The role of voiding cystourethrography in the investigation of children with urinary tract infections

Abstract

Urinary tract infections (UTIs) represent a common bacterial cause of febrile illness in children. Of children presenting with a febrile UTI, 25-40% are found to have vesicoureteral reflux (VUR). Historically, the concern regarding VUR was that it could lead to recurrent pyelonephritis, renal scarring, hypertension, and chronic kidney disease. As a result, many children underwent invasive surgical procedures to correct VUR. We now know that many cases of VUR are low-grade and have a high rate of spontaneous resolution. The roles of surveillance, antibiotic prophylaxis, endoscopic injection, and ureteral reimplantation surgery also continue to evolve. In turn, these factors have influenced the investigation of febrile UTIs.Voiding cystourethrography (VCUG) is the radiographic test of choice to diagnose VUR. Due to its invasive nature and questionable benefit in many cases, the American Academy of Pediatrics (AAP) no longer recommends VCUG routinely after an initial febrile UTI. Nevertheless, these guidelines pre-date the landmark Randomized Intervention of Children with Vesicoureteral Reflux (RIVUR) trial and there continues to be controversy regarding the diagnosis and management of VUR. This paper discusses the current literature regarding radiographic testing in children with febrile UTIs and presents a practical risk-based approach for deciding when to obtain a VCUG.

Pediatric voiding cystourethrography: An essential examination for urologists but a terrible experience for children

“…Most ESRD patients with VUR have congenital reflux nephropathy, which is different from acquired renal parenchymal damage caused by febrile UTI, and is observed in patients with high‐grade VUR . Thus, it is essential to detect high‐grade VUR as early as possible to prevent subsequent renal damage, and hence ordering a VCUG should be based on weighing up the potential risks and benefits …”

“…19 Thus, it is essential to detect high-grade VUR as early as possible to prevent subsequent renal damage, and hence ordering a VCUG should be based on weighing up the potential risks and benefits. 8 VUR is a familial disorder with several inheritance patterns, including autosomal dominant with incomplete penetrance, autosomal recessive, X-linked and polygenic. The prevalence of VUR was reported to be 27-51% for siblings and 66% for parent-to-child transmission.…”

“…VUR management has moved on from open UCN, endoscopic injection and laparoscopic/robotic‐assisted UCN to watchful waiting with or without CAP …”

“…VUR management has moved on from open UCN, endoscopic injection and laparoscopic/ robotic-assisted UCN to watchful waiting with or without CAP. 8 Case report: A representative example of VCUG in practice A 4-month-old boy was hospitalized with febrile UTI, showing a bilateral grade 4 VUR without renal scarring. CAP was started soon after diagnosis despite his parents' concerns about resistance and tolerance.…”

Factors That Would Indicate Diagnosis of Dilating VUR in the Second VCUG of Patients with A Normal First VCUG

“…Voiding cystourethrography (VCUG) is the gold standard imaging method to identify anatomical and some of the functional problems of the lower urinary tract, particularly vesicoureteric reflux (VUR) (1). In pediatric practice, its role in the evaluation of children with urinary tract infection has been well-defined.…”