AUA: Vesicoureteral Reflux (2017): Difference between revisions

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'''See [[Pediatrics: Vesicoureteral Reflux|Vesicoureteral Reflux Chapter Notes]]'''

See [[CUA: Antenatal hydronephrosis (2017)|2017 CUA Guidelines on Antenatal Hydronephrosis]]

== Background ==

*'''Vesicoureteral reflux (VUR) and urinary tract infections may detrimentally affect the overall health and renal function in affected children.'''

*'''VUR is diagnosed by'''

*'''VUR is diagnosed by'''

*#'''Voiding cystourethrogram (VCUG)'''

*#'''Voiding cystourethrogram (VCUG)'''

*#'''Radionuclide cystography'''

*#'''Radionuclide cystography'''

== VUR Grading ==

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* '''RIVUR (NEJM 2014)'''

** '''Population: 607 children with''' dilated and non-dilated '''VUR that was diagnosed after''' a first or second '''febrile or symptomatic UTI'''

*** ~~Population was overwhelmingly female~~ (91%)

*** Majority (91%) female population

*** Half of ~~the~~ study participants were < 11 months of age

*** Half of study participants were < 11 months of age

** '''Randomized to trimethoprim-sulfamethoxazole prophylaxis vs. placebo'''

** '''Primary outcome: recurrence of UTI'''

** '''Results:'''

*** '''45% significant decrease in recurrence of UTI in antibiotic prophylaxis''' (RR: 0.55; 95% CI: 0.38-0.78)

*** '''45% significant decrease in recurrence of UTI with antibiotic prophylaxis''' (RR: 0.55; 95% CI: 0.38-0.78)

**** When stratified into dilated and non-dilated groups, children with dilated VUR were more likely to have symptomatic recurrences than those with non-dilated VUR

**** '''Prophylaxis was particularly effective in children'''

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**'''Voiding cystography is recommended'''

== Follow-up after ~~resolution~~ (surgically or spontaneously) of VUR ==

== Follow-up after Resolution (surgically or spontaneously) of VUR ==

* '''Following the resolution of VUR, general evaluation, including monitoring of blood pressure, height, and weight, and U/A, annually through adolescence is:'''

* '''The long-term concerns of hypertension (particularly during pregnancy), renal functional loss, recurrent UTI, and familial VUR in the child's siblings and offspring should be discussed with the family and communicated to the child at an appropriate age.'''

**'''The long-term health impact of VUR and renal injury may be distant in time''', difficult to accurately predict, and subtle in clinical presentation. This is of particular importance in patients with renal scarring prior to reflux resolution or in whom there is a recurrence of UTI after reflux resolution.

*'''Following the resolution of VUR, general evaluation, including monitoring of blood pressure, height, and weight, and U/A, annually through adolescence is:'''

** '''Recommended if either kidney is abnormal''' by ultrasound or DMSA scanning

** '''Optional if both kidneys are normal''' by ultrasound or DMSA scanning

** '''~~The long-term health impact of VUR and renal injury may be distant in time~~''', difficult to accurately predict, and subtle in clinical presentation. This is of particular importance in patients with renal scarring prior to reflux resolution or in whom there is a recurrence of UTI after reflux resolution.

* '''If febrile UTI following resolution or surgical treatment of VUR, evaluate for (2):'''

* '''With the occurrence of a febrile UTI following resolution or surgical treatment of VUR, ~~evaluation~~ for BBD ~~or recurrent VUR is recommended~~'''

*#'''BBD'''

* '''~~Recommendation: It is recommended that the long-term concerns of hypertension (particularly during pregnancy), renal functional loss, recurrent UTI, and familial~~ VUR ~~in the child's siblings and offspring be discussed with the family and communicated to the child at an appropriate age.~~'''

*#'''Recurrent VUR'''

== Screening for VUR ==

=== Screening in Siblings of Children with VUR ===

* '''~~The prevalence~~ of VUR is 27% in siblings of children with VUR'''

