8/10/2019 Posterior Urethral Valves Clinical Presentation: History, Physical Examination

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Posterior Urethral Valves Clinical

Presentation
Updated: May 09, 2018
Author: Martin David Bomalaski, MD, FAAP; Chief Editor: Marc Cendron, MD more...

PRESENTATION

History
Antenatal diagnosis
The widespread use of antenatal ultrasonography (US) has enabled diagnosis of posterior urethral
valves (PUVs) in many more individuals, with most cases of bladder outlet obstruction recognized in
the second and third trimester of gestation. The diagnosis is usually made before or at birth when a
boy is evaluated for antenatal hydronephrosis. Despite widespread use of antenatal US, some
patients with PUVs do present later in life (see below).

In 1989, Thomas reported that 10% of patients with antenatal hydronephrosis detected by US had
PUVs. [9] In a 1993 report, Dinneen et al reported the sensitivity of antenatal US to be only 45% in
detecting PUVs in 45 patients who presented when younger than 6 months. [10] With improvements in
technology, the sensitivity has increased over the last 10 years.

Patients who have PUVs that are not diagnosed on antenatal US and who do not present with overt
urinary pathology are at risk for delayed presentation of PUVs.

Delayed presentation

Indicators of possible PUVs later in childhood include the following [11] :

Urinary tract infection (UTI)

Diurnal enuresis in boys older than 5 years
Secondary diurnal enuresis
Voiding pain or dysfunction
Abnormal urinary stream

PUVs manifest along a spectrum of disease severity. The clinical significance of minivalves has been
debated. Some studies have indicated that the significance of minor radiographic narrowing in older
boys may be differentiated by means of urodynamic studies. Those with detrusor/sphincter
dyssynergy may have functional or nonanatomic obstruction, and those with detrusor/sphincter
synergy may have true anatomic obstruction that benefits from surgical incision. [12]

PUVs are sometimes discovered during evaluation of abdominal mass or renal failure.
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8/10/2019 Posterior Urethral Valves Clinical Presentation: History, Physical Examination

Incidental diagnosis

Hydronephrosis or proteinuria found on examination for unrelated conditions may be the first sign of
PUVs.

Physical Examination
Most patients with PUV have normal physical examination findings. When present, abnormal physical
findings are the result of severe renal insufficiency.

Neonates may present with severe pulmonary distress caused by lung underdevelopment lung due to
oligohydramnios. An appropriate volume of amniotic fluid (produced by the kidneys) is necessary for
complete and proper branching of the bronchial tree and alveoli. Physical findings can include the
following:

Poor fetal breathing movements

Small chest cavity
Abdominal mass (ascites)
Potter facies
Limb deformities (skin dimpling)
Indentation of the knees and elbows due to compression within the uterus

In older children, physical findings can include poor growth, hypertension, and lethargy. An intermittent
or weak urinary stream is an unreliable sign. A large lower abdominal mass may represent a markedly
distended urinary bladder.

Differential Diagnoses

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