**4. Doppler waveform of ureteric jet**

### **4.1. Pattern of the ureteric jet**

*Parameters of the jet*

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(Matsuda & Saitoh, 1995).

*3.2.2. Clinical implication of ureteric jet*

Summers et al., 1992; Wachsberg, 1998)

**3.3. Previous work on the ureteric jet on animals**

The extension of jet varies from 1 to 5 cm into the bladder but sometimes extended more than 5 cm or less than 1 cm (Dubbins et al., 1981; Elejalde & de Elejalde, 1983; Kremer et al., 1982).

The mean jet velocity in the paediatric group varies between 18 to 31.6 cm/s (from 26 days to 17 years old) while in the adults it varies from 32.1 to 60 cm/s (from 18 to 49 years old (Cox et al., 1992; Jequier et al., 1990; Marshall, 1990; Matsuda et al., 1995; Matsuda& Saitoh, 1995; Sperandeo et al., 1994;). The duration of jet ranges from 0.6 to 7.5 s (Jequier et al., 1990) in paediatric and from 3.5 to 15 s in adult (Catalano et al., 1998; Cox et al., 1992; Kremer et al., 1982; Matsuda et al., 1995). The frequency of jet ranges from 2.4 to 5.4 jets/min in adult (Burge et al., 1991; Catalano et al., 1998; Kremer et al., 1982; Matsuda & Saitoh, 1995). The

Adult subjects have a higher velocity (20 vs. 16 cm/s), duration (2.5 vs. 1.8 s) and frequency

There is symmetry in jet frequency, jet parameters of velocity and duration between right and left side in healthy subjects (Burge et al., 1991; Cox et al., 1992; Matsuda & Saitoh, 1995).

Under the condition of forced diuresis, the jet hasa higher velocity (32.1 vs. 20 cm/s), dura‐ tion (6.7 vs. 2.5 s) and frequency (2.4 vs. 1.2 jets/min) than in the normal physiological state

It has previously been suggested that the presence of ureteric jet implies concurrenturinary tract infection (UTI) (Kalmon et al., 1955; Nevin et al., 1962) and absence of vesicoureteric reflux (VUR) (Kuhns, 1977). Subsequent studies prove that the presence of ureteric jet is just a normal physiologic phenomenon and cannot be used to diagnosis UTI or exclude VUR (Eklöf & Johan‐

However, the presence of jet could be used to exclude ureteric obstruction. The complete ab‐ sence of jet or a continuous low-level waveform is diagnostic for high-grade obstruction from ureteric calculi (Abulafia et al., 1997; Burge et al., 1991; Catalano et al., 1998; Elejalde & de Elejalde, 1983; Laing et al., 1994; Tal et al., 1994; Timor-Tritsch et al., 1997; Wu et al., 1995; Yoon et al., 2000).The difference in jet velocity has been used to study the effect of drug treatment on benign prostatic hyperplasia (Sperandeo et al., 1994, 1996) and to study the physiology of the kidney and ureter, includingthe glomerular filtration rate (Blomley et al., 1997; Burke & Washowich, 1998; Chiu et al., 1999; Han et al., 1996, 1997; Patel et al., 1996;

Lamb et al has found that ureteric jet can be consistently visualized in the dogs. The ureteric jets show variable frequency and duration. Lamb has suggested that the non-visualization of the ureteric jet might be helpful in diagnosing ectopic ureter (Lamb & Gregory, 1994).

son, 1980; Gothlin, 1964; Gudinchet et al., 1997; Jequier et al., 1990; Marshall et al., 1990).

interjet interval ranges from 2 to 150 seconds (Catalano et al., 1998; Cox et al., 1992).

(1.2 vs1 jets/min) than children (Matsuda & Saitoh., 1995).

Ureteric jets areclassified according to the number of peaks within that particular Doppler waveform. Six basic patterns are identified: monophasic (with only one peak), biphasic (two peaks), triphasic (three peaks), polyphasic (number of peaks exceeding three), "square" (a plateau waveform in which no distinct peak be identified but of average duration); and "continuous" when the waveform lasts longer than 20 seconds which can be either polypha‐ sic or plateau form. These waveforms are further classified as three categories. Monophasic jet is classifies as the first category of simple and immature pattern (Fig. 4).

**Figure 4.** The simple, immature monophasic pattern of the ureteric jet

The bi, tri- and polyphasic patterns are classified as the complex and mature pattern (Fig 5).

The last two patterns are the square and continuous forms. These are modified waveform under the state of forced diuresis. They are classified as the diuretic pattern (Fig. 6).