*'''Prevalence of VUR is 27% in siblings of children with VUR'''

* ~~The goal~~ of screening for VUR in siblings is to identify clinically unapparent VUR in order to initiate preventative therapy, usually CAP. However, the value of CAP in preventing febrile UTI and renal damage in VUR is unproven. Therefore, recommendations for screening are limited by the uncertainty of any potential benefit gained by identifying VUR. Identification of VUR may be of some benefit by increasing the awareness of parents and health providers to the potentially increased risk of pyelonephritis and renal scarring

* Goal of screening (through VCUG or radionuclide cystogram) for VUR in siblings is to identify clinically unapparent VUR in order to initiate preventative therapy, usually CAP.

**However, the value of CAP in preventing febrile UTI and renal damage in VUR is unproven. Therefore, recommendations for screening are limited by the uncertainty of any potential benefit gained by identifying VUR.

**Identification of VUR may be of some benefit by increasing the awareness of parents and health providers to the potentially increased risk of pyelonephritis and renal scarring

* '''Option: Given that the value of identifying and treating VUR is unproven, an observational approach without screening for VUR may be taken for siblings of children with VUR, with prompt treatment of any acute UTI and subsequent evaluation for VUR'''

* '''Option: Ultrasound screening of the kidneys in the sibling of a child with VUR may be performed to identify significant renal scarring and to focus attention on the presence and potential further risk of VUR.'''

* '''Option: Ultrasound screening of the kidneys in the sibling of a child with VUR may be performed to identify significant renal scarring and to focus attention on the presence and potential further risk of VUR'''

* '''Screening for VUR~~''' (VCUG or radionuclide cystogram) '''~~in the sibling is recommended if (2):'''

* '''Screening for VUR in the sibling is recommended if (2):'''

*# '''Evidence of renal cortical abnormalities or renal size asymmetry on US''' [of sibling]

*# '''History of UTI in the sibling''' who has not been tested for VUR

* '''Option: Sibling screening of older children who are toilet trained may be offered, although the value of identification of VUR is undefined.'''

=== Screening in ~~Offpsring~~ ===

=== Screening in Offspring ===

* ~~The incidence~~ of reflux in the offspring of a patient with VUR is 36%

* Risk of reflux in the offspring of a patient with VUR is 36%

* '''Screening for VUR in the offspring is optional'''

=== Screening in the neonate with a history of prenatal hydronephrosis ===

* ~~'''Infants~~ with prenatally detected hydronephrosis ~~have an incidence of VUR of~~ 16%~~'''~~

* Risk of VUR in infants with prenatally detected hydronephrosis is 16%

** '''Grade of hydronephrosis is NOT associated with risk of VUR'''

* '''Indications for VCUG in the neonate with a history of prenatal hydronephrosis:'''

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# What are indications for continuous antibiotic prophylaxis in children with VUR?

#What are the treatment options for bladder bowel dysfunction?

#Describe the follow-up of a patient with VUR?

# What are the indications for VCUG in a neonate with antenatal hydronephrosis?

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# What are indications for continuous antibiotic prophylaxis in children with VUR?

#What are the treatment options for bladder bowel dysfunction?

##Behavioral therapy

##Biofeedback (appropriate for children age >5)

##Treatment of constipation

##Anti-cholinergic medications

##Alpha blockers

#Describe the follow-up of a patient with VUR?

