Massive Ureterolithiasis in a Duplicated Ureter: A Case Report

Abstract

This case study presents a patient with massive ureterolithiasis in a duplicated ureter. A 31-year-old female patient underwent two dual-energy X-ray absorptiometry (DEXA) scans, which incidentally revealed an ossific pelvic mass identified by a chiropractor. Pelvic X-ray and CT confirmed ureterolithiasis measuring 6.08 cm x 1.92 cm. Two months later, she developed left-sided lumbar pain radiating to the lower extremity, left lower quadrant abdominal pain, urinary urgency, and persistent fever requiring hospitalization. Clinical investigations, including urinalysis, blood work, and CT, confirmed a urinary tract infection secondary to ureterolithiasis. A follow-up CT scan revealed a completely duplicated ureter on the left side that had been missed on prior studies. The patient was treated with multiple courses of antibiotics over six weeks with limited clinical improvement; subsequently, a ureteral stent was placed. Approximately one month later, the calculus spontaneously passed into the bladder, resulting in significant symptomatic relief. A follow-up CT scan revealed a completely duplicated ureter on the left side that had been missed on prior studies and revealed that the previously placed ureteral stent had been inadvertently inserted into the unobstructed ureter. This case highlights the importance of thorough imaging review, as the urological pathology was initially detected on a DEXA scan. Timely recognition and referral are essential to optimizing patient outcomes in atypical presentations.

Introduction

Ureterolithiasis is a common condition that occurs when a calculus forms within the urinary system. These stones can vary in size but are typically small and pass spontaneously [1]. Passage of stones can occur asymptomatically; however, most individuals experience symptoms ranging from mild discomfort to severe pain that is colicky in nature. Typical pain patterns radiate from the low back into the groin; other symptoms include nausea, vomiting, and changes with voiding habits such as frequency, urgency, hesitancy, hematuria, or dysuria [1]. Various complications can occur, ranging from simple to severe, including urinary tract or kidney infections, ureteral obstruction, hydronephrosis, urosepsis, kidney damage, and chronic kidney disease [1]. Due to the potentially severe nature of symptoms and complications, prompt treatment and monitoring of patients are essential.

Duplicate ureters are a congenital anomaly characterized by either a partial or complete secondary ureter projecting off the same kidney [2]. Secondary ureters can pose the threat of urinary stasis or obstruction, resulting in complications such as reflux, infection, hydronephrosis, and ureterolithiasis [3]. The finding of duplicate ureters is often incidental and only discovered upon imaging related to other conditions, such as urinary tract infections or kidney stones.

The following case report details a unique and atypical presentation of a massive ureterolithiasis in a duplicated ureter system. The presence of massive ureterolithiasis is an uncommon clinical finding, and its concurrent occurrence with a duplicated ureter represents a rare and unique anatomical and pathological presentation. This case begins from the initial incidental discovery of the ureterolithiasis on dual-energy X-ray absorptiometry (DEXA) imaging in an initially asymptomatic patient who later became symptomatic with concurrent complications, to the conclusion with the discovery of the duplicated ureter system, removal of the calculi, and subsequent recovery of the patient over a seven-month period.

This work was previously presented as a poster presentation at the Association of Chiropractic Colleges Research Agenda Conference from March 26-28, 2026.

Case presentation

A 31-year-old female patient underwent two DEXA scans to monitor lean body mass in June 2024 and October 2024. For the purpose of this case report, the day when the second DEXA scan was performed will be denoted “Day 1”, as this is the date the patient started to receive follow-up care. Both scans showed an ossific density in the soft tissues of the pelvis on the left side (Figure 1).

Figure 1. Dual-energy X-ray absorptiometry (DEXA) images (full body and magnified) from (A) June 2024 and (B) October 2024; both of which demonstrated an ossific density within the soft tissues of the pelvis on the left (yellow arrow).

The patient had subsequent pelvic radiographs taken by her chiropractor the day after the second DEXA scan on Day 2, which revealed a laminated ossific mass measuring 6.08 cm x 1.92 cm located in the pelvic basin on the left, likely at the ureterovesical junction (Figure 2).

Figure 2. X-rays of the pelvis.

(A) Anteroposterior (AP) view of the pelvis, (B) magnified AP view of the pelvis with measurements, (C) lateral pelvis x-rays taken on Day 2, revealed a laminated ossific density within the soft tissues of the pelvis on the left (arrow). The ossific density measured 6.08 cm superior to inferior by 1.92 cm medial to lateral and overlies the iliopubic junction on the lateral projection (yellow circle). Incidentally noted were mild osteitis condensans ilii, left-sided paraglenoid sulcus, and spina bifida occulta at S1.

