Cyst Within Cyst
8 y old boy presented to ED for fever and dysuria. History of recurrent UTIs, usually managed by GP with antibiotics. Images of beside ultrasound performed in Emergency department are given below.
- What is your diagnosis?
- Would you consider extending your scan to other organ(s)/ area(s)?
- What is your management plan?
Ultrasound finding: A cystic intravesical mass in right posterior portion of the bladder with dialated right distal ureter. R sided ureteric jet noted.
(Further imaging – Ultrasound of the both kidneys were normal. There was no hydronephrosis or dialation of the proximal ureter. Bilateral ureteric jet noted)
Diagnosis: Rt Ureterocele – Intravesical.
Ureterocele is a cystic dilatation of the terminal ureter within the bladder (intravesical ureterocele) or sometimes a portion of ureter extends in to the urethra (ectopic ureterocele). Clear pathogenesis is unknown, but this can be diagnosed even by antenatal ultrasonography. Four to six times more common in females than males and more common in Caucasians than in other races. Ureteroceles are classified based on its location; Intravesical (ie entirely within the bladder) and ectopic (ie portion of the it extends beyond the bladder neck in to the urethra). Ureteroceles are mostly associated with duplex collecting system1-3
It may be identified as an incidental finding on antenatal ultrasound or postnatally due to UTI or failure to thrive. Hematuria is a rare presentation. In older children, stasis and infection may predispose to stone formation.
Surgery is usually needed in most cases, options ranges from endoscopic correction to open reconstruction. Choice depends upon the clinical setting, duplex or single collecting system and the presence or absence of VUR.
From emergency medicine point of view, should we scan every child that presents with UTI to ED? My answer is “no”. But there are instances where you think this is an atypical presentation or child with recurrent UTIs or child failing to thrive, it is worth scanning their renal system to look for structural abnormalities like hydronephrosis, hydroureter, ureteroceles. This particular case was referred to paediatric urologist from ED. Of course he went through further imaging to confirm the ultrasound findings, but at least we put him on the right track. Identifying the above said abnormalities by bedside ultrasound is easy and achievable in ED setup.
- Shein CP, Liao YJ, Hung CS, Shieh JY, Fu LS, Li YW. Intravesical ureterocele in children. Chung Hua Min Kuo Hsiao Erh Ko I Hsueh Hui Tsa Chih. Nov-Dec 1994;35(6):502-507.
- Debenedectis CM, Levine D. Incidental genitourinary findings on obstetrics/gynecology ultrasound. Ultrasound Q. Dec 2012;28(4):293-298.
- Weiss DA. Management of ureterocele? The search for the holy grail. J. Urol. Feb 2015;193(2):398-399.
- American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on urinary tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. Pediatrics. 1999;103:843–52.
- Hoberman A, Charron M, Hickey RW, et al. Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med. 2003;348:195–202.
- Lebowitz RL, Olbing H, parkkulainen KV, et al. international system of radiographic grading of vesicouretric reflux study. international reflux study in children. Pediatr Radiol. 1985;15:105–9.
- DiPietro MA, Blane CE, Zerin JM. Vesicoureteral reflux in older children: concordance of US and voiding cystourethrographic findings. Radiology. 1997;205:821–2.
- Alon US, Ganapathy S. Should renal ultrasonography be done routinely in children with first urinary tract infection? Clin Pediatr. 1999;38:21–5.
- Mahant S, Friedman J, MacArthur C. Renal ultrasound finding and vesicoureteral reflux in children hospitalized with urinary tract infection. Arch Dis Child. 2002;86:419–20.
- Zamir G, Saan W, Horowitz Y, et al. Urinary tract infection: is there a need for routine renal ultrasonography? Arch Dis Child. 2004;89:466–468.