**Figure 5.** The complex and mature pattern of the ureteric jet: bi (a), tri (b), polyphasic (c)

**Figure 7.** Doppler measurement of the ureteric jet: peak velocity (a), duration (b) and initial slope (c)

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Multispike pattern is defined as the pulsation in the jet pattern as a result of the pulsation transmitted from the adjacent arteries (Fig 9). This pattern is more commonly observed when bladder is maximally full and the incidence is found to be 1.9% of the study popula‐

Change in angle of the jet meant there was a change in the direction of the jet at the begin‐ ning and at the end (Fig. 10). This pattern could be observed at any diuresis status. The inci‐

dence is found to be 4.3% of the study population (Leung et al., 2007b).

**Figure 8.** Presence of break (arrow) within the ureteric jet

tion (Leung et al., 2007b).

**Figure 6.** The diuretic pattern of the ureteric jet: square (a), continuous (b)

### **4.2. Measurement of ureteric jet**

On the Doppler waveform, the maximum velocity (peak velocity), jet duration and initial slope can be measured (Fig 7).

### **4.3. Uncommon modification of the jet**

There are three uncommon but interesting modifications of the jet. They are: presence of breaks, multispike pattern and change in direction of the jet. These patterns are relatively uncommon in the normal population but they provide indirect supportive evidence for the hypothesis of functional sphincter action at the VUJ.

Presence of breaks meant there is a total absence of signal between peaks within the dura‐ tion of that particular wave (Fig 8). Most of the breaks are observed in the maximally full bladder and the incidence is found to be 5.7% of the study population (Leung et al., 2007b).

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**Figure 7.** Doppler measurement of the ureteric jet: peak velocity (a), duration (b) and initial slope (c)

**Figure 8.** Presence of break (arrow) within the ureteric jet

**Figure 5.** The complex and mature pattern of the ureteric jet: bi (a), tri (b), polyphasic (c)

**Figure 6.** The diuretic pattern of the ureteric jet: square (a), continuous (b)

On the Doppler waveform, the maximum velocity (peak velocity), jet duration and initial

There are three uncommon but interesting modifications of the jet. They are: presence of breaks, multispike pattern and change in direction of the jet. These patterns are relatively uncommon in the normal population but they provide indirect supportive evidence for the

Presence of breaks meant there is a total absence of signal between peaks within the dura‐ tion of that particular wave (Fig 8). Most of the breaks are observed in the maximally full bladder and the incidence is found to be 5.7% of the study population (Leung et al., 2007b).

**4.2. Measurement of ureteric jet**

118 Recent Advances in the Field of Urinary Tract Infections

slope can be measured (Fig 7).

**4.3. Uncommon modification of the jet**

hypothesis of functional sphincter action at the VUJ.

Multispike pattern is defined as the pulsation in the jet pattern as a result of the pulsation transmitted from the adjacent arteries (Fig 9). This pattern is more commonly observed when bladder is maximally full and the incidence is found to be 1.9% of the study popula‐ tion (Leung et al., 2007b).

Change in angle of the jet meant there was a change in the direction of the jet at the begin‐ ning and at the end (Fig. 10). This pattern could be observed at any diuresis status. The inci‐ dence is found to be 4.3% of the study population (Leung et al., 2007b).

*5.1.1. General properties of jet*

**Incidence (%)**

dren (22%) than in adult (1.9%) (Table 2).

**Children**

P < 0.01

**Table 2.** Incidence of monophasic jet in children and adult.

78.89 cm/s for the complex pattern.

complex pattern.

**Number Incidence (%)**

**Monophasic Biphasic Triphasic Polyphasic**

0-9.9 30 30.6 23.3 16.1

10-19.9 3.3 28.7 41.1 26.9

20-29.9 0 35.6 40.7 23.7

30-39.9 2.0 35.6 35.1 27.3

40-49.9 2.5 34.1 32.7 30.7

50-59.9 3.8 38.7 30.8 26.7

60-69.9 0 38.0 35.5 26.4

70-79.9 4.7 37.2 37.2 20.9

In the normal population, there is strikingly larger number of monophasic patterns in chil‐

For the mean velocity, it is 34.03 cm/s for the monophasic jet and 61.82 cm/s for the complex pattern in children. While in adult, the mean velocity of the monophasic jet is 57.65 cm/s and

For the mean jet duration, it is 1.17 s for children with monophasic pattern and 5.26 s for the complex pattern. In adults, the mean jet duration is 1.91 s for monophasic jet and 6.9 s for

**Adult**

**Number Incidence (%)**

**Table 1.** Incidence of the four patterns in different age groups of the normal population.

Monophasic 83 22 18 1.9

patterns prevail.

**Age (year)**

In the normal population, four common patterns can be identified: monophasic, biphasic, triphasic and polyphasic (Table 1). The square and continuous patterns occur under force di‐ eresis, which contributes only 1.5% of cases in the normal population. With increasing age from infancy, the proportion of monophasic waveform decreases while the more complex

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**Figure 9.** Multispike pattern (arrows) of the ureteric jet.

**Figure 10.** Changing of angle in the ureteric jet: from vertical at the beginning (a) to slightly inclined at the end (b) of the jet.