The radiographs were subsequently sent to a chiropractic radiologist for review. At this point, the differential diagnoses for the mass included ureterolithiasis, bladder calculi, and post-haemorrhagic or post-haematoma calcification; diagnostic ultrasound was recommended.

Diagnostic ultrasound of the pelvis was recommended and obtained on Day 13, which was reported by the imaging center as “normal,” representing a false-negative. In early December of 2024, the patient experienced symptoms of left lower back pain with radiation down the leg, pain in the lower left abdominal region, urinary urgency, and a persistent fever. On Day 44, a CT scan was obtained, which demonstrated a 5.1 cm obstructing stone in the distal left ureter. The patient was subsequently diagnosed with a kidney infection by her medical provider and given antibiotics as treatment. On Day 57, the patient’s symptoms intensified, and she presented to the ER, where a second CT scan was taken along with blood and urine tests. IV antibiotics were provided in the ER, and the patient was subsequently sent home. 

One month later, on Day 82, the patient’s symptoms intensified once again with the return of fever. She sought care from her primary care provider, who prescribed antibiotics; however, the symptoms continued to intensify. On Day 83, the patient was rushed to the hospital, where she got another CT scan, more blood and urine tests, and sepsis analysis. The CT scan showed dilation of the left kidney in the upper pole, and the patient was hospitalized for emergency surgery, where a ureteric shunt was placed. On Day 101, the patient reported symptoms of increased pain and cramping followed by a spontaneous reduction in symptoms; a follow-up X-ray demonstrated that the ureteric stone had spontaneously moved from the ureterovesical junction to the neck of the bladder (Figure 3).

Figure 3. Follow-up anteroposterior (AP) pelvis radiograph.

Follow-up AP pelvis radiograph taken Day 101 demonstrated the ureteric shunt and the movement of the ureterolithiasis into the bladder (yellow arrow).

The patient’s urologist recommended a visit to the ER and a CT scan, which revealed a left-sided complete duplicate ureter that was previously obscured. The following day, the patient underwent cystolitholapaxy to break up the stone. The patient reported episodes of post-obstructive diuresis and subsequent relief of symptoms after elimination of the stone particles. A timeline of the case is presented in Figure 4.

Figure 4. Timeline of imaging, symptomatology, and treatment.

DEXA: dual-energy X-ray absorptiometry

Outcomes

After imaging, lab work, antibiotic treatment, and shunting, the ureterolithiasis spontaneously passed from the blocked ureter into the bladder; this provided significant symptom relief to the patient. The stone was managed through cystolitholapaxy, a minimally invasive procedure in which a laser cystoscope is used to reach the stone internally and shatter it into small, grain-like fragments that can more easily pass through the urethra. After the procedure, the patient made a full recovery with complete resolution of symptoms and no reported postoperative complications or evidence of residual obstruction.

Discussion

Ureterolithiasis is a prevalent urological condition associated with significant morbidity, affecting millions of individuals worldwide. It classically presents with acute flank pain radiating to the groin, hematuria, nausea, and vomiting. When left untreated, it may progress to serious complications, including obstructive uropathy, pyelonephritis, and renal failure [4]. While these hallmark presentations typically facilitate prompt diagnosis, atypical or subclinical cases pose a substantial diagnostic challenge. The present case underscores this diagnostic vulnerability, describing a massive ureterolithiasis within a duplicated collecting system that remained clinically silent for several months before culminating in severe infection and renal compromise.

Although less common, duplicated ureters represent a well-documented congenital anomaly, with a reported prevalence of 0.8%-1.8% [5]. This condition involves a partial or complete duplication of the ureter arising from a single kidney and is frequently identified incidentally or in the setting of associated complications, including urinary tract infections, nephrolithiasis, obstruction, and vesicoureteral reflux [3]. While typically asymptomatic in isolation, the coexistence of a duplicated collecting system and ureterolithiasis introduces a heightened level of diagnostic and management complexity. In the present case, this anatomical variation contributed to selective dilation of the upper renal moiety and resulted in initial misplacement of the ureteral stent. Furthermore, duplicated systems may obscure expected radiologic patterns of obstruction, increasing the likelihood of misinterpretation. Application of anatomical frameworks, such as the Weigert-Meyer rule, is therefore essential for accurate localization and appropriate clinical decision-making.

A defining feature of this case is the incidental identification of an exceptionally large ureteral calculus by the patient herself on DEXA and plain radiographs, rather than through targeted urological evaluation. Measuring 6.08 cm × 1.92 cm at the ureterovesical junction, this calculus far exceeds the typical size of distal ureteral stones, which are generally a few millimeters in diameter and rapidly become symptomatic [6,7]. Notably, despite its substantial size, the patient remained asymptomatic for approximately four months. However, once symptoms emerged, they progressed rapidly, manifesting as fever, urinary disturbances, lumbar and abdominal pain, and signs consistent with upper urinary tract infection. This clinical trajectory aligns with the known pathophysiological progression of obstructive uropathy and infection secondary to ureteral obstruction [3]. Importantly, the patient’s deterioration was compounded by delays in definitive management, reflecting broader systemic challenges within healthcare delivery. 

