What Is Vesicoureteral Reflux Vur Symptoms Treatment?

Vesicoureteral reflux (VUR) is a condition where urine flows backward from the bladder into the ureters and sometimes up to the kidneys. This backward flow, called reflux, can cause urinary tract infections (UTIs) and, in severe cases, kidney damage. The main symptoms of VUR in children are fevers from UTIs, while adults may experience flank pain or recurrent infections. Treatment ranges from simple monitoring and antibiotics to surgery, depending on the severity grade and whether the child outgrows it.

What Exactly Is Vesicoureteral Reflux (VUR)?

Think of the urinary tract like a one-way drainage system. Urine flows from the kidneys down through tubes called ureters into the bladder. At the point where each ureter enters the bladder, there is a tiny valve. In VUR, that valve does not close properly. When the bladder contracts to push urine out, some urine squirts backward up toward the kidneys instead.

The condition is graded from 1 to 5. Grade 1 is mild — urine backs up only into the ureter. Grade 5 is severe — the ureter is dilated and twisted, and urine reaches the kidney with significant backup. The grade matters a lot for treatment decisions. Low-grade VUR (1-2) often resolves on its own as the child grows. High-grade VUR (4-5) almost never resolves without intervention.

VUR is most commonly found in infants and young children. The National Institute of Diabetes and Digestive and Kidney Diseases reports that about 1-2% of children have VUR. It runs in families. If one child has it, siblings have a 30-50% chance of having it too.

What Are the Symptoms of VUR in Children and Adults?

In infants and young children, the main symptom is a fever without an obvious cause. That fever is usually from a urinary tract infection that traveled up to the kidney (pyelonephritis). Other signs include poor feeding, vomiting, fussiness, or foul-smelling urine. Many children with low-grade VUR have no symptoms at all until they develop a UTI.

Older children may complain of pain or burning when peeing, needing to pee often, or wetting the bed after being dry for months. Some children feel flank pain — a dull ache on one side of the lower back. A child who has repeated fevers without a clear cold or flu should be checked for VUR.

Adults with VUR are less common but do exist. They often have recurrent UTIs, flank pain during urination, or high blood pressure from long-standing kidney damage. Some adults are diagnosed only after they develop kidney stones or show signs of kidney scarring on an ultrasound.

How Is VUR Diagnosed?

The main test for VUR is called a voiding cystourethrogram (VCUG). A thin tube called a catheter is placed into the bladder through the urethra. The bladder is filled with a contrast dye, and X-rays are taken while the child pees. If the dye flows backward into the ureters, VUR is confirmed. The grade is determined by how far up the dye goes and how much the ureter stretches.

Another test is a nuclear medicine scan called a DMSA renal scan. This test looks for kidney scarring. It does not diagnose VUR itself but tells doctors whether the reflux has already caused damage. A kidney ultrasound is often the first test done because it is noninvasive and shows kidney size and structure. But an ultrasound alone cannot confirm or rule out VUR.

Research published in the journal Pediatrics has shown that the timing of the VCUG matters. Doing it too soon after a UTI can give false results because the infection itself can cause temporary reflux. Guidelines from the American Academy of Pediatrics recommend waiting at least a week after treating a UTI before performing a VCUG.

What Treatments Are Available for VUR?

Treatment depends on the grade, the child’s age, and whether kidney damage has already occurred. For low-grade VUR (grades 1-2), the standard approach is watchful waiting. Many children outgrow this by age 5. Doctors may prescribe daily low-dose antibiotics to prevent UTIs while waiting for the reflux to resolve. This is called continuous antibiotic prophylaxis.

For moderate to high-grade VUR (grades 3-5), or if a child keeps getting UTIs despite antibiotics, surgery is often recommended. There are two main surgical options. The first is endoscopic injection, where a gel-like substance is injected at the opening of the ureter to create a better valve. This is a same-day procedure with a success rate of about 80-85% for low-grade cases. The second is ureteral reimplantation surgery, where the ureter is detached and reattached to the bladder at a different angle to create a working valve. This is open surgery with a hospital stay and a success rate above 95%.

One thing that surprises many parents: there is no strong evidence that treating low-grade VUR prevents future kidney damage better than just watching and waiting. A large study called the RIVUR trial, published in the New England Journal of Medicine in 2014, found that antibiotics reduced UTIs in children with VUR but did not reduce kidney scarring. This has led to more conservative treatment recommendations in recent years.

What Happens if VUR Is Left Untreated?

Untreated VUR does not always cause problems. Many children with low-grade VUR outgrow it and never have a single UTI. The risk comes from repeated kidney infections. Each infection can cause scarring on the kidney tissue. Enough scarring can lead to high blood pressure later in life or, in rare cases, kidney failure.

The risk of scarring is highest in children under age 2. Their kidneys are still developing and more vulnerable to damage. This is why doctors tend to be more aggressive about treating VUR in very young children. In older children and adults, the kidneys are more resilient, but repeated infections still pose a risk.

A 2021 study in JAMA Pediatrics followed children with VUR for 10 years. It found that those who had surgery had fewer UTIs than those on antibiotics, but both groups had similar rates of kidney scarring at the end of the study. This suggests that the main benefit of treatment is preventing infections and their immediate discomfort, not necessarily preventing long-term kidney damage.

Common Misconceptions About VUR

Misconception: VUR is caused by potty training too early. There is no evidence that early or late potty training causes VUR. The condition is anatomical — it is about how the ureter connects to the bladder. It is present from birth, not caused by anything a parent does.

Misconception: All children with VUR need surgery. Most children with VUR have low-grade reflux that resolves on its own. Surgery is reserved for high-grade reflux or when medical management fails.

Misconception: Antibiotics for VUR always work. Antibiotics reduce the chance of infection but do not fix the valve problem. They also come with risks like gut microbiome disruption and antibiotic resistance. Some children on prophylaxis still get breakthrough UTIs.

Misconception: VUR always causes symptoms. Many children have no symptoms at all until they get a UTI. Some are diagnosed only because a sibling was found to have VUR and they were screened.

What to Avoid When Managing VUR

Avoid delaying a UTI evaluation in a child with known VUR. A fever in a child with VUR should be taken seriously. Call your doctor promptly. Waiting to see if the fever goes away on its own risks a kidney infection.

Avoid stopping antibiotics without a doctor’s guidance. If your child is on daily prophylaxis, stopping suddenly can increase infection risk. The decision to stop should be based on repeat imaging showing that the reflux has resolved.

Avoid relying solely on cranberry juice or probiotics to prevent UTIs. Some people report that cranberry products help, but strong evidence is limited. A 2023 Cochrane review found that cranberry juice may reduce UTI risk in some women but not in children with VUR. Probiotics have even less evidence for preventing UTIs in this population.

Avoid assuming that one negative VCUG means the problem is gone. VUR can be intermittent. A child may have a normal test one month and show reflux the next. Repeat testing is sometimes needed if symptoms persist.