Genitourinary Sonography in the Child I. Gassner, T.E. Geley

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Introduction

Sonography is usually the first imaging modality applied and is a powerful tool for the evaluation of infants and children suspected of having genitourinary tract anomalies. The intention of this lecture is to provide a broad overview of common genitourinary anomalies and to highlight the strength of ultrasound for the evaluation of these conditions.

Anomalies of the Urinary Tract

Renal Agenesis

Renal agenesis may result from aplasia of the Wolffian duct or absence of the ureteral bud with consecutive lack of metanephrogenic tissue induction.

Unilateral renal agenesis is rather common, occurring in about 1 in 1,000 newborn infants [1]. There is a strong association of renal anomalies with Müllerian duct anomalies. Therefore, in females, the urinary tract and the reproductive system should always be evaluated as a unit.

Renal agenesis may also be mimicked by a multicystic dysplastic malformation of the kidney later in life since the multiple cysts seen in the affected infant disappear with time. In 10% of cases unilateral renal agenesis is associated with aplasia of the ipsilateral adrenal gland. In all other cases a characteristic elongated feature of the adrenal gland is found. Bilateral renal agenesis (Potter syndrome) is incompatible with life and most infants die shortly after birth.

Crossed Renal Ectopia

In crossed renal ectopia one kidney is displaced across the midline and lies on the opposite side of the ureteral insertion into the bladder. Four types of renal crossed ectopia are described (with fusion, without fusion, solitary, bilateral), with the crossed-fused ectopia being the most common.

Standard as well as colour Doppler ultrasound techniques document the location of ureteral orifices through the ureteral jet phenomenon.

Megaureter

The diameter of a normal ureter is rarely more than 5 mm and, therefore, the ureter is not visualised on pre- and postnatal ultrasound. Megaureter as a general term de- scribes a dilated ureter with or without associated dilatation of the upper collecting system. Ureteral dilatation may be in response to anatomical or functional obstruction or vesicoureteral reflux, but may also occur in their absence.

Primary megaureter corresponds to an obstructive di- latation of the ureter above an adynamic segment at the ureterovesical junction. It is caused by hypoplasia and at- rophy of muscle fibres in the distal segment of the ureter associated with an increase in collagen fibres in the pathologic segment and muscular hypertrophy of the proximal ureter.

Ultrasound demonstrates the dilated ureter and an increased peristalsis.

Secondary megaureter occurs as a result of reflux, ure- thral obstructions or bladder abnormalities such as posterior urethral valves or a neuropathic bladder.

Ureteral Duplication

Ureteral duplication (Fig. 1) is the most frequent renal anomaly. The duplications vary from partial to complete separation of the collecting system. Incomplete duplication is thought to result from early branching of a single ureteral bud, resulting in a common distal stem with two ureteral segments impinging on the metanephric blastema.

Complete ureteral duplication results from the formation of two ureteral buds on the same side. During ab- sorption and migration of the distal portion of the mesonephric duct into the developing bladder, the orifices of the ureter draining the lower segment of the kidney migrates more cephalad and lateral than the orifice of the ureter draining the upper segment of the kidney.

Genitourinary Sonography in the Child

I. Gassner, T.E. Geley

Department of Pediatrics, University Hospital Innsbruck, Innsbruck, Austria

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This embryological relationship is known as the Weigert- Meyer-law.

When the area of the ureter to the lower segment buds is displaced closer to the urogenital sinus than normal, the orifice migrates more lateral and cephalad and the lower segment is more likely to be associated with vesicoureteral reflux.

When the area of the ureter to the upper segment, on the other hand, is displaced more proximally on the mesonephric duct than normal, the ureteral orifice will be ectopic in location and may open at the level of the bladder neck or even more distally into the urethra, vestibule or vagina.

Vesicoureteral reflux is the most common abnormal- ity seen in association with complete ureteral duplica-

tion and commonly affects the lower segment due to the fact that the ureter to the lower segment has a more lat- erally placed orifice and a shortened submucosal tun- nel. The ureter from the upper pole may function normally or may be obstructed, but reflux into the upper pole is rare.

Sonography clearly demonstrates malformations of the kidney, such as a dilated ureter due to either stenosis or reflux and ballooning of the submucosal segment of the upper ureter in the bladder (ureterocele). The ureteral jet sign locates the orthotopic as well as the ectopic ureteral orifice.

