Late presentation of posterior urethral valve: two case reports

Delayed Presentation of Urethral Valves: A Diagnosis That Should Be Suspected Despite a Normal Prenatal Ultrasound

Background. Congenital urethral obstruction occurs most frequently as a result of urethral valves. The diagnosis is usually confirmed pre- or neonatally. Though not ideal, delayed diagnosis can occur in childhood, adolescence, or adulthood. Despite a normal prenatal ultrasound, there may still be a delayed diagnosis of urethral valves. Methods. We present 4 patients with delayed diagnosis of posterior urethral valves (PUV) and 1 patient with delayed diagnosis of anterior urethral valves (AUV) who were evaluated by a pediatric urologist at our Institution. We determined the age and symptoms at presentation, physical examination, micturating cystourethrogram (MCU) findings prior to the valve ablation, renal function before and after valve ablation, type of valve ablation, and urine culture and sensitivity. The urological courses following urethral valve ablation including urodynamic study findings are described. Results. The median age at presentation was 33 months. All 5 patients presented with decreased urine output and urinary retention. All 5 patients underwent a MCU that demonstrated bladder trabeculations (3 cases), vesicoureteral reflux (3 cases), and bladder diverticula (2 cases). A urethral valve ablation was performed in all cases. Four patients underwent a renal function panel prior to this procedure, and their serum BUN/creatinine levels decreased 1 day postoperatively. Conclusion. Pediatricians should consider urethral valves as causing urethral obstruction although the prenatal ultrasound may be normal. Early diagnosis and prompt treatment of urethral valves may mitigate the potentially devastating morbidities such as renal failure, congestive heart failure, and respiratory distress that may ensue.

Posterior urethral valves: determinants of outcome in a developing country

AIM

This study aims to evaluate posterior urethral valve (PUV) in a developing country with focus on the profile of the disease, determinants of outcome and the challenges of management.

METHODS

Analysis of data collected prospectively from 31 patients managed for PUV at the University of Nigeria Teaching Hospital, Enugu from January 2008 to December 2009.

RESULTS

The median age at presentation was 2.5 years (range 2 weeks-15 years). Only two (6.5%) had pre-natal diagnosis. Twenty-six (83.9%) had one or more complications of the disease at presentation. The mean estimated glomerular filtration rate was 39.5 mL/min/1.73 m(2) (range 4.4-116.0). There was hydronephrosis involving 50 renal units, and vesicoureteral reflux involving 22 renal units. Eight cases required upper tract diversion and four required dialysis prior to definitive catheter ablation. After average follow-up of 12.6 months (range 3-22 months), 18 (58.1%) cases had clinical and radiological improvement, 9 (29%) had persisting poor renal function and 4 (12.9%) died from acute renal failure and end-stage renal disease. Associated pulmonary hypoplasia in neonates, presentation at adolescent age, bilateral vesicoureteral reflux and estimated glomerular filtration rate <10.0 at presentation adversely affected outcome. Delayed diagnosis, dearth of facilities and resource deficiency remain a challenge.

CONCLUSION

Significant cases of PUV present late with complications in our setting and have high morbidity and mortality. The poor outcome may be related to delayed diagnosis, poor renal function at presentation and poor renal support. Improving time to diagnosis and renal support may lead to better outcome.