Continuing Education Activity

Prune belly syndrome is a rare congenital disorder characterized by deficient abdominal musculature, bilateral cryptorchidism, and urinary tract abnormalities, often associated with significant multisystem complications. Clinician recognition remains variable, contributing to delayed diagnosis and inconsistent management. This activity reviews current evidence on prenatal detection, postnatal evaluation, and risk stratification across the spectrum of disease severity. Emphasis is placed on individualized management strategies, including surgical planning, monitoring renal and pulmonary function, and preventing long-term complications. Participants develop competence in identifying clinical features, coordinating longitudinal care, and providing family-centered counseling. Integration of interprofessional collaboration among clinicians, surgeons, nursing staff, and allied specialists supports comprehensive care, improves diagnostic accuracy, enhances continuity of management, and optimizes renal, reproductive, pulmonary, and developmental outcomes throughout the patient’s lifespan.

Objectives:

• Apply evidence-based approaches to the diagnosis and management of prune belly syndrome, integrating current literature on pathophysiology, severity spectrum, and long-term outcomes to guide clinical decision-making.
• Determine appropriate timing and indications for surgical interventions such as orchiopexy, urinary tract reconstruction, and abdominal wall repair.
• Implement evidence-based strategies for the prevention and management of urinary tract infections in patients with prune belly syndrome, including antibiotic prophylaxis, elective circumcision, and surveillance for progressive renal deterioration.
• Collaborate with neonatologists, pediatric urologists, nephrologists, pulmonologists, geneticists, and social workers to develop and implement a coordinated, family-centered care plan that addresses the multisystemic manifestations of prune belly syndrome across the patient's lifespan.

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Introduction

Prune belly syndrome (PBS), also referred to as Eagle-Barrett syndrome or the triad syndrome, is a rare congenital condition characterized by the triad of deficient abdominal musculature, bilateral cryptorchidism, and urinary tract abnormalities.[1][2] The name "prune belly" is derived from the hypoplastic abdominal wall, which resembles a dried prune.[3] Children born with this condition present a broad spectrum, ranging from incompatibility with life to a near-normal life. Perinatal mortality ranges between 10% and 25% and directly correlates with the severity of pulmonary hypoplasia, which occurs as a result of oligohydramnios from reduced fetal urine production, renal dysplasia, and urinary tract abnormalities leading to the Potter sequence.[4] The severity of renal dysplasia is the greatest determinant of survival and prognosis.[3]

Etiology

The exact etiology of PBS remains unknown, although several theories have been suggested.[5][6][7][8] One theory is the urethral obstruction-malformation complex, which proposes that a urethral obstruction during embryonic development produces bladder distension, which has secondary effects on the development of the urinary tract, abdominal wall, and testicular descent.[8] Other theories attribute PBS to a yolk sac defect or to a possible defect in the lateral plate mesoderm (which, embryologically, gives rise to the ureters, bladder, prostate, urethra, and gubernaculum).[7][9] 

Furthermore, the etiology of PBS could be multifactorial. Most cases of PBS are sporadic and have a normal karyotype.[10] A genetic abnormality has been suggested because a HNF1β mutation has been observed in approximately 3% of cases of prune belly syndrome, but the gene is usually functionally normal.[11] Some cases might be caused by mutations in genes that regulate genitourinary myogenesis in the embryonic phase.[10]

Epidemiology

PBS has a contemporary incidence of 3.8 per 100,000 live male births in the United States.[12] The condition predominantly affects boys, with fewer than 5% of cases occurring in girls.[3] Girls usually present with urinary tract abnormalities and an abdominal appearance characteristic of PBS.[13]

Pathophysiology

Male infants with PBS display bilateral cryptorchidism, with the testes lying intra-abdominally, adjacent to the dilated ureters at the level of the iliac arteries. The cause of the undescended testes is unknown.[3] Hydroureteronephrosis is almost always present and is mostly bilateral.[4]

The massive dilation of the ureters occurs at the distal level, but this finding is variable. The usual causes of hydroureteronephrosis include lower urinary tract obstruction (eg, posterior urethral valves), vesicoureteral reflux (VUR), a histologic deficiency of smooth muscle, and a preponderance of fibrous tissue in the ureters leading to ineffective peristalsis.[14] Interestingly, in PBS, there are more normal-appearing smooth muscle cells in the proximal ureter.[15]

