Prune belly syndrome is a rare congenital disorder characterized by anomalies of the urinary tract, deficiency of the abdominal wall musculature, and bilateral cryptorchidism. It may also feature the involvement of other organ systems as well.
The clinical picture in children with PBS varies and can include a wide spectrum of complications . Common features include urinary obstruction, vesicoureteral reflux, urethral malformations, and other urogenital abnormalities  . As a result, children with PBS may be susceptible to urinary infections.
Additionally, there are consequences that stem from the weak abdominal musculature. For example, these patients have difficulty with increased lung secretions due to their poor cough mechanism. Additionally, they develop constipation since they struggle with performing the Valsalva maneuver.
When inspecting the abdomen, there are remarkable findings. A prominent feature of the abdomen is its wrinkled image and hence its resemblance to a prune since there is an absence of abdominal muscle. It also appears great in size and is lax. Furthermore, the intestinal loops are transparent through the thin wall. Patients may have transverse skin folds and a midline crease the spans the navel to the pubic region. The navel can consist of a vertical slit.
A majority of individuals with PBS will have a horizontal depression under the lower border of the chest, a finding known as Harrison groove. The overall chest appears deformed in many patients.
- Vascular Disease
Among the former group, atherosclerosis, arthritis, and collagen vascular disease are the most common, whereas liver biopsy or other radiologic interventions (ie, percutaneous abscess drainage) are frequent iatrogenic causes. [ncbi.nlm.nih.gov]
Atherosclerosis, arthritis, and collagen vascular disease are the most common etiologies of inflammation that result in such aneurysms. [emedicine.com]
- Wrinkled Abdominal Skin
Examination showed wrinkled abdominal skin, bilateral undescended testes and an hypoplastic rectus abdominis, below the umbilicus. Further evaluation revealed enlarged bladder, bilateral megaureters and right intra-abdominal testis. [ncbi.nlm.nih.gov]
The patient had defect abdominal muscles, wrinkled abdominal skin, cryptorchidism, urethral atresia, vesico-subumbilical skin fistula and normal kidney function. [aclr.com.es]
Definition / general Prune belly syndrome (PBS) is a congenital disorder of the urinary system with renal, ureteral and urethral abnormalities The syndrome is named for the mass of wrinkled abdominal skin often present First described in 1839 by Frölich [pathologyoutlines.com]
In addition, the risk of torsion must be at the forefront of the differential diagnosis in a prune-belly renal transplant patient with acute onset of oliguria. [ncbi.nlm.nih.gov]
His urine output only possible with catheter, otherwise oliguria, urinary retention and glob vesicale occurs. Urinary ultrasonography showed enlargement of bladder and mild hydroureteronephrosis in left renal pelvis. [alliedacademies.org]
In the developed world in which women have access to adequate prenatal care, a majority of cases with PBS are detected through obstetric ultrasonography followed by a confirmation at birth  . The newborn suspected to have PBS should undergo a thorough evaluation that consists of the antenatal and family history, a physical exam, and key studies.
Since renal obstruction is very common in patients with PBS, there are numerous tests that should be obtained such as the serum concentrations of sodium, potassium, chloride, glucose, blood urea nitrogen (BUN), and carbon dioxide, which are collectively known as the SMA-6. Creatinine is also important since it reveals information about the renal function. Furthermore, urinary output and electrolytes are pertinent. Note that findings such as the elevation in creatinine and BUN accompanied by a low urine output are suggestive of obstruction.
The medical team should perform the following imaging techniques to ascertain the specific details about the location and number of abnormalities as well as the degree of their involvement.
Ultrasonography of the kidney and bladder should be the initial diagnostic technique in the neonatal period. This can also be performed periodically to track the progress of the patient.
Kidney, ureter, and bladder (KUB) radiography is warranted in neonates. The findings are notable for bowels appearing on the lateral border of the abdominal wall. Additionally, this imaging tool is paramount for surgical planning.
The intravenous pyelogram (IVP) is crucial in the visualization of the genitourinary tract anomalies. Additionally, voiding cystourethrography (VCUG) to evaluate the flow of urine through the tract.
The management of PBS is tailored towards the manifestations and their severity.
Urogenital tract abnormalities can be managed through various surgical procedures. For example, urinary retention can be managed with a vesicostomy, which facilitates the elimination of urine. Some cases will benefit from a cystoplasty.
Cryptorchidism is managed by a pediatric urologist and can be repaired through an orchidopexy.
Abdominal muscle can be reconstructed in order to improve the respiratory function and cosmetic appearance.
Obstetric cases with a PBS fetus are managed by perinatology specialists. They frequently employ fetal ultrasonography as a mode to monitor the renal function and the volume of the amniotic fluid. Intervention in the prenatal period is crucial in order to preserve the patient's renal function . Procedures such as vesicoamniotic shunting may be an option  to help prevent lung hypoplasia and kidney dysplasia. In fact, this may improve the prognosis in the neonate. In certain cases, the perinatologist may recommend early delivery depending on factors such as the severity of renal impairment and neonatal viability .
Special consults will be required for patients with orthopedic, cardiac, and/or gastrointestinal sequelae.
