Primary Ureterocele with Secondary Bladder Outlet Obstruction Causing Recurrent Urinary Retention in a Preschool Child

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Description

A four-year-old girl was brought to a pediatric emergency service because of acute inability to pass urine for nearly twelve hours associated with increasing lower abdominal pain and irritability. The parents reported that the child had a history of intermittent urinary dribbling, foul-smelling urine, and two prior episodes of febrile urinary tract infection treated at peripheral clinics. Toilet training had been delayed due to inconsistent voiding patterns and frequent urgency episodes.

On arrival, the child appeared distressed with a visibly distended lower abdomen. Palpation revealed a tense suprapubic mass consistent with a full urinary bladder. External genital examination was normal without labial fusion or discharge. There were no spinal abnormalities or lower limb neurological deficits. Vital signs were stable except for mild tachycardia related to pain. Initial catheterization attempt was partially successful, yielding a small volume of urine followed by obstruction and resistance. Laboratory analysis of urine showed pyuria and bacteriuria. Blood tests demonstrated mild leukocytosis without renal impairment. Because of suspected structural obstruction, an urgent ultrasound examination was performed.

Ultrasonography demonstrated a markedly distended urinary bladder with thickened walls and a rounded intravesical cystic lesion arising near the right ureteric orifice. The lesion intermittently prolapsed into the bladder neck during attempts, causing functional obstruction. Mild right-sided hydroureteronephrosis was also observed. The findings were suggestive of an ureterocele. Voiding cystourethrography confirmed a filling defect within the bladder corresponding to an ureterocele originating from a duplex collecting system. During voiding phase, the lesion prolapsed inferiorly, intermittently obstructing bladder outlet flow. Magnetic resonance urography further delineated a single-system intravesical ureterocele associated with distal ureteral dilation.

Given recurrent infections and episodes of urinary retention, surgical intervention was planned. The child underwent endoscopic incision of the ureterocele under general anesthesia. A small transurethral incision was made at the dome of the cystic structure to allow decompression and improve urinary drainage. Clear urine was observed draining immediately after incision. Postoperatively, urinary flow improved significantly. The patient voided spontaneously within hours of recovery without evidence of residual retention. Antibiotic therapy was continued for five days to treat ongoing infection. She was discharged with normal voiding function and scheduled for follow-up evaluation. At three-month review, ultrasonography demonstrated marked reduction in ureterocele size with resolution of bladder outlet obstruction. Hydronephrosis had regressed, and postvoid residual urine volume was negligible. The child had successfully progressed with toilet training and no further episodes of urinary retention were reported.

At one-year follow-up, renal function remained normal, and no recurrent urinary tract infections were documented. The patient maintained stable voiding patterns with no evidence of ureterocele re-expansion.

An ureterocele represents a cystic dilation of the distal ureter within the bladder wall, resulting from abnormal development of the ureteric bud and incomplete muscular incorporation into the bladder trigone. Pediatric cases are often associated with duplicated collecting systems, although single-system ureteroceles may also occur. Clinical presentation varies depending on size and location. Small ureteroceles may remain asymptomatic, whereas larger lesions can cause obstruction of urinary flow, recurrent infection, or vesicoureteral reflux. In this child, intermittent prolapse of the ureterocele into the bladder neck resulted in episodic urinary retention and incomplete bladder emptying.

Diagnosis relies heavily on imaging. Ultrasonography is typically the first modality and may reveal a cystic intravesical lesion with associated hydronephrosis. Voiding cystourethrography helps demonstrate filling defects and dynamic changes during voiding. Magnetic resonance imaging offers detailed anatomical assessment, particularly in complex or equivocal cases. Endoscopic incision remains a commonly used initial treatment option for symptomatic intravesical ureteroceles in young children. The procedure allows immediate decompression and restoration of urinary flow. However, long-term follow-up is essential because some patients may develop vesicoureteral reflux or require secondary reconstructive procedures depending on upper tract anatomy.

Conclusion

In this patient, early intervention prevented progression of upper urinary tract damage and resolved recurrent infection. Improvement in bladder emptying also supported normal development of continence and successful toilet training. Careful monitoring after ureterocele incision includes periodic imaging to assess renal growth and exclude recurrent obstruction. Urodynamic symptoms such as urgency or recurrent infection may indicate the need for further evaluation. This case illustrates primary intravesical ureterocele presenting as acute urinary retention in a preschool child. Timely imaging and endoscopic decompression resulted in complete symptom resolution and restoration of normal urinary function with preserved renal integrity.