List of Abbreviations
UTI – urinary tract infection
UTI – urinary tract infection
VUR – vesicoureteral reflux
VUJ – vesicoureteral junction
US – ultrasound examination
Terms and Definitions
Lower urinary tract dysfunction – impairment of lower urinary tract function developing secondary to confirmed innervation disorders.
Urinary tract infection – a non-specific infectious process affecting all parts of the urinary system.
Posterior urethral valve – a congenital anomaly of the urethra characterized by an obstructive membrane located in the posterior urethra and causing significant impairment of bladder emptying.
Voiding cystourethrography – an X-ray examination of the urethra and bladder performed by introducing a water-soluble contrast medium into the bladder.
Vesicoureteral reflux – the retrograde flow of urine from the bladder into the upper urinary tract.
Vesicoureteral junction – an anatomical structure formed by the intramural part of the ureter and multidirectional detrusor muscle fibers, which performs the function of draining urine from the ureter into the bladder and a valvular function that prevents the development of vesicoureteral reflux.
Reflux nephropathy – secondary changes (scarring) of the renal parenchyma resulting from vesicoureteral reflux.
Lower urinary tract symptoms – urination disorders of various origins associated with pathological processes in the lower urinary tract, which include the bladder and urethra.
Chronic kidney disease – a collective concept combining kidney diseases of various origins that have a progressive course resulting in end-stage renal failure.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Vesicoureteral reflux (VUR) – the retrograde flow of urine from the bladder into the upper urinary tract [1].
Vesicoureteral reflux is a condition of anatomical and/or functional nature leading to serious consequences such as renal parenchymal scarring, hypertension, and renal failure. The severity of the described disorders in patients with VUR varies [2].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Etiology
Primary vesicoureteral reflux. Its occurrence is associated with a fundamental impairment of the antireflux mechanism of the vesicoureteral junction (VUJ).
Secondary vesicoureteral reflux. It occurs due to factors not directly related to the anatomical and functional state of the vesicoureteral junction [3,4,5].
1.3 Epidemiology of the Disease or Condition
The morbidity and prevalence of vesicoureteral reflux among the pediatric population of the Russian Federation are not precisely known. In foreign studies, the incidence of VUR in children varies widely: from 0.8% to 30% [6].
A number of modern studies have shown that the ratio of reflux prevalence in boys and girls can reach 3:1 at the age of 0 to 6 months, decreasing to approximately 1:1 by 21–24 months [7].
To date, there are sufficient literature sources evaluating the prevalence of vesicoureteral reflux among siblings. The detection rate of VUR in siblings of sick children, who mainly suffer from UTIs, is approximately 30%, but some studies report a frequency reaching 50% [1,8,9,10,11,12].
1.4 Features of Coding the Disease or Condition
N11.0 Non-obstructive chronic reflux-associated pyelonephritis
N13.7 Vesicoureteral reflux-associated uropathy
N13.8 Other obstructive and reflux uropathy
N13.9 Obstructive and reflux uropathy, unspecified
Q62.7 Congenital vesicoureutero-renal reflux
1.5 Classification of the disease or condition
Classification of vesicoureteral reflux by etiology:
Primary.
Secondary.
Classification of vesicoureteral reflux by side of lesion:
Unilateral.
Bilateral.
Classification of vesicoureteral reflux by intravesical pressure level at which reflux occurs:
Passive (filling reflux).
Active (voiding reflux).
Mixed [13].
International Reflux Study Committee classification of vesicoureteral reflux:
Grade 1 – reflux into an undilated ureter.
Grade 2 – reflux into the renal pelvis and calyces without their dilation.
Grade 3 – mild or moderate dilation of the ureter, renal pelvis, and calyces with minimal blunting of the fornices.
Grade 4 – moderate ureteral tortuosity and dilation of the pelvis and calyces.
Grade 5 – marked dilation of the ureter, pelvis, and calyces; disappearance of the papillary impressions; ureteral tortuosity [1].
1.6 Clinical presentation of the disease or condition
Vesicoureteral reflux in children has no specific clinical presentation; therefore, VUR symptoms are associated with concomitant urinary tract infection, clinical manifestations of reflux nephropathy, and the course of neurogenic bladder dysfunction.
