Presentation
Mass protruding from the vagina. Irregular periods.
Patient Data
The palpable abnormality corresponds with a cystic structure anterior to the vagina and inferior to the symphysis pubis. A shadowing echogenic focus is present along its posterior aspect. There is an apparent left ureteric jet identified within this abnormality noted. Definite direct communication between the abnormality and the bladder was not demonstrated.
The right ureter was identified with a normal jet into the base of the bladder. No left ureteric jet at the level of the bladder identified.
Normal appearance of an anteverted uterus with volume of 33 ml. Right and left ovaries have volumes of 3.2 ml and 1.7 ml respectively.
Small amount of free fluid noted in the pouch of Douglas.
Right and left kidneys measure at 108 mm and 80 mm respectively. No pelvicalyceal dilatation.
MRI confirms a left-sided ureterocoele which descends through the urethra down into the vaginal introitus where it is manifest as a thin-walled blind ending cystic structure. This cystic structure contains a 7 mm calculus.
The urinary bladder is partially filled and the contralateral right ureter is not well demonstrated. The left ureter inserts slightly lower and more medially than expected, likely indicating an ectopic insertion close to the bladder neck. The urinary bladder is partially collapsed but otherwise normal.
The right distal ureter is normal in caliber and difficult to identify.
The right kidney is normal in size and appearance. The left kidney is slightly reduced in overall size with moderate dilatation of the renal pelvis up to 18 mm in AP diameter. Mild fullness of the upper pole central calyces is present. The lower pole calyces are essentially normal. Only a single left ureter is readily identified.
The vagina contains significant distension with fluid, perhaps representing vaginal secretions secondary to partial obstruction of the vaginal orifice by the cystic ureterocoele.
Anteverted uterus is normal in size for age and demonstrates low dependent layering T2 hypointense fluid-fluid interface, likely representing hemorrhage from current menstruation.
Urethral catheter with balloon within the bladder and vaginal catheter with balloon within the upper vagina.
Cystic structure with 7 mm calculus along its posterior aspect, is noted to the left of the bladder catheter balloon, consistent with known left ureterocele.
Following urethral instillation of contrast into bladder lumen, the ureterocele appears as a filling defect outlined by contrast on all sides except its most posterior aspect, confirming its location within bladder. It is attached posteriorly to bladder wall very close to the bladder neck, suggesting ectopic inferomedial insertion of the left ureter. The ureter is difficult to identify given the distortion of anatomy from the vaginal cathether balloon.
This study confirms the intravesical location of ectopic left ureterocele that had prolapsed through the bladder neck and urethra on the previous studies, and has now been reposed within the bladder lumen by the bladder catheter.
Case Discussion
A cecoureterocele is a very rare subtype of ectopic ureterocele where the orifice of the affected ureter is within the bladder, but the cavity of the ureterocele extends beyond the bladder neck into the urethra.
Ectopic ureteroceles are more common in girls than boys. They predispose to vesicoureteric refluex and recurrent infections. Calculi may develop in ureteroceles due to urinary stasis.
The overwhelming majority of ureteroceles are associated with a duplex collecting system. A duplex system was not definitively identified in this case but remains suspected given the dilatation of the left upper pole calyces on MRI.