Anterior and posterior urethral valves: a rare association

doi:10.4236/ojped.2011.13009

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Open Journal of Pediatrics, 2011, 1, 34-36

doi:10.4236/ojped.2011.13009 Published Online September 2011 (http://www.SciRP.org/journal/ojped/ OJPed

Published Online September 2011 in SciR es. http://www.scirp.org/journal/OJPed

Anterior and posterior urethral valves: a rare association

Sahnoun Lassaad1*, Lamiri Rachida1, Ben Saad Manel1, Salem Randa2, Mekki Mongi1,

Maazoun Kais1, Krichene Imed1, Jamila Chahed1, Nouri Abdellatif1

1Department of Pediatric Surgery, Fattouma Bourguiba Hospital, Monastir, Tunisia;

2Department of Radiology, Fattouma Bourguiba Hospital, Monastir , Tunisia.

Email: *[email protected]

Received 7 May 2011; revised 15 June 2011; accepted 22 July 2011.

ABSTRACT

Association of anterior and posterior urethral valve is

a rare congenital anomaly causing lower urinary

tract obstruction in children. This paper highlights

our experience with a two-month-old boy with double

urethral valves. Antenatal ultrasonography failed to

detect any abnormality. At the age of 1 month, he

presented with urinary dribbling, straining at mic-

turition, and febrile urinary tract infection. Clinically,

the urethra was dilated at micturition. Diagnosis was

confirmed by retrograde urethrogram and urethro-

scopy. Endoscopic ablation of both valves was done

by electrocautery hook.

Keywords: Anterior Urethral Valve; Posterior Urethral

Va lve; Renal Disorders; Double Infravesical Obstruction

1. INTRODUCTION

Posterior urethral valve (PUV) is the most common

cause of congenital obstructive uropathy in boys. How-

ever anterior urethral valve (AUV) is an uncommon

cause of a lower urinary tract obstruction. Association of

the two is extremely rare and only four cases have been

reported [1]. In this study, we describe our case.

2. CASE REPORT

A two-month-old boy with a history of febrile urinary

tract infection at the age of one month, was referred to

our department for evaluation of continuous dribbling of

urine and straining at micturition. Clinical examination

revealed a palpable bladder. The external genitalia were

normal. A swelling was palpable in the region of the

bulbar urethra. Urinalysis, urine culture, and renal func-

tion tests were normal. The catheterization was not suc-

cessful because the catheter did not pass through the

urethra. An anterior urethral valve or urethral diverticu-

lum was recognized.

Renal ultrasonography showed a thick walled bladder

without hydronephrosis (Figure 1).

A retrograde cysto-urethrogram revealed the double

infravesical obstruction and the dilated urethra sugges-

tive of concomitant anterior and posterior urethral valves.

The AUV was located at the bulbar urethra (Figure 2).

There was no vesicoureteral reflux.

With the patient under general anesthesia, an endo-

scopic ablation of both valves was done by electrocau-

tery hook. The bladder appeared trabeculated. An urinary

catheter was left in place.

Postoperatively, the patient was able to pass urine

with good stream and had normal stable renal function.

He was discharged 12 days after surgery.

Three months later, the patient presented with urinary

infection and dribbling. A renal ultrasou nd scan failed to

show any abnormality. On cystoscopy, there were obs-

Figure 1. Thic kened bl adder wal l.

S. Lassaad et al. / Open Journal of Pediatrics, 2011, 1, 34-36 35

Figure 2. Voiding cystography showing double obstruction and

urethral dilatation: (a) anterior urethral valve; there is a bul-

bous dilatation of the anterior urethra ending in a smooth bulge,

which marks the site of the AUV; (b) posterior urethral valve:

an elongated and dilated posterior urethra with abrupt nar-

rowing.

tructting anterior and posterior residual urethral valves.

An electrocautery hook was done to both the residual

valves.

The postoperative course was uneventful. The patient

is now 2 years old and continues to void with good

stream.

3. DISCUSSION

The association of anterior urethral valve (AUV) with

posterior urethral valve (PUV) is rare; only 4 cases have

been reported [1-3].

PUV is seven times more common than AUV; how-

ever, the obstructive effects of AUV can be equally dam-

aging.

The association of AUV and PUV could not be ex-

plained on an embryological basis as the source of AUV

and PUV development is different.

The etiology of AUV is still controversial, but faulty

union of the glandular and penile urethral segments, in-

complete formation of the corpus spongiosum, congeni-

tal cystic dilation of the periurethral glands, and abortive

attempt at urethral duplication have been proposed as

possible mechanisms [1,2,4].

AUV can be located anywhere distal to the membra-

nous urethra and, in terms of distribution; these valves

are most common in the bulbar urethra (40%) [1,2,5].

The clinical manifestation of AUV and PUV is highly

variable and depends on patient age and degree of ob-

struction. It may range from minimal obstruction to se-

vere obstruction with bilateral severe hydroureteroneph-

rosis, end-stage renal disease, and even bladder rupture

[1,2,6,7]. Physical examination fin di n gs ca n be no rmal.

Prenatal ultraso nography may sug gest the diagnosis of

AUV and PUV through visualization of urethral dilata-

tion and hydronephrosis, oligohydramnios and bladder

distension highly suggestive of infravesical obstruction.

(a) In our case, the antenatal and the postnatal ultrasono-

graphy were normal probably because the obstruction was

not complete.

(b)

Cystourethrography is the mainstay of the diagnosis.

It can reveal a thickened trabeculated bladder, a dilated

or elongated posterior urethra, a dilation of the anterior

urethra, and a hypertrophied bladder neck. Diverticula

and vesicoureteral reflux may also be present .

The spectrum of severity of AUV ranges from mild

urethral dilatation to bilateral hydronephrosis with renal

insufficiency (Figure 3) [8,9].

Figure 3. The four types of AUV.

S. Lassaad et al. / Open Journal of Pediatrics, 2011, 1, 34-36

The simplest form is the type 1 like our case [5].

There are various treatment methods such as open ure-

throtomy and excision of the valve, segmental urethrec-

tomy of the valve-bearing area along with a primary end-

to-end anastomosis, cold disruption and transurethral

resection of the valve. But endoscopic valve ablation by

electrocautery has been the procedure of choice. In our

case the endoscopic resection gave good results after 6

months of follow up.

OJPed

4. CONCLUSIONS

Association of AUV and PUV is a rare entity generally

described in case reports. It can cause early proximal

urinary tract damage and renal failure if not intervened

in time. Transurethral resection is the treatment of choice.

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