ectopic ureters are common in females , 80% of which are duplicated and present at birth or in childhood . the urethra and vaginal vestibule are the most common sites of drainage in females .
furthermore , their drainage in a completely developed mullerian system has been reported only once before , although there are reports of bilateral single - system ureteral ectopia into the urogenital sinus .
we report one such case of bilateral , single ectopic ureters draining into a grossly dilated vagina that presented late in an adolescent female .
a 16-year - old female presented with a complaint of involuntary leakage of urine since birth .
the previous leak of a few drops had increased in amount over the past 2 months , thus prompting medical attention .
she could manage with 2 to 3 pads during the day , with 10 to 12 daytime voids in amounts ranging from approximately 90 to 240 ml .
her nighttime incontinence was severe ; she consistently woke up wetting her bed every night . on examination ,
the external urethral meatus was normal as was the external genitalia , and the vaginal introitus was moist .
the right kidney was hydronephrotic with a dilated ureter and dilated vagina wrongly interpreted as a normal urinary bladder ( fig .
a diethylenetriaminepentaacetic acid renal scan showed a nonfunctioning left kidney , delayed excretion phase of the right kidney , and a glomerular filtration rate of 65.71 ml / min .
on cystovaginoscopy , the external urethral meatus and urethra appeared normal , with a small urinary bladder with approximately 20-ml capacity and an absent trigone .
computed tomography revealed calcification in the left kidney and left ureter , a nonexcreting left kidney , hdun changes on the right side with delayed excretion , and a small urinary bladder separate from the capacious vagina ( fig .
the right ureter was moderately dilated , and the left ureter was minimally dilated and calcified .
the bowel contributed 90% of the reconstructed bladder wall , because the native bladder was atrophic .
clean intermittent self - catheterization fourth hourly was advised for the initial few months , which the patient was later weaned from because she maintained good voiding .
in our review of the available literature for the past 50 years , we found only one such published case report of bilateral , single vaginal ectopic ureters by chatterjee and chatterjee   in 2011 .
sheldon and welch   and more recently singh et al .   reported bilateral , single ectopic ureters draining into the urogenital sinus .
the ureters find their way into the definitive bladder as the distal mesonephric duct is absorbed into the developing bladder to form the trigone , bladder neck , and proximal urethra .
ectopic ureters draining into the female genital tract are thought to be via embryonic remnants of the mesonephric duct ( gartner 's duct ) , which breaks open into the mullerian system .
this elusive embryonic event is unexplained and rare , more so in bilateral , single ectopic ureters .
occurrence of a simultaneous urogenital abnormality is expected here , such as agenesis of urinary bladder or persistent urogenital sinus .
bilateral single - system vaginal ectopia in a completely differentiated urogenital tract should arguably be very rare .
bilateral ectopic ureters in females usually present early with constant dribbling of urine . in this case , however , the presentation was during adolescence and with 150 to 200 ml voided apparently normally .
this is explained by the fact that patient had , over the years , learned to hold the urine in her vagina by contracting the pelvic floor musculature .
computed tomography was crucial for arriving at a diagnosis in this case , as was reported by other authors in similar cases , although magnetic resonance urogram can be further precise . there was a therapeutic dilemma regarding reconstruction of the urinary tract .
an ileocystoplasty with right ureteric reimplantation was done anticipating future need of a continence procedure or undiversion to nonorthotopic diversion . because apparently good urethral mucosal coaptation was seen on cystoscopy , orthotopic diversion was preferred .
the issue of continence is also discussed by podesta et al .   in their article ,
in which they inferred that the bladder in bilateral , single ectopic ureters may retain a good continence mechanism with adequate augmentation .
hence , on the basis of this evidence , no bladder neck continence procedures were attempted in our case .
fortunately , the patient was continent with cystometric capacity of 300 ml at 3 months .
she was weaned off clean intermittent self - catheterization by 6 months and at present voids satisfactorily by abdominal straining ( fig .
 a 16-year - old female presented with dribbling of urine along with voluntary voiding since birth . 
 renal imaging revealed hydroureteronephrosis on the right side ; the uterus and ovary were normal . 
 a radionuclide scan showed a left nonfunctional kidney . 
 on cystovaginoscopy , the urethra was shown to be normal and the urinary bladder was tubular with small capacity and an absent trigone . 
 although the vagina was capacious , no ureteric orifices were found . 
 computed tomography corroborated the diagnosis of bilateral , single ectopic ureters draining into a grossly dilated vagina . 
 this case is unique because it is a bilateral single - system ureteral ectopia in a completely differentiated female genital tract that presented late in adolescence . to the best of our knowledge , 
 this is the second such ureteral abnormality reported in the literature so far . 
 the patient underwent ileocystoplasty with right ureteric reimplantation and nephroureterectomy for the left nonfunctional kidney , which histopathology showed to be tuberculosis . 
 the patient is continent with cystometric capacity of more than 300 ml . 
INTRODUCTION
CASE REPORT
DISCUSSION