Ureteral Ectopia in Single and Duplex Collecting Systems

A ureter that opens anywhere but into the trigone of the bladder is considered ectopic (Fig. 2). About 20% of ectopic insertions of the ureter drain a kidney with a single collecting system. The remainder are associated with the affected ureter draining the upper pole of a duplex kidney.

In males, the ectopic ureter may empty into the lower bladder, posterior urethra, seminal vesicle, vas defer- ens or ejaculatory duct. In females it may insert into the lower bladder, urethra, vestibule, vagina, uterus or rem- nants of the Gartner’s duct. Ureteral ectopia is more common in females and affected girls are frequently found to be incontinent due to the ectopic ureter termi- nating at a level distal to the continence mechanisms of the bladder neck and external sphincter. Ectopic ureters may show reflux, but obstruction is more common.

When the collecting system is dilated the lack of an intravesical ureterocele suggests an insertion of the ectopic ureter on another side, such as the bladder neck or the proximal urethra. Ultrasound documents a dilated ureter on a lower and more medial level than expected and the exact location of the orifice may be documented via the ureteral jet sign.

Ureterocele in Single and Duplex Collecting Systems

Ureteroceles represent cystic dilatation of the intravesical segment of the ureter as a response to obstruction, and may be associated with single or duplex ureters (Fig. 1).

They are called orthotopic or simple when found with a single collecting system, and ectopic when found with a duplicated collecting system. Ectopic ureteroceles are positioned beyond the confines of the trigone and frequently represent the distal portion of the upper pole ureter. On ultrasound the ureterocele appears as a cystic structure within the bladder. The ureteral jet sign documents the orifice of simple ureteroceles opposite the bladder wall.

In ectopic ureteroceles the orifice is commonly located next to the bladder wall.

Posterior Urethral Valves (Case no. 1 on CD-ROM)

Posterior urethral valves are the commonest urethral ab- normality occurring in boys. A thick membrane is found a

b

Fig. 1. Complete ureteropelvic duplication on the left with obstruc- tive upper-pole ureterocele. Urinary tract infection in the upper pole collecting system in a 21-day-old male. a Longitudinal, b transverse pelvic scan. The dilated upper pole ureter (U) and the ectopic ureterocele (C) are full of debris (purulent exudate), B, bladder. (Reprinted with permission from [2])

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in the posterior urethra with a pinhole opening positioned posteriorly near the verumontanum. During voiding, the anterior portion of the membrane bulges. This urethral obstruction causes high intraluminal pressure during the early phases of foetal development, leading to abnormal bladder function and anatomy (trabeculation, bladder neck hypertophy), renal dysplasia, hydronephrosis, and vesicoureteral reflux. Vesicoureteral reflux often persists after relief of the obstruction. Prenatal and postnatal ultrasound document bilateral hydroureteronephrosis associated with parenchymal dysplasia and a thick-walled bladder. In cases of severe hydronephrosis, rupture of the intrarenal collecting system at the calyceal fornix leads to perirenal urinoma and urine ascites.

Anomalies of Renal Vessels (Fig. 3)

Each kidney is normally supplied by a single renal artery, although one or more accessory renal arteries are not un- common. The renal artery originates from the abdominal aorta and runs behind the vena cava to reach the hilar re- gion of the kidney.

In patients with interruption of the inferior vena cava with azygos continuation, the azygos vein increases in size and might be mistaken for the inferior vena cava.

Cross-sectional imaging techniques document the course of the renal artery to be ventral to the azygos vein.

Azygos continuation is frequently associated with cardiac and situs anomalies and awareness of the anatomic rela- a

d e

b c

f

Fig. 2. Duplex kidney with obstructed ectopic upper-pole ureter. The ureter is inserted into the urethra. Newborn female. a, b Longitudinal scans of the left kidney reveal a dilated upper-pole collecting system. c Transverse pelvic scan and d transperineal sagittal scan show the upper-pole ureter (U) behind the bladder (B) and before insertion (arrow) into the urethra (xxx). V = vagina; S, pubic symphysis. e Transperineal sagittal color flow Doppler image shows retrograde ureteral jet from the urethra into the bladder. f 2-year-old girl.

Cyclic voiding cystourethrogram shows pinpoint opening of the ectopic ureter. (Reprinted with permission from [2])

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tionship between the renal artery and the azygos vein can aid in diagnosis [3].

