Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children
2010
These are the official guidelines specified by the American Urology Association for treating VUR, which all urologists should be following.
“Because VUR and UTI may affect renal structure and function, performing renal ultrasound to assess the upper urinary tract is recommended.”
“DMSA renal imaging can be obtained to assess the status of the kidneys for scarring and function.”
Note: Nowhere in the guidelines does it say that children should receive a VCUG upon initial presentation.
“Involvement of the family in clinical decision making related to VUR is critical, and must include balanced and objective education to permit informed decisions regarding imaging and therapy, particularly when one approach may have no demonstrable benefit or advantage over another.“
“If clinical evidence of BBD [bladder and bowel dysfunction] is present, treatment of BBD is indicated, preferably before any surgical intervention for VUR is undertaken.”
Note: Again, there is no mention of VCUG. Although a VCUG might be clinical evidence of BBD, renal ultrasounds and urinalysis (both previously discussed in the guidelines) are also examples of clinical evidence that can very effectively indicate BBD.
“For high-grade VUR, follow-up as soon as 12 months may be too early, but for low grade it may be appropriate. Compliance with follow-up as well as parental anxiety are factors in this determination. There is little rationale for repeating a VCUG within 12 months of the previous study, and an outer limit of 24 months appears to be a reasonable time frame to avoid loss of follow-up or prolonged use of unnecessary CAP if the VUR has resolved.”
Note: It is mentioned that compliance with follow-up and parental anxiety can be issues, but they don’t go as far as to offer a rationale for this assertion.
“Voiding cystography (radionuclide cystogram or low-dose fluoroscopy, when available) is recommended every 12 to 24 months with longer intervals between follow-up studies in patients in whom evidence supports lower rates of spontaneous resolution (i.e. those with higher grades of VUR [grades III–V], BBD and older age). This is to limit the overall number of imaging studies performed.”
“For children with grade I–II VUR and more likely spontaneous resolution, follow-up imaging to identify VUR is considered an option. While follow-up VCUG is appropriate, there are no data to support its necessity. This is particularly true if CAP is not being used, as the VCUG findings are not likely to alter management.”
Note: If there are no data to support the necessity of VCUG in follow-up, why do many physicians incessantly push parents to conduct regular follow-up VCUGs? Perhaps this happens so urologists can confirm the resolution of VUR and thus boast higher success rates.