Posterior urethral valves presenting as abdominal distension and undifferentiated shock in a neonate: the role of screening emergency physician-directed bedside ultrasound.

We present a case of shock in a 7-week-old neonate with obstructive uropathy secondary to posterior urethral valves (PUV). The antenatal ultrasound and the 2-week maintenance visit were unremarkable. A screening emergency physician directed bedside ultrasound (SEPUS) served to rapidly establish the diagnosis, initiate appropriate management, and facilitate early relief of urinary obstruction. We discuss the potential role of SEPUS in a critically ill neonate and briefly review the management of PUV.

A rare case of positive prenatal intervention by early delivery for fetal hydronephrosis.

A male fetus followed for prenatal hydronephrosis thought to be bilateral ureteropelvic junction (UPJ) obstruction experienced severe acute oligohydramnios at 30 weeks gestation and was delivered at 32 weeks by Cesarean section. Postnatal bilateral UPJ obstruction was confirmed and anuria documented along with renal failure. Percutaneous nephrostomies were performed with reversal of the renal failure, and bilateral pyeloplasties were performed with a good outcome.

Calcification in a Deflux bleb thought to be a ureteral calculus in a child.

A child admitted for abdominal pain was evaluated with an abdominal computed tomography scan. Calcification was noted at the ureterovesical junction. The child had undergone successful bilateral Deflux injection 3 years earlier. No hydronephrosis was noted and an intravenous pyelogram was normal. Ureteroscopy revealed no intraluminal stones, and a follow-up scan showed the lesion to be still present and unchanged. This case illustrates that calcifications within a Deflux bleb can be mistaken for a ureteral calculus, and the entire clinical picture should be kept in mind when evaluating a patient with abdominal pain. Due to the widespread use of Deflux to treat vesicoureteral reflux, this phenomenon may be seen more frequently as this population ages.

Clinical experience with positional installation of contrast cystography and simultaneous Deflux injection in children with occult vesicoureteral reflux.

Forty-seven otherwise healthy children with a diagnosis of urinary tract infection and pyelonephritis were referred for evaluation following standard imaging studies which showed no renal abnormalities and a normal voiding cystourethrogram. All were evaluated with positional instillation of contrast at the time of cystoscopy using spot fluoroscopy to detect vesicoureteral reflux. Simultaneous Deflux injection was performed if reflux was demonstrated at cystoscopy. Seventy-five per cent had reflux demonstrated and were treated. The study group was followed for an average of 16 months and the incidence of pre- and post-treatment febrile infections were compared. A significant reduction in febrile infections was noted following treatment. Three children continued to have febrile urinary infections and were successfully reimplanted and experienced no further febrile urinary infections. No complications from this study occurred and some factors were discovered which may help in deciding which patients may benefit from this approach. These findings may provide new insights on the entity of non-refluxing pyelonephritis.

Ultrasound screening of asymptomatic siblings of children with vesicoureteral reflux: a long-term followup study.

PURPOSE: Siblings of patients with vesicoureteral reflux (VUR) are at greater risk of having reflux than the general population, and the role of screening in this group is widely accepted. While voiding cystourethrogram (VCUG) is the gold standard for diagnosis of VUR, ultrasound (US) is often used for screening select patients. We examine the outcomes of a conventional US screening program in older asymptomatic siblings. MATERIALS AND METHODS: Between 1984 and 2003 asymptomatic siblings older than 5 years as well as children whose parents refused VCUG were screened with conventional US and urine studies. If US showed a discrepancy in renal size, renal scarring or hydronephrosis, or a change in the size of the renal pelvis during the study, then VCUG was performed. Additionally, any child with a normal US who subsequently had symptoms of urinary tract infection was then referred for VCUG. Chart review was performed and 117 siblings were identified who met these criteria (age range 2 months to 15 years). An attempt was made to contact all 117 siblings to obtain long-term followup data. RESULTS: Of the 117 siblings 11 (9.4%) were referred for VCUG secondary to abnormal US findings (9) and development of urinary tract infection (2). VCUG was negative in the 2 symptomatic children, while 5 of the 9 (55.6%) with abnormal US were found to have VUR. Telephone contact was established with 85 of the 117 (72.6%) siblings or their parents (average followup 8.3 years, range 2 months to 19 years). All 85 siblings with available followup information had normal US, and none had had symptoms or complications of VUR since screening. CONCLUSIONS: Given the lower incidence and seemingly innocuous nature of VUR in older asymptomatic siblings of known patients with reflux, observation alone in this group is an acceptable form of management. If either parental or physician anxiety exists in this approach, then conventional US offers a reliable alternative to invasive VCUG screening in this population.

Furosemide nephrolithiasis causing ureteral obstruction and urinoma in a preterm neonate.

Nephrolithiasis and nephrocalcinosis in low-birth-weight, preterm neonates are well-documented complications of furosemide administration. Perinephric urinomas and urinary ascites have been previously reported as complications of obstruction due to posterior urethral valves or ureteropelvic junction obstruction. We present an unusual case of furosemide-induced nephrolithiasis causing ureteral obstruction, urinoma, and acute renal failure in a preterm neonate.