Experience with vesicoureteral reflux in children: clinical characteristics.

Objective: We reviewed our 9-year experience with a large population of children with vesicoureteral reflux who were evaluated and treated according to contemporary concepts.

Methods: From 1985 to 1993 we followed 288 boys and 752 girls with vesicoureteral reflux. If surgery was not performed, patients were on antibiotic prophylaxis and evaluation was done every 18 months with contrast voiding cystography and radionuclide renal imaging. Urine cultures were obtained every 4 months. Two negative voiding cystourethrograms 1 year apart were required to discontinue prophylaxis.

Results: The major reasons for initial evaluation were urinary tract infection in 560 children (54%), voiding dysfunction without urinary tract infection in 156 (15%), sibling surveys in 122 (12%) and prenatal hydronephrosis in 23 (2%). In 150 kidneys (10%) in 132 children scarring at presentation was grade 0 in 10 (7%), I in 18 (12%), II in 27 (18%), III in 30 (20%), IV in 48 (32%) and V in 17 (11%). Of these 132 patients 17 presented at ages less than 1 year (13%), 29 at ages 1 to 3 (22%), 50 at ages 4 to 6 (38%), 24 at ages 7 to 9 (18%) and 12 at ages greater than 10 (9%). No new scars were seen in children on prophylaxis without breakthrough infection. After 1 negative voiding cystourethrogram reflux was noted again in 27% of the cases. Breakthrough infections developed in 62 children of whom a third were older than 7 years. Reimplantation in 205 children (20%) was performed for grade IV to V reflux (101), breakthrough infection (62), advanced age (18), large periureteral diverticulum (12) and noncompliance (3). Five boys and 57 girls (30% of all children) had urinary tract infections after successful reimplantation.

Conclusions: Almost half of the children with vesicoureteral reflux have no history of culture proved urinary tract infection. Scarring may be associated with any reflux grade and it may be initially diagnosed at any age. Only half of the scars are noted with higher grades of reflux (IV and V). Continuous prophylaxis prevents new scarring. Breakthrough infections are rare but they can occur at ages greater than 7 years. Two consecutive negative cystograms are necessary before discontinuing prophylaxis. Children should be monitored after reimplantation for recurrent urinary tract infection.