Vesicoureteral Reflux (VUR) Symptoms

Vesicoureteral Reflux (VUR) Treatment in Indore

Vesicoureteral reflux (VUR) is one of the most important conditions to consider in the case of a child with repeated fevers and urinary infections without an obvious explanation and one of the most important to detect early. VUR is a structural problem with the valve mechanism that normally prevents urine from backing up from the bladder into the ureter and kidney. When a child with VUR develops a urinary tract infection, the infected urine can reflux up to the kidney and cause pyelonephritis – kidney infection – which can leave permanent scars on the developing kidney.

VUR is one of the most common urologic problems seen in children, occurring in approximately 1 to 2 percent of all children and in 30 to 40 percent of children presenting with a urinary tract infection. The condition ranges from mild (Grade I) in which most cases resolve spontaneously as the child grows to severe (Grade V) in which surgical correction is usually required to prevent progressive kidney damage. Early detection, appropriate grading and a management plan tailored to the individual child’s risk of kidney damage is the key to good outcomes.

What Is Vesicoureteral Reflux (VUR)?

Vesicoureteral reflux is the retrograde passage of urine from the bladder into the ureter and, in the more severe form, into the kidney. Normally the ureter goes through a tunnel at an angle through the bladder wall . This acts as a one way valve . When the bladder fills and contracts to urinate , the pressure inside the bladder is higher than the pressure inside the ureter , so the tunnel closes and urine is not pushed back up the ureter . This valve mechanism is deficient in VUR, most commonly due to an abnormally short submucosal tunnel or abnormal positioning of the ureteric orifice. This allows retrograde flow of urine, particularly during voiding when bladder pressure is highest.

VUR is graded I to V using the International Reflux Study grading system, based on the appearance of the urinary tract on a voiding cystourethrogram (VCUG), which is an X-ray study performed as the bladder fills with contrast and the child voids. The grade correlates with the risk of spontaneous resolution and the risk for renal impairment. The grading system is detailed in the table below:

Grade	Description	Reflux Extent	Typical Management
Grade I	Reflux into the ureter only, not reaching the renal pelvis	Ureter only	Often resolves spontaneously; observation
Grade II	Reflux reaches the renal pelvis and calyces without dilation	Pelvis & calyces, no dilation	High spontaneous resolution; antibiotic prophylaxis if recurrent UTI
Grade III	Mild to moderate dilation of ureter, pelvis & calyces; calyceal fornices preserved	Mild–moderate dilation	Moderate resolution rate; prophylaxis ± endoscopic treatment
Grade IV	Moderate dilation with blunting of calyceal fornices; ureteral tortuosity	Significant dilation, tortuous ureter	Lower spontaneous resolution; endoscopic or surgical correction often needed
Grade V	Gross dilation and tortuosity of the ureter; loss of papillary impressions	Severe dilation, gross reflux	Surgical correction usually required; high renal damage risk

VUR is classified as primary (due to a congenital abnormality of the ureterovesical junction itself, being the most common form in children) or secondary (due to another condition such as bladder outlet obstruction, neurogenic bladder or high-pressure voiding dysfunction leading to increased bladder pressure to overwhelm a normal valve mechanism). This difference is central to management as primary VUR is managed according to grade and clinical course of the child and secondary VUR is managed by eliminating the causative factor as the primary intervention.

What Causes Vesicoureteral Reflux?

VUR occurs when the normal one way valve mechanism at the junction of the ureter and bladder does not work properly. This failure may be a primary developmental abnormality present from birth, or it may be secondary to another condition which overwhelms an otherwise adequate valve mechanism with excess bladder pressure.

Congenital Defect in the Ureterovesical Junction (UVJ)

Primary VUR is caused by a developmental defect in the position or development of the ureteric bud during foetal life.
The ureteric orifice may be ectopically situated, laterally displaced, with a reduction in the length and angle of the submucosal tunnel.
Primary VUR is the most common type seen in infants and young children and is often identified when investigating antenatal hydronephrosis or the first UTI.
Family history is important: siblings of children with VUR have a 25 to 30 percent chance of also having VUR.

Short Submucosal Ureter Tunnel – Why the Valve Mechanism Fails

The valve mechanism depends on a submucosal tunnel of sufficient length in relation to the diameter of the ureter, generally a length to diameter ratio of 5: 1 being required for competence.
If the tunnel is too short, the increase in pressure in the bladder on voiding is transmitted directly up the ureter rather than compressing it closed.
As children mature, the ureteric tunnel lengthens and this is the predominant mechanism for spontaneous resolution of lower grade VUR with age.
This explains the lower spontaneous resolution rates in higher reflux grades which are associated with shorter, more severely deficient tunnels.

