|Year : 2016 | Volume
| Issue : 3 | Page : 180-182
Ureterocele as a cause of recurrent loin pain
Suleiman Lawal1, Joseph B Igashi1, Muhammad I Zaria1, Nuhu D Chom1, Ahmad T Lawal2
1 Department of Radiology, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Urology, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
|Date of Web Publication||17-Mar-2017|
Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria
Source of Support: None, Conflict of Interest: None
Ureterocele is a congenital saccular dilatation of the terminal portion of the ureter within the urinary bladder. It is an uncommon cause of urinary tract obstruction in the young patient and one of the more challenging anomalies to the urologists. Ureterocele poses a diagnostic and therapeutic dilemma as it manifests a wide spectrum of perplexing clinical symptoms. We report a case of single system ureterocele in a patient presenting with acute severe transformation of recurrent loin pain.
Keywords: Congenital, loin pain, recurrent, Ureterocele
|How to cite this article:|
Lawal S, Igashi JB, Zaria MI, Chom ND, Lawal AT. Ureterocele as a cause of recurrent loin pain. Arch Int Surg 2016;6:180-2
| Introduction|| |
Ureterocele is a congenital saccular dilatation of the terminal portion of the ureter within the urinary bladder., It is one of the more challenging urologic anomalies that face pediatric and adult urologists, occurring in 1:4000 children in America and Europe; it is 4–7 times more common in females and is found almost exclusively in Whites. Ureterocele poses a diagnostic and therapeutic dilemma because it manifests as a wide spectrum of anatomic abnormalities and can produce perplexing clinical symptoms. It has varied effects in regard to obstruction, reflux, continence, and renal function. It is classified as a single or duplex system, orthotopic (intravesical) or ectopic, whereas the orifices are classified as stenotic, sphincteric, sphincterostenotic, and cecoureterocele. It is commonly unilateral, however, is bilateral in 10% of the cases. Single-system ureterocele is usually found in adults, and is less prone to obstruction and renal dysplasia. The most common presentation is that of urinary tract infection or urosepsis in children. Stasis of urine can lead to calculus formation, and thus a cause of severe colicky pain. Some children may present with palpable mass due to hydronephrotic kidney. Adults often present with recurrent flank pain from infection, obstruction, or calculus.,
Cyst may prolapse into internal urethral opening causing obstruction to bladder outflow. This condition may remain unrecognized until adult life. Ureterocele is usually discovered on radiological examination or during endoscopy. This case is being presented because of its rarity among non-Whites, especially in this case a Black individual.
| Case Report|| |
Our patient is a 32-year-old man who presented to the surgical outpatient unit of Ahmadu Bello University Teaching Hospital with acute exacerbation of recurrent left loin pain, fever, and abrupt termination of micturition, with a feeling of incomplete voiding of 1 year duration. General physical examination did not reveal any abnormality apart from the severe lower abdominal tenderness with guarding. A working diagnosis of urolithiasis was made.
Laboratory investigations showed numerous pus cells on urine microscopy and culture. Abdominopelvic ultrasonography revealed mild left hydronephrosis, cyst within cyst appearance with a calcific focus [Figure 1]. On intravenous urography (IVU), the control film revealed a small calcific density in the left side of the pelvis, the contrast films showed the classical “Cobra Head” appearance which was observed at the left ureterovesical junction. Fullness of the left pelvicalyceal system, left calyceal cyst, and dilatation of the distal left ureter were observed. The right pelvicalyceal system and right ureter were essentially normal in appearance [Figure 2].
|Figure 1: Ultrasound scan showing cyst in cyst appearance of the ureterocele within the urine filled bladder. An echogenic mass with posterior acoustic shadowing in keeping with calculus (c) is noted within ureterocele|
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|Figure 2: A 15-minute excretory urographic film showing left calyceal cyst and a dilated contrast filled oval shaped intravescical distal left ureter with a cobra head appearance|
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The patient had a successful transvesical excision and re-implantation of the left ureter, and has remained symptom free for approximately 2 months now post surgery. The post surgery ultrasound scan and IVU were within normal limit.
| Discussion|| |
The precise embryologic etiology of the ureterocele has been debated.,, Several theories exist, including obstruction of the ureteral orifice, incomplete muscularization of the intramural ureter, and excessive dilatation of the intramural ureter during the development of the bladder, as well as trigone, Schistosoma hematobium infection, and trauma. The most commonly accepted theory of ureterocele formation is the obstruction of the ureteral orifice during embryogenesis, with incomplete dissolution of the Chwalla membrane (a primitive thin membrane that separates the ureteral bud from the developing urogenital sinus). Failure of this membrane to completely perforate during development of the ureteral orifice is thought to explain the occurrence of ureterocele. In a study by Ahmad et al., though on a limited number of cases of Black origin, 80% have an associated pathology, thus throwing more weight behind the theory of an acquired origin.
