Quiz: Pediatric recurrent UTIs, abdomen pain

Exhibit 1

A 5-year-old girl is evaluated for recurrent urinary tract infections and lower abdomen pain. Her past surgical history is notable for endoscopic correction of left grade IV reflux at 2 years of age with postoperative confirmation of reflux resolution based on a nuclear cystogram and no hydronephrosis based on a sonogram. A KUB x-ray and computed tomography are obtained (Exhibit 1 and 2, respectively).

Exhibit 2

What is the key finding(s) on the imaging studies?

A. Calcifications within the left distal ureter

B. Calcifications along the course of the left distal ureter

C. Left distal ureteral Steinstrasse

D. Pelvic phlebolith

Continue to the next page for the answer.

Answer: B. Calcifications along the course of the left distal ureter

This patient has calcifications after endoscopic treatment of vesicoureteral reflux along the course of the left ureter. The calcifications are most likely outside of the urinary tract based on lack of hydronephrosis on sonogram. A finite number of patients who undergo endoscopic VUR treatment end up with calcifications along the course of the previously injected endoscopic material. Long-term significance remains unknown, but it is generally thought to be benign since calcifications outside the urinary tract rarely, if ever, cause issues.

The calcification therefore, is unlikely to be the cause of recurrent UTI. The recurrent UTI should be worked up with concern for bladder/bowel dysfunction with a focus on normal voiding and treating constipation.

Suggested reading                  

Distal ureteral calcification secondary to deflux injection: a reality or myth? Palagiri AV, Dangle PP. Urology 2011; 77:1217-9.

Radiologic features of implants after endoscopic treatment of vesicoureteral reflux in children. Cerwinka WH, Kaye JD, Scherz HC, Kirsch AJ, Grattan-Smith JD. AJR Am J Roentgenol 2010; 195:234-40.

Calcification in a Deflux bleb thought to be a ureteral calculus in a child. Noe HN. J Pediatr Urol 2008; 4:88-9.

The fate of the iatrogenic retroperitoneal stone. Evans CP, Stoller ML. J Urol 1993; 150:827-9.

To get weekly news from the leading news source for urologists, subscribe to the Urology Times eNews.