Secondary VUR Due to Bladder Outlet Obstruction

Posterior urethral valves (in boys) cause severe bladder outlet obstruction, very high voiding pressures that push urine backwards through the UVJ.
The bladder becomes thick-walled, trabeculated and high-pressure, the resulting VUR is frequently severe and bilateral.
The primary goal is to treat the underlying obstruction (valve ablation) and VUR may improve once bladder pressures normalize following relief of the obstruction.
Secondary VUR from obstruction is at higher risk of kidney damage as obstruction and reflux act on the kidney at the same time.

Neurogenic Bladder Causing Secondary VUR

Conditions affecting bladder nerve control, spina bifida, sacral agenesis, spinal cord injury, lead to abnormal bladder pressure dynamics that may result in VUR.
High-pressure poorly compliant neurogenic bladders generate sustained high pressures that overcome the UVJ valve mechanism.
Management of the bladder dysfunction itself requires treatment, clean intermittent catheterisation, anticholinergic medication or bladder augmentation, in addition to VUR-specific therapy.
Urological surveillance of patients with neurogenic bladder is necessary for life because of the ongoing risk to kidney function.

High Bladder Pressure & Bladder Dysfunction as a Cause

Bladder and bowel dysfunction (BBD) includes overactive bladder, dysfunctional voiding, and constipation. BBD is a common cause of secondary VUR in otherwise healthy children.
Inadequate relaxation of the pelvic floor during voiding (dysfunctional voiding) causes increased voiding pressures that may contribute to or exacerbate VUR.
Constipation causes rectal distension, which mechanically compresses the bladder and bladder neck and contributes to dysfunctional voiding patterns.
Many children with BBD can have VUR improved or resolved without surgery with urotherapy, bowel management, and biofeedback.

Symptoms of Vesicoureteral Reflux You Should Not Ignore

The reflux of urine is not felt by the child , VUR itself does not cause direct symptoms . The symptoms of VUR are the symptoms of the conditions it leads to: urinary tract infections and, in advanced cases, kidney damage. It is important to recognize these patterns early in order to preserve kidney function.

Recurrent Urinary Tract Infections (UTIs) in Children

Two or more UTIs in a child, especially febrile UTIs, should always be investigated for VUR as an underlying cause.
VUR enables bacteria to ascend from the bladder directly to the kidney during voiding, converting a simple bladder infection into a kidney infection.
Recurrent UTIs in boys are of particular concern as UTI is uncommon in boys without an underlying structural abnormality.
Each febrile UTI in a child with VUR has the potential to lead to new renal scarring, thus prevention of recurrence is an important aspect of management.

Fever Without Obvious Cause in Infants & Young Children

Febrile UTI without any obvious cause in an infant, particularly under 12 months of age, should always prompt urine testing as febrile UTI may occur without urinary symptoms localising to any particular part of the urinary tract.
Infants can not describe urinary symptoms Fever, irritability, poor feeding and vomiting may be the only signs of pyelonephritis.
If an infant is febrile, with infection demonstrated in a clean-catch or catheter urine specimen, renal ultrasound and consideration of VCUG for VUR should be performed.
Delayed diagnosis of febrile UTI in infants is one of the most common preventable causes of renal scarring due to VUR.

Flank or Abdominal Pain During or After Urination

Older children with VUR may complain of flank or abdominal discomfort during or immediately after voiding, which is the sensation of refluxing urine distending the renal pelvis.
This symptom is uncommon and subtle but, when present and reproducible, is a useful clinical clue to VUR.
Children with a history of UTIs presenting with flank pain during voiding should have VCUG evaluation if not already performed.

Poor Weight Gain & Failure to Thrive in Infants With VUR

Recurrent febrile UTIs in infants with VUR can lead to poor feeding, vomiting and poor weight gain, failure to thrive.
Poor growth can be influenced by chronic kidney impairment (scarring from VUR) through decreased erythropoietin, acidosis, and diminished appetite.
Urinalysis and renal ultrasound should be a routine part of the work‑up of any infant with unexplained failure to thrive.
In this setting, the failure to thrive can be reversed with early identification and treatment of VUR once recurrent infections are controlled.

Bedwetting (Enuresis) & Daytime Urinary Accidents

Secondary VUR is a common consequence of bladder and bowel dysfunction and usually presents as bedwetting beyond the age of normal continence (5 years) and daytime urinary accidents.
These symptoms are suggestive of dysfunctional voiding patterns that may both cause VUR and increase the risk of UTI.
Evaluation of VUR in these children should be accompanied by assessment for BBD including bladder diary, uroflowmetry and constipation history.
Treatment of the underlying voiding dysfunction often improves the incontinence symptoms and the VUR.

How Does VUR Damage the Kidney?

