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Prof. Dr. Ali Avanoğlu
Vesicoureteral Reflux (VUR) • By age and special situations

VUR in Young Children (1–5 Years): Vesicoureteral Reflux During Toilet Training

The years between one and five are when the course of vesicoureteral reflux (VUR) changes the most: bladder and bowel habits become established alongside toilet training, reflux resolves on its own in some children, while in others holding behavior and constipation trigger infections. On this page we explain the follow-up and treatment logic specific to this age group.

Who this is forFamilies of children aged 1–5 who have been diagnosed with vesicoureteral reflux or who have been followed since infancy
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ByProf. Dr. Ali AvanoğluUpdated
This page is part of vesicoureteral reflux.Read the full treatment overview on the hub page
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01 · How does reflux come to attention at this age?02 · Toilet training and the onset of bladder-bowel dysfunction (BBD)03 · The difference between girls and boys: the Swedish Reflux Trial04 · Surveillance or antibiotic prophylaxis?05 · When is endoscopic injection considered at this age?06 · For families: what helps during this period?
In brief5 madde
  • How does reflux come to attention at this age?: Between one and five years of age, vesicoureteral reflux either continues as a diagnosis followed since infancy, or is found for the first time after a febrile…
  • Toilet training and the onset of bladder-bowel dysfunction (BBD): Toilet training is the period when a child learns to voluntarily hold urine; while acquiring this skill, some children develop a habit of “holding too much,” which…
  • The difference between girls and boys: the Swedish Reflux Trial: The most important basis for sex entering the treatment decision in this age group is the Swedish Reflux Trial (2010), which followed children aged 1–2 with grade…
  • Surveillance or antibiotic prophylaxis?: After one year of age, active surveillance without antibiotics is an accepted option in a child with low-grade (I–II) reflux, healthy kidneys, and no infection or…
  • When is endoscopic injection considered at this age?: Endoscopic injection (placing a bulking agent beneath the ureteral opening; Deflux) is a same-day, incision-free option, and the preschool period often comes up as a…
01

How does reflux come to attention at this age?

Between one and five years of age, vesicoureteral reflux either continues as a diagnosis followed since infancy, or is found for the first time after a febrile urinary tract infection (UTI).

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  • At this age the child can describe symptoms more clearly: burning on urination, frequent urination, abdominal or flank pain, wetting accidents, and of course fever. Reflux is found in about 25–40% of children who have had a febrile UTI; in this period, infection frequency in girls overtakes that in boys. A family history, an abnormal ultrasound, or a second febrile episode brings the decision for VCUG forward.
  • For children followed since infancy, these years are when the question “will it resolve?” begins to find its answer. Spontaneous resolution accumulates over the years; but moderate-to-high-grade reflux that has not closed by age five has a lower chance of resolving later. For this reason, follow-up in this period is not simply about waiting, but about identifying and removing the factors that make resolution harder.
02

Toilet training and the onset of bladder-bowel dysfunction (BBD)

Toilet training is the period when a child learns to voluntarily hold urine; while acquiring this skill, some children develop a habit of “holding too much,” which directly affects the course of reflux.

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  • Bladder-bowel dysfunction (BBD) is the combined name for, in a child who has completed toilet training, holding maneuvers such as postponing urination, urgency, squatting, or leg-crossing, incomplete emptying, and the constipation that frequently accompanies it. A full bowel presses on the bladder, the pelvic floor cannot relax, the bladder does not empty completely, and the residual urine provides a breeding ground for bacteria. A joint analysis of the RIVUR and CUTIE trials found infection recurrence to be highest in children with both reflux and BBD; the success of endoscopic injection and surgery is also lower when BBD is present.
  • For this reason, our rule is clear: in every child who has completed toilet training, BBD is looked for and treated before a decision on reflux treatment is made. Assessment is carried out with a voiding diary, the DVSS questionnaire, uroflowmetry (urine flow measurement), and residual urine on ultrasound; treatment mostly consists of correcting constipation and urotherapy (timed voiding, correct sitting posture, fluid schedule).
03

The difference between girls and boys: the Swedish Reflux Trial

The most important basis for sex entering the treatment decision in this age group is the Swedish Reflux Trial (2010), which followed children aged 1–2 with grade III–IV reflux.

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  • In the trial, children were assigned to surveillance alone, antibiotic prophylaxis (CAP), or endoscopic injection. In girls, CAP and endoscopic treatment reduced both febrile infection and new kidney scarring compared with surveillance; in boys, no clear difference was seen between arms. This is consistent with the observation that the tendency toward infection persists in girls during the preschool years.
  • In practice, this translates into a more protective approach (CAP or early injection) for girls with moderate-to-high-grade reflux, and a more watchful approach for boys without infection. The child's own infection history, kidney findings, and BBD status have the final say.
04

Surveillance or antibiotic prophylaxis?

