Robert L. Lebowitz, M.D. Children' s Hospital, Harvard Medical School Boston, Massachusetts

This girl had a febrile urinary infection at age 2 months and a VCUG showed right grade 3 reflux with the right ureter inserting into a bladder diverticulum (figure 1). She had medical management (antibiotic prophylaxis), and a VCUG elsewhere several years later was normal, and so antibiotic prophylaxis was stopped. Recently, at age 6, she had several more episodes of febrile urinary infection. Repeat voiding cystogram showed that there was right grade 3 reflux again and that the right ureter still inserted into a bladder diverticulum (figure 2). This case shows that secondary reflux with the ureter inserting into a diverticulum is unlikely to resolve spontaneously as the child gets older, as primary reflux often does. It also demonstrates that secondary reflux with the ureter inserting into a diverticulum can be elusive on voiding cystography, and that children whose refluxing ureter inserts into a diverticulum usually needs surgical correction.