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Anterior Urethral Valve in an Adolescent with Nocturnal Enuresis
Case Report Anterior Urethral Valve in an Adolescent with Nocturnal Enuresis Chia Chang Wu, Stephen Shei Dei Yang, and Yao Chou Tsai The anterior urethral valve (AUV) is a rare congenital urethral anomaly that can lead to variable urinary tract symptoms. We report on a 13-year-old boy with AUV who was referred from a primary care physician for nocturnal enuresis. AUV was disclosed by videourodynamic study and confirmed by simultaneous retrograde cystourethroscopy and antegrade urethroscopy. The AUV was ablated by neodymium:yttrium-aluminum-garnet contact laser at the 5-o’clock and 7-o’clock directions. A postoperative videourodynamic study depicted a patent urethra, a good maximal flow rate, and improved bladder capacity. His nocturnal enuresis had completely subsided at a follow-up period of longer than 24 months. UROLOGY 70: 1008.e13–1008.e15, 2007. © 2007 Elsevier Inc.
T
he anterior urethral valve (AUV) is a rare congenital urethral anomaly that can lead to variable urinary tract symptoms, depending on the patient’s age and the degree of obstruction. We present a case of AUV in an adolescent with refractory nocturnal enuresis.
CASE REPORT A 13-year-old boy was referred by his primary care physician for nocturnal enuresis. The nocturnal enuresis was refractory to behavioral modifications and medication with anticholinergics and desmopressin. On presentation, the boy complained of only mild objective lower urinary tract symptom such as urinary frequency. Routine urinalysis was normal. The patient had not undergone a previous urologic operation or noted any urinary tract infections, and renal ultrasonography did not reveal upper tract distension. The patient completed a 3-day bladder diary, which demonstrated a decreased functional bladder capacity of 200 mL and voiding interval of 1.5 to 2 hours. Uroflowmetry showed an obstructive flow pattern with a maximal flow rate of 10.1 mL/s. Suprapubic ultrasonography revealed a 20-mL postvoid residual urine volume. A videourodynamic study was arranged and disclosed a small, but compliant, bladder with an elevated detrusor pressure and maximal flow rate of 102 cm H2O. No detrusor overactivity was observed during the examination. Under fluoroscopy, a dilated proximal urethra with a point stenosis at the anterior urethra causing caliber discrepancy was clearly depicted (Fig. 1A). At surgery, a small, valve-like lesion was detected in From the Department of Urology, Buddhist Tzu Chi General Hospital, Taipei Branch; Department of Public Health, Taipei Medical University School of Medicine, Taipei; and Tzu Chi University Medical College, Hualien, Taiwan Reprint requests: Yao Chou Tsai, M.D., Department of Urology, Buddhist Tzu Chi General Hospital, Taipei Branch, 289 Jianguo Road, Xindian City, Taipei, Taiwan. E-mail: [email protected] Submitted: April 7, 2007; accepted (with revisions): August 15, 2007
© 2007 Elsevier Inc. All Rights Reserved
the anterior urethra by retrograde cystourethroscopy (Fig. 2A). The endoscopic finding was not compatible with what we had observed on preoperative fluoroscopy, which showed a point stenosis at the anterior urethra. Therefore, antegrade urethroscopy was performed by inserting an 8F flexible ureterorenoscope through the cystostomy tract to visualize the structure of the valve-like lesion and its mechanism of causing obstruction. Dynamic urethral obstruction induced by the valve was clearly visualized when normal saline irrigant flowed antegradely into the urethra (Fig. 2C). The valve was ablated using an neodymium:yttrium-aluminum-garnet contact laser retrogradely at the 5-o’clock and 7-o’clock directions. The cystostomy tract was closed soon after the operation, and a 14F Foley catheter was left in place for 3 days. Postoperative uroflowmetry showed a normal bellshaped flow pattern with an improved maximal flow rate of 18.5 mL/s. The follow-up videourodynamic study depicted a patent urethra with a detrusor pressure of 36 cm H2O and an enlarged bladder capacity of 350 mL (Fig. 1B). His urinary frequency improved objectively, and the bladder diary confirmed this improvement. The nocturnal enuresis had completely subsided at a follow-up period of longer than 24 months.