Patients with VUR may exhibit the following symptoms:
Delayed physical development.
Changes in urine properties (turbidity, discoloration, foul odor).
Pain in the lumbar region and/or lower abdomen.
Acute increase in body temperature to febrile levels against the background of complete prior health.
Intermittent increase in body temperature to subfebrile levels.
Daytime or nocturnal urinary incontinence.
Elevated blood pressure [13].
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for establishing the diagnosis/condition:
The diagnosis of vesicoureteral reflux is established upon detecting retrograde urine flow from the bladder into the upper urinary tract according to X-ray or radionuclide cystography combined with a confirmed absence of patency disorders at the vesicoureteral junction (exclusion of VUJ obstruction).
2.1 Complaints and Anamnesis
When taking complaints from patients with suspected vesicoureteral reflux (taking medical history and complaints in renal and urinary tract pathology) to obtain initial information about possible urodynamic disorders, it is recommended to check for the following symptoms:
o recurrent urinary tract infection course;
o urination rhythm disorders, changes in urinary fraction volume during urination;
o urination with a thin, sluggish urinary stream;
o sensation of incomplete bladder emptying;
o daytime and nocturnal urinary incontinence;
o urgent urinary urges;
o pain and discomfort preceding or following urination;
o two-stage urination (repeated urination shortly after micturition due to the presence of a large volume of true or false residual urine in the bladder) [13,1].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
When taking medical history (initial examination (inspection, consultation) by a pediatric urologist-andrologist), it is recommended to clarify the following information from children with suspected vesicoureteral reflux and/or their parents:
o prenatal ultrasound data (to exclude antenatal dilatation of the pelvicalyceal system);
o data from routine examination methods of the child (blood and urine tests, renal and urinary tract sonography) to assess early manifestations of a latent course of urinary tract infection, and to detect indirect signs of VUR;
o episodes of body temperature rise to febrile or subfebrile values against the background of prior complete health;
o periodic pain in the abdomen, lower abdomen, or lumbar region;
o episodes of changes in physical properties of urine (turbidity, appearance of a sharp odor, etc.);
o previous surgical interventions on the urogenital organs, especially the lower urinary tract and urethra;
o family history (presence of other children in the family, clinical manifestations of urinary system diseases in close relatives) [1,16,17].
GCR BLoE 3Level of Evidence B (Level of Confidence of Evidence – 3)
2.2 Physical Examination
Vesicoureteral reflux has no pathognomonic symptoms, therefore, during the examination, it is necessary to pay attention to the structure of the external genitalia and identify possible infravesical obstruction as a cause of secondary vesicoureteral reflux:
To assess the physical development of the child due to the direct link between vesicoureteral reflux and the development of chronic kidney disease, it is recommended to perform a physical examination of the patient, including measuring and recording height, body weight, and blood pressure (measurement of blood pressure on peripheral arteries) in children with suspected vesicoureteral reflux [1,18,19].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
To exclude pathology of the external genitalia (visual inspection of the external genitalia) and infravesical obstruction in children with suspected vesicoureteral reflux, it is recommended to inspect and assess:
o the penis in boys;
o the vaginal vestibule in girls;
o the external urethral meatus;
o the presence or absence of foreskin changes;
o the presence or absence of labia minora changes;
o the state of the perineum;
o the presence of postoperative scars and cicatricial deformations of the external genitalia;
o the presence or absence of urethral discharge;
o signs of sclerosus lichen of the external genitalia [20,21,22,23].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
2.3 Laboratory Diagnostics
To assess the state of the urogenital tract and the activity of the microbial-inflammatory process, children with suspected vesicoureteral reflux are recommended to undergo the following tests:
1) general (clinical) urine analysis [24];
2) microbiological (cultural) urine analysis for aerobic and facultatively anaerobic opportunistic microorganisms with determination of sensitivity to antimicrobial agents [24,25];
3) general (clinical) blood count [24,25];
4) blood biochemistry test (general therapeutic blood chemistry analysis, study of creatinine and urea levels in the blood) [25];
5) assessment of serum acute-phase protein levels (study of procalcitonin level in the blood, study of C-reactive protein level in blood serum) [24,25,26].
