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uro.pediatric-vur.v1

Pediatric Vesicoureteral Reflux (VUR) — grade I–V; primary / secondary / antenatal-hydronephrosis pathway; prophylaxis / surgical / behavioural management

urologychronicpediatricneonataloutpatientacuteinpatient
Start encounter →Print handoutPRODUCTION

Phase C wave-14 initial author (2026-05-15): SCAFFOLDED with full §5.5 depth — 9 phenotypes encoded as severity_triggers (VUR grade I–II low, grade III intermediate, grade IV–V high, voiding dysfunction overlay, primary familial, secondary obstructive/neurogenic, renal scarring DMSA, breakthrough on prophylaxis, antenatal hydronephrosis postnatal), 4 settings (home / outpatient / ed / inpatient), 6-PMID anchor set, 1 regimen axis with 8 steps (BBD-first / low / intermediate / high / breakthrough / antenatal / secondary / surveillance), 3 sibling rows pointing at REAL existing engines (uro.uti.pediatric.v1, uro.uti.complicated.v1, peds.febrile-infant.core.v1). RIVUR (Hoberman NEJM 2014) — TMP-SMX 2 mg/kg/day low-dose continuous prophylaxis reduces UTI recurrence ~50% in VUR; PRIVENT 2010 — nitrofurantoin alternative; both 6–12 mo trial then reassess. BBD-FIRST doctrine: bowel-bladder dysfunction is dominant modifiable risk factor for recurrent UTI in VUR; treating BBD often resolves recurrent UTI without changing VUR management (AAP 2011). Antenatal hydronephrosis postnatal workup: renal + bladder US at 3–7 d (avoid <48 h false negative); VCUG if persistent moderate-severe; consider amoxicillin interim prophylaxis in <2 mo (TMP-SMX contraindicated for kernicterus) (NICE NG224). AVOID classes: TMP-SMX <2 mo (kernicterus), nitrofurantoin <1 mo (G6PD), nitrofurantoin in pyelonephritis (no renal tissue penetration), fluoroquinolones (cartilage), tetracyclines <8 yo (teeth). Circumcision counseling (AAP 2012) for recurrent UTI in uncircumcised male infant — ~10× UTI risk in first year; informed parental decision. Surgical correction (ureteral reimplantation OR endoscopic Deflux) for failed prophylaxis, breakthroughs, or parental preference; ~95% success reimplant, ~70% Deflux per injection. Sibling pivots: uro.uti.pediatric.v1 (acute UTI engine drives imaging algorithm; this engine drives chronic VUR management), uro.uti.complicated.v1 (adolescent transitioning to adult care), peds.febrile-infant.core.v1 (<2 mo fever sepsis workup leads). Promoted SCAFFOLDED→INTEGRATED 2026-05-22 (shard-5 build campaign): all 6 prior placeholder PMIDs were mis-attributed/fabricated (incl. 28291561=olmesartan enteropathy; 27977840 is NOT the real RIVUR trial which is 24795142) and replaced with the live-verified AUA VUR-in-children guideline (20650499); RIVUR/PRIVENT/AAP/NICE cited by name. RxCUIs corrected: TMP-SMX 10180→10831 (combo), amoxicillin 733→723 (was ampicillin), PEG-3350 8203→221147; nitrofurantoin RxNav-verified. Schema-blocked downstream: peds.vur.surgical.v1, calc.vur_grade, protocol.vcug, protocol.dmsa, workup.antenatal_hydronephrosis, panel.vur_surveillance — none yet in clinical-tools-registry.ts. Tickets surfaced in depth brief §6. Dossier registered in _registry.ts as part of this commit (Phase C wave-14 shard-3 scope).

Entry points (9)

  • lab_abnormality
    VCUG-positive vesicoureteral reflux (grade I–V) — entry to VUR pathway (AAP 2011; AUA pediatric VUR)
    vcug_positive_vur_diagnosis
  • history
    First febrile UTI 2–24 mo with renal + bladder US findings → VCUG planning (AAP 2011)
    first_febrile_uti_2_to_24mo_with_vur_workup
  • history
    Recurrent febrile UTI (≥2 in 6 mo OR ≥3 in 12 mo) → VUR workup (AAP 2011)
    recurrent_febrile_uti_in_child
  • imaging
    Antenatal hydronephrosis on prenatal US → postnatal renal + bladder US within 3–7 d → VCUG if persistent (NICE NG224)
    antenatal_hydronephrosis_postnatal_workup
  • history
    First-degree relative with VUR or renal scarring → screening US (AAP 2011)
    family_history_vur_or_renal_scarring
  • history
    Known VUR on prophylaxis with breakthrough UTI → reassess + culture-directed switch (RIVUR)
    breakthrough_uti_on_prophylaxis
  • history
    Bowel-bladder dysfunction (holding, encopresis, constipation) ± VUR — TREAT FIRST (route uro.urinary-incontinence-eval.v1)
    voiding_dysfunction_bowel_bladder_overlap
  • history
    Secondary VUR — neurogenic bladder, posterior urethral valves, UPJ obstruction — different pathway (AUA pediatric)
    known_neurogenic_bladder_or_obstructive_anomaly
  • problem_list
    Established VUR follow-up — annual US / VCUG / DMSA per grade + UTI history
    known_vur_surveillance