Around 75% of patients with PBS have VUR, and it is bilateral in most cases.[4] Approximately half of patients have renal dysplasia with variable severity, and about 40% to 50% will require renal replacement therapy in the future.[16] Favorable prognostic indicators include at least 1 normal-appearing kidney on ultrasonography and a nadir serum creatinine level of less than 0.7 mg/dL during the first year of life.[4][17]

The severity of abdominal wall musculature deficiency is variable. Rare cases exhibit a complete absence of abdominal wall musculature, and the deficiency is often located in the lower abdomen. The rectus muscles and internal and external obliques are often less well developed, and in severe cases, skin, subcutaneous fat, and a single fibrous layer may be all that overlie the peritoneum. In addition to the characteristic triad, about 75% of children with PBS have abnormalities in other organ systems.[18] These abnormalities include respiratory tract (eg, pulmonary hypoplasia), cardiac (eg, patent ductus arteriosus, ventricular septal defect, atrial septal defect, and tetralogy of Fallot), gastrointestinal tract (eg, esophageal atresia, malrotation of the midgut, bowel atresia, and anorectal anomalies), and musculoskeletal defects (eg, scoliosis, talipes equinovarus, and hip dysplasia).[3][4][19]

History and Physical

The characteristic dried, prune-like, wrinkled appearance of the abdominal wall is the most notable physical finding and the reason for the name "prune belly syndrome." This abdominal finding is attributable to either deficient or absent abdominal musculature.[19] However, as children with prune belly syndrome grow, adipose tissue deposits in the subcutaneous layer of the abdominal wall, which diminishes the wrinkled appearance.

This change occurs gradually over the first year of life, when the abdomen begins to take on a more pot-bellied appearance due to a deficiency in the underlying musculature. Despite the deficiency in abdominal musculature, gait is usually not affected; however, motor milestones may be delayed. Additionally, many patients also have associated lordosis.[20] Apart from bilateral cryptorchidism in boys, other systemic findings may be present in the affected individuals depending on the extent of involvement of the respiratory, cardiac, gastrointestinal, and skeletal systems. In some girls with PBS, external genital structures cannot be clearly identified as male or female, requiring a karyotype analysis.[21]

Evaluation

During the second trimester of pregnancy, PBS may be suspected on prenatal ultrasonography screening.[19] Prenatal ultrasonography may indicate urinary tract abnormalities such as a distended bladder, dilated ureters, and hydronephrosis, and may also demonstrate a deficient or absent abdominal muscle wall. Severe cases can lead to oligohydramnios.[22] 

In infants with severe renal dysplasia, the resulting oligohydramnios can lead to pulmonary hypoplasia. These infants are either stillborn or die in the early neonatal period. Infants with pulmonary hypoplasia require aggressive neonatal resuscitation with respiratory support, including mechanical ventilation and respiratory management.

A chest radiograph will show small, underdeveloped, low-volume lungs in these cases. Postnatal workup should include a complete renal evaluation to assess renal function. Renal and bladder ultrasonography can evaluate the nature and severity of the urinary tract abnormalities.

An enlarged bladder with significant residual urine may be present. An early voiding cystourethrogram is also indicated to assess for VUR, evaluate the bladder outlet, and assess bladder emptying capacity. Wide bladder neck and urethral malformations (including dilated prostatic urethra) are also commonly noted on voiding cystourethrogram.[19] 

An early voiding cystourethrogram is also indicated to assess for VUR, evaluate the bladder outlet, and assess bladder emptying. Wide bladder neck and urethral malformations (including dilated prostatic urethra) are also commonly noted in voiding cystourethrogram.[23] Urodynamic studies may indicate poor detrusor contractility.[24] Computed tomography and technetium 99m dimethylsuccinic acid renal scanning can be performed for renal evaluation.[21] Echocardiography, abdominal radiography, and abdominal ultrasonography should be performed if the cardiac and gastrointestinal systems are affected.

Treatment / Management

Medical Treatment

Nearly 80% of patients born with PBS will have at least 1 urinary tract infection (UTI), and one-third of these patients will develop pyelonephritis.[4] The high likelihood of UTI is due to the comorbidities such as VUR, ureteral urinary stasis due to ineffective peristalsis, and poor bladder emptying. Urologists commonly recommend prophylactic antibiotics and elective circumcision to minimize the risk of UTIs.

