Vesicoureteral reflux

Last updated: March 24, 2022

Summarytoggle arrow icon

Vesicoureteral reflux (VUR) is the retrograde flow of urine from the bladder into the ureter. Primary VUR is the most common type and is due to a congenital defect of the terminal portion of the ureter. Bladder outlet obstruction, cystitis, and congenital ureteral anomalies (e.g., ureteral duplication, ectopic ureter) may cause secondary VUR. Children with VUR are usually asymptomatic until they develop a urinary tract infection (presenting with fever, dysuria, urgency, flank pain). Other manifestations include hypertension, uremia, and kidney failure in advanced cases of reflux nephropathy. The initial workup for VUR includes laboratory tests (creatinine levels, electrolytes) and renal ultrasound for evaluation of kidney function and possible structural damage. Voiding cystourethrogram is the diagnostic test of choice for demonstrating urinary reflux and the severity of the disease. Most cases of primary VUR resolve spontaneously as the child ages. Medical management with prophylactic antibiotics (e.g., trimethoprim-sulfamethoxazole, nitrofurantoin) and behavioral modification (timed micturition) has proven successful in treating and preventing complications. Patients with higher grades of primary VUR with ureteral dilation and hydronephrosis or with recurrent UTIs require endoscopic/surgical correction of the vesicoureteral junction. Treatment of the underlying cause corrects secondary VUR. Complications of VUR include hydronephrosis, obstructive nephropathy, pyelonephritis, and chronic kidney disease.

Epidemiologytoggle arrow icon

  • Incidence: ∼ 1% of newborns [1]
  • Age: : children < 2 years [2]
  • Sex: > (2:1) [2]
  • Race: more common in white children [2]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Primary VUR (most common type) [3]

  • Short intramural ureter vesicoureteric junction (VUJ) fails to close completely during bladder contraction → VUR

Secondary VUR

Clinical featurestoggle arrow icon

VUR is generally asymptomatic until it causes a urinary tract infection.

Diagnosticstoggle arrow icon

Laboratory studies



Contrast voiding cystourethrogram (micturating cystourethrogram)

Grading of vesicoureteral reflux [6]
Grades Findings on voiding cystourethrogram

Grade I

  • Reflux limited to the ureter
  • No ureteral dilation

Grade II

Grade III

Grade IV

Grade V

DMSA renal scan [7]

  • Nuclear imaging method based on the injection of radioactive dimercaptosuccinic acid
  • Assessment of cortical tissue, renal function, and scarring (indicated in the case of hypodense photopenic lesions)
  • Further indicated for follow-ups and treatment monitoring

MAG3 scan (radionuclear cystourethrography)

  • A nuclear medicine scan using the radiolabelled isotope MAG3 (mercaptoacetyltriglycine)
  • Detects VUR, especially if caused by obstructions , measures renal function
  • Follow-ups

Urodynamic testing

  • Indicated in the evaluation of secondary VUR

Treatmenttoggle arrow icon

Conservative treatment

Surgical treatment

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

  1. Capozza N, Gulia C, Heidari Bateni Z, et al. Vesicoureteral reflux in infants: what do we know about the gender prevalence by age?. Eur Rev Med Pharmacol Sci. 2017; 21 (23): p.5321-5329.doi: 10.26355/eurrev_201712_13916 . | Open in Read by QxMD
  2. Chand DH, Rhoades T, Poe SA, Kraus S, Strife CF. Incidence and severity of vesicoureteral reflux in children related to age, gender, race and diagnosis.. J Urol. 2003; 170 (4 Pt 2): p.1548-50.doi: 10.1097/01.ju.0000084299.55552.6c . | Open in Read by QxMD
  3. Fröber R. Surgical anatomy of the ureter. BJU International. 2007; 100 (4): p.949=965.
  4. dos Santos J, Varghese A, Williams K, Koyle MA. Recommendations for the Management of Bladder Bowel Dysfunction in Children. Pediat Therapeut. 2014; 4 (1).doi: 10.4172/2161-0665.1000191 . | Open in Read by QxMD
  5. Dillon MJ, Goonasekera CD. Reflux nephropathy. J Am Soc Nephrol. 1998; 9 (12): p.2377-2383.
  6. Voiding cystourethrography. Updated: January 16, 2017. Accessed: January 16, 2017.
  7. Shaikh N, Spingarn RB, Hum SW. Dimercaptosuccinic acid scan or ultrasound in screening for vesicoureteral reflux among children with urinary tract infections. Cochrane Database Syst Rev. 2016; 7: p.CD010657.doi: 10.1002/14651858.CD010657.pub2 . | Open in Read by QxMD
  8. Elder JS, Peters CA, Arant BS, et al. Pediatric Vesicoureteral Reflux Guidelines Panel summary report on the management of primary vesicoureteral reflux in children. J Urol. 1997; 157 (5): p.1846-1851.doi: 10.1016/S0022-5347(01)64882-1 . | Open in Read by QxMD
  9. Hoberman A, Greenfield SP, Mattoo TK, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med. 2014; 370 (25): p.2367-2376.doi: 10.1056/NEJMoa1401811 . | Open in Read by QxMD
  10. Peters CA, Skoog SJ, Arant BS, et al. Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children. J Urol. 2010; 184 (3): p.1134-1144.doi: 10.1016/j.juro.2010.05.065 . | Open in Read by QxMD
  11. Puri P, Chertin B, Velayudham M, Dass L, Colhoun E. Treatment of vesicoureteral reflux by endoscopic injection of dextranomer/hyaluronic Acid copolymer: preliminary results. J Urol. 2003; 170 (4 Pt 2): p.1541-1544.

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