Over the years many amazing cases have been presented during the PEMPix presentation at the American Academy of Pediatrics’ annual national Conference and Exhibition during the Section on Emergency Medicine Sessions. PEMPix Classic is a featured series on PEMBlog that will highlight some of those classic cases.

The Case

A 7 year old female with a history of constipation developed a protuberant, painful mass while straining to defecate. She noted that, “there’s a bubble coming out of my vagina” and that she unable to urinate. She also noted increasing left sided flank pain and blood spotting on her underwear.

On genitourinary physical exam you note the following:

An ultrasound was subsequently obtained.

What is the diagnosis?

A. Urethral prolapse
B. Vaginal foreign body
C. Sarcoma botyroides
D. Imperforate hymen
E. Prolapsed ureterocele


E. Prolapsed ureterocele

The ultrasound showed that our patient has a left sided ureterocele, as well as some mild hydronephrosis. A ureterocele is a saccular distal ureter that “balloons” out and can cause a number of important obstructive complications including:

  • Urinary obstruction and retention if it prolapses out of the bladder into the urethera
  • Vesicoureteal reflux if it obstructs at the level of the ureterovesicular junction
The overall incidence is 1:500 to 1:4000. There is a female predominance, and more occur on the left side. Imaging findings include hydroureter, hydronephrosis, and other signs of obstruction. Perhaps this patient’s stringing associated with defecation was enough “pressure” to prolapse the ureterocele out into her vagina.