Anomalies of the Female Reproductive System Embryology

The internal genital organs, as well as the lower urinary system, originate from two paired urogenital structures that develop in both sexes, the mesonephric ducts (Wolffian ducts) and the paramesonephric ducts (Müllerian ducts).

In female development the Müllerian ducts are divid- ed into two segments. The distal segments move towards the midline and soon fuse into a single tube, the uterovaginal canal. The resulting septum that divides the uterovaginal canal disappears soon after. Failure of later- al fusion of the Müllerian ducts results in a wide variety of abnormalities of the uterus, cervix and vagina. The development of the vagina is induced by the fusion of the uterovaginal canal with the urogenital sinus (transversal fusion). Due to the close developmental relationship be- tween the genital and the urinary tract, association of anomalies in both systems are common [4].

Normal Appearance and Ultrasound Techniques

During normal growth and development the uterus and ovaries undergo a series of changes in size and configuration.

Under the influence of maternal and placental hor- mones, the neonatal uterus is remarkably prominent with a thick myometrium and a definable endometrial lining [5].

At two to three month of age, the uterus regresses to its prepubertal size and tubular configuration. The endometri- um is usually not visualised, making it rather difficult to evaluate uterine anomalies in infants and older children.

The post-pubertal uterus has the adult pear-shape appearance and the echogenicity and thickness of the endometrial lining varies according to the menstrual cycle [6].

High-resolution, real-time sonography has become the first-step imaging technique for the evaluation of the pelvis in infants, children and adolescents. Using the filled bladder as an acoustic window, the internal genital organs and the lower urinary tract are easily evaluated. In infants and young children who are not able to maintain a full bladder, filling of the bladder with sterile saline solution via a 5 to 8 French feeding tube might be necessary [7]. The same prin- ciple can also be used to outline the vagina (water vaginog- raphy), the rectum (water enema) or the urogenital sinus in complex congenital anomalies of the genitourinary tract. A transperineal sonographic approach should always be considered in cases of anomalies of the lower pelvis, since it al- lows an excellent documentation of the urethra, the peri- urethral soft tissue, the rectum and the distal genital tract.

Müllerian Duct Anomalies

Based upon the embryological development of the female genital system, uterovaginal malformations are classified as Müllerian agenesis in cases of a developmental defect of the caudal portion of the Müllerian ducts (Mayer- Rokitansky-Küster-Hauser syndrome), disorders of the lateral fusion resulting from failure of the two Müllerian ducts to fuse and disorders of the vertical fusion that are caused by faults in the union between the Müllerian tuber- cle and derivatives of the urogenital sinus (transverse vaginal septum, cervical agenesis, disorders of the hymen).

Mayer-Rokitansky-Küster-Hauser Syndrome

The Mayer-Rokitansky-Küster-Hauser syndrome is char- acterised by the absence of the entire or, more frequent-

a b c

Fig. 3. Azygos continuation of inferior vena cava. a Drawing. b Longitudinal scan and c transverse color-coated duplex sonogram show right renal artery (arrows) ventral to azygos vein (asterisks)

AZYGOS VEIN

AORTA

RIGHT RENAL ARTERY

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ly, the proximal two thirds of the vagina, absence or abnormalities of the uterus and malformations of the upper urinary tract. The most frequently found subtype of the syndrome consists of two rudimentary uterine horns located on a higher level than expected and normal Fallopian tubes, ovaries and kidneys.

Sonographic evaluation aided by instillation of fluid into the bladder as well as the rectum may demonstrate the absence of vagina and uterus. MR imaging is frequently needed to clearly document the ovaries and the rudimentary uterus.

Uterus Didelphys (Fig. 4)

Disorders of the lateral fusion of the distal segments of the two Müllerian ducts include septate, bicornuate, didelphys and unicornuate uterus. In the absence of obstruction, these malformations are asymtomatic during

childhood or at puberty. A uterus didelphys or bicornuate uterus can readily be documented on sonographic evaluation of the newborn.