VUR damages primarily the kidney through recurrent pyelonephritis, a kidney infection due to bacteria refluxing from the bladder to the renal parenchyma during episodes of urinary tract infection. Each episode of pyelonephritis causes an inflammatory response in the kidney tissue, which, if severe or recurrent, leads to permanent scarring. Areas of the kidney’s filtering tissue are replaced by non-functional fibrous scar tissue. This is called reflux nephropathy. Multiple scarred segments over a childhood of recurrent infections can have a cumulative effect resulting in a significant overall reduction in renal function and, in severe bilateral cases, can progress to chronic kidney disease, hypertension and, in a small proportion of severely affected individuals, end-stage renal disease requiring dialysis or transplant in adulthood. The severity of damage is directly correlated with the VUR grade, the number and severity of febrile UTI episodes and, critically, the age at which the first infection occurs, with infants under one year being at the greatest risk of new scar formation.

When Should You See a Doctor for VUR in Indore?

One of the most important things a parent can do to protect their child’s long-term kidney health is to get early specialist assessment for suspected or confirmed VUR. The following situations specifically indicate prompt urological referral.

Child With Recurrent Fever & UTIs – Always Investigate Further

Refer for VCUG evaluation any child who has had 2 or more febrile UTIs or one febrile UTI with an abnormal renal ultrasound.
Repeated courses of antibiotics for UTI should not be accepted without investigation into the underlying cause, recurrence indicates a structural reason needs to be found.
Early referral enables prophylactic measures to be instituted before further renal scarring occurs.

Antenatal Hydronephrosis Found on Foetal Scan

Hydronephrosis seen on the fetal anomaly scan is one of the commonest ways to diagnose VUR, VCUG is part of the standard postnatal evaluation protocol.
Post-natal ultrasound should be arranged for babies with antenatal hydronephrosis prior to discharge or in the first week of life.
Antenatal counselling with a paediatric urologist helps parents to understand the evaluation pathway before their baby is born.

First Febrile UTI in a Child Under 5 Years

The current paediatric urology guidance recommends renal and bladder ultrasound after the first febrile UTI in any child under the age of 5 years.
VCUG is considered selectively based on ultrasound findings, recurrence and presence of atypical features (poor response to antibiotics, non-E.coli organism, raised creatinine).
The initial febrile UTI is a chance for early detection, do not wait for a second episode before investigating.

High-Grade VUR Detected on Routine Postnatal Scan

Any indication for VCUG with Grade IV or V VUR should be referred urgently to paediatric urology because of the low rates of spontaneous resolution and the significant risk of renal damage.
High-grade VUR requires antibiotic prophylaxis while awaiting specialist assessment and discussion of endoscopic or surgical correction.
Differential renal function (MAG3 or DMSA scan) should be assessed at the time of diagnosis of high grade VUR to establish baseline kidney function.

Child With High Blood Pressure & Recurrent Infections

Hypertension is an uncommon finding in the child and always warrants investigation, VUR with renal scarring being an important reversible or modifiable cause.
Reflux nephropathy is one of the most common causes of secondary hypertension in children and young people.
Blood pressure should be checked at each visit in children with known VUR or renal scarring , early detection of hypertension permits prompt treatment .

Adults With Recurrent UTIs & Kidney Scarring on Imaging

Adults with a history of childhood VUR, which was not investigated or treated, may present in adulthood with recurrent UTIs, hypertension, proteinuria or chronic kidney disease.
The presence of renal scarring on adult imaging, especially asymmetric kidney size or cortical thinning, should raise the possibility of underlying VUR as the cause.
Evaluation of adult-onset VUR includes assessment of kidney function, blood pressure, proteinuria and, where relevant, VCUG or MAG3 scanning to characterise the reflux and its functional impact.

Real Patient Experiences in Urology Care

Frequently Asked Questions About Vesicoureteral Reflux

Will my child's VUR go away on its own?

The likelihood of spontaneous resolution of VUR depends primarily on its grade. In 70 to 80 percent of children, Grade I and II VUR resolve spontaneously, usually during the first few years of life as the ureteric submucosal tunnel lengthens with growth. Grade III VUR will resolve spontaneously in approximately 40 to 50 percent of cases. Spontaneous resolution rates for grade IV and V VUR are much lower, usually less than 20 to 30 percent, and correction is more often required surgically or endoscopically. Resolution is also more likely in younger children and unilateral as opposed to bilateral reflux. Resolution is followed up with regular VCUG studies (usually at 12-18 month intervals).

What is a VCUG and is it painful for my child?

A voiding cystourethrogram (VCUG) is an X-ray study. A small catheter is placed in the bladder and contrast dye is placed to fill the bladder. X-ray images are taken as the bladder fills and as the child voids capturing any reflux of contrast up the ureters. There is some mild discomfort from catheter placement ( like a urine catheter ) but it is not significantly painful . Most children tolerate it well, particularly with preparation and a calm environment. The radiation dose is low and the information obtained, grading the reflux and assessing the bladder and urethra is essential to management planning and cannot be obtained with ultrasound alone.

