Question

Embryology, clinical presentation, diagnosis & management of ectopic ureter in a girl child.

Hint:

Early diagnosis and surgical correction are essential in preventing kidney damage and improving quality of life in children with ectopic ureter.

Answer 1

Ectopic ureter is a congenital anomaly where the ureter does not connect to the bladder as it should. Instead, it may open into the urethra, vagina, or even the uterus, which can lead to complications such as incontinence or recurrent urinary tract infections.
Step 1: Embryology:
1. Development of Ureters: The ureters develop from the mesonephric ducts during the 6th to 8th week of embryonic life. In female embryos, the mesonephric ducts typically regress, and the ureters form as an outgrowth from the mesonephric duct. In cases of ectopic ureter, this process goes awry, leading to an abnormal connection of the ureter.
2. Ureteric Bud: The ureteric bud forms the collecting system and connects to the developing kidney. In ectopic ureters, this connection can be abnormal, leading to the ectopic location.
Step 2: Clinical Presentation:
1. Incontinence: The most common presenting symptom in a girl with ectopic ureter is incontinence, especially during the day. This is because the ectopic ureter may drain into the urethra or vagina, bypassing the bladder.
2. Recurrent Urinary Tract Infections (UTIs): Due to the abnormal drainage of urine, recurrent UTIs are common in these children.
3. Abdominal or Pelvic Pain: Some children may present with pain due to associated anatomical anomalies.
Step 3: Diagnosis:
1. Ultrasound: Renal ultrasound is the first-line imaging modality, which may show hydronephrosis or a dilated ectopic ureter.
2. Voiding Cystourethrogram (VCUG): This imaging modality helps evaluate the position of the ureter and identify any reflux or abnormalities in the bladder.
3. Magnetic Resonance Urography (MRU): This technique provides a detailed image of the urinary tract and helps identify the exact location of the ectopic ureter.
4. CT Urography: A more invasive method that may be used if MRI is not available, to get detailed images of the kidney and ureter.
Step 4: Management:
1. Surgical Treatment: The main treatment for ectopic ureter is surgery to reimplant the ureter into the bladder at a normal anatomical position. This can be done via open surgery or laparoscopic techniques.
2. Long-Term Follow-Up: Patients require long-term follow-up to monitor renal function, especially if there is any history of renal damage or incontinence.
3. Incontinence Management: If there is persistent incontinence after surgical correction, additional interventions such as bladder training or augmentation may be necessary.