VUR Treatment: Risk Profile and Decision (Low–Moderate–High)

In VUR, the goal is not to eliminate reflux but to prevent kidney infection (pyelonephritis) and the permanent scarring it can leave behind. Because the likelihood of reflux harming the kidney is not the same in every child, treatment cannot be the same either.

There are four main paths in VUR treatment, and these are not alternatives to one another but steps that follow one another:

• Active surveillance: for a child who has completed toilet training, has low-grade reflux, has not had an infection, and has a healthy kidney; the habit of obtaining a culture with any fever is the foundation of this surveillance
• Antibiotic prophylaxis: for an infant under 1 year old who has had a febrile infection, in high-grade reflux, and to reduce recurrence while bladder-bowel dysfunction is being treated
• Endoscopic injection: injecting a bulking agent at the point where the ureter enters the bladder, using a minimally invasive method; for low-to-moderate grade reflux, and in cases where surgery is to be avoided
• Ureteral reimplantation (VUR surgery): for high-grade reflux, reflux with febrile infection continuing despite antibiotic prophylaxis, or reflux threatening kidney function

• If bladder-bowel dysfunction and constipation are present, treating these comes first regardless of which step is being considered; procedures performed without correcting them have lower success.

Guidelines (EAU/ESPU 2024, AUA) and major studies (RIVUR, CUTIE, Swedish Reflux Trial, PREDICT) define the risk profile using several factors. None of these is decisive on its own; they are read together.

• Grade of reflux: grade I–II is considered low risk, III moderate, and IV–V (dilated reflux) high risk; the chance of spontaneous resolution decreases as grade increases
• Age and toilet training: below one year of age the chance of resolution is high, but infection affects the kidney more easily; after toilet training, resolution slows down and BBD comes into play
• History of febrile urinary tract infection: none, a single episode, recurrent, or occurring despite antibiotic prophylaxis (breakthrough) — each step up raises the risk
• Kidney status: scarring on DMSA renal scan, a drop in split (differential) function, or a small/dysplastic kidney on ultrasound
• Bladder-bowel dysfunction (BBD): its presence markedly increases infection recurrence
• Sex: after one year of age, infection risk continues in girls; in boys, especially if circumcised, it decreases markedly (Swedish Reflux Trial)
• Side and anatomy: bilateral reflux, duplex collecting system, ureterocele, or paraureteral diverticulum lower the chance of resolution

The grouping below is a simplified summary of the EAU/ESPU approach; the boundaries are not sharp, and the group changes as the child's findings change. The goal is to give families a concrete framework for the question 'where does my child stand.'

• Low risk: older than one year, grade I–II (unilateral) reflux, no febrile infection or a single episode, normal DMSA/ultrasound, no BBD. First step: active surveillance without antibiotic prophylaxis; culture with any fever; yearly ultrasound and clinical check-up; injection/surgery is not on the table.
• Moderate risk: grade III (or bilateral I–II) reflux; or a child with high-grade reflux who has not had a febrile infection and has normal kidneys; or an infant under one year who has had a febrile infection; or low-grade reflux with BBD. First step: surveillance ± antibiotic prophylaxis (CAP in infants and during BBD treatment), BBD urotherapy, circumcision as an option in male infants; if there is no improvement in 2–3 years or infection recurs, injection is discussed.
• High risk: grade IV–V reflux together with febrile infection, scarring or loss of function on DMSA, febrile infection despite antibiotic prophylaxis, high grade combined with BBD, or an anatomical anomaly. First step: antibiotic prophylaxis and close follow-up (with simultaneous treatment if BBD is present); corrective treatment (injection or reimplantation) is on the table early; surgery is considered when high grade combined with scarring persists after toilet training.

In the low-risk group, the first step is watching and waiting; this waiting means a urine culture with every febrile illness and a yearly check-up. The next step is taken when a febrile infection recurs, or when a new finding appears on ultrasound or DMSA.

The risk group provides a roadmap; the decision itself is made jointly by the family and the team. Two families in the same risk group can differ in their access to hospital care, their view of long-term medication, and their level of concern about infection; this is why guidelines count 'family preference' among the factors in the decision.

• The conversation should answer these questions: what is my child's risk group, and why; what is the first step, and for how long; which finding would change the plan; what is the expected success and risk of injection and surgery for this particular child; and how will follow-up continue. In our practice, this conversation continues with the same two pediatric urologists from diagnosis through treatment and on into adolescent–adult follow-up; because injection and reimplantation are performed by the same team, the choice of method is based on the child's findings rather than personal preference.