What is the workup for a female with recurrent Urinary Tract Infections (UTIs) and bilateral ureteroceles?

Workup for a Female with Recurrent UTIs and Bilateral Ureteroceles

For females with recurrent UTIs and bilateral ureteroceles, CT Urography (CTU) is the primary recommended imaging test, providing detailed anatomic depiction of the urinary tract, including the kidneys, collecting systems, ureters, and bladder. 1

Initial Evaluation

• Recurrent UTIs with bilateral ureteroceles represent a complicated UTI scenario requiring comprehensive imaging workup 2
• Ureteroceles are cystic dilations of the distal ureter that can cause obstruction and are more common in females 3
• Bilateral ureteroceles are rare but can present with severe lower urinary tract symptoms and even urinary retention 4

Recommended Imaging Studies

First-Line Imaging

• CT Urography (CTU) is the primary recommended test for evaluation of recurrent complicated UTIs with structural abnormalities like ureteroceles 2, 1

  • Includes unenhanced, nephrographic phase, and excretory phase images
  • Provides detailed anatomic depiction of the urinary tract
  • Excellent for detecting congenital anomalies and obstruction 2
  • Can identify the exact location and extent of ureteroceles 1

• Ultrasound of kidneys, bladder, and retroperitoneum may be used as an initial screening tool 1

  • Particularly useful for initial detection of ureteroceles
  • Can identify hydronephrosis associated with obstructing ureteroceles 3

Additional Imaging Based on Clinical Presentation

• MR Urography (MRU) is an alternative to CTU in patients with contraindications to CT or iodinated contrast 2

  • Provides more functional information than CT
  • Useful for evaluating suspected urinary tract obstruction and congenital anomalies 2

• Voiding Cystourethrography should be considered when vesicoureteral reflux is suspected 2, 3

  • Vesicoureteral reflux is observed in approximately 50% of cases with ureteroceles 3
  • Important to assess before planning any surgical intervention 3

Functional Assessment

• 99m-technetium dimercapto-succinic acid (DMSA) renal scan is recommended to evaluate the function of different portions of the kidney 3
  • Essential for determining the functional status of renal tissue associated with ureteroceles
  • Helps guide management decisions, particularly if surgical intervention is being considered 3

Cystoscopic Evaluation

• Cystoscopy should be performed in females with recurrent complicated UTIs and known structural abnormalities like ureteroceles 2
  • Allows direct visualization of ureteroceles
  • Can identify if ureteroceles are prolapsing or causing obstruction 4
  • May be both diagnostic and therapeutic, as endoscopic incision can be performed 5

Management Considerations

• Endoscopic puncture or incision of ureteroceles is often the first-line treatment approach 5, 6

  • Success rates of 79-94% have been reported 5, 6
  • May require additional procedures in some cases 3

• Be aware that endoscopic treatment may induce vesicoureteral reflux in approximately 40% of cases 6

  • Not all cases of post-procedure reflux will require surgical intervention 6

Important Caveats

• Ureteroceles may be classified as intravesical (contained inside the bladder) or extravesical (extending to the urethra or bladder neck) 3

  • The type of ureterocele affects management decisions and outcomes
  • Ectopic ureteroceles typically require more complex management 3

• Ureteroceles often occur in association with duplex collecting systems 7

  • The workup should carefully assess for this common association
  • The presence of a duplex system may affect management decisions 7

• Even though ureteroceles are typically diagnosed in childhood, they can present for the first time in adulthood with recurrent UTIs 7

  • Adult presentation may be more subtle and require high clinical suspicion 7