Find out about treatment options

Vesicoureteral reflux (VUR) treatment options

Understanding the differences

Vesicoureteral reflux (VUR) treatment leaves many parents like you wondering exactly what to expect in terms of treatment for their child. What options do you have? And, what’s best for your child?

It is important to note that antibiotics have been proven ineffective in reducing the rate of kidney infections and renal damage/scarring in children under 30 months of age and who had VUR grades 2-4.2

The more you know, the more you can make an informed decision that best fits your family. A doctor who specializes in urinary conditions in children, called a pediatric urologist, is best equipped to discuss your options, so ask your doctor to refer you right away if your child has been diagnosed with VUR.

There are basically four ways your child’s pediatric urologist or doctor may decide to treat your child, depending on the severity of your child’s VUR. The higher the grade, the more likely that treatment is needed.1

Watchful waiting

If your child has a milder case of VUR (grade I), your child’s doctor may suggest “watchful waiting,” also called surveillance. (With mild cases, children sometimes outgrow VUR.) This means that you will need to keep an eye out for signs of a urinary tract infection (UTI) with fever (called a febrile UTI or fUTI). A new febrile UTI could mean your child’s VUR is getting worse or that the infected urine is reaching the kidney.

You probably know the common signs of a UTI, like burning during urination or odd-smelling urine. But it’s important to know that your child may not show any symptoms beyond being irritable or uninterested in eating. Your child may not be able to communicate that he or she is uncomfortable, so be sure to call your doctor if you suspect your child has a febrile UTI.

Antibiotics

If your child has an active UTI with a fever, also called a febrile UTI, your child’s doctor may use antibiotics to treat the bacteria in the urine. Especially with the first occurrence. This will help keep the infection from spreading to the kidneys – but will not treat VUR. In children with moderate to severe VUR (higher grades), low-dose antibiotics are also used continuously as a way to prevent future febrile UTIs before they happen. However, this course of treatment may require long periods of antibiotic prescriptions. It is important to note that antibiotics have been proven ineffective in reducing the rate of kidney infections and renal damage/scarring in children under 30 months of age and who had VUR grades 2-4.2

Some children are allergic to the different medications; some experience side effects like abdominal pain, nausea, and vomiting—and all children run the risk of developing something called antibiotic resistance, where the antibiotics have reduced efficacy over time. If your child develops antibiotic resistance, any infections (not just UTIs) become harder to treat with the medication.

With antibiotic treatment, your child’s doctor will need to do occasional exams and tests to see if your child may be outgrowing VUR and monitor for any breakthrough UTIs, which are infections that develop even while taking antibiotics.

What happens when antibiotics aren’t working?

For children with moderate-to-severe cases of VUR that don’t outgrow VUR or where antibiotics don’t prevent febrile UTIs, intervention may be necessary. There are two ways to do this, endoscopic treatment with Deflux and open surgery.

The idea of any kind of procedure may concern you, but you should know that both types of intervention have high success rates.

Endoscopic treatment with Deflux

Treatment with Deflux is minimally invasive, and no cuts or incisions are made. It is usually performed on an outpatient basis, although general anesthesia is used for the child’s comfort and to keep the child from moving.

First, your doctor will use a small camera called a cystoscope (a type of endoscope used to view the bladder) to examine the bladder. Then he or she will inject Deflux, a hyaluronic acid (HA) gel containing dextranomer beads, around the ureter that may help the valve between the bladder and ureter close properly. Hyaluronic acid is a naturally occurring material. The HA in Deflux is Non-Animal Stabilized Hyaluronic Acid (NASHA®) and NASHA has been used for over two decades in more than 40 million procedures worldwide3, often as a dermal filler for wrinkle correction.

The treatment usually takes only about 15 minutes and allows children to go back to normal activities the day after it’s done.4 There’s minimal pain, and there’s no scarring. There are some risks generally associated with endoscopic treatments of all kinds that include infection and bleeding, but these are usually mild and short-lived.

In studies, minimally invasive endoscopic treatment with Deflux was proven effective in up to 93% of children with VUR grades 2-4.5 Most children require just one treatment, but in some cases, a second may be needed.

Open surgery

To repair the defect in the valve your pediatric urologist may determine a more invasive open surgery is the preferred option for severe cases, particularly if your child continues to have febrile UTIs even while taking antibiotics. General anesthesia is used while an incision is made in the lower abdomen, through which the pediatric urologist repairs the bladder defect. Your child will need to stay in the hospital for a few days.

While rare, there are risks such as infection, blood clots, and bleeding with open surgery.6

References:
  1. Elder JS, Peters CA, Arant BS Jr, et al. Pediatric vesicoureteral reflux guidelines panel summary report on the management of primary vesicoureteral reflux in children. J Urol. 1997;157(5):1846-1851.
  2. Pennesi M, Travan L, Peratoner L, et al. Is antibiotic prophylaxis in children with vesicoureteral reflux effective in preventing pyelonephritis and renal scars? A randomized, controlled trial. Pediatrics. 2008;121(6):e1489-e1494.
  3. Data on file.
  4. Cerwinka WH, Scherz HC, Kirsch AJ. Endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid in children. Adv Urol. 2008;1-7.
  5. Kalisvaart JF, Scherz HC, Cuda S, Kaye JD, Kirsch AJ. Intermediate to long-term follow-up indicates low risk of recurrence after double hit endoscopic treatment for primary vesicoureteral reflux. J Pediatr Urol. 2012;8(4):359-365.
  6. Beaumont Health. Vesicoureteral Reflux (VUR). Available at: https://www.beaumont.org/conditions/vesicoureteral-reflux. Accessed November 1, 2019.
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