##Annual history and physical exam (including measurement of blood pressure, height, and weight)

##Urinalysis

##Ultrasound

##If continuous antibiotic prophylaxis used, then VCUG between 12 and 24 months

# What are the indications for VCUG in a neonate with antenatal hydronephrosis?

@@ Line 4: / Line 4: @@
 '''See [[Pediatrics: Vesicoureteral Reflux|Vesicoureteral Reflux Chapter Notes]]'''
+See [[CUA: Antenatal hydronephrosis (2017)|2017 CUA Guidelines on Antenatal Hydronephrosis]]
 == Background ==
 *'''Vesicoureteral reflux (VUR) and urinary tract infections may detrimentally affect the overall health and renal function in affected children.'''
-*'''VUR is diagnosed by'''
+*'''<span style="color:#ff0000">VUR is diagnosed by'''
-*#'''Voiding cystourethrogram (VCUG)'''
+*#'''<span style="color:#ff0000">Voiding cystourethrogram (VCUG)'''
-*#'''Radionuclide cystography'''
+*#'''<span style="color:#ff0000">Radionuclide cystography'''
 == VUR Grading ==
@@ Line 109: / Line 111: @@
 * '''<span style="color:#ff00ff">RIVUR (NEJM 2014)'''
 ** '''Population: 607 children with''' dilated and non-dilated '''VUR that was diagnosed after''' a first or second '''febrile or symptomatic UTI'''
-*** Population was overwhelmingly female (91%)
+*** Majority (91%) female population
-*** Half of the study participants were < 11 months of age
+*** Half of study participants were < 11 months of age
 ** '''Randomized to trimethoprim-sulfamethoxazole prophylaxis vs. placebo'''
 ** '''Primary outcome: recurrence of UTI'''
 ** '''Results:'''
-*** '''45% significant decrease in recurrence of UTI in antibiotic prophylaxis''' (RR: 0.55; 95% CI: 0.38-0.78)
+*** '''45% significant decrease in recurrence of UTI with antibiotic prophylaxis''' (RR: 0.55; 95% CI: 0.38-0.78)
 **** When stratified into dilated and non-dilated groups, children with dilated VUR were more likely to have symptomatic recurrences than those with non-dilated VUR
 **** '''Prophylaxis was particularly effective in children'''
@@ Line 227: / Line 229: @@
 **'''<span style="color:#ff0000">Voiding cystography is recommended'''
-== Follow-up after resolution (surgically or spontaneously) of VUR ==
+== Follow-up after Resolution (surgically or spontaneously) of VUR ==
-* '''<span style="color:#ff0000">Following the resolution of VUR, general evaluation, including monitoring of blood pressure, height, and weight, and U/A, annually through adolescence is:'''
+* '''<span style="color:#ff0000">The long-term concerns of hypertension (particularly during pregnancy), renal functional loss, recurrent UTI, and familial VUR in the child's siblings and offspring should be discussed with the family and communicated to the child at an appropriate age.'''
+**'''The long-term health impact of VUR and renal injury may be distant in time''', difficult to accurately predict, and subtle in clinical presentation. This is of particular importance in patients with renal scarring prior to reflux resolution or in whom there is a recurrence of UTI after reflux resolution.
+*'''<span style="color:#ff0000">Following the resolution of VUR, general evaluation, including monitoring of blood pressure, height, and weight, and U/A, annually through adolescence is:'''
 ** '''Recommended if either kidney is abnormal''' by ultrasound or DMSA scanning
 ** '''Optional if both kidneys are normal''' by ultrasound or DMSA scanning
-** '''The long-term health impact of VUR and renal injury may be distant in time''', difficult to accurately predict, and subtle in clinical presentation. This is of particular importance in patients with renal scarring prior to reflux resolution or in whom there is a recurrence of UTI after reflux resolution.
+* '''If febrile UTI following resolution or surgical treatment of VUR, evaluate for (2):'''
-* '''With the occurrence of a febrile UTI following resolution or surgical treatment of VUR, evaluation for BBD or recurrent VUR is recommended'''
+*#'''BBD'''
-* '''Recommendation: It is recommended that the long-term concerns of hypertension (particularly during pregnancy), renal functional loss, recurrent UTI, and familial VUR in the child's siblings and offspring be discussed with the family and communicated to the child at an appropriate age.'''
