AUA: Vesicoureteral Reflux (2017): Difference between revisions

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 == Initial Management of the Child with VUR ==
-* Standard: Family and patient education regarding VUR should include 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.
+* Family and patient counseling
-*'''The goals of management of the child with VUR are:'''
+**Discuss the rationale for treating VUR, the potential consequences of untreated VUR, the equivalency of certain treatment approaches,
-*# '''Prevent recurring febrile UTIs'''
+**Assess likely adherence with the care plan, determine parental concerns
-*#* '''While resolution of VUR will reduce the incidence of febrile UTI/pyelonephritis''', '''the overall incidence of UTI may remain unchanged'''
+**Accommodate of parental preferences when treatment choices offer a similar risk-benefit balance
-*# '''Prevent renal injury'''
-*#* '''In the setting of acute pyelonephritis, VUR significantly increases the risk of developing renal scarring'''
+=== Goals of management (3): ===
-*# '''Minimize the morbidity of treatment and follow-up'''
+# '''Prevent recurring febrile UTIs'''
-* '''Antibiotic prophylaxis'''
+#* '''While resolution of VUR will reduce the incidence of febrile UTI/pyelonephritis''', '''the overall incidence of UTI may remain unchanged'''
-** '''RIVUR'''
+# '''Prevent renal injury'''
-*** '''Population: 607 children with''' dilated and non-dilated '''VUR that was diagnosed after''' a first or second '''febrile or symptomatic UTI'''
+#* '''In the setting of acute pyelonephritis, VUR significantly increases the risk of developing renal scarring'''
-**** Population was overwhelmingly female (91%)
+# '''Minimize the morbidity of treatment and follow-up'''
-**** Half of the study participants were < 11 months of age
-*** '''Randomized to trimethoprim-sulfamethoxazole prophylaxis vs. placebo'''
+=== '''Antibiotic prophylaxis''' ===
-*** '''Primary outcome: recurrence of UTI'''
+* '''RIVUR'''
-*** '''Results:'''
+** '''Population: 607 children with''' dilated and non-dilated '''VUR that was diagnosed after''' a first or second '''febrile or symptomatic UTI'''
-**** '''45% significant decrease in recurrence of UTI in antibiotic prophylaxis''' (RR: 0.55; 95% CI: 0.38-0.78)
+*** Population was overwhelmingly female (91%)
-***** 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
+*** Half of the study participants were < 11 months of age
-***** '''Prophylaxis was particularly effective in children'''
+** '''Randomized to trimethoprim-sulfamethoxazole prophylaxis vs. placebo'''
-*****# '''Whose index infection was febrile'''
+** '''Primary outcome: recurrence of UTI'''
-*****# '''Those with baseline BBD'''
+** '''Results:'''
-**** '''No difference in the occurrence of renal scarring'''
+*** '''45% significant decrease in recurrence of UTI in antibiotic prophylaxis''' (RR: 0.55; 95% CI: 0.38-0.78)
-*** '''Criticisms:'''
+**** 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
-**** '''Population may not reflect typical patient in practice'''
+**** '''Prophylaxis was particularly effective in children'''
-***** '''Majority female and half under age 11 months'''
+****# '''Whose index infection was febrile'''
-***** '''Trial does not address patients with VUR and no history of UTI'''
+****# '''Those with baseline BBD'''
-*** RIVUR Trial Investigators. Antimicrobial prophylaxis for children with vesicoureteral reflux. NEJM 2014; 370: 2367.
+*** '''No difference in the occurrence of renal scarring'''
-* '''Management of VUR based on age (cut-off age 1 year)'''
+** '''Criticisms:'''
-** '''Child age < 1 with VUR'''
+*** '''Population may not reflect typical patient in practice'''
-*** '''VUR resolution occurs in ≈50% of these children within 24 months'''
+**** '''Majority female and half under age 11 months'''
-*** Infants age < 1 may not show clinical evidence of pyelonephritis as clearly as older children and they may have a greater risk of infection-related morbidity.
+**** '''Trial does not address patients with VUR and no history of UTI'''
-*** '''Continuous antibiotic prophylaxis (CAP)'''
+** [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3691529/ RIVUR Trial Investigators. Antimicrobial prophylaxis for children with vesicoureteral reflux. NEJM 2014; 370: 2367.]
