Sex: female
Age: 41 years
History
Recurrent urinary infections (E. Coli), reported occasional dribbling.
Laboratory data
No relevant findings.
Physical findings
No relevant findings.
Case text
The patient was referred to the radiologist, on an outpatient basis, to perform a US investigation of the urinary tract because of urinary infections and dribbling.
Image 1-4
Ultrasound of the urinary tract.
Longitudinal scans of the right kidney (image 1: Lower pole, image 2: upper pole), axial scan of the bladder (image 3), longitudinal scan of the bladder, close to the midline, on the right (image 4).
Image 5
Excretory urogram.
Full length view of the urinary tract 15 min following injection of contrast material.
Image 6-9
MRI of the urinary tract.
Coronal T2-weighted TSE (turbo spin-echo) images (TR/TE 2695/150) of the urinary tract (images 6,7). Axial T2-weighted TSE images (TR/TE 4492/150) of the pelvis (images 8,9).
Image 10
Retrograde pielography.
During the exploration of the vulva, a small meatus was actually detected and cannulated. Contrast media was injected.
A-P view of the pelvis following introduction of contrast agent through the meatus located in the vulva.
Image 1-4
1. What are the abnormalities present on the US scan of the urinary tract?
An elongated liquid cavity is shown at the upper pole of the right kidney. Parenchymal thinning is evident around the cavity. Scan of the bladder (image 4) shows a round liquid cavity, 3.5 cm in diameter, posterior to the bladder, close to the midline, on the right (uterus and adnexa are normal).
2. What is your diagnosis?
Duplication of the renal collecting system on the right with dilatation of the upper unit. Fluid collection posterior to the bladder.
3. What is the differential diagnosis?
Duplication of the renal collecting system on the right with dilatation of the upper unit and segmental dilatation of the pelvic ureter.
4. What is your next diagnostic step?
Excretory urogram.
Image 5
5. What is the abnormality present on the excretory urogram.
Duplication of the renal collecting system on the right with faint opacification of an upper dilated calix. No opacification of the right upper ureter.
6. Are there other findings as to the urinary tract?
No other abnormalities.
7. What is your diagnosis?
Duplication of the renal collecting system on the right with dilatation of the upper unit.
8. What is your next diagnostic step?
MRI of the urinary tract.
Image 6-9
9. What is the abnormality present on the MRI of the urinary tract?
Duplication of the renal collecting system on the right with thinning of the upper pole. The upper unit is dilated and the dilated ureter can be recognized till the pelvis, where it appears tortuous and approaches a fluid cavity which is located posterior to the bladder, close to the midline, on the right (see images 8,9).
10. What condition should be ruled out?
Ectopy of the dilated ureter, which could be suggested because of the clinical presentation.
11. What is your next diagnostic step?
External genitalia should be checked for a possible ureteral meatus; ureteroscopy could be suggested.
Image 10
12. What is the abnormality present on the retrograde pielography?
A thin tubular structure is opacified and communicates with a sac-like cavity close to the midline, corresponding to the structure shown posterior to the bladder both on US and MRI. No opacification of the ureter above.
13. What is your diagnosis?
Duplication of the renal collecting system on the right, dilatation of the upper unit and segmental stenosis of the ectopic ureter above and below its pelvic sac-like dilatation.
The patient underwent surgical ligation of the dilated ectopic ureter and recovered from dribbling.
Final diagnosis
Duplication of the renal collecting system on the right, dilatation of the upper unit and segmental stenosis of the ectopic ureter above and below its pelvic sac-like dilatation.
Differential diagnosis
None.
Discussion
An ectopic ureter can be defined as an ureter with a meatus in a location different from the bladder trigonum. It is usually detected before the age of 20 years, but detection occurs in adults in as much as 40% of cases. Females are more frequently affected (5:1). A double pyelocalyceal district is associated in 80-90% of cases in the European and American literature. In females the ectopic ureter more often reaches the urethra (within or below the sphincter) in 35% and the vulva in 25% of cases. The ectopic ureter is frequently associated to dysplasia/atrophy of the parenchyma of the upper moiety.
Symptoms are recurrent urinary infections, ncontinence, dribbling and are related to the different site of the ectopic meatus (within or below the sphincter).
US allows to detect the possible dilatation of the upper ureter, while i.v. urography confirms the double unit and eventually shows the poor function of the upper one. Voiding retrograde cystourethrography can show opacification of the ectopic ureter (in 30-50% of cases), while cystourethroscopy can directly show the ectopic meatus.
MRI allows a comprehensive view of the urinary tract, showing both the renal parenchyma and the excretory pathway and can be of value when i.v. urography fails because of the faint opacification. Moreover MRI can be relevant in more complex cases, such as this one, presenting, besides the congenital anomaly, segmental stenoses likely related to superimposed infections.