Introduction
Ectopic ureter is present at birth. It causes conditions like urinary incontinence, infection, and swelling. Usually, the ureter is drained to the trigon. Urethral duplication (two urethral channels having different locations and extensions) is seen in 80 % of women with ectopic ureters. In contrast, in men, it is associated with a single renal collecting system. Diagnostic tools involve computed tomography, magnetic resonance urography, and ultrasound.
What Is an Ectopic Ureter?
The role of a ureter is to drain the urine from the kidneys to the bladder. The ureters are a pair of narrow tubes, each ureter is connected to a kidney, and the other side is connected to the bladder. An ectopic ureter is a congenital anomaly where the ureter is connected to the wrong place, and the urine is drained to a different location than the bladder.
The location of the ureter other than the ureter may involve :
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Rectum (the last part of the large intestine, located between the anus and the final segment of the colon).
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Bladder neck (it is located at the base of the bladder that surrounds the urethral orifice, which leads to the urethra).
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Urethra (the tube through which the urine leaves the body).
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Seminal vesicles (they are a pair of glands in males which produce a liquid that help in the formation of semen).
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Vas deferens (they transport mature sperm to the urethra during ejaculation).
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Vagina.
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Cervix.
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Uterus.
What Is the Cause of Ectopic Ureter?
The cause has not yet been identified. However, scientists have suggested that it is a congenital anomaly and runs in the family. If one of the parents has this defect, then it is more likely that the child may have the condition. Ectopic ureter is more common in girls than boys and can also be associated with abnormalities related to the kidney and urinary system.
What Are the Signs and Symptoms of Ectopic Ureter?
The signs and symptoms involve:
1) Urinary Incontinence: Involuntary leakage of urine due to the absence of bladder contraction resulting due to increased abdominal pressure. This happens when the pelvic floor muscles, urethral sphincter, and fascial tissues fail to provide closure. In girls, the condition may be left undiagnosed for years. The symptoms include leaky urine since the ureter drains into the vagina or near it, and there will be overall moistness before the individual loses bladder control. The problem is more evident after toilet training. In boys, the ureter drains into the body, making them less likely to have urinary incontinence. Instead, they present with urinary tract infections and swelling.
2) Swelling: Hydronephrosis is a condition in which the kidney cannot drain urine, causing swelling of one or both kidneys. It can be detected by ultrasound, and prenatal ultrasound can detect ectopic ureters during pregnancy.
3) Urinary Tract Infection: Children with ectopic ureters are more prone to urinary tract infections because of poor drainage of urine. A urinary tract infection is when bacteria migrate to the bladder through the urine, causing a burning sensation while passing urine.
4) Vesicoureteral Reflux: The backward flow of urine from the bladder to the ureter is called vesicoureteral reflux. This leads to kidney infections and is one of the main causes of urinary tract infections.
How Is an Ectopic Ureter Diagnosed?
The following diagnostic tools are used:
- Prenatal Ultrasound: It helps detect hydronephrosis or swelling of the kidney and also cases of kidney duplication, which is a cause of ectopic ureter.
- Abdominal Ultrasound: It is a diagnostic tool that helps in viewing the internal organs while functioning by using high-frequency sound waves and producing images of the blood vessels, organs, and tissues. They also help in assessing blood flow to the vessels.
- Bladder X-Ray (Voiding Cystourethrogram-Vcug): It examines the urinary tract. A catheter is used to prepare the bladder by draining out the urine, and then the bladder is filled with a liquid dye. The test will help detect any reverse flow of urine into the kidneys and ureter.
- Renal Flow Scan (Mag 3 or Magnetic Resonance Urogram): This technique is conducted by injecting a radioactive fluid into the vein with the help of a diagnostic nuclear imaging technique. It provides signals that are produced on a camera. To detect any blockage in the urinary tract, a diuretic medication is given midway between the procedure. This also helps speed the urine flow through the kidneys.
- Cystoscopy: In this test, a small telescope is injected into the urethra to find the openings of the ureters. This is done with the help of a dye.
- Computed Tomography (CT) Or Magnetic Resonance Imaging (MRI): Is used to examine the part of the kidney drained by the ectopic ureter.
What Is the Treatment for Ectopic Ureter?
The treatment modalities involve:
- Nephrectomy (Upper Pole Heminephrectomy): It is a surgical procedure where the part of the kidney which is drained by the ectopic ureter or the entire kidney is removed. There is no flow of urine to the ectopic ureter, which helps treat urinary incontinence and infection. The surgeon may use minimally invasive techniques such as laparoscopy, where a small opening is created to perform the procedure. If the individual suffers from vesicoureteral reflux, there may be a risk of contracting infections. The disadvantage of this surgery is the loss of good kidney tissue or injury to the blood supply.
- Ureteroureterostomy or Ureteropyelostomy: The ectopic ureter is sectioned near the bladder. It is then attached to the normal ureter of the lower kidney. This helps easily flow urine from the upper part of the kidney. This surgery risks injury to the lower part of the ureter and urine leak. There are cases where a temporary internal drainage stent may be placed.
- Ureteral Reimplantation: In this technique, an incision is placed above the pubic bone, and the ectopic ureter is sectioned at the bottom and attached to the bladder. This prevents the backward flow of urine and helps in complete drainage. Post-surgical complications involve developing vesicoureteral reflux, further increasing the risk of blockage. This procedure is difficult to be performed on newborns.
What Happens After Surgery?
For the surgery, hospital admission may be required until healing takes place. A catheter tube is removed before the individual is discharged. In cases where an internal drain is used, it is removed three to four weeks after surgery.
Conclusion
The ectopic ureter is a defect in the anatomy of the ureter and is located in the wrong position, due to which the urine is drained to the wrong location. It causes conditions like urinary incontinence, infection, and swelling. Treatment is done by surgical techniques such as ureteral reimplantation, ureteroureterostomy, and nephrectomy. Early diagnosis can prevent kidney damage.