Beyond its clinical complexity, this case highlights critical vulnerabilities within diagnostic imaging pathways. Ultrasound is widely utilized as an initial imaging modality for suspected urolithiasis; however, its diagnostic sensitivity is highly variable and dependent on factors such as anatomical location, operator experience, and stone characteristics [8, 9]. Distal ureteral calculi and stones associated with congenital anomalies are particularly prone to being missed. In this case, the false-negative ultrasound raises concerns regarding technical limitations as well as challenges associated with integrating prior imaging findings into the interpretation process. Although previous imaging studies had documented the abnormality, these findings were not incorporated into the ultrasound assessment, and the examination was subsequently reported as normal. Such findings are consistent with literature demonstrating that diagnostic errors in radiology frequently arise from system-level failures, particularly inadequate clinical communication and incomplete imaging requisitions [10]. This case, therefore, exemplifies how deficiencies in communication across the diagnostic process, from ordering images to interpretation, can directly contribute to delayed or missed diagnoses.

A definitive diagnosis was ultimately achieved through CT imaging, which confirmed the presence of left-sided ureterolithiasis and revealed the previously unrecognized duplicated ureter. This finding provided critical insight into the patient’s atypical presentation and the earlier diagnostic challenges, as duplicated systems are known to reduce the sensitivity of ultrasound and complicate anatomical interpretation [3]. Additionally, CT imaging demonstrated that the initial ureteral stent had been placed in the non-obstructed ureter. Although uncommon, stent misplacement is a recognized complication that may result in persistent symptoms, ongoing obstruction, and failure of clinical improvement [3]. In this context, the anatomical anomaly not only obscured diagnosis but also directly influenced the effectiveness of treatment.

Collectively, this case highlights several important clinical implications. First, it underscores the necessity of correlating imaging findings with clinical presentation and maintaining a high index of suspicion when discordance exists. Overreliance on imaging reports, without independent review or clinical correlation, may contribute to diagnostic delay. Second, it emphasizes the critical role of detailed and targeted imaging requisitions in guiding appropriate evaluation and interpretation. Third, it reinforces the need for increased awareness of anatomical variants, such as duplicated ureters, which may significantly alter both diagnostic accuracy and therapeutic outcomes.

The Weigert-Meyer rule provides an essential anatomical framework for interpreting duplicated collecting systems, describing the characteristic insertion patterns of the ureters. Specifically, the upper moiety ureter inserts more medially and inferiorly and is more prone to obstruction, whereas the lower moiety ureter inserts more laterally and superiorly and is more susceptible to reflux [11]. Application of this principle is particularly valuable in complex cases, as it aids in the accurate localization of pathology and informs appropriate intervention strategies.

Finally, this case underscores the importance of an interprofessional, patient-centered approach to care. Portal-of-entry providers play a critical role in early detection, imaging referral, and coordination of care, particularly in patients presenting with nonspecific or atypical symptoms. Delays in diagnosis and treatment may result in life-threatening complications, including sepsis and irreversible renal damage [12]. As clinicians frequently involved in the evaluation of musculoskeletal complaints, chiropractic physicians are uniquely positioned to identify incidental but clinically significant findings. In this capacity, they serve as essential patient advocates, ensuring that abnormal findings are pursued, patient concerns are validated, and appropriate follow-up is obtained. Strengthening these roles within the healthcare system may help mitigate diagnostic delays and improve outcomes, particularly in complex and atypical presentations such as the one described.

Limitations

This case report is based on findings that occurred with a single patient. It is important to note that the initial finding of the ureterolithiasis on the DEXA scan was incidental and only seen due to its large size. It is unknown how long the calculi had been present, as it was initially asymptomatic, and there was no previous imaging to compare. Additionally, the CT and ultrasound imaging, as well as diagnostic test results, were unavailable for review for the purposes of the case report. The cause and composition of the stone also remain unknown. The presence of the ureteral anomaly also creates limitations in the study. Due to these factors, the findings of this report cannot be generalized to other cases. 

Conclusions

This case describes a rare presentation of massive ureterolithiasis within a complete duplicated ureter that was initially identified incidentally on DEXA imaging and remained asymptomatic for several months before progressing to infection and urinary obstruction. This case highlights the importance of careful review of imaging studies, clinical correlation of incidental findings, and consideration of anatomical variants that may complicate diagnosis and management.