Imperforate Hymen (Fig. 5)

Although the hymen membrane is entirely of urogenital sinus origin, imperforate hymen is commonly listed to- gether with defects of the vertical fusion of the Müllerian ducts. Imperforate hymen may either be symptomatic in the newborn period or after onset of puberty when development of hydrocolpos/hydrometrocolpos or hematocol- pos/hematometrocolpos, respectively occurs. Sonographic evaluation shows the cystic dilatation of the vagina with the less distensible uterus attached to it. Internal echoes reflect cellular debris. Fluid may also be found in the peritoneal cavity due to spillage of genital secretion via the Fallopian tubes. Larger hydro- or haematocolpos may ob- struct one or both ureters resulting in hydronephrosis.

Association of Lateral and Vertical Fusion Anomalies (Case no.

2 on CD-ROM)

The frequent association of vertical with lateral fusion anomalies means that it is useful to consider vaginal anomalies according to the presence or the absence of obstruction. Nonobstructive vaginal anomalies encompass bifid vagina, longitudinal vaginal septum and incomplete transverse septum. Among the obstructive vaginal anomalies are imperforate hymen, complete transverse vaginal septum, unilateral obstructive longitudinal vaginal septum, obstruction of a unilateral rudimentary horn and atresia of the uterine cervix or the vagina. Sometimes obstructive disorders already present at birth due to accu- mulated genital secretion. More commonly, however, the Fig. 4. Bicornuate

uterus. 6-day-old newborn female newborn with congenital segmental dilatation of the colon (C). Trans- verse image through the pelvis shows two separate uter- ine horns (arrows), B = bladder. (Re- printed with permission from [4])

a b c

Fig. 5. Imperforate hymen with hydrometrocolpos and ascites due to spillage of genital se- cretions via the fallopian tubes into the peritoneal cavity. a, b Sagittal scans. The vagina (V) as well as the uterus (U) are dilated, with broad communication through the cervical ostium (open arrowheads). The vagina shows a fluid-debris level (closed arrowheads). c Distended, fluid-filled abdomen. The air-filled loops of bowel cluster in the center of the abdomen. The lateral edge of the liver (arrowheads) is visible. (Reprinted with permission from [4])

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patient seeks medical advice at puberty with cyclic abdominal pain and a pelvic mass is found. The whole spectrum of Müllerian duct anomalies from the obstructed hemivagina in association with an uterus didelphys to the unicornuate uterus, which reflects the extreme end of the spectrum, are almost always associated with severe ipsilateral renal anomalies (renal agenesis, renal dysplasia, ectopia, ipsilateral ectopic ureter, and hydronephrosis).

This strong association should urge the physician to evaluate always both systems when a malformation is de- tected in one of them.

Urogenital Sinus Malformation

Urogenital sinus is suspected during physical examina- tion of a newborn with a normally placed anus in association with either ambiguous genitalia or normal female external genitalia but only a single opening within the vestibulum. It is either found isolated or in association with chromosomal and hormonal abnormalities or as a cloacal variant.

Female Hypospadia

In female hypospadias the urethral meatus is positioned in the anterior wall of the vagina. Proximal hypospadias often show a narrowing of the urethra with signs of urinary outflow obstruction and are commonly associated with cloacal anomalies and female pseudohermaphroditism. Diagnostic evaluation will, therefore, be dis- cussed below.

Distal hypospadia is more likely to have a urethra of normal diameter with no meatal stenosis and is frequently asymptomatic. In these girls the urethral meatus is on the roof of the vagina just inside the introitus and the urethra has to be catheterised blindly.

Congenital Adrenal Hyperplasia

In most instances, female pseudohermaphroditism results from the exposure of a female fetus to excessive androgens. The most common causes are congenital adrenal hyperplasia (an autosomal recessive disorder of adrenal steroidogenesis). The increased level of androgens within the foetal bloodstream causes virilisation of the external genitalia, which may vary from minimal phallic enlargement of the clitoris to almost complete masculinisa- tion. At birth these patients present with marked clitoral enlargement, a variable degree of labioscrotal fold fusion and rugation. The opening of the urogenital sinus at the clitoral base may mimic penile hypospadia. Urinary tract anomalies are common and encompass renal agenesia, ectopia, and cystic dysplasia as well as uni- and bilateral hydronephrosis, vesicoureteral reflux and signs of urinary outflow obstruction.

The primary task of the radiologist is to demonstrate the level of communication between the vagina and the urethra, the anatomy of the internal genitalia, to rule out

kidney anomalies and to document adrenal gland hyperplasia.

