POSTERIOR URETHRAL VALVES PRESENTING AS VENOUS OBSTRUCTION HOWARD BAUCHNER, M . D . WILLIAM CRANLEY, M.D. ROBERT VINCI, M.D.
From the Departments of Pediatrics and Radiology, Boston City Hospital, Boston, Massachusetts
ABSTRACT--A patient with posterior urethral valves presented with unilateral lower leg ecchymosis and edema. He initially had significant renal Junction impairment. The ecchymosis and edema resolved after appropriate therapy, and his renal ]unction returned to normal.
valves (PUV) are congenital clinical presentation of which The spectrum of presenting ms include abdominal mass, ~tion, failure to thrive, inconemia, and renal failure, x-3We ~r a neonate who presented veiling of his right leg due to by venous obstruction. ~ase Report ld black male was seen in the tcy room with a swollen right 200 g male infant born to a gravida 3 female, by spontavery. The Apgar score was 6 at at five minutes. The child was tnated at both four and nine and was discharged from the ~ys of age. He remained well ,ly two hours prior to his preslergency room, at which time that his right leg v~as swollen discoloration. There was no ~, lethargy, fever, change in :equency or the "stream of wet diaper one hour prior to of his swollen leg. amination revealed a well-delrished, vigorous, alert male
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VOLUME XXXVIII, NUMBER 1
in no apparent distress. The temperature was 37.5°C, pulse 128, respiratory rate 56, and weight 3.6 kg. The right leg was mottled, swollen, ecchymotic, and slightly cool with normal femoral, posterior tibial, and dorsalis pedis pulses. There was an obvious discrepancy between the size of his legs (Fig. 1). On abdominal examination the bladder was easily palpated and both kidneys were thought to be significantly enlarged. Laboratory data showed a hematocrit of 33.7 and a leukocyte count of 20,O00/mm 3, with 3 percent bands and 65 percent polymorphonuclear cells. The urine obtained by catheterization was remarkable for albumin (1 ÷), glucose (3 ÷), 40-50 red blood cells per high-powered field (hpf) and 8-10 white blood cells/hpf. There were no casts or bacteria seen. Serum chemistries were sodium 126 mEq/L, potassium 6.3 mEq/L, chloride 101 mEq/L, carbon dioxide 12 mEq/L, creatinine 9.4 mg/100 mL, and blood urea nitrogen (BUN) 79 mg/100 mL. Blood gas showed a pH of 7.24, pCO2 of 34 torr and a pO2 of 94 tort. The urine culture was sterile. A plain film of the abdomen revealed bilateral retroperitoneal masses, the renal ultrasound demonstrated bilateral moderate to marked hydronephrosis with a mildly distended bladder, and the voiding cystourethrogram
57
showed PUV with grade V reflux on the right with no reflux on the left (Fig. 2). Evaluation by the vascular surgery service showed no evidence of arterial occlusion, but plethysmography revealed diminished respiratory variation of the right femoral venous flow consistent with iliac or femoral vein obstruction.
A Foley catheter was placed during the void ing cystourethrogram (VCUG) and left in plae for drainage. The child was stabilized durin~ the next forty-eight hours with careful attentiol to his fluid a n d electrolyte status. Withil twenty-four hours his right leg had become les mottled, less ecchymotic, and diminished in cit cumference. Two days after admission he wa taken to the operating room w h e r e he undei w e n t fulguration of his PUV with dilatation c the urethra. W h e n discharged on the fore teenth hospital day, he was a healthy-appearin male with a normal right lower extremity. Hi BUN was 5 mg/100 m L and creatinine 0.6 m~ 100 mL. Comment I n c r e a s e d venous pressure and edema secondary to urinary retentio attributed to overdistention of the adults with bladder outlet obstruetJ hypertrophied prostate, 4 and in eas( of the bladder with massive urinary Hopkins, Mattens, and Pierce 6 pert nous pressure measurements in a se tients with normal and elevated blac ities. In each patient with lower these investigators found a m a r k e d femoral venous pressure with disten bladder and a return to normal pr( urinary drainage. Since the original description ( 1919, 7 a n u m b e r of reviews note the
FmU~E 1. Both legs projected simultaneously demonstrate clinically apparent size discrepancy. Edema of superficial soft tissues on right can be identified.
