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Prof. Dr. Ali Avanoğlu
Vesicoureteral Reflux (VUR) • Treatment pathways

Does Vesicoureteral Reflux Resolve on Its Own? Active Surveillance

For families who have just received a diagnosis of vesicoureteral reflux (VUR), the first question is usually, 'Will it go away on its own?' For most children, the answer is yes — but the likelihood depends on the grade of reflux, the child's age, and other contributing factors. This page explains how resolution happens, in which children it is more likely, and what 'active surveillance' means.

Who this is forFamilies whose child has just been diagnosed with vesicoureteral reflux and want to know whether treatment is needed
Reading≈6 min
ByProf. Dr. Ali AvanoğluUpdated
This page is part of vesicoureteral reflux.Read the full treatment overview on the hub page
%0%25%50%75%100DIAGNOSIS1 YR2 YR3 YR4 YR5 YRSHARE OF CHILDREN WITH PERSISTING REFLUXGrade I–IIGrade IIIGrade IV–VApproximate literature trend; spontaneous resolution is more likely at lower grades and younger ages. Individual course varies.
spontaneous resolution curves: grade I–II, III, IV–V
01 · Resolution happens with growth: the tunnel lengthens02 · Likelihood of resolution by grade03 · Factors that reduce the chance of resolution: the Estrada nomogram04 · What does active surveillance mean?05 · When is watchful waiting abandoned?
In brief5 madde
  • Resolution happens with growth: the tunnel lengthens: Most cases of vesicoureteral reflux result from a short ureteral tunnel within the bladder wall…
  • Likelihood of resolution by grade: The strongest factor determining the likelihood of resolution is the grade found on VCUG (voiding cystourethrogram, commonly called the 'voiding film').
  • Factors that reduce the chance of resolution: the Estrada nomogram: Grade alone is not the whole picture — assessing several factors together gives a more accurate prediction of resolution.
  • What does active surveillance mean?: 'Waiting for it to resolve on its own' is not the same as doing nothing.
  • When is watchful waiting abandoned?: Surveillance is chosen to give reflux the chance to resolve without harming the kidney.
01

Resolution happens with growth: the tunnel lengthens

Most cases of vesicoureteral reflux result from a short ureteral tunnel within the bladder wall (the segment of the ureter — the urine channel between the kidney and the bladder — that runs obliquely through the bladder wall). This tunnel works like a valve: when the bladder fills and contracts, the wall compresses the ureter and closes it, preventing urine from flowing back up to the kidney.

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  • As the child grows, the bladder enlarges and the ureter's tunnel within the wall lengthens. A normal tunnel is about five times the diameter of the ureter; as a tunnel that was short at birth approaches this ratio over the years, it begins to function as a valve and the reflux disappears. This is the mechanism behind spontaneous resolution — it is not a process that can be sped up with medication or diet.
  • Completing toilet training and establishing regular, complete bladder emptying also contribute to this process. This is why correcting constipation and voiding habits (treating bladder-bowel dysfunction, BBD) benefits not only infection prevention but also the chances of reflux resolving.
02

Likelihood of resolution by grade

The strongest factor determining the likelihood of resolution is the grade found on VCUG (voiding cystourethrogram, commonly called the 'voiding film'). The cumulative resolution rates reported in guidelines and long-term follow-up studies are approximately as follows; these figures represent totals reached over the years and vary by center and case.

  • Grade I–II: about 70–80%
  • Grade III: about 50%
  • Grade IV: about 30%
  • Grade V: about 10–15%
  • Source: EAU/ESPU 2024, AUA 2010; rates are cumulative over years and vary by center
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  • In low-grade reflux (I–II), the large majority of children see the reflux disappear within a few years; at grade III, this likelihood is roughly one in two. At grade IV and V — where the ureter and renal pelvis are markedly dilated — spontaneous resolution is less expected, and treatment options are discussed earlier.
  • Timing also matters: most reflux that will resolve does so within the first 3–5 years. Reflux that persists past age five, especially moderate-to-high-grade reflux, becomes progressively less likely to resolve on its own; at this point, the decision between continued waiting and corrective treatment is revisited together with the family.
03

Factors that reduce the chance of resolution: the Estrada nomogram

Grade alone is not the whole picture — assessing several factors together gives a more accurate prediction of resolution. The Estrada nomogram was developed for this purpose: based on the child's characteristics, it estimates the probability that reflux will resolve within a given time frame, and it is referenced in guidelines as a decision-support tool.

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  • The main factors entered into the nomogram that lower the likelihood of resolution are: high grade, bilateral reflux, older age at diagnosis, presentation with febrile urinary tract infection (UTI), recurrent UTI, bladder-bowel dysfunction, and scarring detected on DMSA (renal scan). None of these alone means the reflux 'won't resolve' — but when several are present together, the benefit of prolonged waiting diminishes.
  • On the other hand, in small infants found through antenatal hydronephrosis who have never had a UTI, resolution rates are more encouraging even when the grade is high. Making this distinction determines which child is best served by patient watchful waiting and which by earlier action.
04

What does active surveillance mean?

'Waiting for it to resolve on its own' is not the same as doing nothing. Active surveillance is a structured, regular program aimed at protecting the kidney from infection while reflux persists and catching any change in a timely manner. Whether or not antibiotic prophylaxis (CAP) is given, the backbone of surveillance is the same.