COMMENT AUV is a rare congenial urologic anomaly and is reported less frequently than the posterior variety. The reported consequences caused by AUV include urinary retention, incontinence, nocturnal enuresis, bladder rupture, and end-stage renal disease.1– 4 Firlit et al.5 classified the AUV into four classes, and the adolescent reported in the present study met the criteria for a type 1 AUV, with a demonstrable valve associated with proximal urethral distension. The severity of the urologic symptoms depends on the grade of urethral obstruction. A partial urethral obstruction caused by AUV might simply induce an irritative bladder and subsequent small functional 0090-4295/07/$32.00 1008.e13 doi:10.1016/j.urology.2007.08.033
dren with AUV might have only the symptoms of daytime urinary frequency and nocturnal enuresis. The AUV can be located anywhere distal to the membranous urethra (bulbar urethra 40%, penoscrotal junction 30%, and penile urethra 30%).1 In previous reports, voiding cystourethrography was the principal examination used for a bladder and urethra study.4,6 In the present report, we used a videourodynamic study to detect the anatomy of the urinary tract and the physiologic functions of the urinary bladder and pelvic floor. Thus, a definite diagnosis of the urethral anomaly and a quantitative measurement of the bladder volume were acquired. Zaontz and Gibbons7 advocated the advantages of antegrade incision for posterior urethral valves because a more precise physiologic and anatomic visualization of the valves could be obtained. In a series of 4 boys with an AUV, Takeda et al.8 performed antegrade urethroscopy using a 10.8F flexible ureterorenoscope through a cystostomy tract to assist in retrograde fulguration of the AUV. With the refinement of endourologic instruments, we used an 8F flexible ureterorenoscope to perform antegrade urethroscopy. Under antegrade irrigant flow, a check valve mechanism causing urethral obstruction was easily seen and recorded. To our knowledge, we have presented a set of pictures indicating a check valve mechanism that was not clearly demonstrated previously. Valve ablation can be performed using transurethral electrofulguration, cold knife, or neodymium:yttriumaluminum-garnet contact laser incision.3,8 –10 Electrofulguration might injure the urethra and result in extensive urethral fibrosis and stricture. We chose the neodymium: yttrium-aluminum-garnet contact laser to incise the urethral obstructive lesion, because it provides a precise incision, and the minimal depth of the energy penetration reduces the possibility of recurrent urethral stricture.9,10
CONCLUSIONS
Figure 1. (A) Fluoroscopy during videourodynamic study showing point stenosis (arrow) at anterior urethra with proximal urethral dilation. (B) Postoperative fluoroscopy revealed patent anterior urethra (arrow).
bladder capacity and nocturnal enuresis. Yamanishi et al.2 reported that partial urethral obstruction could lead to detrusor overactivity and some degree of sphincter decompensation, possibly predisposing the patient to urinary incontinence and nocturnal enuresis. Some of the children with such daytime voiding symptoms might adopt behavior modifications, for example, timed voiding, to avoid daytime urinary incontinence. Thus, chil-
1008.e14
Surgical relief of the obstructive AUV can improve the urinary flow rate and the obstruction-related lower urinary tract symptoms. Our patient was free of hypertonic bladder, a low urinary flow rate, and nocturnal enuresis after the operation. To diagnose postoperative urethral stricture early, long-term follow-up of the voiding parameters is mandatory. Acknowledgement. To Dr. Charles J. Wu and Ann Patrice Rinker, with thanks, for their assistance in grammar modification and encouragement during the writing of this article.
References 1. Khim A, Harris RD, and Raffel J: Anterior urethral valve presenting in an adult male. Urol Radiol 12: 196 –198, 1991. 2. Yamanishi T, Yasuda K, Hamano S, et al: Urethral obstruction in patients with nighttime wetting: urodynamic evaluation and outcome of surgical incision. Neurourol Urodyn 19: 241–248, 2000. 3. Obara W, Konda R, Seo T, et al: Neonatal abdominal wall urinoma due to rupture of anterior urethral diverticulum. Int J Urol 13: 395–396, 2006.
UROLOGY 70 (5), 2007
Figure 2. (A) Retrograde cystourethroscopy to visualize valvular lesion (arrows). (B) Antegrade urethroscopy to visualize valvular lesion. (C) Dynamic urethral obstruction of valve induced by antegrade irrigant flow.
4. Aygun C, Guven O, Ilteris M, et al: Anterior urethral valve as a cause of end-stage renal disease. Int J Urol 8: 141–143, 2001. 5. Firlit RS, Firlit CF, and King LR: Obstructing anterior urethral valves in children. J Urol 119: 819 – 821, 1978. 6. Lo WC, Wang CR, and Lim KE: Diagnosis of the congenital urethral anomalies of male child by voiding cystourethrography. Acta Paediatr Sin 40: 152–156, 1999. 7. Zaontz MR, and Gibbons MD: An antegrade technique for ablation of posterior urethral valves. J Urol 132: 982–984, 1984.
