A 7-year-old girl presents with her second febrile UTI confirmed with mid-stream urine culture showing >10⁵ CFU/mL of E. coli. DMSA scan reveals bilateral renal scarring. MCUG reveals bilateral vesicoureteric reflux grade III. Which of the following is the current recommended management approach for VUR with renal scarring in a child of this age?
- A Immediate bilateral ureteric reimplantation surgery
- B Antibiotic prophylaxis, regular surveillance of urine, monitoring of renal function and blood pressure, with surgery reserved for breakthrough infections or progressive scarring ✓
- C Long-term low-dose antibiotic prophylaxis alone without further imaging
- D Deflux (dextranomer/hyaluronic acid) injection into both ureters as first-line intervention
Explanation
For children with VUR and renal scarring (reflux nephropathy), current guidelines (EAU/ESPU 2023) recommend conservative management as the initial approach: low-dose antibiotic prophylaxis (trimethoprim or nitrofurantoin), regular urine surveillance, monitoring of blood pressure and renal function, and imaging follow-up with DMSA and MCUG at intervals. Surgical intervention (reimplantation or Deflux) is reserved for breakthrough UTIs on prophylaxis, grade IV-V reflux with ongoing infections, or progressive renal scarring. The RIVUR and PREVENT trials showed prophylaxis reduces febrile UTI recurrence but does not consistently prevent new scars. Immediate surgery is not indicated for grade III VUR in a 7-year-old girl.
Reference: Ghai Essential Pediatrics, 10th ed.
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Written and medically reviewed by the StethoPrep medical team.