Presentation
Right loin pain, dysuria, and bad smell of urine for three days. History of frequency, urgency, incontinence, and vaginal itching for a long period.
Patient Data
a duplex right renal pelvicalyceal system with double ureter
an obstructing stone is noted at the lower third of the right ureter opposite sacral promontory with proximal hydroureteronephrosis and perirenal fat stranding
fluid-filled vagina and vestibule
a single gallstone is seen with a peripheral calcified outline
abnormal shape of symphysis pubis with joint irregularity and sclerosis
The excretory phase of CT urography revealed partial enhancement of the right kidney's lower moiety with early excretion of contrast.
A second delayed scan after one hour was done, the available 3D VRT images show:
a duplex right renal pelvicalyceal system with double ureters that unite at the level of the body of the L4 vertebra, reflecting incomplete duplication of the right ureter (bifid ureter)
an obstructing stone is noted at the lower third of the right ureter opposite sacral promontory with proximal hydroureteronephrosis and perirenal fat stranding
the trigone of the urinary bladder is directly connecting to the upper anterior wall of the vagina in keeping with a vesicovaginal fistula
Case Discussion
Vesicovaginal fistula was responsible for the incontinence of the patient. Badly, it was neglected by the patient and was only discovered in a CT urography for a ureteric stone in a duplex collecting system.
Bifid ureter refers to incomplete duplication of the ureter in a duplex collecting system. An obstructing stone distal to the point of uniting of both ureters leads to hydronephrosis of both moieties which is diagnostic in non-contrast study as in this case.
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