After one year of age, active surveillance without antibiotics is an accepted option in a child with low-grade (I–II) reflux, healthy kidneys, and no infection or only a single episode.

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  • In moderate-to-high-grade reflux, especially in girls, or when there is recurrent infection or scarring on DMSA (renal scan), CAP is continued or started; CAP can also accompany BBD treatment. The RIVUR trial showed that CAP roughly halves the recurrence of febrile infection but does not change the scarring rate and increases resistant bacteria; for this reason, the question of “how long” CAP should continue is revisited every six to twelve months.
  • Follow-up imaging should be used judiciously at this age: routine repeat VCUG is not needed for low-grade reflux, ultrasound and clinical follow-up are enough; before a treatment decision, or in high-grade reflux, VCUG or radiation-free ceVUS is considered every 12–24 months. Yearly ultrasound, blood pressure measurement, and urinalysis form the backbone of follow-up.
05

When is endoscopic injection considered at this age?

Endoscopic injection (placing a bulking agent beneath the ureteral opening; Deflux) is a same-day, incision-free option, and the preschool period often comes up as a family's way out of CAP.

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  • According to guidelines, injection is justified by a febrile infection while on CAP, new or progressing scarring, moderate-to-high-grade reflux that has not resolved despite two to three years of follow-up, and a family's preference for a one-time procedure over long-term antibiotics. Single-session success is reported at about 80–90% for grade I–II, 70–75% for grade III, and 60–65% for grade IV; with repeat treatment this approaches 85%. Because injection performed without treating BBD first has a lower success rate, the order matters: the bowel and bladder first, then the ureteral opening.
  • In our practice, endoscopic injection and ureteral reimplantation (reconnecting the ureter to the bladder) are both performed by the same two specialists; which one suits the child is determined together with the grade, kidney findings, and the family's expectations.
06

For families: what helps during this period?

The habits a family establishes during the toilet-training years are the invisible but most effective part of reflux management.

  • Do not rush toilet training; begin when the child is ready, without pressure and with consistency.
  • Keep bowel movements daily, soft, and pain-free; if there is constipation, treat it together with your doctor.
  • Make it a habit to go to the toilet every 2–3 hours, without waiting for urgency.
  • Provide a comfortable sitting position with the feet flat on the floor or a step and the knees slightly apart; do not rush the child.
  • Offer water at regular intervals through the day; do not concentrate fluids in the evening.
  • See a doctor for a urine culture if fever, foul-smelling urine, or new-onset wetting occurs.
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Frequently asked questions
Does toilet training make reflux worse?
Not training itself, but the holding habit and constipation that can take hold during training are what cause problems. When training is pressure-free and consistent, and bowel movements are kept soft, toilet training can even contribute to the reflux improving; the bladder empties more regularly and completely.
My daughter is 3 years old with grade III reflux; what should we do?
First, infection history, DMSA findings, and BBD are assessed. In girls at this grade, CAP or endoscopic injection has been shown to reduce infection and scarring compared with surveillance; if BBD is present, it is corrected first. The decision is made together with these findings and the family's preference.
My son is 4 years old and has never had an infection; is antibiotic needed?
In a boy without infection and with healthy kidneys, surveillance without antibiotics is a suitable option for low-to-moderate grade reflux; the Swedish trial did not show a clear benefit of CAP in boys. If the grade is high and there is dilation on ultrasound, CAP or injection is discussed.
Up to what age can we expect it to resolve?
Resolution is cumulative and occurs mostly within the first five years. After age five, the likelihood of moderate-to-high-grade reflux closing decreases markedly; for reflux that has not resolved by around this age, injection or surgical options are discussed more concretely.
←Previous • By age and special situationsVesicoureteral Reflux in Infants (0–1 Years)Next • By age and special situationsVUR in Adolescents and Adults: Follow-up and Pregnancy→
Related pagesFull index →
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.Bladder and bowelDoes Constipation Cause Urinary Tract Infection and Reflux?Constipation is one of the most commonly overlooked causes of urinary tract infection in children, and in a child with vesicoureteral reflux (VUR), it increases infection recurrence and delays the resolution of reflux. This page explains how constipation is recognized, how it affects the bladder, and how it is treated.Bladder and bowelUrotherapy: Timed Voiding, Fluids, and Toilet HabitsUrotherapy is a drug-free, non-invasive education program that teaches the child to empty the bladder at the right time, in the right way, and completely. It is the first step of treatment in a child with vesicoureteral reflux (VUR) who also has voiding dysfunction or constipation, and it begins to show its effect within weeks.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.
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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