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Anterior Urethral Valves: A Case Report
Vol. 100, .lub JJrinted in CJ:-'.A
THE'. JocnKAL 01<' °EROLOGY
Copyrigl1t @) 19G8 by The \Yilliams & VVilkins Co.
ANTERIOR URETHRAL VALVES: A CASE REPORT CHENG-YANG CHANG* fi'1·om /he Section of Urnlogy, Deparlrnenl of Surgery, Universily of Michigan Medical Center,
Ann Arbor, JI ichigan
Only 8 c-ases of anterior valve in the male urethra have been reported.H Another such case which has been recently obsern·d is the subject of thi,; report (fig. l). \Vith increasing utilization of the voiding cystourethrogram, anterior valves of the male urethra probably will be disc(l\'ered
These -valves are situated in the urethra. a.nd a.rise symm.etrically from the latf:ral urethral walls, extending from proximal to distal and fuse in the m.iclline, in a m.anner that has the gross appearance of vocal cords. Beyond tlw point of fusion the valves create a thin transverne membrane that is fused distally to the urethral floor forming an end-pouch in the urethra. The obstructing action is produced as in a flutter valn, by the ballooning of the valve into the urethral lumen during micturition (fig. 2). Chief symptoms and signs are voiding with a poor stream or without stream, sepsis, infected
Fm. 2. Drawing shows position of uret.hr,tl valve and meehanisrn of obstruction during micturition.
Fm. 1. Voiding cystourethrogram of 3½month-old boy demonstrates profile of anterior urethral valve including lineal filling defect, small calibrated distal urethra and dilatation of proximal urethra.
urine and enuresis. The parents' observation always an important clue of being strnpicious oi this disease. A correct diagnosis 111.ust. depend upon a voiding cystourethrogram. If the urine is not infected we usually do a voiding cystourethro. gram following excretory urography to eliminate catheterization. The young infant can be put on
more often. If this entity is kept in mind when a child presents with symptoms of obstruction, a correct diagnosis should be made without difficulty.
2 Hope, J. W., Jameson, P. J. and Michie, Diagnosis of anterior urethral valve by nrethrography: report of two cases. Radiology, 74: 798, 1960. 3 Waterhouse, K. and Scordamaglia, L. .J.: Anterior urethral valve: a rare cause of bilat.en1l hydronephrosis. J. Urol., 87: 556, HJ62. 4 Nesbit, R. :u. and Labardini, M. :\f.: Urethral valves in the male child. ,T. Urol., 96: 218, HJ(i(i.
Aecepted for publication July 10, 1967. * Current address: National Defense Medical Center, P. 0. Box 7432, Taipei, Taiwan, Republic of China. 1 Williams, D. I.: Urology in childhood. In: Encyclopedia of Urology. Edited by C. E. Alken, V. W. Dix, H. JV[. Weyrauch a.nd E. Wildbolz. Berlin: Springer-Verlag, 1[):58, vol. 15, pp. 81-86. 29
30
CHANG
the x-ray table with a cork block under one hip in order to obtain an oblique projection roentgenogram during urination. vVhen this technique is unsatisfactory a retrograde urethrocystogram should be done. Contrast medium is injected through a No. 8 French catheter and, when the bladder becomes distended, a voiding contraction
Fro. Ei. A, drawing of operative findings. B, excision of urethral valve.
Fra. 3. Excretory urogram shows left ureter dilatation and bladder trabeculation.
Fm. 6. One month postoperative voiding cystourethrogram demonstrates fully distended distal urethra and absence of previous filling defect.
Fm. 4. Operative inspection reveals urethral valve. Posterior wall of urethra has been opened.
