Does Voiding Cystourethrogram Exclude Posterior Urethral Valves in Late Presenting Cases?

Abstract

Introduction Delayed presentation of posterior urethral valves (PUVs) is a rare condition. Presentation and diagnosis of the patients with late PUVs are challenging. Voiding cystourethrogram (VCUG) is mainly practiced. In this study, we aimed to evaluate the children with late-presented PUVs, and the reliability of VCUG in this group. Materials and Methods Between January 2003 and December 2017 records of patients who were diagnosed with late-presented PUVs were analyzed. Delayed presentation of PUV was defined as patients who were diagnosed and treated after infancy. Cases were examined in terms of age at diagnosis, presenting symptoms, urinalysis, urinary ultrasound, urodynamic studies, VCUG, and dimercaptosuccinic acid scintigraphy findings. Postoperative follow-up conditions were also assessed. Results Seventeen boys were diagnosed with late-presented PUVs (mean age was 7.35 years). The most common symptoms at presentation were frequency (58.8%), day and nighttime incontinence (47%), and febrile urinary infection (41%). PUV was noted by VCUG in 10 patients alone. The classical sign of dilated posterior urethra was detected in 9 patients. The 10th patient had posterior urethral irregularity. Urethra could not be evaluated due to unsuccessful voiding in one patient. Six patients had normally appearing urethra on VCUG. Reflux was detected in nine (52.9%) patients. Conclusion Late-presented PUVs may be missed on VCUG. Whether a PUV might be present is crucial in boys with a history of recurrent urinary infection, persistent reflux, and repetitive daytime incontinence. Based on our results, we conclude that cystoscopic examination should be preferred for those cases to diagnose PUVs regardless of VCUG results.

<p>Is Endoscopic Transurethral Incision Really Effective for Boys with Refractory Daytime Incontinence?</p>

“…Previous studies suggested that boys treated for PUV had improved urinary symptoms of DUI and NE. [3][4][5][6][7][8][9][10][11] However, in the present study, only two boys (17%) achieved daytime continence at 6 months after TUI and no boy was cured of NE at 6 months after TUI. Nakamura divided boys with PUV into two groups before TUI: those with a synergic pattern on urodynamics with a quiet electromyogram during filling and those with a dyssynergic pattern with increased electromyogram activity as the bladder filled.…”

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

“…6 Infants and older children with delayed presentations of urethral valves may present with recurrent urinary tract infections, poor urinary stream, urinary frequency, nocturnal enuresis, urinary incontinence, anemia, and voiding pain or dysfunction. 2,[4][5][6][7]9,11,15,17 In Odetunde and colleagues' study of 21 patients with late presentation of PUVs, the median age was 3 years (2 days-13 years), and the mean duration of symptoms before presentation was 2.6 years. 18 Nineteen (91%) patients presented with urosepsis, while 8 (36%) patients presented with significant renal insufficiency.…”

An Unusual Urological Manifestation of Williams-Beuren Syndrome: Posterior Urethral Valve

“…While a few reports identify delayed presentation as a risk factor for poor renal function, others suggest that late presenting valves have good prognosis in terms of better recovery of lower urinary tract symptoms in the absence of hydroureteronephrosis. Eventually, there is a controversy about the prognosis of children with late presenting PUVs [11, 12]. The initial symptoms of delayed presentation of obstruction are age-dependent and nonspecific, and differ from those of early diagnosed PUVs [12].…”

“…Eventually, there is a controversy about the prognosis of children with late presenting PUVs [11, 12]. The initial symptoms of delayed presentation of obstruction are age-dependent and nonspecific, and differ from those of early diagnosed PUVs [12]. In this case, because of the absence of PUV based on the previous cystoscopy finding in a different clinic, the case was diagnosed as non-neurogenic neurogenic bladder and followed up.…”

“…Although a proposed standard procedure for the diagnosis of urethral obstruction does not exist, worldwide, a normal-appearing posterior urethra in VCUG is widely accepted to exclude PUV in children [12]. The patient could not be diagnosed with congenital PUV defect until he was 12 years old, so the renal parenchyma had become thinner with years due to reflux.…”