Required inputs (20)

  • age_monthsrequired
    demographic • used at FRAME
    Age stratifies management: <1 yr higher resolution rate; older child observation vs prophylaxis decision uses RIVUR data
  • sexrequired
    demographic • used at FRAME
    Sex stratifies risk — VUR more common in girls; circumcision counseling in uncircumcised males (AAP 2012)
  • weight_kgrequired
    demographic • used at TREATMENT
    All pediatric dosing is weight-based (mg/kg/day) — prophylaxis TMP-SMX 2 mg/kg/day or nitrofurantoin 1–2 mg/kg/day (RIVUR)
  • circumcision_status_malerequired
    history • used at CONTEXT
    Uncircumcised male infants have ~10× UTI risk in first year vs circumcised; AAP 2012 informed parental decision
  • vur_grade_per_vcugrequired
    history • used at RISK_STRATIFICATION
    Grade I–II low (resolves ~80%); III intermediate; IV–V high (RIVUR prophylaxis benefit; surgical candidacy) (AAP 2011)
  • prior_uti_countrequired
    history • used at CONTEXT
    Recurrent UTI history drives prophylaxis decision per RIVUR / PRIVENT
  • voiding_dysfunction_or_constipationrequired
    history • used at CONTEXT
    Bowel-bladder dysfunction (BBD) is a dominant modifiable risk factor; TREAT FIRST before deciding prophylaxis vs surgery (AAP 2011; RIVUR)
  • family_history_vur_or_scarring
    history • used at CONTEXT
    First-degree relative with VUR (~30% sibling risk) — screening US in siblings (AAP 2011)
  • antenatal_hydronephrosis_history
    history • used at CONTEXT
    Antenatal hydronephrosis → postnatal renal + bladder US within 3–7 d (NICE NG224)
  • secondary_vur_causerequired
    history • used at CONTEXT
    Posterior urethral valves, UPJ obstruction, neurogenic bladder — secondary VUR requires different management (AUA pediatric)
  • prophylaxis_status_and_agent
    history • used at CONTEXT
    Current prophylaxis agent + breakthrough history; breakthrough → switch agent per culture (RIVUR)
  • allergy_sulfa_or_otherrequired
    history • used at TREATMENT
    TMP-SMX contraindicated in sulfa allergy; choose nitrofurantoin alternative (RIVUR / PRIVENT)
  • temprequired
    vital • used at RED_FLAGS
    Fever in known VUR → STAT UA + culture; febrile UTI on prophylaxis = breakthrough (RIVUR)
  • sbp
    vital • used at MONITORING
    Hypertension surveillance — renal scarring can cause HTN; check BP at every visit (AAP)
  • renal_bladder_usrequired
    imaging • used at INITIAL_WORKUP
    Renal + bladder ultrasound after first febrile UTI 2–24 mo; antenatal hydronephrosis postnatal workup (AAP 2011; NICE NG224)
  • vcug_or_radionuclide_cystogramrequired
    imaging • used at INITIAL_WORKUP
    VCUG = gold-standard for VUR diagnosis and grading; radionuclide cystogram for surveillance (less radiation) (AAP 2011)
  • dmsa_scintigraphy_for_scarring
    imaging • used at BRANCHING_WORKUP
    DMSA = gold-standard for renal scarring detection; baseline + surveillance in moderate-high grade VUR
  • urinalysis_with_culturerequired
    lab • used at INITIAL_WORKUP
    UA + catheter / SPA culture in <2 yo for every fever episode (AAP 2011)
  • creatinine_or_cystatin_crequired
    lab • used at INITIAL_WORKUP
    Baseline + serial renal function — eGFR by Schwartz; cystatin C if available (KDIGO peds)
  • urine_protein_creatinine_ratio
    lab • used at MONITORING
    Surveillance for renal scarring → proteinuria predicts progression (AAP)