causes voiding around the catheter which is quickly withdrawn. Continued voiding occurs and roentgen exposures are made. Vve have been successful in using this method in infants. The profile of an anterior urethral valve on the voiding cystourethrogram demonstrates dilatation of the
31
ANTERIOR URETHRAL VALVES
proximal portion of the urethra, a lineal filling defect which identifies the obstrncting valve and a cmall calibrated distal portion of the urethra. The value of endos1copy in the diagnosis of an anterior urethral valve in the male infant is limite(l by the small urethral caliber and by the fact that we ourselves have been unable to identity this type of valrn by endoscopy. Treatment is exploration of the suspicious portion of the urethra through a perineal incision a~ cle,;cribed by Nesbit and Labarclini. 4 Total excision of the urethral valve can be performed easil_1·. Pm,toperatiwly the patient is left on inrhwlling urethral catheter draiuage for 5 to 7 da_1·6 1Villiams csuggestecl u~ing periodic dilatation al'trr local excision to prevent stricture formation but we did not observe stricture formation in our case. Fulguration through endo~copy is not the treatn1ent of choice because of difficulty in recognizing anterior urethral valves and abo becau~e of the Rize of the infant's urethra. Early diagnosis and early treatment of anterior urethral valves in the infant are important. If the lesion is discovered before damage to the kidney ha~ occurred, the prognosis should be excellent. The operation itself is simple with low morbidity and no mortality. CASE REPORT
No. 1054222, a 3½-month-old boy, was aclmitt1cd to the university of Michiga11 Medical Center in January 1967 because his parents noticed that he voided "·ithout any stream. The infant had been hospitalized when he was 1 month olrl for the same reason, but excretory
urograms and a voiding cystourethrogra.m were inconclusive. Because of a. negative the infant was follmYed as an outpatient. A urinary 1,ract infection developed which responded to gantrisin; hmYever, the urinary stream did not improve. In December 1966 excretory urograms demonstrated dilatation of the left ureter and probable bladder trabeculation (fig. 3). The child was readmitted to the hospital frn further evaluation. Physical examinat,ion wa8 essentially negative; voiding withoLlt stream observed. Laboratory studies were within normal lin1its. The urine was negative for ~igns of i11. fection. A voiding cystourethrogram elem.on strated typical findings as,~ociated \Yith anterior urethral valves. On January 17 an exploratory under general anesthesia revealed typical anterior urethral valve, about 2.5 cm. long, located at the pendulous urethra just proximal to the peno· scrotal junction (figs. 4 and The valve was completely excised and the urethra was closed in layers. Indwelling urethral catheter drainage was instituted for 7 days. Follmving removal ol tlif, catheter the infant urinated with a forceful stream; he was discharged 9 One month later the boy was observed to void with a forceful stream. Urinalysis wa;; An excretory urogram and voiding gram demonstrated a fully distended distal urethra and absence of the previous filling defect (fig. 6). SUMMARY.
The ninth case of an anterior urethral valve ts reported with a brief discussion of the pathogen,". diagnosis, treatment and prognosis.
THE'. JocnKAL 01<' °EROLOGY
Copyrigl1t @) 19G8 by The \Yilliams & VVilkins Co.
ANTERIOR URETHRAL VALVES: A CASE REPORT CHENG-YANG CHANG* fi'1·om /he Section of Urnlogy, Deparlrnenl of Surgery, Universily of Michigan Medical Center,
Ann Arbor, JI ichigan
Only 8 c-ases of anterior valve in the male urethra have been reported.H Another such case which has been recently obsern·d is the subject of thi,; report (fig. l). \Vith increasing utilization of the voiding cystourethrogram, anterior valves of the male urethra probably will be disc(l\'ered
These -valves are situated in the urethra. a.nd a.rise symm.etrically from the latf:ral urethral walls, extending from proximal to distal and fuse in the m.iclline, in a m.anner that has the gross appearance of vocal cords. Beyond tlw point of fusion the valves create a thin transverne membrane that is fused distally to the urethral floor forming an end-pouch in the urethra. The obstructing action is produced as in a flutter valn, by the ballooning of the valve into the urethral lumen during micturition (fig. 2). Chief symptoms and signs are voiding with a poor stream or without stream, sepsis, infected
Fm. 2. Drawing shows position of uret.hr,tl valve and meehanisrn of obstruction during micturition.
Fm. 1. Voiding cystourethrogram of 3½month-old boy demonstrates profile of anterior urethral valve including lineal filling defect, small calibrated distal urethra and dilatation of proximal urethra.
urine and enuresis. The parents' observation always an important clue of being strnpicious oi this disease. A correct diagnosis 111.ust. depend upon a voiding cystourethrogram. If the urine is not infected we usually do a voiding cystourethro. gram following excretory urography to eliminate catheterization. The young infant can be put on
more often. If this entity is kept in mind when a child presents with symptoms of obstruction, a correct diagnosis should be made without difficulty.
2 Hope, J. W., Jameson, P. J. and Michie, Diagnosis of anterior urethral valve by nrethrography: report of two cases. Radiology, 74: 798, 1960. 3 Waterhouse, K. and Scordamaglia, L. .J.: Anterior urethral valve: a rare cause of bilat.en1l hydronephrosis. J. Urol., 87: 556, HJ62. 4 Nesbit, R. :u. and Labardini, M. :\f.: Urethral valves in the male child. ,T. Urol., 96: 218, HJ(i(i.