What is the STING procedure for VUR?

STING (Subureteric Transurethral Injection) also known as HIT (Hydrodistension Implantation Technique) is an endoscopic day-case procedure under general anaesthesia, where a bulking agent (typically dextranomer/hyaluronic acid copolymer) is injected underneath the ureteric orifice through a cystoscope. This creates a ‘mound’ which improves the valve mechanism and reduces or eliminates reflux. There is no incision, it takes about 20 to 30 minutes and the child usually goes home the same day. Success rates (resolution of reflux on follow-up VCUG) are around 70 to 90 percent for Grade I to III VUR and somewhat lower for Grade IV to V. It is a good choice for children who need active treatment but who are not candidates for major reconstructive surgery, or whose families want to avoid it.

Does my child need surgery for VUR?

Not necessarily, the decision will depend on the grade of VUR, clinical course of the child (breakthrough infections on prophylaxis, new renal scarring), age and whether bladder/bowel dysfunction is also contributing. Many children, especially those with Grade I to III VUR, are successfully managed with antibiotic prophylaxis and observation while awaiting spontaneous resolution. Active treatment (endoscopic STING or surgical reimplantation) should be considered in children with high-grade VUR (IV-V), breakthrough febrile UTIs despite prophylaxis, new or worsening renal scarring, or parental preference for definitive treatment rather than prolonged observation with prophylactic antibiotics. The decision is individual and made in partnership with the family after much discussion of the options.

What is the difference between primary and secondary VUR?

Primary VUR is due to a congenital developmental abnormality of the ureterovesical junction itself, usually a short or abnormally positioned submucosal ureteric tunnel, existing from birth and not related to other conditions. This is the commonest type, particularly in infants and young children. Secondary VUR is when a secondary condition generates pressures that overwhelm an otherwise adequate UVJ valve mechanism, such as bladder outlet obstruction (e.g. posterior urethral valves), neurogenic bladder, or bladder/bowel dysfunction with high voiding pressures. This is an important distinction, because in secondary VUR the main intervention is to treat the cause of the reflux. If the reflux is treated (by STING or reimplantation) but the underlying high-pressure state is not corrected, it is unlikely to be successful.

How often should my child have follow-up scans for VUR?

Follow-up frequency depends on VUR grade, treatment approach and clinical course. Children with observation/prophylaxis with Grade I to III VUR are usually followed with repeat VCUG at 12–18 month intervals for resolution. Renal ultrasound is generally performed annually to assess kidney growth and exclude new scarring. Renal scarring is usually assessed with DMSA (nuclear medicine) scans at diagnosis and repeated if breakthrough febrile UTIs occur. Resolution is confirmed with a follow-up VCUG at six months after endoscopic STING or surgical reimplantation, followed by ultrasound surveillance. Hypertension may develop years after VUR has apparently resolved and blood pressure should be checked at every visit.

Can VUR cause kidney failure?

Severe, bilateral, high-grade VUR with recurrent pyelonephritis and progressive bilateral renal scarring (reflux nephropathy) can in a minority of severely affected individuals progress to CKD and, rarely, ESRD requiring dialysis or transplant. This is however the extreme end of the spectrum and is rare with proper management. In the great majority of children with VUR, especially those with lower grades, unilateral disease, and those who receive prompt treatment of febrile UTIs and appropriate management of VUR, significant impairment of kidney function does not occur. Long-term renal outcomes are determined by early detection, prophylaxis for prevention of febrile UTIs, and adequate intervention for high-grade or progressive disease.

Should siblings of a child with VUR be tested?

Children with a sibling with VUR have about a 25 to 30 percent chance of having VUR themselves, much higher than the 1 to 2 percent rate in the general population. The screening of asymptomatic siblings is an ongoing topic of discussion . Some specialists recommend renal ultrasound screening of younger siblings (especially those under 2 years), with VCUG reserved for those with abnormal ultrasound or any UTI history . Older siblings who are asymptomatic with normal urinary tracts on ultrasound and no history of UTI are usually not screened as most VUR found this way is low grade and resolves spontaneously without ever causing symptoms. Dr Vikas Singh Discusses Sibling screening individually based on index child’s VUR grade and family circumstances.

Is there a connection between constipation and VUR in children?

Yes, constipation is a well-known contributing factor to the development and persistence of VUR via its role in bladder and bowel dysfunction (BBD). A loaded rectum mechanically compresses the bladder and bladder neck leading to dysfunctional voiding patterns and elevated bladder pressures that can lead to or exacerbate VUR. Children with VUR and constipation have lower spontaneous resolution rates and higher breakthrough UTI rates on prophylaxis compared with children with normal bowel habits. Management of constipation by dietary modification, adequate fluid intake and laxatives when required, is an important and often underutilised component of management of VUR, and may improve both the reflux itself and the associated UTI risk.