A 2-year-old girl presents with her second culture-proven UTI (E. coli >10^5 CFU/mL). Renal ultrasound shows bilateral hydroureteronephrosis. VCUG demonstrates bilateral grade IV vesicoureteric reflux. After treatment of acute infection, what is the MOST important next step in long-term management?

• A Prophylactic nitrofurantoin and DMSA scan in 6 months to assess for renal scarring ✓
• B Immediate open ureteric reimplantation surgery
• C Repeat VCUG every 6 months until reflux resolves spontaneously
• D No further management needed as E. coli UTI is self-limiting

Explanation

Grade IV bilateral VUR carries high risk of recurrent pyelonephritis and renal scarring (reflux nephropathy). The immediate priority after treating the acute infection is antibiotic prophylaxis (trimethoprim or nitrofurantoin) to prevent recurrent infections, followed by DMSA scanning to document existing renal parenchymal damage (cortical scars appear as photopenic areas). Surgical correction (open reimplantation or endoscopic STING procedure) is considered for high-grade VUR with breakthrough infections or progressive scarring despite prophylaxis.

Reference: Ghai Essential Pediatrics, 10th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.