UROLOGY 70 (5), 2007
8. Takeda M, Katayama Y, Kawasaki, et al: Application of flexible renoureteroscope for antegrade urethroscopy in the treatment of congenital anterior urethral valve. Eur Urol 22: 190 –193, 1992. 9. Perkash I: Ablation of urethral strictures using contact chisel crystal firing neodymium:YAG laser. J Urol 157: 809 – 813, 1997. 10. Tsai YC, Yang SSD, and Wang CC: Neodymium:YAG laser incision of congenital obstructive posterior urethral membrane in boys with urinary incontinence and low uroflow. J Formos Med Assoc 103: 872– 875, 2004.
1008.e15
T
he anterior urethral valve (AUV) is a rare congenital urethral anomaly that can lead to variable urinary tract symptoms, depending on the patient’s age and the degree of obstruction. We present a case of AUV in an adolescent with refractory nocturnal enuresis.
CASE REPORT A 13-year-old boy was referred by his primary care physician for nocturnal enuresis. The nocturnal enuresis was refractory to behavioral modifications and medication with anticholinergics and desmopressin. On presentation, the boy complained of only mild objective lower urinary tract symptom such as urinary frequency. Routine urinalysis was normal. The patient had not undergone a previous urologic operation or noted any urinary tract infections, and renal ultrasonography did not reveal upper tract distension. The patient completed a 3-day bladder diary, which demonstrated a decreased functional bladder capacity of 200 mL and voiding interval of 1.5 to 2 hours. Uroflowmetry showed an obstructive flow pattern with a maximal flow rate of 10.1 mL/s. Suprapubic ultrasonography revealed a 20-mL postvoid residual urine volume. A videourodynamic study was arranged and disclosed a small, but compliant, bladder with an elevated detrusor pressure and maximal flow rate of 102 cm H2O. No detrusor overactivity was observed during the examination. Under fluoroscopy, a dilated proximal urethra with a point stenosis at the anterior urethra causing caliber discrepancy was clearly depicted (Fig. 1A). At surgery, a small, valve-like lesion was detected in From the Department of Urology, Buddhist Tzu Chi General Hospital, Taipei Branch; Department of Public Health, Taipei Medical University School of Medicine, Taipei; and Tzu Chi University Medical College, Hualien, Taiwan Reprint requests: Yao Chou Tsai, M.D., Department of Urology, Buddhist Tzu Chi General Hospital, Taipei Branch, 289 Jianguo Road, Xindian City, Taipei, Taiwan. E-mail: [email protected] Submitted: April 7, 2007; accepted (with revisions): August 15, 2007
© 2007 Elsevier Inc. All Rights Reserved
the anterior urethra by retrograde cystourethroscopy (Fig. 2A). The endoscopic finding was not compatible with what we had observed on preoperative fluoroscopy, which showed a point stenosis at the anterior urethra. Therefore, antegrade urethroscopy was performed by inserting an 8F flexible ureterorenoscope through the cystostomy tract to visualize the structure of the valve-like lesion and its mechanism of causing obstruction. Dynamic urethral obstruction induced by the valve was clearly visualized when normal saline irrigant flowed antegradely into the urethra (Fig. 2C). The valve was ablated using an neodymium:yttrium-aluminum-garnet contact laser retrogradely at the 5-o’clock and 7-o’clock directions. The cystostomy tract was closed soon after the operation, and a 14F Foley catheter was left in place for 3 days. Postoperative uroflowmetry showed a normal bellshaped flow pattern with an improved maximal flow rate of 18.5 mL/s. The follow-up videourodynamic study depicted a patent urethra with a detrusor pressure of 36 cm H2O and an enlarged bladder capacity of 350 mL (Fig. 1B). His urinary frequency improved objectively, and the bladder diary confirmed this improvement. The nocturnal enuresis had completely subsided at a follow-up period of longer than 24 months.
