candidates for close observation with surveillance urine cultures while not receiving antibiotic therapy, especially if they are over 4 years of age and circumcised. Circumcision lowers the incidence of urinary tract infection. In severe VUR the function of the affected kidney should be evaluated with a functional study (radionuclide renal scan). High-grade VUR in nonfunctioning kidneys is unlikely to resolve spontaneously, and nephrectomy may be indicated to decrease the risk of urinary tract infection and avoid the need for uroprophylactic antibiotic therapy. In patients with functioning kidneys who have high-grade VUR, the likelihood for resolution should be considered. Severe VUR, especially if bilateral, is unlikely to resolve spontaneously. Proceeding directly to repeat implantation may be indicated in some cases. Medical therapy with uroprophylactic antibiotics and serial VCUG may also be used, reserving surgical therapy for those in whom resolution fails to occur.

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