Level of reliability of recommendations 5Level of evidence (for 1, 2, 3, 4) C (level of evidence – 5)
Level of reliability of recommendations 1Level of evidence (for 5) A (level of evidence – 1)
Comment: laboratory test results allow evaluation of the filtration and secretory functions of the kidneys (serum creatinine, urea). In the presence of a urinary tract infection, an increase in acute-phase indicators (leukocytes, C-reactive protein, procalcitonin) is possible. Assessment of inflammation marker levels makes it possible to choose the optimal phased treatment tactics depending on the activity of the microbial-inflammatory process. Determining the sensitivity of microorganisms to antibacterial drugs allows drawing up a regimen of rational antibiotic therapy and subsequent antibiotic prophylaxis for a specific patient [25,26].
2.4 Instrumental Diagnostics
2.4.1 Non-invasive special diagnostics
Sonography (ultrasound examination of the urinary tract, ultrasound examination of the kidneys, ultrasound examination of the ureters, ultrasound examination of the bladder) is recommended for all patients with suspected vesicoureteral reflux to exclude anatomical anomalies of the urinary tract structure, dilatation of the ureter and renal collecting system, as well as to assess renal blood flow and signs of secondary changes in renal tissue [27,28,29,30].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
2.4.2 Invasive special diagnostics
To assess lower urinary tract function, children with signs of neurogenic lower urinary tract dysfunction are recommended to undergo a urodynamic study (cystometry, urethral profilometry, measurement of urine flow rate (uroflowmetry) [1,31].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform micturition cystourethrography in all patients to detect vesicoureteral reflux [34,35,36].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
It is recommended to perform radioisotope cystography (cystography) in patients to diagnose vesicoureteral reflux. The study has a significantly lower radiation dose for the patient, but does not allow a detailed assessment of the anatomical structure of the lower urinary tract, including the urethra. In addition, there is no possibility of visualizing grade I VUR. Due to the listed features of the method, radioisotope cystography is not the method of choice and should be considered as an additional technique for diagnosing reflux and assessing long-term treatment outcomes [32,33,34,37].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
When ureteral dilatation is detected according to sonography or X-ray cystography, patients are recommended to undergo excretory urography (intravenous urography) to exclude a violation of the evacuatory function of the vesicoureteral junction (i.e., to exclude urinary tract obstruction at the VUJ level). The bladder must first be drained with a urinary catheter (bladder catheterization) [13].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
2.5 Other Procedures
It is recommended to perform static nephroscintigraphy (angionephroscintigraphy) in patients to identify secondary pathological changes in the renal parenchyma against the background of VUR and recurrent urinary tract infections (nephrosclerosis, renal hypodysplasia) [38,39,40].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
It is recommended for all patients to undergo diagnostic cystoscopy to assess the structure and location of the ureteral orifices, their number, and to determine the length of the intramural part of the ureter [41,42].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
3.1.1 Dynamic monitoring
Dynamic follow-up includes, according to indications, the treatment of urinary tract infection (UTI) episodes. Medical assistance should be sought when symptoms indicating a UTI appear, or when fever of unknown origin develops.
To assess long-term outcomes, dynamic follow-up (initial/follow-up examination (inspection, consultation) by a urologist) is recommended for children with low-grade reflux (grades I and II) who are toilet-trained and can independently report UTI symptoms [42,43].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
Comment: for patients with high-grade reflux (grades III–V), as well as children who are not toilet-trained or unable to report symptoms of infection, antibiotic prophylaxis is advisable as it reduces the risk of recurrent UTIs. Nevertheless, watchful waiting is a viable option for parents/caregivers who prefer to avoid prophylactic antibiotic therapy and strictly follow medical care and follow-up recommendations [42,43].
3.1.2 Antibacterial prophylaxis
Recommended medical therapy for the treatment of VUR, including daily prophylactic antibiotic use. Indications for prescribing antibiotic prophylaxis:
o All patients with high-grade reflux (grades III, IV, V).
o Children with low-grade reflux (I and II) if the child has a history of urinary tract infection, is not toilet-trained, and shows no signs of renal nephrosclerosis or other congenital renal anomalies.
o All patients with neurogenic bladder dysfunction regardless of the grade of VUR [17,44,45].
