CASE REPORTS
OBSTRUCTING VALVES
POSTERIOR
URETHRAL
IN OCTOGENARIAN
PETER T. NIEH,
M.D.
W. HARDY HENDREN,
M.D.
From the Urological Service and Department of Pediatric Surgery, Massachusetts General Hospital, and the Department of Surgery, Harvard Medical School, Boston, Massachusetts
ABSTRACT-A unique case of bladder outlet obstruction secondary to posterior urethral valves in an octogenarian is presented.
Congenital posterior urethral valves are widely recognized as limited to the pediatric population. We present a unique case of obstructing urethral valves in an elderly man. Case Report An eighty-year-old white man had a twentyyear history of frequency every three to four hours and nocturia two to three times per night, but without hesitancy, noticeable decrease in force of stream, incontinence, suprapubic discomfort, or irritative symptoms. Several weeks earlier, an episode of gross total painless hematuria had occurred after a brief course of anticoagulant therapy for presumed thrombophlebitis. The anticoagulants were discontinued, and no further gross bleeding was noted. Physical examination was unremarkable except for a small right inguinal hernia and a benign-feeling 15-Gm. prostate. Analysis showed his urine to be loaded with red blood cells, urine cytology was negative, and all blood chemistries were within normal limits. An intravenous urogram demonstrated normal upper tracts, but a severely trabeculated bladder with large diverticula and large postvoid residual (Fig. 1). Cystourethroscopy revealed markedly enlarged type I posterior urethral valves, with well-defined circumferential attachments including an anterior fusion, 0.5 cm. proximal to the
412
FIGURE 1. Zntravenous pyelogram showing severely trabeculated bladder with multiple diverticula, increased residual urine, and minimal prostatic indentation.
UROLOGY
/ APRIL 1979 / VOLUME
XIII.
NUMBER 4
FIGURE 2. Urethroscopy with distended bladder: (A) view from external sphincter, with type 1 posterior urethral valves sweeping from verumontanum at 6 o’clock position; (B) another view from sphincter, with anterior fusion of valve leaflets at 12 o’clock position. (C) Urethroscopy after fulguration of left valve leaflet, revealing small lateral lobes. external sphincter (Fig. 2A, B). The prostatic lateral lobes were widely separated and nonhypertrophied, while the bladder neck was patulous. The bladder was markedly trabeculated with inflamed mucosa and blood clots within the diverticula. The urethral valves were fulgurated with the Bugbee electrode (Fig. 2C), and a Foley catheter was used overnight. Postoperatively, the patient has noted marked improvement in urinary stream, frequency, and nocturia. Comment Obstructing posterior urethral valves are generally detected in the pediatric population, with between 50 and 75 per cent diagnosed before valves five years of age. 1,2 Partially obstructing may be found in young adult males with chronic
UROLOGY
/
APRIL
1979
/
VOLUME
XIII,
NUMBER
4
prostatitis, and rarely in older males concurrently with prostatic hypertrophy. These valves are often incomplete or diaphanous membranes of questionable significance in the outlet obstruction. However, our elderly patient had outlet obstruction purely from urethral valves. This points out the importance of evaluating for posterior urethral valves in all patients, regardless of age. Massachusetts General Hospital Boston, Massachusetts 02114 (DR. NIEH) References 1. Cass AS, and Stephens FD: Posterior urethral valves: diagnosis and management, J. Ural. 112: 519 (1974). 2. Hendren WH: Posterior urethral valves in boys. a broad clinical spectrum, ibid. 106: 298 (1971).
413
OBSTRUCTING VALVES
POSTERIOR
URETHRAL
IN OCTOGENARIAN
PETER T. NIEH,
M.D.
W. HARDY HENDREN,
M.D.
From the Urological Service and Department of Pediatric Surgery, Massachusetts General Hospital, and the Department of Surgery, Harvard Medical School, Boston, Massachusetts
ABSTRACT-A unique case of bladder outlet obstruction secondary to posterior urethral valves in an octogenarian is presented.
Congenital posterior urethral valves are widely recognized as limited to the pediatric population. We present a unique case of obstructing urethral valves in an elderly man. Case Report An eighty-year-old white man had a twentyyear history of frequency every three to four hours and nocturia two to three times per night, but without hesitancy, noticeable decrease in force of stream, incontinence, suprapubic discomfort, or irritative symptoms. Several weeks earlier, an episode of gross total painless hematuria had occurred after a brief course of anticoagulant therapy for presumed thrombophlebitis. The anticoagulants were discontinued, and no further gross bleeding was noted. Physical examination was unremarkable except for a small right inguinal hernia and a benign-feeling 15-Gm. prostate. Analysis showed his urine to be loaded with red blood cells, urine cytology was negative, and all blood chemistries were within normal limits. An intravenous urogram demonstrated normal upper tracts, but a severely trabeculated bladder with large diverticula and large postvoid residual (Fig. 1). Cystourethroscopy revealed markedly enlarged type I posterior urethral valves, with well-defined circumferential attachments including an anterior fusion, 0.5 cm. proximal to the
412
FIGURE 1. Zntravenous pyelogram showing severely trabeculated bladder with multiple diverticula, increased residual urine, and minimal prostatic indentation.
UROLOGY
/ APRIL 1979 / VOLUME
XIII.
NUMBER 4
FIGURE 2. Urethroscopy with distended bladder: (A) view from external sphincter, with type 1 posterior urethral valves sweeping from verumontanum at 6 o’clock position; (B) another view from sphincter, with anterior fusion of valve leaflets at 12 o’clock position. (C) Urethroscopy after fulguration of left valve leaflet, revealing small lateral lobes. external sphincter (Fig. 2A, B). The prostatic lateral lobes were widely separated and nonhypertrophied, while the bladder neck was patulous. The bladder was markedly trabeculated with inflamed mucosa and blood clots within the diverticula. The urethral valves were fulgurated with the Bugbee electrode (Fig. 2C), and a Foley catheter was used overnight. Postoperatively, the patient has noted marked improvement in urinary stream, frequency, and nocturia. Comment Obstructing posterior urethral valves are generally detected in the pediatric population, with between 50 and 75 per cent diagnosed before valves five years of age. 1,2 Partially obstructing may be found in young adult males with chronic
UROLOGY
/
APRIL
1979
/
VOLUME
XIII,
NUMBER
4
prostatitis, and rarely in older males concurrently with prostatic hypertrophy. These valves are often incomplete or diaphanous membranes of questionable significance in the outlet obstruction. However, our elderly patient had outlet obstruction purely from urethral valves. This points out the importance of evaluating for posterior urethral valves in all patients, regardless of age. Massachusetts General Hospital Boston, Massachusetts 02114 (DR. NIEH) References 1. Cass AS, and Stephens FD: Posterior urethral valves: diagnosis and management, J. Ural. 112: 519 (1974). 2. Hendren WH: Posterior urethral valves in boys. a broad clinical spectrum, ibid. 106: 298 (1971).
413