+*#'''Recurrent VUR'''
 == Screening for VUR ==
 === Screening in Siblings of Children with VUR ===
-* '''The prevalence of VUR is 27% in siblings of children with VUR'''
+*'''Prevalence of VUR is 27% in siblings of children with VUR'''
-* The goal of screening for VUR in siblings is to identify clinically unapparent VUR in order to initiate preventative therapy, usually CAP. However, the value of CAP in preventing febrile UTI and renal damage in VUR is unproven. Therefore, recommendations for screening are limited by the uncertainty of any potential benefit gained by identifying VUR. Identification of VUR may be of some benefit by increasing the awareness of parents and health providers to the potentially increased risk of pyelonephritis and renal scarring
+* Goal of screening (through VCUG or radionuclide cystogram) for VUR in siblings is to identify clinically unapparent VUR in order to initiate preventative therapy, usually CAP.
+**However, the value of CAP in preventing febrile UTI and renal damage in VUR is unproven. Therefore, recommendations for screening are limited by the uncertainty of any potential benefit gained by identifying VUR.
+**Identification of VUR may be of some benefit by increasing the awareness of parents and health providers to the potentially increased risk of pyelonephritis and renal scarring
 * '''Option: Given that the value of identifying and treating VUR is unproven, an observational approach without screening for VUR may be taken for siblings of children with VUR, with prompt treatment of any acute UTI and subsequent evaluation for VUR'''
-* '''Option: Ultrasound screening of the kidneys in the sibling of a child with VUR may be performed to identify significant renal scarring and to focus attention on the presence and potential further risk of VUR.'''
+* '''Option: Ultrasound screening of the kidneys in the sibling of a child with VUR may be performed to identify significant renal scarring and to focus attention on the presence and potential further risk of VUR'''
-* '''<span style="color:#ff0000">Screening for VUR</span>''' (VCUG or radionuclide cystogram) '''in the sibling is recommended if (2):'''
+* '''<span style="color:#ff0000">Screening for VUR in the sibling is recommended if (2):'''
 *# '''<span style="color:#ff0000">Evidence of renal cortical abnormalities or renal size asymmetry on US</span>''' [of sibling]
 *# '''<span style="color:#ff0000">History of UTI in the sibling''' who has not been tested for VUR</span>
 * '''Option: Sibling screening of older children who are toilet trained may be offered, although the value of identification of VUR is undefined.'''
-=== Screening in Offpsring ===
+=== Screening in Offspring ===
-* The incidence of reflux in the offspring of a patient with VUR is 36%
+* Risk of reflux in the offspring of a patient with VUR is 36%
 * '''Screening for VUR in the offspring is optional'''
 === Screening in the neonate with a history of prenatal hydronephrosis ===
-* '''Infants with prenatally detected hydronephrosis have an incidence of VUR of 16%'''
+* Risk of VUR in infants with prenatally detected hydronephrosis is 16%
 ** '''Grade of hydronephrosis is NOT associated with risk of VUR'''
 * '''Indications for VCUG in the neonate with a history of prenatal hydronephrosis:'''
@@ Line 266: / Line 272: @@
 # What are indications for continuous antibiotic prophylaxis in children with VUR?
+#What are the treatment options for bladder bowel dysfunction?
 #Describe the follow-up of a patient with VUR?
 # What are the indications for VCUG in a neonate with antenatal hydronephrosis?
@@ Line 272: / Line 279: @@
 # What are indications for continuous antibiotic prophylaxis in children with VUR?
+#What are the treatment options for bladder bowel dysfunction?
+##Behavioral therapy
+##Biofeedback (appropriate for children age >5)
+##Treatment of constipation
+##Anti-cholinergic medications
+##Alpha blockers
 #Describe the follow-up of a patient with VUR?
+##Annual history and physical exam (including measurement of blood pressure, height, and weight)
+##Urinalysis
+##Ultrasound
+##If continuous antibiotic prophylaxis used, then VCUG between 12 and 24 months
 # What are the indications for VCUG in a neonate with antenatal hydronephrosis?