Duplex system.

10 years old female child with history of

1 foul smelling urine 7 days.
2 Fever 7 days.
Urine culture  showed growth.started on antibiotics.fever n smell settled.
 came to me with CT ivp attached. 
How to investigate further?
What to advise to parents? Surgery or non surgical management?

Duplex system.Duplex system.Duplex system.


  • Gyanendra Sharma
    Gyanendra Sharma
    20 Mar 2020 04:02:41 PM

    Dear Dr. Majumdar

     There are certain points which I would like to make
    1. It would be highly appreciable if all other relevant details are also posted i.e  Urine C/S showing which organism, USG findings, what was her total count, which antibiotic has been given & for how long. These details though may seem trial add great value o over all management approach--atleast for me
    2. If the child has been afebrile for > 72 hours & is under cover of antibiotics then I would do an MCU ( VCUG)  under antibiotic cover
    Further management would depend on it 
    Though on accunf of some technical gltch at my end I could not appreciate the CT IVU images as I would have liked to--it seems there is a ureterocele--hence a VCUG would be all the more mandatory before deciding further management
    Also, as you mention that the patient came with CT IVU-- I personally feel that it gives lot of radiation for a child &for me this wouldnot be the preferred functional imaging modality in such cases

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    20 Mar 2020 04:36:16 PM

    Thank u sir...I will try to get urine cs n others details n post it

    she was under treatment of a paediatrician who refered the case 

  • JG Lalmalani
    JG Lalmalani
    20 Mar 2020 05:02:47 PM


    Obstructed R Upper Moiety with a suggestion of Filling Defect ? Ureterocoel in the available bladder plates. 
    Will merit treatment by endoscopy if confirmed as cause of obstruction; else treat on merits.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    20 Mar 2020 06:06:33 PM

    In any proven case of febrile UTI, like this case there is almost non controversial protocol for investigations. CT IVU do not come anywhere in that protocol. It is over kill and heavy exposure to radiations to whole body and in specific female gonads.

    We have to really discourage this kind of haphazard and hazardous investigations.

    On confirming positive culture in this female patient of pyrexia next investigations would have been: USG with full bladder to look at bladder and lower ureter and with full and empty bladder to look kidneys and upper ureters in detail.
    On picking up changes in USG which I will enumerate later next is VCUG as advised by Dr. Gyanendra under antibiotic cover.
    Next diuretic scan or DMSA depends on findings of USGs and VCUG.
    These investigations would have picked up duplex system with possible ureterocele without any doubt.
    In your posted case there is a possibility of obstructed right upper moiety, confirm it with listed investigation, at present no need of renal scan if ueterocele picked up in USG and/or VCUG.
    Cystoscopy with incision of ureterocele recommended to relieve her from sepsis. 

  • Ravindra Sabnis
    Ravindra Sabnis
    21 Mar 2020 06:34:47 PM

    I agree with Gyanendra. CT pictures are not clear. I feel instead of putting all plates in one photo, it can be posted seperately. Otherwise difficult to enlarge & understand 

  • Dr. Isteaq Shameem
    Dr. Isteaq Shameem
    23 Mar 2020 11:00:11 PM

    Dr Isteaq Shameem

    Dr Anil has rightly pointed about CT urogram, good USG pic will clearly show ureterocele. VCUG can be done which can help to find VUR on ipsilateral lower moiety and to lesser percent in contralateral renal unit. CT urogram usually results radiation of more than 20mSV
    Regards to all

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