Vesico-ureteral reflux in paediatric patients - Update on treatment

The pathogenesis and the appropriate treatment of vesico-ureteral reflux (VUR) and correlated nephropathy is still very controversial, despite its frequence in infancy and childhood. We reviewed the pathogenetic hypothesis and the current management options of VUR and related nephropathy. VUR prevalence is estimated at up to 1% of children within three years of age. In newborns and infants, VUR is more severe and frequent in male gender compared with pre-school and school-age girls with recurrent urinary tract infections (UTIs). Renal damage occurs in 40-45% of VUR as a consequence of acquired renal scarring secondary to febrile acending UTIs. Recently, pre-natally determined renal hypodysplasia has been recognised as congenital nephropathy associated with VUR. Appropriate VUR treatment is still not defined, as long-term antimicrobial prophylaxis and early surgery by open or laparoscopic techniques have classically been adopted. Endoscopic treatment by subureteral bulking agents (i.e. dextranomer in jaluronic acid) has recently gained popularity. The role of antimicrobial prophylaxis in presenting UTIs and new renal damage has been discussed and no prophylactic treatment has been advocated. In conclusion, definitive results on the different therapeutic options are still lacking. Correct information and minimally invasive, early endoscopic treatment should be offered, taking into account the preference of the parents. Dysfunctional elimination syndrome requires appropriate urotherapy in any toilet-trained child with abnormal voiding habits.