12-phase flow (12)

  1. 1FRAME
    Pediatric patient (neonate through adolescent) with VUR — primary (familial, idiopathic) vs secondary (PUV, UPJ obstruction, neurogenic bladder); grade I–V determines management ladder (AAP 2011)
    inputs: age_months, sex, vur_grade_per_vcug, secondary_vur_cause
    advance: engine scope confirmed
  2. 2ENTRY
    VCUG-positive VUR / first febrile UTI 2–24 mo with workup / recurrent UTI / antenatal hydronephrosis postnatal / family history / breakthrough on prophylaxis (AAP 2011; NICE NG224)
    advance: entry captured
  3. 3CONTEXT
    Age, sex, weight, circumcision, prior UTI count, voiding dysfunction / constipation, family history, antenatal hydronephrosis history, secondary cause, current prophylaxis, allergy (RIVUR; PRIVENT)
    inputs: weight_kg, circumcision_status_male, prior_uti_count, voiding_dysfunction_or_constipation, family_history_vur_or_scarring, antenatal_hydronephrosis_history, prophylaxis_status_and_agent
    advance: context complete
  4. 4RED_FLAGS
    Febrile UTI on prophylaxis (breakthrough — RIVUR); urosepsis → admit; AKI on KDIGO peds; secondary VUR with PUV in infant (surgical emergency)
    inputs: temp
    advance: no red flags OR routes engaged
  5. 5INITIAL_WORKUP
    Renal + bladder US; VCUG (or radionuclide cystogram for surveillance); UA + culture; CMP / creatinine; check BP; bowel-bladder dysfunction screen (AAP 2011; NICE NG224)
    inputs: renal_bladder_us, vcug_or_radionuclide_cystogram, urinalysis_with_culture, creatinine_or_cystatin_c
    actions: panel.ua, panel.renal
    advance: imaging + labs complete + grade assigned
  6. 6BRANCHING_WORKUP
    DMSA scintigraphy if recurrent UTI / high grade / renal asymmetry on US; urodynamics if neurogenic bladder suspected; cystoscopy / further imaging if PUV / UPJ; bowel-bladder dysfunction full workup
    inputs: dmsa_scintigraphy_for_scarring
    advance: branching diagnostics complete
  7. 7DIFFERENTIAL
    Primary VUR (familial, idiopathic) vs secondary VUR (PUV, UPJ, neurogenic bladder) vs bowel-bladder dysfunction (no VUR, but recurrent UTI) vs renal scarring vs antenatal hydronephrosis without VUR vs other reflux nephropathy (AAP 2011)
    advance: differential narrowed
  8. 8RISK_STRATIFICATION
    VUR grade (I–II low / III intermediate / IV–V high) + age + sex + UTI history + bowel-bladder dysfunction + renal scarring on DMSA → ladder step (RIVUR / PRIVENT)
    advance: ladder tier assigned
  9. 9TREATMENT
    STEP 1 — Bowel-bladder dysfunction TREAT FIRST (behavioural + PEG laxative; route uro.urinary-incontinence-eval.v1). STEP 2 — Low-grade I–II observation (no prophylaxis). STEP 3 — Intermediate grade III observation vs prophylaxis based on age + UTI history. STEP 4 — High-grade IV–V continuous TMP-SMX 2 mg/kg/day OR nitrofurantoin 1–2 mg/kg/day qhs × 6–12 mo (RIVUR / PRIVENT); circumcision counseling for uncircumcised males. STEP 5 — Surgical correction (ureteral reimplantation OR endoscopic Deflux) for failed prophylaxis / breakthrough / parental preference. STEP 6 — Breakthrough on prophylaxis → switch agent per culture (RIVUR)
    inputs: weight_kg, allergy_sulfa_or_other
    advance: ladder step selected
  10. 10DISPOSITION
    Outpatient primary + pediatric urology referral if moderate-high grade / recurrent / scarring / antenatal; ED for febrile UTI in known VUR; admit if urosepsis or post-op (AAP 2011)
    advance: disposition documented
  11. 11MONITORING
    Annual re-evaluation; UA + culture for fever episodes; BP each visit; renal function annually; renal + bladder US annually if high grade / scarring; VCUG or radionuclide cystogram at 12–18 mo for resolution; DMSA q2–3 yr if high grade / scarring (AAP 2011)
    inputs: sbp
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Trial off prophylaxis after 6–12 mo if no breakthroughs in moderate; transition to adult care; counsel lifelong HTN surveillance + pregnancy considerations if scarring; family screening for siblings (AAP 2011)
    advance: follow-up scheduled