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Vesicoureteral reflux

Key sources
The following summarized guidelines for the evaluation and management of vesicoureteral reflux are prepared by our editorial team based on guidelines from the European Association of Urology (EAU/ESPU 2023), the American College of Radiology (ACR 2023), the American Urological Association (AUA 2017), and the American Academy of Pediatrics (AAP 2016).


1.Screening and diagnosis

Screening of siblings: as per EAU 2023 guidelines, inform parents of patients with vesicoureteric reflux that siblings and offspring have a high prevalence of VUR.
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2.Diagnostic investigations

History and physical examination: as per EAU 2023 guidelines, obtain a detailed evaluation for the presence of lower urinary tract dysfunction in all patients, especially in children after toilet training. Treat lower urinary tract dysfunction first if identified.

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  • Laboratory tests

  • Renal ultrasound

  • Voiding cystourethrography

  • Voiding urosonography

  • DMSA scan

  • Radionuclide cystography

  • Abdominopelvic CT

3.Medical management

General principles
Decide on the most appropriate management based on:
presence of renal scars
clinical course
grade of reflux
ipsilateral renal function
bladder function
associated anomalies of the urinary tract
age and gender
parental preference
Offer a more aggressive, multidisciplinary approach in high-risk patients already having renal impairment.

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  • Conservative management

  • Continuous antibiotic prophylaxis

  • Management of bladder/bowel dysfunction

  • Management of breakthrough UTI

4.Surgical interventions

Indications for surgery: as per EAU 2023 guidelines, offer reimplantation in patients with persistent high-grade reflux and endoscopic correction for lower grades of reflux.
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5.Patient education

General counseling: provide family and patient education regarding VUR, including a discussion of the rationale for treating VUR, the potential consequences of untreated VUR, the equivalency of certain treatment approaches, assessment of likely adherence with the care plan, determination of parental concerns and accommodation of parental preferences when treatment choices offer a similar risk-benefit balance.
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6.Follow-up and surveillance

Serial clinical and laboratory assessment
Obtain annual evaluation, including BP, height, and weight monitoring.
Obtain annual urinalysis for proteinuria and bacteriuria, including a urine culture and sensitivity if the urinalysis is suggestive of infection.

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  • Serial imaging assessment

  • Postoperative evaluation

  • Surveillance after VUR resolution