GCR ALOE 2Grade of Recommendation A (Level of Evidence – 2)
Comment: this approach is based on the premise that the use of antibiotics for 2 years maintains sterile urine, in which case prolonged reflux of sterile urine does not cause renal damage, alongside the expectation of spontaneous resolution of reflux [17,44,45]. Clinical studies continue to demonstrate the benefits of antibiotic prophylaxis, as recurrent UTIs occur less frequently with antibiotic use [46].
Drugs and dosage:
For the prevention of urinary tract infection episodes (cystitis, pyelonephritis) in children from birth with VUR, it is recommended to use #sulfamethoxazole + trimethoprim** (2 mg/kg trimethoprim + 10 mg/kg sulfamethoxazole in 2 divided doses [47]) or #nitrofurantoin in children older than 1 month (1.5 mg/kg orally once daily, maximum 100 mg/dose). The recommended duration of antibacterial prophylaxis is 2 years [44,45,47].
GCR ALOE 2Grade of Recommendation A (Level of Evidence – 2)
Comment: antibiotics may be substituted if side effects occur or resistance develops. Prophylactic antibiotic therapy is discontinued when VUR resolves spontaneously or when surgical correction is performed, as confirmed by cystourethrography or radionuclide cystography [48].
3.2 Surgical Treatment
To perform surgical correction of VUR, the aim of which is to reconstruct the ureterovesical junction and establish antireflux protection, currently used methods include endoscopic transurethral ureteral orifice injection (endoscopic subfascial/submucosal implantation of a bulking agent), open ureterocystoneoinplantation, as well as robotic and laparoscopic ureteral reimplantation.
Surgical correction in children with VUR is recommended to reconstruct the ureterovesical junction, establish antireflux protection, and prevent irreversible nephron damage:
In children with grade I-II reflux:
Who suffer from recurrent urinary tract infections or show new foci of nephrosclerosis despite ongoing antibacterial prophylaxis.
In children with grade III-IV reflux:
Who fail conservative treatment, do not adhere to recommendations, and are unable to undergo prophylactic antibiotic therapy for various reasons, including social factors.
Who experience urinary tract infections despite prophylactic antibiotic therapy.
In children with grade IV/V reflux [49,50,76,77].
ACR BLEL 3Level of Clinical Recommendation B (Level of Evidence – 3)
3.2.1 Endoscopic injection of bulking agent into the ureteral orifice
Currently, various biopolymer gels differing in chemical composition are used in the Russian Federation. The use of these agents achieves high efficacy in patients with various grades of VUR and concomitant functional bladder disorders.
Efficacy — treatment success of VUR with one or more procedures ranges from 75% to over 90%. The success rate of initial VUR correction depends on the reflux grade and anatomical factors, ranging from 59% to 89% [51,52,53,54,55].
Endoscopic ureteral orifice injection (Cystoscopy with ureteral orifice modeling) is recommended as the first-line surgical treatment for the correction of vesicoureteral reflux due to its minimally invasive nature and low tissue trauma combined with high efficacy, except for patients in whom biopolymer gel injection is known to be ineffective due to severe anatomical anomalies of the ureterovesical junction [48,49,51,52,53].
GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3)
3.2.2 Laparoscopic and robotic ureteral reimplantation
Laparoscopic and robotic ureteral reimplantations are techniques that reconstruct the ureterovesical junction to establish antireflux protection and normalize urine flow. Studies on the efficacy of endosurgical treatments for VUR confirm similar success rates between open surgery and laparoscopic/robotic interventions, while offering the lower tissue trauma characteristic of endosurgery [45,59,60,61].
It is recommended to perform endosurgical reconstructions of the ureterovesical junction (Ureterocystoneostomy [Cohen ureteral reimplantation]) for the correction of vesicoureteral reflux in children who have not responded to previous transurethral endoscopic ureteral orifice injection with bulking agents [61,62,63].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
When performing reconstructive surgery (Ureterocystoneostomy [Cohen ureteral reimplantation]) at the ureterovesical junction in children for the correction of vesicoureteral reflux, it is recommended to aim for antireflux protection with a ratio of the reimplanted ureter diameter to the length of the submucosal tunnel of 1:5, which conforms to the principles previously used in traditional open surgical interventions [61,62,63,64,65,66,67,68].
