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Case 1 Presentation
An 11-year-old boy presents with a long history of left flank pain and enuresis and a new finding of left renal atrophy. The patient’s left flank pain began at age 3 years during potty training. At age 4 years, he underwent computed tomography (CT) and renal ultrasonography (RUS), which revealed a thickened bladder and a smaller left kidney (left kidney, 7.1 cm; right kidney, 8.0 cm). Urinalysis was normal. A pediatric urologist at another institution thought the pain was musculoskeletal.
The patient’s pain continued, and he was reevaluated at age 10 years when he began experiencing penile pain concomitant to the flank pain. Subsequent RUS revealed a lack of left renal growth. Voiding cystourethrogram (VCUG) was nondiagnostic because the patient could not void at that time. A technetium-99m-mercaptoacetyltriglycine scan (MAG3) revealed reduced radiotracer uptake on the left, which was consistent with a minimally functioning left kidney (13%) but good clearance of tracer bilaterally demonstrating no evidence of obstruction.
Our pediatric urology team was subsequently consulted out of concern for infravesical obstruction from posterior urethral valves (PUVs), leading to secondary, left-sided, vesicoureteral reflux (VUR). VCUG findings (Figure 1) are abnormal in that the patient’s bladder capacity was 500 mL, greater than expected given his age, and he required 2 attempts to void to completion. No dilation of the posterior urethra, as typically seen with PUV, or VUR, was identified.
Voiding cystourethrogram shows elevated bladder capacity and normal urethra. Arrow indicates the sphincter.
Because of the patient’s difficulty voiding and decline in renal function, the patient is taken to the operating room, where a cystourethroscopy is performed, revealing his diagnosis.
Case 2 Presentation
An 8-year-old boy is admitted with fever and a red, swollen left knee. One week before admission, he developed left knee pain and limp. There was no fever, swelling, or redness of …
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