Similarly, antibiotics are necessary before any urinary tract manipulation, including voiding cystourethrogram. Constipation is common in patients with prune belly syndrome due to the defective Valsalva maneuver required for defecation, which can predispose to UTIs as well.[20] The defective abdominal musculature leads to an ineffective cough and increases the risk of respiratory tract infections.[20] Patients with end-stage renal disease require renal replacement therapy. 

Surgical Treatment

Patients with PBS may undergo surgical procedures involving the testis, urinary tract, and abdominal wall, including:

• Orchiopexy
• Urinary tract reconstruction
• Abdominoplasty and abdominal wall reconstruction

The timing and sequence of these procedures vary among individuals based on the severity of urinary tract abnormalities and the presence of comorbidities. Orchiopexy is almost always indicated in PBS, and bilateral orchiopexy is recommended at an early age. A delayed orchiopexy can significantly worsen the prognosis, as in other cases of undescended testes.

In some cases, orchiopexy can be performed in conjunction with procedures such as abdominoplasty.[25] The optimal timing for the orchiopexy for the cryptorchid testis is by 18 months of age (American Urological Association). Performing orchiopexy in prepubertal boys at the time of cryptorchidism diagnosis confers clinical benefits.[26] Results from many studies recommend orchiopexy between 6 and 12 months of age.[27]

The timing for urinary tract reconstructive procedures varies among clinicians, and the decision should be based on the clinical severity.[28] Some centers advocate early intervention, believing that addressing urinary stasis and VUR may improve renal function.[28] Other centers recommend a delayed approach with close surveillance to improve urinary tract obstruction and renal function.[28] Urinary tract reconstructive procedures are strongly recommended in patients with recurrent febrile UTIs or progressive renal deterioration.

Abdominal wall reconstruction is necessary in patients with moderate-to-severe abdominal wall deficiencies. Abdominoplasty is usually performed in conjunction with other procedures, including orchiopexy, vesicostomy, or urinary tract reconstruction. Apart from cosmetic outcomes, abdominoplasty may improve muscle tone, which can aid in bladder emptying through an efficient Valsalva maneuver.[29] Additional procedures may be required based on systemic involvement (eg, scoliosis requiring corrective procedures).

Differential Diagnosis

The presence of the characteristic triad and the pathognomonic finding of abdominal wall involvement suggests the clinical diagnosis of prune belly syndrome. Clinicians must identify the severity and potential causes of urinary tract abnormalities and consider all other comorbid conditions associated with prune belly syndrome, beyond the characteristic triad. Prune belly syndrome should be differentiated from pseudo-PBS or megacystis–megaureter syndrome, in which patients have the typical urinary tract abnormalities but may have either normally placed testes (or unilateral cryptorchidism) or a normal abdominal wall (or partial and unilateral laxity).[3][30]

Prognosis

Children born with PBS present on a spectrum ranging from incompatibility with life to leading a normal, healthy life. Perinatal mortality ranges between 10% and 25% and correlates with the level of prematurity and severity of pulmonary hypoplasia as a direct result of urinary tract abnormalities.[4] About 40% of infants are born prematurely, and nearly half require mechanical ventilation at birth.[11] Most affected infants have normal cognition, but overall prognosis depends on the severity of renal and pulmonary dysfunction and other associated comorbidities.[10]

Woodard broadly classified patients with PBS into 3 clinical groups:

1. The first group (20%) includes infants with severe renal and pulmonary hypoplasia; most of these infants are either stillborn or die shortly after birth. An infant can present with the Potter sequence (micrognathia, flat nasal bridge, flat palpebral fissure, low-set ears, and prominent epicanthal fold), which is secondary to severe oligohydramnios.[25]
2. The second group (40%) includes infants with the full spectrum of PBS who have adequate renal function at birth. Due to significant renal abnormalities, renal function may deteriorate later in life from ongoing urinary tract obstruction or frequent UTIs requiring aggressive management.
3. The third group (40%) has the best prognosis, with mild urological abnormalities, normal renal function, and a near-normal quality of life.[31] 

Infertility in men with prune belly syndrome may be multifactorial, attributable to cryptorchidism, an incompetent bladder neck (leading to retrograde ejaculation), and prostatic hypoplasia. With advancements in management options such as orchiopexy (done in a timely fashion), sperm retrieval techniques, and intracytoplasmic sperm injection, many men with PBS can father children.[21][32] Azoospermia and oligospermia are found in 75.7% and 21.6% of patients with PBS, respectively, and assisted reproductive techniques can be beneficial in these cases.[33] 