GCR CLoE 3Grade of Recommendation C (Level of Evidence – 3)
Comment: it should be noted that laparoscopic and robotic reconstructions of the ureterovesical junction ought to be performed in specialized departments with sufficient endosurgical experience and adequate material and technical resources for such reconstructive procedures. If the above conditions are not met, preference should be given to highly effective traditional open ureterocystoinplantations [69].
3.2.3 Open ureterocystoneostomy
Open surgical ureteral reimplantation in children is a highly effective procedure, with success rates ranging from 95% to 99%, regardless of the VUR grade.
Open surgical ureteral reimplantation is recommended for children with any grade of VUR as an alternative to laparoscopic and robotic surgeries for VUR correction. There are several principal approaches to performing such interventions.
- Intravesical approach — cystotomy is performed, and the ureters are reimplanted through the detrusor, creating a submucosal tunnel long enough to act as a valve that provides antireflux function.
- Extravesical approach — With this approach, reimplantation is performed without a full-thickness bladder incision, but the principle of establishing submucosal antireflux protection remains the same [70,71,72,73].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
Comment: open surgical interventions are advisable in patients with any grade of VUR across all age groups in whom endoscopic ureteral orifice injection has not led to recovery and laparoscopic or robotic reconstructions are not feasible due to contraindications [63,65].
3.3 Other Treatment
None.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Not applicable.
5. Prevention and Dispensary Observation
Following the resolution of vesicoureteral reflux — whether spontaneous or achieved via surgical treatment — patients with signs of reflux nephropathy are recommended to undergo long-term clinical monitoring until adolescence to evaluate renal function. This should include periodic renal ultrasound examinations. If secondary changes in the renal parenchyma are present, static renal scintigraphy (renal and urinary tract scintigraphy) is indicated. The absence of vesicoureteral reflux is confirmed by voiding cystography (micturition cystourethrography) [74,75,78].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
Comment: follow-up cystography is performed 6–12 months after surgery, renal ultrasound is advisable at 12-month intervals, and static renal scintigraphy is indicated at 6–12 month intervals.
6. Organization of Medical Care
Pre-hospital outpatient consultation.
Scheduled hospitalization for surgical treatment including additional instrumental examinations and surgical intervention in the absence of contraindications.
Discharge from the medical organization for outpatient follow-up according to the recommendations.
Indications for hospitalization in a medical organization:
Scheduled hospitalization: presence of a diagnosis of vesicoureteral reflux confirmed by voiding cystourethrography (voiding cystography), radioisotope cystography, ureterocystoscopy (urethroscopy, cystoscopy), or clinical presentation.
Emergency hospitalization: acute pyelonephritis.
Indications for hospital discharge
Patient discharge is possible on days 1–7 after diagnostics or surgical treatment, provided the patient is in a satisfactory condition, with no signs of hyperthermia or urinary tract infection, and has restored spontaneous urination or adequate temporary or permanent urinary bladder drainage.
Patients may be discharged from the hospital with a urethral and/or suprapubic catheter, followed by outpatient monitoring according to the recommendations.
7. Additional Information
Not applicable.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance evaluation |
|---|---|---|
1 | Cystography performed | Yes/no |
2 | A general (clinical) urinalysis was performed | Yes/no |
3 | Ultrasound examination of the kidneys and urinary bladder performed | Yes/no |
4 | Diagnostic cystoscopy | Yes/no |
5 | Antibacterial prophylaxis prescribed | Yes/no |
6 | Surgical treatment performed | Yes/no |
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Appendix A1. Working Group Composition
Kozyrev German Vladimirovich – Doctor of Medical Sciences, Professor, Head of the Department of Pediatric Urology and Andrology at the Patrice Lumumba Peoples' Friendship University of Russia, Professor of the Department of Pediatrics at the Bashkir State Medical University, Director of the Association of Pediatric Urologists and Andrologists (APUA), pediatric urologist-andrologist at the Morozov Children's City Clinical Hospital of the Moscow Healthcare Department.