Sonographic evaluation of the patient is usually the first-step imaging technique, followed by conventional radiology using contrast material. Transabdominal ultrasound will demonstrate the internal genitalia, the kidneys and adrenal glands, and show any obstructions such as hydrocolpos and hydrometrocolpos [8]. Demonstration of enlarged adrenal glands with wavy limb configuration, however, is highly indicative of congenital adrenal hyperplasia [6].

Fluoroscopic studies with water-soluble contrast material are required to examine the exact anatomy of the malformation.

Cloacal Malformation

The cloacal malformation, the most complex type of imperforate anus, is a complex congenital malformation with a common outflow of the urinary, genital and intestinal tract into a urogenital sinus. Cloaca is exclusive- ly seen in phenotypic females.

The diagnosis of cloacal malformation is made when, in addition to an absent anus, only one perineal orifice is found between the labia. Every newborn girl with imper- forate anus should be considered to have a cloacal mal- formation until proven otherwise.

Associated anomalies include uterus didelphys [9], renal anomalies, ectopia of the ureter, bladder diverticula, lower spinal cord abnormalities, anomalies of the pelvic osseous structures such as sacral agenesis or hypoplasia, dysraphism and pubic diastasis.

Obstruction of the cloaca may occur at any level and determines whether the proximal distended urinary and/or genital system is filled solely with genital secre- tions or contains urine and/or meconium as well.

Ultrasound is the most efficient first-step imaging technique in the diagnostic work-up of these patients.

Performed early after birth, no or only little intestinal gas will be present and a clearer documentation of the in- trapelvic structures can be obtained. An abdominal mass in the neonate with cloacal malformation is almost always a distended vagina and/or uterus filled with urine and/or meconium because the path of least resistance for their egress was into the vagina instead of the cloaca.

Obstruction of the common outlet can lead to retrograde flow via the fallopian tubes and accumulation of intra- abdominal fluid. In cases where urine enters the rectum and colon, the meconium may calcify in utero and intra- luminal calcification can be documented sonographically as well as radiologically. The distance between the blind end of the rectum and the perineum should be measured by transperineal ultrasound, and the kidneys should be evaluated, as well as the spinal cord [6].

Sonographic features of spinal anomalies, occurring with a frequency of nearly 50% in patients with cloacal malformations, are either a high lying plump conus or a tethered cord with a thickened filum terminale.

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The next step in the imaging process are fluoroscopic studies using water-soluble contrast material to visualise the often unpredictable and erratic courses of the communication between the multiple structures, and to provide functional information about reflux and competence of the urinary sphincter.

MR imaging is gaining acceptance in imaging congenital abnormalities of the genital tract, but should be used in conjunction with other imaging modalities.

References

1. De Bruyn R (2005) The urinary tract. In: de Bruyn R (ed) Pediatric ultrasound. Elsevier Churchill Livingstone, pp 39- 112

2. Gassner I (2005) Fetal genitourinary anomalies. Perinatal and postnatal management with imaging techniques. Radiologe 45:1067-1077

3. Geley TE, Unsinn KM, Auckenthaler TM et al (1999) Azygos

continuation of the inferior vena cava: sonographic demonstration of the renal artery ventral to the azygos vein as a clue to diagnosis. AJR Am J Roentgenol 172:1659-1662

4. Gassner I, Geley TE (2004) Ultrasound of female genital anomalies. Eur Radiol 4:L107-L122

5. Nussbaum Balsk AR, Sanders RC, Gearhart JP (1991) Obstructed uterovaginal anomalies: demonstration with sonography, Part I: Neonates and infants. Radiology 179:79-83

6. Teele R, Share J (1992) Ultrasonography of the female pelvis in childhood and adolescence. Radiol Clin North Am 30:743-758

7. Kiechl-Kohlendorfer U, Geley TE, Unsinn KM, Gassner I (2001) Diagnosing neonatal female genital anomalies using saline-enhanced sonography. AJR Am J Roentgenol 177:1041- 1044

8. Nussbaum Balsk AR, Sanders RC, Rock JA (1991) Obstructed uterovaginal anomalies: demonstration with sonography. Part II: Teenagers. Radiology 179:84-88

9. Jaramillo D, Lebowitz RL, Hendren WH (1990) The cloacal malformation: Radiologic findings and imaging recommenda- tion. Radiology 177:441-448