-**** '''Recommended in children age < 1 with (2):'''
-****# '''A history of a febrile UTI or'''
+=== Management of VUR based on age (cut-off age 1 year) ===
-****# '''VUR grade ≥III''' who is identified through screening, even in the absence of a history of febrile UTIs
-**** '''Optional in children age < 1 with:'''
+==== Child age < 1 with VUR ====
-***** '''VUR grades I–II''' who is identified through screening, even in the absence of a history of febrile UTIs
+* '''VUR resolution occurs in ≈50% of these children within 24 months'''
-*** '''Circumcision'''
+* Infants age < 1 may not show clinical evidence of pyelonephritis as clearly as older children and they may have a greater risk of infection-related morbidity.
-**** '''May be considered in the infant male with VUR''' based on an increased risk of UTIs in boys who are not circumcised compared to those who are circumcised.
+* '''Continuous antibiotic prophylaxis (CAP)'''
-***** Although there are insufficient data to evaluate the degree of this increased risk and its duration, parents need to be made aware of this association to permit informed decision-making.
+** '''Recommended in children age < 1 with (2):'''
-** '''Child age > 1 with VUR'''
+**# '''A history of a febrile UTI or'''
-*** Recommendations are somewhat different from those age < 1, due to:
+**# '''VUR grade ≥III''' who is identified through screening, even in the absence of a history of febrile UTIs
-**** Greater likelihood of BBD
+** '''Optional in children age < 1 with:'''
-**** Lower probability of spontaneous resolution of VUR
+*** '''VUR grades I–II''' who is identified through screening, even in the absence of a history of febrile UTIs
-**** Lower risk of acute morbidity from febrile UTI
+* '''Circumcision'''
-**** Greater ability of the child to verbally complain of symptoms to indicate acute infection
+** '''May be considered in the infant male with VUR''' based on an increased risk of UTIs in boys who are not circumcised compared to those who are circumcised.
-*** '''Treatment of BBD, if present, is recommended, preferably before any surgical intervention for VUR'''
+*** Although there are insufficient data to evaluate the degree of this increased risk and its duration, parents need to be made aware of this association to permit informed decision-making.
-**** There are insufficient data to recommend a specific '''treatment regimen for BBD'''
-**** '''Options include:'''
+==== Child age > 1 with VUR ====
-***** '''Behavioral therapy'''
+* Recommendations are somewhat different from those age < 1, due to:
-***** '''Biofeedback (appropriate for children age > 5)'''
+** Greater likelihood of BBD
-***** '''Treatment of constipation'''
+** Lower probability of spontaneous resolution of VUR
-***** '''Anticholinergic medications'''
+** Lower risk of acute morbidity from febrile UTI
-***** '''Alpha blockers'''
+** Greater ability of the child to verbally complain of symptoms to indicate acute infection
-**** Monitoring the response to BBD treatment is recommended to determine whether treatment should be maintained or modified.
+* '''Treatment of BBD, if present, is recommended, preferably before any surgical intervention for VUR'''
-*** '''Indications for CAP in a child age > 1 year with VUR (3):'''
+** There are insufficient data to recommend a specific '''treatment regimen for BBD'''
-***# '''BBD'''
+** '''Options include:'''
-***# '''Recurrent febrile UTI'''
+*** '''Behavioral therapy'''
-***# '''Renal cortical abnormalities on imaging'''
+*** '''Biofeedback (appropriate for children age > 5)'''
-**** '''In the absence of these features, CAP or observation,''' with prompt initiation of antibiotic therapy for UTI, '''are options'''
+*** '''Treatment of constipation'''
+*** '''Anticholinergic medications'''
+*** '''Alpha blockers'''
+** Monitoring the response to BBD treatment is recommended to determine whether treatment should be maintained or modified.
+* '''Indications for CAP in a child age > 1 year with VUR (3):'''
+*# '''BBD'''
+*# '''Recurrent febrile UTI'''
+*# '''Renal cortical abnormalities on imaging'''
+** '''In the absence of these features, CAP or observation,''' with prompt initiation of antibiotic therapy for UTI, '''are options'''
 == Follow-up of the Child with VUR not undergoing surgical intervention ==