Evaluation and management of pediatric vesicoureteric reflux: Clinical guidelines review and introduction of the primary reflux evaluation and severity scoring severity score for vesicoureteric reflux

Background: Vesicoureteric reflux (VUR) in children constitutes a peculiar and challenging problem in therapy. The inherent nature of the disorder necessitates invasive imaging procedures for diagnosis and follow-up. The anatomical derangement, the severity of disease, and renal affection in each case are highly variable. Similarly, the natural history is also variable, with the possibility of spontaneous resolution in some cases and the potential for worsening reflux with progressive renal functional deterioration in others. These factors contribute to the complexity of decision-making in evaluation and therapy. Objective: This article aims to review the common management pathways in VUR and further proposes a severity scoring system for primary reflux based on anatomical and functional criteria that will help to guide the management. Methods: The current literature, clinical guidelines, and recommendations were reviewed, and critical factors determining the severity and prognosis of primary reflux were identified in light of clinical experience. These factors were integrated to construct the new severity scoring system. Results: The new risk stratification proposed here for primary VUR incorporates important clinical criteria. The broad management pathways suggested here with regard to the diagnosis, evaluation, and management of VUR can serve only as an outline for the decision-making process. Therapeutic decisions need to be individualized in every case. It is also important to recognize VUR as a disorder with systemic problems and the potential for chronic and long-term functional sequelae. Conclusions: The severity scoring system proposed here (primary reflux evaluation and severity scoring) will function as a prognostic indicator as well as a guide to therapeutic decision-making. An understanding of the physiology and natural history of the disorder is key to the treatment. The treatment protocol has to be tailored to the specific situation of each patient while minimizing morbidity and maximizing therapeutic benefit.