Aecepted for publication July 10, 1967. * Current address: National Defense Medical Center, P. 0. Box 7432, Taipei, Taiwan, Republic of China. 1 Williams, D. I.: Urology in childhood. In: Encyclopedia of Urology. Edited by C. E. Alken, V. W. Dix, H. JV[. Weyrauch a.nd E. Wildbolz. Berlin: Springer-Verlag, 1[):58, vol. 15, pp. 81-86. 29
30
CHANG
the x-ray table with a cork block under one hip in order to obtain an oblique projection roentgenogram during urination. vVhen this technique is unsatisfactory a retrograde urethrocystogram should be done. Contrast medium is injected through a No. 8 French catheter and, when the bladder becomes distended, a voiding contraction
Fro. Ei. A, drawing of operative findings. B, excision of urethral valve.
Fra. 3. Excretory urogram shows left ureter dilatation and bladder trabeculation.
Fm. 6. One month postoperative voiding cystourethrogram demonstrates fully distended distal urethra and absence of previous filling defect.
Fm. 4. Operative inspection reveals urethral valve. Posterior wall of urethra has been opened.
causes voiding around the catheter which is quickly withdrawn. Continued voiding occurs and roentgen exposures are made. Vve have been successful in using this method in infants. The profile of an anterior urethral valve on the voiding cystourethrogram demonstrates dilatation of the
31
ANTERIOR URETHRAL VALVES
proximal portion of the urethra, a lineal filling defect which identifies the obstrncting valve and a cmall calibrated distal portion of the urethra. The value of endos1copy in the diagnosis of an anterior urethral valve in the male infant is limite(l by the small urethral caliber and by the fact that we ourselves have been unable to identity this type of valrn by endoscopy. Treatment is exploration of the suspicious portion of the urethra through a perineal incision a~ cle,;cribed by Nesbit and Labarclini. 4 Total excision of the urethral valve can be performed easil_1·. Pm,toperatiwly the patient is left on inrhwlling urethral catheter draiuage for 5 to 7 da_1·6 1Villiams csuggestecl u~ing periodic dilatation al'trr local excision to prevent stricture formation but we did not observe stricture formation in our case. Fulguration through endo~copy is not the treatn1ent of choice because of difficulty in recognizing anterior urethral valves and abo becau~e of the Rize of the infant's urethra. Early diagnosis and early treatment of anterior urethral valves in the infant are important. If the lesion is discovered before damage to the kidney ha~ occurred, the prognosis should be excellent. The operation itself is simple with low morbidity and no mortality. CASE REPORT
No. 1054222, a 3½-month-old boy, was aclmitt1cd to the university of Michiga11 Medical Center in January 1967 because his parents noticed that he voided "·ithout any stream. The infant had been hospitalized when he was 1 month olrl for the same reason, but excretory
urograms and a voiding cystourethrogra.m were inconclusive. Because of a. negative the infant was follmYed as an outpatient. A urinary 1,ract infection developed which responded to gantrisin; hmYever, the urinary stream did not improve. In December 1966 excretory urograms demonstrated dilatation of the left ureter and probable bladder trabeculation (fig. 3). The child was readmitted to the hospital frn further evaluation. Physical examinat,ion wa8 essentially negative; voiding withoLlt stream observed. Laboratory studies were within normal lin1its. The urine was negative for ~igns of i11. fection. A voiding cystourethrogram elem.on strated typical findings as,~ociated \Yith anterior urethral valves. On January 17 an exploratory under general anesthesia revealed typical anterior urethral valve, about 2.5 cm. long, located at the pendulous urethra just proximal to the peno· scrotal junction (figs. 4 and The valve was completely excised and the urethra was closed in layers. Indwelling urethral catheter drainage was instituted for 7 days. Follmving removal ol tlif, catheter the infant urinated with a forceful stream; he was discharged 9 One month later the boy was observed to void with a forceful stream. Urinalysis wa;; An excretory urogram and voiding gram demonstrated a fully distended distal urethra and absence of the previous filling defect (fig. 6). SUMMARY.
The ninth case of an anterior urethral valve ts reported with a brief discussion of the pathogen,". diagnosis, treatment and prognosis.