Conversely, girls constitute only 5% of those with PBS, and they exhibit a deficiency of abdominal wall musculature and an anomalous urinary tract without any gonadal abnormality.[4] The published literature on PBS in women is limited. Reproductive tract abnormalities are uncommon, with fertility usually intact, and women with PBS have been reported to have normal pregnancies.[21][34] 

The prevalence of chronic kidney disease is variable (8% to 66%) in PBS, and many cases require primary renal transplant and adequate follow-up.[35] The outcomes after renal transplant are variable, but equivalent or improved in comparison to congenital kidney disease.[36] Timely diagnosis and treatment of patients with PBS can help delay the need for renal transplant or renal replacement therapy.[21]

Complications

Prune belly syndrome has multiorgan system manifestations and is associated with many potential complications. In severe cases, the complications of pulmonary hypoplasia and renal dysplasia predominate. These require management by an interdisciplinary team, including maternal-fetal medicine specialists, neonatologists, urologists, nephrologists, geneticists, pulmonologists, and respiratory therapists. Families should be thoroughly informed about the condition of the fetus (or infant) and receive counseling about the possible outcomes. Families should receive assistance with informed decisions, and the team of experienced specialists should address all relevant ethical considerations.

Beyond the neonatal period, urinary tract complications predominate, and about one-third of patients may eventually progress to require a renal transplant.[19] Results from a study of patients with prune belly syndrome showed that the presence of bilateral abnormal kidneys on imaging, a nadir creatinine level over 0.7 mg/dL, and pyelonephritis were poor prognostic factors.[17] Urological consultation for a thorough evaluation of urinary tract obstruction and prevention of further complications is necessary (eg, antibiotic prophylaxis and circumcision to prevent UTIs).

Deterrence and Patient Education

Patients and families should be educated on the following:

• The multifocal etiology of PBS means there are no antenatal preventive measures. 
• Parents should be educated about the involved systems and the varied spectrum of presentation in PBS.
• Timed orchidopexy is necessary to preserve testicular functions and prevent complications.
• Adequate follow-up to manage urinary abnormalities and renal dysfunction is essential.

Pearls and Other Issues

Infants born with PBS present on a spectrum ranging from incompatible with life to near-normal life. The care plan requires individualization based on the type and severity of the presentation. 

Enhancing Healthcare Team Outcomes

Prune belly syndrome is a condition with variable severity and multisystemic manifestations. An interprofessional team approach is the cornerstone of management. The role of the neonatologist or pediatrician is vital in navigating the early management and workup. Pediatric surgery and urology consultations are important to manage the classic triad of symptoms. Other specialists should be consulted (cardiology, orthopedic surgery, pulmonology, gastroenterology, pediatric surgery, cardiac surgery, nephrology) depending upon the systemic involvement.

In severe cases with poor prognoses, families should be thoroughly informed about the infant's condition. Families should be guided to make informed decisions, with all relevant ethical considerations addressed by the team of experienced specialists. Palliative care consultation may also be appropriate in select cases.

In patients with less-severe manifestations of PBS, parental education and support are important during the early perinatal period to ensure adequate follow-up and surgical planning. Timely orchiopexy is necessary to preserve testicular function and reduce the malignant potential, and abdominal wall reconstruction can be planned concurrently. Urinary tract reconstruction is usually avoided unless patients develop recurrent febrile urinary tract infections or demonstrate progressive renal deterioration.

Some children may need temporizing urologic interventions, such as a cutaneous vesicostomy, to safely drain the bladder while the infant grows, for more definitive procedures such as ureteral reconstruction and reimplantation at a later age. Families can also receive support from resources such as the Prune Belly Syndrome Network. Patients with PBS often require surgical procedures and are at higher risk of anesthetic complications because of a deficiency in abdominal wall musculature, which compromises cough effectiveness, potentially leading to retention of pulmonary secretions and subsequent pneumonia.

During hospitalizations, these patients should be closely monitored for the development of atelectasis. Outcomes can be improved by managing these patients with an interprofessional team maintaining close communication. Due to multisystem organ involvement, most patients require lifelong follow-up with a pediatrician, urologist, relevant specialists, and a social worker.

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Disclosure: Supriya Bisht declares no relevant financial relationships with ineligible companies.

Disclosure: Priyam Pattnaik declares no relevant financial relationships with ineligible companies.

Disclosure: Senthilkumar Sankararaman declares no relevant financial relationships with ineligible companies.