FIGURE 2. (A) Posterior urethral valves (curved arrows) with distended bladder (B') distended prostatic urethra (P), and nondistended urethra distal to level of valves. (B) Large bladder, grade 5 reflux on right side and residual contrast at base of bladder in prostatic urethra proximal to valves.
B'
p
:~
k_ A J~
58
UROLOGY / JULY 1991
VOLUME XXXVlII, NUMBElt[I!~
)oth the age and the manner of ff PUV. However, w e were able to other patient w i t h venous obm presenting sign of PUV. 8 struction is an u n c o m m o n present', despite the frequency of assoion of the bladder. However, as lemonstrates, the anatomic reladistended bladder and iliac veins 9struction can occur. P U V should in the differential diagnosis of an esents with evidence of venous oble leg. Boston, M a s s a c h u s e t t s 02118 (DR. V I N C I )
i
Referenees 1. Williams DI, and Eckstein HB: Obstructive valves in the posterior urethra, J Urol 93:236 (1965). 2. Hendren WH: Posterior urethral valves in boys. A broad clinical spectrum, J Urol 106:298 (1971). 3. Cass AS, and Stephens FD: Posterior urethral valves: diagnosis and management, J Urol 112:519 (1974). 4. YoungTW, and Mitchell JP: Distension of the bladder leading to vascular compression and massive oedema, Br J Urol 48: 248 (1968). 5. Yaqin H: Distension of the bladder presenting as oedema of legs, Br Med J 4:369 (1968). 6. Hopkins WF, Mattens WA, andPiereeJM: Increased venous pressure and edema in the lower extremities secondary to urinary retention, Invest Urol 3:117 (1965). 7. Young HH, Frontz WA, and Baldwin ]C: Congenital obstruction of the posterior urethra, J Urol 3:289 (1919). 8. Carlsson E, and Garsten P: Compression of the common iliac vessels by dilatation of the bladder, Aeta Radiol 53:449 (1960).
59
From the Departments of Pediatrics and Radiology, Boston City Hospital, Boston, Massachusetts
ABSTRACT--A patient with posterior urethral valves presented with unilateral lower leg ecchymosis and edema. He initially had significant renal Junction impairment. The ecchymosis and edema resolved after appropriate therapy, and his renal ]unction returned to normal.
valves (PUV) are congenital clinical presentation of which The spectrum of presenting ms include abdominal mass, ~tion, failure to thrive, inconemia, and renal failure, x-3We ~r a neonate who presented veiling of his right leg due to by venous obstruction. ~ase Report ld black male was seen in the tcy room with a swollen right 200 g male infant born to a gravida 3 female, by spontavery. The Apgar score was 6 at at five minutes. The child was tnated at both four and nine and was discharged from the ~ys of age. He remained well ,ly two hours prior to his preslergency room, at which time that his right leg v~as swollen discoloration. There was no ~, lethargy, fever, change in :equency or the "stream of wet diaper one hour prior to of his swollen leg. amination revealed a well-delrished, vigorous, alert male
t991
/
VOLUME XXXVIII, NUMBER 1
in no apparent distress. The temperature was 37.5°C, pulse 128, respiratory rate 56, and weight 3.6 kg. The right leg was mottled, swollen, ecchymotic, and slightly cool with normal femoral, posterior tibial, and dorsalis pedis pulses. There was an obvious discrepancy between the size of his legs (Fig. 1). On abdominal examination the bladder was easily palpated and both kidneys were thought to be significantly enlarged. Laboratory data showed a hematocrit of 33.7 and a leukocyte count of 20,O00/mm 3, with 3 percent bands and 65 percent polymorphonuclear cells. The urine obtained by catheterization was remarkable for albumin (1 ÷), glucose (3 ÷), 40-50 red blood cells per high-powered field (hpf) and 8-10 white blood cells/hpf. There were no casts or bacteria seen. Serum chemistries were sodium 126 mEq/L, potassium 6.3 mEq/L, chloride 101 mEq/L, carbon dioxide 12 mEq/L, creatinine 9.4 mg/100 mL, and blood urea nitrogen (BUN) 79 mg/100 mL. Blood gas showed a pH of 7.24, pCO2 of 34 torr and a pO2 of 94 tort. The urine culture was sterile. A plain film of the abdomen revealed bilateral retroperitoneal masses, the renal ultrasound demonstrated bilateral moderate to marked hydronephrosis with a mildly distended bladder, and the voiding cystourethrogram
57
showed PUV with grade V reflux on the right with no reflux on the left (Fig. 2). Evaluation by the vascular surgery service showed no evidence of arterial occlusion, but plethysmography revealed diminished respiratory variation of the right femoral venous flow consistent with iliac or femoral vein obstruction.
