Editing AUA: Vesicoureteral Reflux (2017) (section)

== Diagnosis and Evaluation of a Child with VUR ==

=== UrologySchool.com Summary ===
*'''<span style="color:#ff0000">Recommended (3):'''
*# '''<span style="color:#ff0000">History (specifically, symptoms of bladder/bowel dysfunction) + physical (specifically, height, weight, BP)'''
*# '''<span style="color:#ff0000">Laboratory: U/A, +/- Cr if bilateral renal abnormalities'''
*# '''<span style="color:#ff0000">Imaging: US'''
* '''<span style="color:#ff0000">Optional (2):'''
*# '''<span style="color:#ff0000">Laboratory: Cr (in patients without bilateral renal abnormalities)'''
*# '''<span style="color:#ff0000">Imaging: DMSA'''

=== History and Physical Exam ===
* '''<span style="color:#ff0000">History'''
**'''<span style="color:#ff0000">Assess for symptoms of bladder/bowel dysfunction (BBD) including (6):'''
**# '''<span style="color:#ff0000">Urinary frequency and urgency'''
**# '''<span style="color:#ff0000">Prolonged voiding intervals'''
**# '''<span style="color:#ff0000">Daytime wetting'''
**# '''<span style="color:#ff0000">Perineal/penile pain'''
**# '''<span style="color:#ff0000">Holding maneuvers (posturing to prevent wetting)'''
**# '''<span style="color:#ff0000">Constipation/encopresis</span>''' (soiling of underwear with stool by children who are beyond age of toilet training)
*** '''<span style="color:#ff0000">Bladder bowel dysfunction (BBD)</span>''', dysfunctional voiding, dysfunctional elimination syndrome and dysfunctional lower urinary tract symptoms, refer to a common but poorly characterized '''<span style="color:#ff0000">complex of symptoms typically including urinary incontinence, frequency or infrequent voiding, dysuria, UTI, and constipation'''
*** '''Untreated BBD associated with:'''
**** '''Increased incidence of breakthrough UTI in children on continuous antibiotic prophylaxis (CAP)'''
**** '''Decreased resolution rates of VUR at initial follow-up in children treated with endoscopic surgery'''
***** '''BBD does not alter surgical resolution rates in children treated with open surgery'''
* '''<span style="color:#ff0000">Physical exam'''
**'''<span style="color:#ff0000">General medical evaluation including measurement of''' 
***'''<span style="color:#ff0000">Height'''
***'''<span style="color:#ff0000">Weight'''
***'''<span style="color:#ff0000">Blood pressure'''

=== Labs ===
*'''<span style="color:#ff0000">Serum creatinine'''
**'''<span style="color:#ff0000">Indications'''
***'''<span style="color:#ff0000">Absolute (1):'''
****'''<span style="color:#ff0000">Bilateral renal abnormalities'''
***'''Relative'''
****'''Children with VUR but without bilateral renal abnormalities''' to establish an estimate of glomerular filtration rate (GFR) for future reference.
* '''<span style="color:#ff0000">Urinalysis'''
**'''Evaluate for proteinuria and bacteriuria'''
***If the urinalysis indicates infection, a urine culture and sensitivity is recommended

=== Imaging ===
* '''<span style="color:#ff0000">Recommended (1)''':
*#'''<span style="color:#ff0000">Renal ultrasound''' 
*#*VUR and UTI may affect renal structure and function
* '''<span style="color:#ff0000">Optional (1)'''
*#'''<span style="color:#ff0000">DMSA</span>''' (technetium-99m-labeled dimercaptosuccinic acid) 
*#*'''<span style="color:#ff0000">To assess the status of the kidneys for scarring and function'''
*#** '''Children with higher grades of VUR (i.e. grades III to V) are at greater risk of having renal cortical abnormalities.'''
*#** DMSA scanning can be useful to identify pre-existing abnormalities.