Ureteroceles have a particular predilection for race and gender. They occur most frequently in females (4–7:1) and commonly in Whites, although our index case is a male and of the Black race.
Single system ureteroceles are those associated with a single kidney, a single collecting system, and a solitary ureter, whereas double-system ureteroceles are associated with kidneys that have a completely duplicated collecting system and two ureters; the index case is a single system ureterocele.
Approximately 10% of ureterocele are bilateral. Eighty percent of duplicated system ureteroceles arise from the upper pole. Single system ureterocele is known as a simple ureterocele, they have a slight left-sided preponderance and is usually found in adults; hence, its also called an “adult” ureterocele, all of these apply to this patient. This single system ureterocele is less prone to the severe obstruction and dysplasia associated with duplicated system, only mild hydrocalycosis and distal ureteral dilatation is seen in this index case. Some patients could present with ectopic ureteroceles, which refers to those ureteroceles whose orifices are located outside the trigone, such as bladder, neck, or urethra, and are common in pediatric population. Eighty percent of pediatric patients present with ectopic ureterocele. This patient has a normal trigonal insertion, i.e., orthotopic ureterocele, which is the common type seen in adult patients.
Patients with ureterocele may manifest with failure to thrive or as abdominal or pelvic pain. The index case is of average built with a height of 1.73 cm, which is not surprising as the clinical features correspond to mild radiological findings. Ureterocele may evert into the ureter and appear to be a diverticulum; this is not the case in this index patient. Although most cases of ureterocele are diagnosed after birth, in-utero diagnosis and management is also possible. Fetal bladder-outlet obstruction from ureteroceles is well recognized and documented; when this is diagnosed the fetus is monitored in-utero and then at birth an endoscopic incision of the ureterocele may be done. However, such obstruction may result in bilateral renal damage, oligohydramnios, pulmonary hypoplasia, and neonatal death, hence necessitating in-utero intervention. Quintero et al. described a successful cytoscopic-guided laser incision with no complication of an ureterocele that was causing bladder-outlet obstruction in a fetus of 19 weeks and 6 days gestation. This case in our center would have been a source of apprehension and concern as the laser facility is not available, and the patient would have to undergo the stress of the conventional transvesical excision and re-implantation postpartum.
The imaging studies provide a significant amount of insight into the effects of ureterocele on normal anatomy and physiology. Renal and bladder ultrasonography is the first-line imaging study. Ureterocele is seen as a fluid filled intravesical mass, which is the classical “cyst in cyst” appearance, as noted in the urinary bladder sonogram of this patient with an additional content of rounded echogenic focus with posterior acoustic shadowing in keeping with calculus. Hydroureteronephrosis is observed as dilatation of renal pelvicaliceal system and ureter; the index case, however, showed mild dilatation of the distal left ureter. IVU is useful for delineating anatomy and renal function; the urogram of the index case showed a left calyceal cyst and a dilated contrast-filled oval-shaped intravescical distal left ureter with the typical “cobra head” appearance of ureterocele. Nuclear scan (e.g., with dimercapto succinic acid) may demonstrate subtle changes in renal function and presence or absence of obstruction. However, this was not done in our case, as the facility is not available in our centre and will not add much in the management of this patient.
Because ureteroceles have a broad spectrum of presentation, anatomy and pathophysiology, their management cannot be generalized., No single method suffices for all the cases. Single system ureteroceles more readily lend themselves to transvesical excision and re-implantation, with any muscular defect corrected as necessary. These are also amenable to endoscopic excision. Transvesical excision and re-implantation was carried out for this patient because we have no facility for endoscopy surgery.
| Conclusion|| |
Ureterocele though taught to be rare in non-Whites, the true incidence in this part of the world is yet unknown and could in fact be under reported. The imaging diagnosis of ureterocele is straightforward and can easily be made in any young patient with obstructive uropathy.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]