A Foley catheter was placed during the void ing cystourethrogram (VCUG) and left in plae for drainage. The child was stabilized durin~ the next forty-eight hours with careful attentiol to his fluid a n d electrolyte status. Withil twenty-four hours his right leg had become les mottled, less ecchymotic, and diminished in cit cumference. Two days after admission he wa taken to the operating room w h e r e he undei w e n t fulguration of his PUV with dilatation c the urethra. W h e n discharged on the fore teenth hospital day, he was a healthy-appearin male with a normal right lower extremity. Hi BUN was 5 mg/100 m L and creatinine 0.6 m~ 100 mL. Comment I n c r e a s e d venous pressure and edema secondary to urinary retentio attributed to overdistention of the adults with bladder outlet obstruetJ hypertrophied prostate, 4 and in eas( of the bladder with massive urinary Hopkins, Mattens, and Pierce 6 pert nous pressure measurements in a se tients with normal and elevated blac ities. In each patient with lower these investigators found a m a r k e d femoral venous pressure with disten bladder and a return to normal pr( urinary drainage. Since the original description ( 1919, 7 a n u m b e r of reviews note the
FmU~E 1. Both legs projected simultaneously demonstrate clinically apparent size discrepancy. Edema of superficial soft tissues on right can be identified.
FIGURE 2. (A) Posterior urethral valves (curved arrows) with distended bladder (B') distended prostatic urethra (P), and nondistended urethra distal to level of valves. (B) Large bladder, grade 5 reflux on right side and residual contrast at base of bladder in prostatic urethra proximal to valves.
B'
p
:~
k_ A J~
58
UROLOGY / JULY 1991
VOLUME XXXVlII, NUMBElt[I!~
)oth the age and the manner of ff PUV. However, w e were able to other patient w i t h venous obm presenting sign of PUV. 8 struction is an u n c o m m o n present', despite the frequency of assoion of the bladder. However, as lemonstrates, the anatomic reladistended bladder and iliac veins 9struction can occur. P U V should in the differential diagnosis of an esents with evidence of venous oble leg. Boston, M a s s a c h u s e t t s 02118 (DR. V I N C I )
i
Referenees 1. Williams DI, and Eckstein HB: Obstructive valves in the posterior urethra, J Urol 93:236 (1965). 2. Hendren WH: Posterior urethral valves in boys. A broad clinical spectrum, J Urol 106:298 (1971). 3. Cass AS, and Stephens FD: Posterior urethral valves: diagnosis and management, J Urol 112:519 (1974). 4. YoungTW, and Mitchell JP: Distension of the bladder leading to vascular compression and massive oedema, Br J Urol 48: 248 (1968). 5. Yaqin H: Distension of the bladder presenting as oedema of legs, Br Med J 4:369 (1968). 6. Hopkins WF, Mattens WA, andPiereeJM: Increased venous pressure and edema in the lower extremities secondary to urinary retention, Invest Urol 3:117 (1965). 7. Young HH, Frontz WA, and Baldwin ]C: Congenital obstruction of the posterior urethra, J Urol 3:289 (1919). 8. Carlsson E, and Garsten P: Compression of the common iliac vessels by dilatation of the bladder, Aeta Radiol 53:449 (1960).
59
