Here’s an example of
posterior urethral valves.
This is a voiding
We have injected a dye into the bladder
and now we’ve had the child
pee while taking an x-ray.
Bear with me here because this might
be a confusing picture for you.
This child has a mega ureter,
a huge ureter as a result of
longstanding vesicoureteral reflux.
You can see along the top
that this huge ureter
is going into what is
really a distended bladder.
But the bladder needs to empty out in the
body and it will go through the urethra.
If you notice at the outlet of this
urethra, there is a little bit of a valve,
but then there is this dilatation
within the proximal urethra.
There are valves at the end of that.
This is not a true valve.
These are little flaps of tissue that
are essentially acting like valves
and preventing the urine from getting
out of the bladder particularly well,
so you see this distended bladder
and vesicoureteral reflux.
This problem is more prevalent in
infants who we call boys who dribble.
If you ask a parent who has had a baby
boy, what’s it like when you see them pee?
They’ll tell you, "He
sprays all over the place."
Most parents have been tagged with urine.
As they're changing the diaper, the
baby pees that can go all over them.
This is a problem but in weird
way it’s also consoling
because you can be pretty
confident that your
baby boy does not have
posterior urethral valves.
In babies with posterior urethral
valves, they can’t generate that stream
and the urine sort
of dribbles out.
And parents usually have noticed
this when you ask them.
These patients can have
They may present in the perinatal
period or shortly after birth
with a total urinary obstruction.
Those kids can be very sick
and they can develop peritonitis or
even death if it’s not intervened with.
Or it can present much later
on, say 5 years of age,
with recurrent UTIs and you
find that they had valves.
These patients generally will
have abdominal distention.
Their bellies will bloat
because of the giant bladder
but perhaps also because
of peritoneal involvement
and they will tend to
strain with urination.
So let’s look at how we would
diagnose a posterior urethral valve
if we suspected it.
Generally, we’ll start with
an abdominal ultrasound.
Here’s an ultrasound we can see,
and what you can see is this child
has a very thickened bladder wall.
That’s a key finding in these patients.
Alternatively, we could get
a voiding cystourethrogram
like the one we showed previously
that would show an outpouching
and you would also see that
thickened bladder wall.
The bladder wall is thickened because the
child has been straining against that valve
and it’s become a
more muscular organ.
For posterior urethral valves,
we’ll manage them by first correcting any
electrolyte problems that maybe present
and then we’ll generally
just place a Foley catheter.
Sometimes getting that catheter through
the first time can be problematic,
may cause some blood
and ironically, you could even fix the
problem by ripping through those valves.
But we have to place this Foley because
this child has to drain their urine.
Then later on or approximately,
we’ll do a cystoscopic repair.
We’ll call our urology colleagues to
come in and really fix the problem.
Afterwards, there’s a phenomenon
called a post-obstructive diuresis.
Patients who’ve had an
obstruction for a prolonged time
maybe excessively diuretic afterwards
so we have to take care of that.
These patients if they have
renal damage may need dialysis
or a transplant if there is
substantial damage done.
Let’s switch gears to another secondary
cause of vesicoureteral reflux.
This one is UPJ obstruction or
ureteropelvic junction obstruction.
As that ureter is coursing in
its retroperitoneal course
just over the pelvic
junction, it can kink.
This can cause a partial or total blockage
of the urinary flow along that ureter
and so the urine bounces
back up into the kidney.