Burkin Artem Gagikovich – Candidate of Medical Sciences, Head of the Department of Pediatric Urology and Andrology at the Z.A. Bashlyaeva Children's City Clinical Hospital of the Moscow Healthcare Department.
Kulaev Artur Vladimirovich – Candidate of Medical Sciences, Assistant at the Department of Pediatric Urology and Andrology at the Patrice Lumumba Peoples' Friendship University of Russia, pediatric urologist-andrologist at the Morozov Children's City Clinical Hospital of the Moscow Healthcare Department.
Guseinov Anar Yasharovich – Candidate of Medical Sciences, Head of the Surgical Uroandrological Department, Russian Children's Clinical Hospital, branch of the Pirogov Russian National Research Medical University.
Manasherova Dina Tamazievna – Junior Researcher at the S.P. Botkin Moscow City multidisciplinary Clinical Center, Secretary of the Association of Pediatric Urologists and Andrologists (APUA) of the Moscow Healthcare Department.
Gazimiev Magomed-Salah Alkhazurovich – Doctor of Medical Sciences, Professor, Deputy Director for Academic and Educational Work at the Institute of Urology and Human Reproductive Health, Sechenov First Moscow State Medical University of the Ministry of Health of Russia (Sechenov University), Executive Director of the Russian Society of Urology (RSU).
Conflict of interest: none.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Urologists
Pediatric urologists-andrologists
Pediatric surgeons
Pediatricians
Nephrologists
Table 1. Scale for assessing the levels of evidence (LE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for evaluating the levels of убедительности рекомендаций (LoR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Order of the Ministry of Health of Russia No. 804n dated October 13, 2017 (as amended on September 24, 2020, with rev. dated October 26, 2022) "On Approval of the Nomenclature of Medical Services."
Federal Law No. 323-FZ dated November 21, 2011 (as amended on December 29, 2025) "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation" (with rev. and add., effective April 1, 2026).
Decree of the Government of the Russian Federation No. 3867-r dated December 18, 2025 "On Approval of the List of Vital and Essential Medicines, as well as Lists of Medicines for Medical Use and the Minimum Assortment of Medicines Required for Medical Care".
Order of the Ministry of Health of Russia No. 205n dated May 2, 2023 (as amended on June 3, 2025) "On Approval of the Nomenclature of Positions of Medical and Pharmaceutical Workers."
Order of the Ministry of Health of Russia No. 561n dated October 31, 2012 (as amended on February 21, 2020) "On Approval of the Procedure for Providing Medical Care in the Profile 'Pediatric Urology-Andrology'."
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Vesicoureteral reflux (VUR) is the retrograde flow of urine from the urinary bladder into the ureter and kidney, caused by a congenital impairment of the antireflux mechanism at the junction between the ureter and the urinary bladder.
You should consult a doctor if you develop the following symptoms:
Cloudy urine, discoloration, and foul odor.
Pain in the lumbar region and/or lower abdomen.
Acute increase in body temperature to febrile levels against the background of complete prior health.
Periodic increases in body temperature to subfebrile levels.
Daytime and/or nocturnal urinary incontinence.
Elevated blood pressure in the absence of confirmed cardiovascular diseases.
Diagnostics in the presence of the above symptoms includes:
Monitoring of urinalysis parameters.
Ultrasound examination of the kidneys and urinary tract with determination of bladder volume and post-void residual urine volume.
Voiding cystography.
Urinalysis parameters help determine the presence of a urinary tract infection and provide recommendations for further management and diagnostics of its underlying causes.
Ultrasound imaging can identify indirect signs of congenital anomalies of the kidneys and urinary tract.
Voiding cystography is the "gold standard" in the diagnosis of vesicoureteral reflux.
After confirmation of the diagnosis, depending on the severity of the disease, either conservative therapy/monitoring or surgical intervention will be required.
Surgical interventions should be performed in specialized departments.
Following successful surgical treatment, the patient needs to be monitored during the first year at intervals determined by the operating surgeon depending on the performed surgery, and subsequently every two to three years until reaching adulthood.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
None provided.