COMMENT AUV is a rare congenial urologic anomaly and is reported less frequently than the posterior variety. The reported consequences caused by AUV include urinary retention, incontinence, nocturnal enuresis, bladder rupture, and end-stage renal disease.1– 4 Firlit et al.5 classified the AUV into four classes, and the adolescent reported in the present study met the criteria for a type 1 AUV, with a demonstrable valve associated with proximal urethral distension. The severity of the urologic symptoms depends on the grade of urethral obstruction. A partial urethral obstruction caused by AUV might simply induce an irritative bladder and subsequent small functional 0090-4295/07/$32.00 1008.e13 doi:10.1016/j.urology.2007.08.033
dren with AUV might have only the symptoms of daytime urinary frequency and nocturnal enuresis. The AUV can be located anywhere distal to the membranous urethra (bulbar urethra 40%, penoscrotal junction 30%, and penile urethra 30%).1 In previous reports, voiding cystourethrography was the principal examination used for a bladder and urethra study.4,6 In the present report, we used a videourodynamic study to detect the anatomy of the urinary tract and the physiologic functions of the urinary bladder and pelvic floor. Thus, a definite diagnosis of the urethral anomaly and a quantitative measurement of the bladder volume were acquired. Zaontz and Gibbons7 advocated the advantages of antegrade incision for posterior urethral valves because a more precise physiologic and anatomic visualization of the valves could be obtained. In a series of 4 boys with an AUV, Takeda et al.8 performed antegrade urethroscopy using a 10.8F flexible ureterorenoscope through a cystostomy tract to assist in retrograde fulguration of the AUV. With the refinement of endourologic instruments, we used an 8F flexible ureterorenoscope to perform antegrade urethroscopy. Under antegrade irrigant flow, a check valve mechanism causing urethral obstruction was easily seen and recorded. To our knowledge, we have presented a set of pictures indicating a check valve mechanism that was not clearly demonstrated previously. Valve ablation can be performed using transurethral electrofulguration, cold knife, or neodymium:yttriumaluminum-garnet contact laser incision.3,8 –10 Electrofulguration might injure the urethra and result in extensive urethral fibrosis and stricture. We chose the neodymium: yttrium-aluminum-garnet contact laser to incise the urethral obstructive lesion, because it provides a precise incision, and the minimal depth of the energy penetration reduces the possibility of recurrent urethral stricture.9,10
CONCLUSIONS
Figure 1. (A) Fluoroscopy during videourodynamic study showing point stenosis (arrow) at anterior urethra with proximal urethral dilation. (B) Postoperative fluoroscopy revealed patent anterior urethra (arrow).
bladder capacity and nocturnal enuresis. Yamanishi et al.2 reported that partial urethral obstruction could lead to detrusor overactivity and some degree of sphincter decompensation, possibly predisposing the patient to urinary incontinence and nocturnal enuresis. Some of the children with such daytime voiding symptoms might adopt behavior modifications, for example, timed voiding, to avoid daytime urinary incontinence. Thus, chil-
1008.e14
Surgical relief of the obstructive AUV can improve the urinary flow rate and the obstruction-related lower urinary tract symptoms. Our patient was free of hypertonic bladder, a low urinary flow rate, and nocturnal enuresis after the operation. To diagnose postoperative urethral stricture early, long-term follow-up of the voiding parameters is mandatory. Acknowledgement. To Dr. Charles J. Wu and Ann Patrice Rinker, with thanks, for their assistance in grammar modification and encouragement during the writing of this article.
References 1. Khim A, Harris RD, and Raffel J: Anterior urethral valve presenting in an adult male. Urol Radiol 12: 196 –198, 1991. 2. Yamanishi T, Yasuda K, Hamano S, et al: Urethral obstruction in patients with nighttime wetting: urodynamic evaluation and outcome of surgical incision. Neurourol Urodyn 19: 241–248, 2000. 3. Obara W, Konda R, Seo T, et al: Neonatal abdominal wall urinoma due to rupture of anterior urethral diverticulum. Int J Urol 13: 395–396, 2006.
UROLOGY 70 (5), 2007
Figure 2. (A) Retrograde cystourethroscopy to visualize valvular lesion (arrows). (B) Antegrade urethroscopy to visualize valvular lesion. (C) Dynamic urethral obstruction of valve induced by antegrade irrigant flow.
4. Aygun C, Guven O, Ilteris M, et al: Anterior urethral valve as a cause of end-stage renal disease. Int J Urol 8: 141–143, 2001. 5. Firlit RS, Firlit CF, and King LR: Obstructing anterior urethral valves in children. J Urol 119: 819 – 821, 1978. 6. Lo WC, Wang CR, and Lim KE: Diagnosis of the congenital urethral anomalies of male child by voiding cystourethrography. Acta Paediatr Sin 40: 152–156, 1999. 7. Zaontz MR, and Gibbons MD: An antegrade technique for ablation of posterior urethral valves. J Urol 132: 982–984, 1984.
UROLOGY 70 (5), 2007
8. Takeda M, Katayama Y, Kawasaki, et al: Application of flexible renoureteroscope for antegrade urethroscopy in the treatment of congenital anterior urethral valve. Eur Urol 22: 190 –193, 1992. 9. Perkash I: Ablation of urethral strictures using contact chisel crystal firing neodymium:YAG laser. J Urol 157: 809 – 813, 1997. 10. Tsai YC, Yang SSD, and Wang CC: Neodymium:YAG laser incision of congenital obstructive posterior urethral membrane in boys with urinary incontinence and low uroflow. J Formos Med Assoc 103: 872– 875, 2004.
1008.e15