Vesicoureteric reflux (VUR) in children: causes, tests and treatment

Urine is made in the kidneys and travels to the bladder through two narrow tubes called ureters. Cambridge University Hospitals explains that the ureters normally have a one-way valve that prevents the backflow of urine. In some children this does not work properly, so urine backtracks up the ureters towards one or both kidneys. This is vesicoureteric reflux, VUR or simply reflux.

The leaflet describes the benefit of treatment as preventing urinary tract infections caused by the reflux and so helping to protect the kidneys.

Reflux can affect one or both kidneys, and the right plan depends on the individual child, which is why the paediatric team's advice matters more than any general rule.

Most children with reflux are identified because of a urine infection. The NHS lists the signs of a urinary tract infection in children as a high temperature, appearing generally unwell, babies and young children being irritable and not feeding, eating or drinking properly, wetting the bed or themselves, and being sick. Older children may describe pain or a burning feeling when passing urine, needing to go more often, tummy or back pain, or cloudy or blood-stained urine.

The NHS says to ask for an urgent GP appointment or get help from NHS 111 if you think your child may have a urinary tract infection and they are aged 15 or younger. It also says to call 999 or go to A&E if a child is confused, drowsy or has difficulty speaking. A suspected urine infection in a baby or child should not be left to settle on its own.

NICE guidance on urinary tract infection in under 16s lists a family history of vesicoureteric reflux or kidney disease, antenatally diagnosed kidney abnormality, constipation, poor urine flow, poor growth and high blood pressure among the risk factors for infection and serious underlying problems that clinicians should record.

NICE sets out which scans are advised after a urine infection, depending on the child's age and how the infection behaves. It recommends a urinary tract ultrasound during the acute infection for babies and children with an atypical infection, to identify structural problems such as obstruction. Babies younger than 6 months with a first infection that responds to treatment are advised to have an ultrasound within 6 weeks, and children who have recurrent infections are also sent for ultrasound within 6 weeks.

A DMSA scan (a scintigraphy scan, a type of nuclear medicine scan) is advised 4 to 6 months after the acute infection for babies and children with atypical or recurrent infections in the younger age groups, and for recurrent infections in children aged 3 and over. NICE says imaging to identify VUR itself should not be routine. A micturating cystourethrogram (MCUG), an X-ray test of the bladder as it fills and empties, is advised for babies younger than 6 months with atypical or recurrent infection, and is otherwise considered only when specific features are present, such as dilatation on ultrasound or poor urine flow.

NICE adds that when an MCUG is done, prophylactic antibiotics should be given by mouth for 3 days, with the MCUG on the second day. Your child's team will explain which tests apply and why, since the schedule differs by age.

Cambridge University Hospitals states that many children with VUR can be managed conservatively, given antibiotics and monitored as outpatients. Where infections are recurrent or severe, treatment or surgery is usually required to protect the kidneys. Your paediatric team will weigh the grade of reflux, your child's age and the history of infections.

The leaflet explains that Deflux is an injectable gel that acts as a bulking agent, placed where the ureter opens into the bladder to prevent backflow. It is given through a cystoscope, a fine camera passed up the urethra, under a general anaesthetic in children. It may also be called a STING or HIT procedure.

Blood in the urine and a stinging feeling when passing urine are common afterwards and should settle in one to two days. The leaflet says about 1 in 20 children have lower back pain on the injected side for around 24 hours, and some develop a urine infection needing antibiotics. Reflux sometimes continues despite treatment, and in approximately 1 in 100 children too much gel can cause a blockage of the ureter needing a further procedure. The consultant will discuss risks specific to your child.

The leaflet lists several things that help prevent urine infections: drinking enough so that urine is clear in colour during the day, passing urine regularly (six to eight times a day), avoiding constipation, and for girls wiping from front to back. It gives suggested daily fluid intakes by age, for example 1000 to 1400 ml for children aged 4 to 8. It also notes that supplements such as cranberry or D-mannose are sometimes used and recommends discussing them with a doctor or nurse specialist first.

Keep a note of any infections, temperatures and treatments. If your child has a temperature or seems unwell with symptoms of a urine infection, seek advice promptly, and make sure any urine sample is collected before antibiotics are started, as NICE advises.

On the NHS, reflux is usually diagnosed and managed by paediatric teams, often with a paediatric nephrologist or urologist, after referral from a GP or from hospital care following an infection. Scans, antibiotics, injections and surgery are all provided within that pathway.

Some families choose a private paediatric urology or nephrology opinion for faster access or a second view. The tests and treatment options are the same ones described here, and a private consultant will usually liaise with the NHS team that holds your child's records. Whichever route you use, ask who coordinates follow-up scans and what should prompt an urgent review.