PBS has a mortality rate of 20%. Stillbirths and neonatal deaths are common in this condition. The poor prognosis and fatal outcomes are attributed to lung hypoplasia, kidney failure, and/or the cumulative effects of the congenital diseases present.
The cause of PBS has not been fully established. It has been suggested though that there is a genetic role in the development of this condition. There are three hypotheses that may explain the etiology.
Some researchers propose that a defect in the developing bladder causes urine to accumulate in the organ, leading to the distension of the bladder, ureters, and kidneys. Consequently, the other features of the triad, abdominal muscle atrophy, and cryptorchidism, may stem from the obstructive effects of the enlarged bladder. Note that obstruction in the urinary tract may be resolved by the time of birth.
Another theory postulates that the abnormal development of abdominal muscles is the etiology of this disorder.
Finally, the third possibility speculates that the urinary and muscular manifestations arise from a common cause that has yet to be identified. Moreover, the abdominal muscle abnormality may have actually developed from a defective nervous system.
In addition to the clinical triad of PBS, this congenital disorder encompasses a broad range of anatomic defects with various degrees of severity. These manifestations include involvement of the respiratory, cardiovascular, gastrointestinal, skeletal . and central nervous systems.
Genitourinary and pulmonary
Numerous structures may be affected including the kidneys, ureters, and urethra. Findings can include hydronephrosis, hydroureter, and vesicoureteral reflux . The latter may predispose the children to urinary tract infections.
A main complication of PBS is the underdevelopment of the lung.
While PBS cannot be prevented since the defects occur during fetal development, early identification through a prenatal ultrasound can lead to appropriate intervention and the possible avoidance of complications such as renal failure and pulmonary hypoplasia. Increasing detection of PBS and other congenital disorders can be achieved by extending the use of ultrasonography to developing regions.
Prune belly syndrome (PBS) is a rare disorder typified by the clinical triad of urinary tract malformations, abdominal muscle deficiency, and bilateral cryptorchidism (in males). Although the etiology is not fully understood, there are several possibilities regarding the development of this congenital condition.
The clinical presentation varies and may include a broad range of sequelae with different levels of severity. In addition to the typical features of PBS, patients may also have pulmonary, cardiac, musculoskeletal, and/or gastrointestinal conditions. With regards to patient demographics, PBS has a predilection for males.
PBS can be identified through prenatal ultrasonography but is confirmed during the neonatal period through a clinical assessment comprised of a physical exam, laboratory tests, and imaging modalities. The latter includes ultrasonography, radiography, and other techniques to evaluate the degree of involvement of the urogenital tract.
The therapeutic approach in these children is dependent on the clinical picture. Patients may require surgical repair of pathologies such as urinary retention, urinary obstruction, cryptorchidism, abdominal muscle defect, etc.
The poor prognosis in fetuses and neonates is associated with serious complications. Therefore, early recognition and prompt intervention may lead to a better prognosis. In patients with milder manifestations, timely treatment and management can improve the outcomes.
What is Prune Belly Syndrome?
Prune belly syndrome (PBS) is a disorder consisting of three birth defects:
- Urinary tract abnormalities
- Absence (partial or complete) of abdominal muscles
- Undescended testes in males
The developing fetus likely has a urinary tract defect that causes the abdomen to collect fluid and become swollen. This fluid eventually disappears by birth but causes the appearance of a prune-like belly.
The majority of all affected individuals are males.
What causes this condition?
The exact cause of PBS is not known.
What are signs and symptoms of PBS?
In addition to the three main features discussed above, there is a wide range of complications that may occur in these patients:
- Pulmonary- underdeveloped lungs
- Skeletal- hip deformities, absence of limbs, clubbed feet
- Gastrointestinal- defects of the esophagus, colon, rectum, etc.
- Cardiac- ventriculoseptal defects, tetralogy of Fallot
The following signs are typical features seen on the newborn exam:
- Wrinkled belly that resembles a prune
- Large and lax abdomen
- Intestinal loops are visible through the skin
- Skin folds that span across the abdomen
- Crease that spans from the navel to the pubic area
- Caving of the chest
- Overall deformed looking chest
How is it diagnosed?
Diagnosis can be made while the baby is still in the womb during a prenatal ultrasound. It is then confirmed after birth when the clinician examines the newborn and performs key studies such as ultrasound, x-ray, and intravenous pyelogram. These imaging techniques can help the medical team determine the extent of defects in the baby's urogenital tract. Also, there are laboratory tests to assess the function of the kidneys.
How is it treated?
It is important to diagnose this disorder early in order to prevent serious medical issues. The treatment depends on what abnormalities the patient has and how severe they are.
Some patients will need surgery to help relieve the bladder or repair the ureters or bladder.
A pediatric urologist will evaluate the patients and likely repair the undescended testes with a procedure called orchiopexy.
The abdominal muscles can be surgically reconstructed.
What is the prognosis?
The prognosis may depend on how soon the condition is diagnosed and treated. Intervention may need to begin while the baby is still in the womb. Additionally, the baby may need to be delivered before the due date (if the baby has reached a viable gestational age).
In unborn babies and newborns with severe complications, stillbirths and newborn deaths are likely to occur.
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