Knowing which grade of VUR your child has helps their doctor understand whether they can benefit from treatment and what type of treatment might be best.
Vesicoureteral reflux (VUR) is when urine flows backward from your child’s bladder into one or both of their ureters and sometimes their kidneys. The ureters are the tubes that carry urine from your child’s kidneys to their bladder.
VUR most commonly affects young children. Doctors often grade it from 1 to 5 using the International Reflux Classification. Grade 1 is the mildest form, while grade 5 is the most severe.
| Description | Grade 1 | Grade 2 | Grade 3 | Grade 4 | Grade 5 |
|---|
| Urine reaches ureters | ✓ | ✓ | ✓ | ✓ | ✓ |
|---|
| Urine reaches kidneys | | ✓ | ✓ | ✓ | ✓ |
|---|
| Swelling of the collecting system inside the kidney | | | ✓ | ✓ | ✓ |
|---|
| Kinking of the ureter | | | possibly | possibly | ✓ |
|---|
| Damage to kidney tissues (intraparenchymal damage) | | | | | ✓ |
|---|
Vesicoureteral reflux grade 1
Grade 1 is the mildest form of VUR. Children with grade 1 have backflow only into their ureters and not into their kidneys. The ureter is not dilated or minimally dilated, meaning it isn’t swollen.
VUR doesn’t cause any specific symptoms, but it increases the chances that your child will develop a urinary tract infection (UTI) .
Symptoms of a UTI can include:
Fever is often the only apparent symptom in young children. Your child may complain of abdominal pain once they complete toilet training and can speak.
Vesicoureteral reflux grade 2
Children with grade 2 VUR have reflux that reaches their kidneys, but there’s no swelling in the urine-collecting system inside their kidneys.
Both grade 1 and grade 2 VUR are often referred to as low grade VUR.
UTIs are a possible side effect.
Vesicoureteral reflux grade 3
Grade 3 VUR is characterized by mild or moderate swelling of the ureters with or without twisting or bending (called “kinking”). The urine collection system in your child’s kidneys is also moderately swollen, and they might have a structural change in part of the fornices of the kidney.
UTIs are most common in grades 3 to 5.
Children with grades 3 to 5 VUR have an especially high risk of UTIs and kidney scarring. These grades are often referred to as high grade VUR.
Vesicoureteral reflux grade 4
Stage 4 vesicoureteral reflux is characterized by moderate swelling, which causes an abnormal kidney shape. The typically pointed fornices in your child’s kidney now appear blunt on imaging.
Vesicoureteral reflux grade 5
Grade 5 VUR is characterized by severe swelling and kinking of the ureter. There’s significant swelling in the urine collecting system in your child’s kidney.
Urine flows deeper through the ducts in their kidneys and can cause damage to the kidney tissues.
Vesicoureteral reflux treatment by grade
The best treatment for VUR depends on factors like the grade of your child’s VUR and the underlying cause. Treatment might include:
- antibiotics to prevent or treat UTIs
- waiting to see if it gets better on its own
- injections
- surgery
Vesicoureteral reflux grade 1 treatment
Grade 1 vesicoureteral reflux often goes away by itself. Intense treatment isn’t usually required.
Children with grades 1 to 4 VUR might be suitable candidates for endoscopic injections. These injections are inserted into the tissue around the ureter to prevent the backflow of urine.
Regular follow-ups with or without antibiotic therapy are recommended for children with grades 1 or 2 VUR without a UTI and who have not achieved toilet independence. Antibiotics are generally always recommended for children who have not achieved toilet independence and who have a UTI.
Antibiotics are optional for children with toilet independence and a UTI but are recommended if they have bladder and bowel dysfunction.
Vesicoureteral reflux grade 2 treatment
Children with grade 2 VUR also often improve by themselves without treatment.
Endoscopic injections are considered most useful for children with grades 2 to 4 disease. Your child’s doctor might recommend antibiotics if your child has a UTI or bowel and bladder dysfunction.
Vesicoureteral reflux grade 3 treatment
In children with grades 3 to 5 VUR, antibiotics are typically administered to prevent UTIs before they occur. This is called prophylactic antibiotic therapy.
Vesicoureteral reflux grade 4 treatment
Your child’s doctor is most likely to recommend surgery if your child has:
- persistent grade 4 or 5 VUR, which is often considered VUR that persists past age 3
- progressive kidney scarring or failure
- multiple serious UTIs or kidney infections
- intolerance or non-compliance to antibiotics
- poor kidney growth
- parental request
Learn more about vesicoureteral reflux surgery.
Vesicoureteral reflux grade 5 treatment
As with grade 4, your child’s doctor may recommend that your child undergo surgery to prevent future infections or kidney damage.
What is the long-term outlook for vesicoureteral reflux?
The outlook for vesicoureteral reflux tends to be better the earlier it’s diagnosed and treated. It can be a challenge for doctors to figure out which children will outgrow VUR and which ones won’t. Abnormal bowel function is associated with a higher risk of developing UTIs.
About 75% of children with grade 1 and 2 disease resolve spontaneously without treatment by age 5. Spontaneous resolution occurs in about 60% to 70% of children with grades 3 and 4. It’s most likely to resolve if it only occurs on one side and is diagnosed before age 2.
In cases where VUR develops on both sides, only about 10% to 20% of children have spontaneous resolution over 5 years.
Takeaway
Vesicoureteral reflux is graded from 1 to 5 based on its severity. Grades 1 and 2 are often considered low grade, while grades 3 to 5 are often considered high grade.
Low grade VUR may go away on its own spontaneously. Children with high grade VUR or repeated UTIs may need surgery to prevent future kidney damage or infections.
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