  • Annual kidney-bladder ultrasound: kidney growth, dilation, bladder emptying
  • Urine culture before antibiotics with every febrile illness
  • Annual blood pressure measurement and urinalysis
  • DMSA scan for scarring 4–6 months after any febrile UTI
  • Constipation and voiding habits reviewed at every check-up after toilet training
  • Follow-up VCUG: not routinely required in low grade; if needed, at 12–24-month intervals or with radiation-free ceVUS
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  • The most critical rule of surveillance concerns fever: in a child with reflux, any unexplained fever requires a urinalysis and urine culture obtained by an appropriate method before starting antibiotics. When pyelonephritis (kidney infection) is recognized and treated early, the risk of scarring is significantly reduced — this is the single most important responsibility given to the family of a child under surveillance.
  • In our practice, surveillance is carried out by the same two pediatric urology specialists who made the diagnosis, following the same program throughout; whether the reflux resolves or treatment becomes necessary, the decision is made within the same team, with full knowledge of the child's history.
05

When is watchful waiting abandoned?

Surveillance is chosen to give reflux the chance to resolve without harming the kidney. When signs appear that this window has closed, the approach shifts from waiting to corrective treatment; the decision is made jointly by the family, the child, and the two specialists.

  • These signs include a febrile UTI occurring despite antibiotic prophylaxis, new or progressive scarring on DMSA, high-grade reflux that fails to improve over the years, and accompanying anatomical abnormalities. A family's wish not to continue carrying the burden of ongoing antibiotics and testing is also a legitimate reason; same-day endoscopic injection is an option in that situation.
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Frequently asked questions
If reflux resolves on its own, can it come back?
Primary reflux shown to have resolved on VCUG is not expected to recur; once the tunnel has lengthened, it does not shorten again. Rarely, it may reappear temporarily during a period of severe constipation or a voiding disorder — which is why bladder-bowel habits remain important.
How many years is it reasonable to wait?
Most resolution occurs within the first 3–5 years. In a child with low-grade reflux and no infections, surveillance can continue for years; with high grade or recurring infection, a decision is made earlier. For moderate-to-high-grade reflux persisting past age five, the benefit of continued waiting is reconsidered together with the family.
Is antibiotic prophylaxis mandatory during surveillance?
No, it is not mandatory in every case. In children over one year of age with low-grade reflux and no history of infection, surveillance without antibiotics is a recognized option in guidelines. In infants under one year of age and those with a history of febrile infection, antibiotic prophylaxis is recommended.
The kidneys look normal on ultrasound — does that mean the reflux is gone?
No. Ultrasound shows kidney growth and dilation, but it cannot show whether reflux is present or its grade. Only VCUG or ceVUS (contrast-enhanced voiding urosonography) can show that reflux has resolved; however, in low-grade reflux, routine repeat imaging to confirm this is often not necessary.
Prof. Dr. Ali Avanoğlu's publications on this topic · 1
  1. Ulman I, Avanoğlu A, Erikçi V, et al. (1998). Is resolution of vesicoureteric reflux by conservative management predictable in patients with myelodysplasia? European urology. PubMed ↗
Next • Treatment pathwaysAntibiotic Prophylaxis (CAP) in VUR: Who Needs It, and for How Long?→
Related pagesFull index →
BasicsWhat Do VUR Grades (1–5) Mean?Vesicoureteral reflux (VUR) is classified into five grades, from 1 to 5; the grade describes how far up the urine flows and to what extent the ureter and the kidney's collecting system are dilated. The grade is determined with a VCUG (voiding cystourethrogram) and is the strongest predictor of spontaneous resolution; however, it does not determine the treatment decision on its own.Treatment pathwaysAntibiotic Prophylaxis (CAP) in VUR: Who Needs It, and for How Long?In the surveillance of vesicoureteral reflux (VUR), antibiotic prophylaxis (CAP, continuous antibiotic prophylaxis) is a low-dose, once-daily medication given to protect the kidney from infection. It is not needed by everyone; large studies have increasingly clarified who benefits from it. This page explains the evidence, how it is used, and the duration.Bladder and bowelWhat Is Bladder-Bowel Dysfunction (BBD), and How Does It Affect Reflux?Bladder-bowel dysfunction (BBD) is a condition in toilet-trained children in which voiding problems are intertwined with constipation. In children with vesicoureteral reflux (VUR), BBD both increases the recurrence of urinary tract infections and delays the resolution of reflux; for this reason, it is screened for and treated before deciding on reflux treatment.After treatment and follow-upWhen Is a Follow-up VCUG Required?In a child diagnosed with vesicoureteral reflux (VUR), the first VCUG (voiding cystourethrogram; informally, the “catheter film”) is unavoidable; however, how often it should be repeated afterward is one of the questions families ask most, and one where practice varies most between centers. Current guidelines keep repeat studies to a minimum: this page explains three separate policies — for observation, after injection, and after surgery.
Vesicoureteral Reflux (VUR) topic clustersMain treatment page →
Basics 6Diagnosis and evaluation 6By age and special situations 5Bladder and bowel 5Treatment pathways 10Kidney health and infection 5After treatment and follow-up 6
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