Paediatric urology · KIMS Secunderabad
Ectopic Ureter — When the Ureter Opens in the Wrong Place
A ureter normally inserts into the trigone (the triangular posterior wall) of the bladder at a precisely defined position — above the bladder neck and above the external urethral sphincter. An ectopic ureter is one that inserts below its normal position — in the bladder neck, the urethra, the vaginal vestibule, the vagina, or (rarely) the rectum in females, or the posterior urethra, seminal vesicle, or vas deferens in males. The clinical consequences of ectopic ureteral insertion depend on where below the sphincter the ureter opens.
In females, an ectopic ureter inserting below the external urethral sphincter causes continuous urinary leakage — because the kidney continues to produce urine that drains directly into the vaginal vestibule or urethra below the sphincter, without the bladder functioning as a reservoir. The classic presentation: a girl who appears to void normally (her normal contralateral system functions correctly) but is persistently wet. This presentation — normal voiding + continuous dampness — is pathognomonic of ectopic ureter in females. In males, an ectopic ureter always inserts above the external sphincter (it cannot insert below the sphincter in males) — so males with ectopic ureter do not present with incontinence but with recurrent UTI, epididymitis, or haematospermia.
Association with duplex collecting system
Duplex system with ectopic upper pole ureter — the typical pattern
The vast majority of ectopic ureters (80 to 90%) are associated with a duplex (duplicated) collecting system — a kidney with two separate collecting systems, each with its own ureter. Following the Weigert-Meyer rule: in a duplex system, the upper pole ureter always inserts below and medial to the lower pole ureter. This lower, medial insertion of the upper pole ureter predisposes it to: ectopic insertion (below the sphincter in females), ureterocele formation (ballooning of the distal ureter), and obstruction with associated upper pole hydronephrosis and poor function.
Ectopic ureter with a single (non-duplex) collecting system
Ectopic ureters associated with a single (non-duplex) collecting system are less common — they represent a solitary kidney draining ectopically. These are more serious because the entire kidney's drainage is compromised.
Diagnosis
Renal ultrasound
The first investigation — identifies the duplex collecting system (if present), the degree of hydronephrosis in the affected renal unit, and sometimes visualises the ectopic ureteral insertion site.
CT urogram — the definitive imaging investigation
A delayed excretory phase CT urogram traces the full course of both ureters from kidney to their insertion points. The ectopic ureter and its abnormal insertion site are identified on CT. The upper pole of a duplex kidney draining into an ectopic ureter is typically hydronephrotic and shows delayed excretion of contrast.
DMSA scan
Determines the differential function of each renal unit (particularly the upper pole contribution in a duplex system). If the affected upper pole contributes less than 10% of total function, heminephrectomy (removal of the non-functioning upper pole) is preferred over reimplantation.
MRI urogram
Particularly useful for ectopic ureter in young girls where minimising radiation exposure is important. MRI provides excellent soft tissue detail of the ectopic ureteral course without ionising radiation.
Cystoscopy
At the time of planned surgical correction — confirms the ureteral insertion positions, rules out associated ureterocele, and assesses bladder anatomy before reimplantation.
Treatment at KIMS
Ureteric reimplantation — for ectopic ureter with functioning renal unit
The ectopic ureter is detached from its abnormal insertion site and reimplanted into the bladder in the correct antireflux position (above the sphincter). If the ectopic ureter is associated with a duplex system, a common sheath reimplantation (reimplanting both ureters of the duplex system together in a single submucosal tunnel) or a uretero-ureterostomy (joining the upper pole ureter to the lower pole ureter at the level of the pelvis) avoids the need for bladder reimplantation. Performed laparoscopically or open at KIMS.
Upper pole heminephrectomy — for non-functioning upper pole
If the upper pole contributes less than 10% of total renal function on DMSA (severely damaged from chronic obstruction and infection), laparoscopic removal of the upper pole and its ectopic ureter eliminates the source of leakage, infection, and obstruction while preserving the functioning lower pole. The preferred operation for most ectopic ureters with poorly functioning upper poles.
A girl aged 3 to 8 years who has persistent urinary dampness — appearing continuously wet despite apparently normal toileting — and does not have a neurological cause for her incontinence should be evaluated for ectopic ureter before being diagnosed with 'idiopathic incontinence' or 'overactive bladder'. A renal ultrasound identifying a duplex collecting system is often the first diagnostic clue. At KIMS Paediatric Urology, this diagnosis is specifically considered in all girls with unexplained persistent dampness.
Book a Paediatric Urology Assessment for Ectopic Ureter at KIMS. Call 040-4488-5000
Frequently Asked Questions — Ectopic Ureter
Yes — this is the classic presentation of ectopic ureter in girls: a child who appears to void normally (using the toilet at appropriate intervals) but is continuously damp, day and night. The normal voiding occurs because the contralateral kidney drains normally into the bladder. The continuous dampness occurs because the affected kidney (typically the upper pole of a duplex system) drains through the ectopic ureter directly into the vaginal vestibule or urethra below the sphincter — without the bladder as a reservoir. The volume of leakage depends on the function of the ectopic unit — a poorly functioning upper pole may cause only mild dampness, while a well-functioning one causes significant continuous wetting. Renal ultrasound should be performed immediately in any girl with this presentation.
In males, the anatomy prevents a ureter from inserting below the external urethral sphincter — the embryological insertion point for an ectopic male ureter is always above the sphincter, in the posterior urethra, seminal vesicle, or vas deferens. Because the insertion is above the sphincter, urine from the ectopic ureter reaches the bladder or urethra above the continence mechanism — the sphincter can still function normally and the boy remains continent. Instead, males with ectopic ureter present with: recurrent UTIs (from the ectopic ureter draining into structures above the sphincter), epididymitis or scrotal pain (if the ureter drains into the vas deferens or epididymis), or haematospermia (if it drains into the seminal vesicle).
Ectopic ureter is a congenital developmental anomaly — it occurs during embryological development of the urinary tract when the ureteric bud arises from an abnormal position on the Wolffian duct. It is not typically hereditary in the Mendelian sense (single gene inheritance), but there is a familial tendency — the risk of ureteric and collecting system anomalies is higher in siblings and first-degree relatives of children with ectopic ureter. Ectopic ureter is frequently associated with other urinary tract anomalies (VUR, ureterocele, duplex collecting system) that should be looked for in the affected patient and screened for in siblings with renal ultrasound.
Surgical outcomes for ectopic ureter at experienced paediatric urology centres are excellent. Upper pole heminephrectomy for a non-functioning upper pole eliminates the source of leakage and infection — incontinence resolves completely in over 95% of cases, and the functioning lower pole is preserved. Ureteric reimplantation for an ectopic ureter associated with a functioning renal unit achieves continence and normalises drainage in the large majority of cases. Complications (VUR after reimplantation, anastomotic stricture) are uncommon at experienced centres and are managed by the KIMS paediatric urology team with specific protocols.
KIMS Secunderabad — Dr. Neil Narendra Trivedi (MCh Urology KEM Mumbai, Member SIU, Paediatric Urology), renal ultrasound, CT urogram, DMSA split function, MRI urogram for radiation-sensitive patients, laparoscopic heminephrectomy, ureteric reimplantation, uretero-ureterostomy. NABH and NABL accredited. Call 040-4488-5000.