A clinical case of Posterior Urethral Valve from Bangladesh Institute of Child health.

1. Clinical Case Presentation
Dr. Sazid Imtiaz
MS Resident (Phase-A)
Urology, NIKDU

2. Particulars
•Name: Emam Hossain
•Age: 6 months
•Sex: Male
•Father: Md. Masum
•Address: Raipura, Narshindi
•Ward/Bed: 15/8
•Date of Admission: 19 March ‘19
•Date of Examination: 19 March ‘19

3. Presenting Complaints
•Poor flow of urine with straining since
birth.
•Fever for last 5 days.

4. H/O Present Illness
According to the statement of informant
mother her baby has poor flow of urine
with straining since birth. She noticed
dribbling of urine after each micturition.
But baby remains dry between each
episode.

5. Her baby also had fever for last 5 days.
His fever is high grade, continuous and
highest recorded temperature was
102oF. She gave h/o similar episode of
fever for 4-5 times in last 6 months. Her
baby has no h/o sudden inability to pass
the urine, per urethral catheterization.
His bowel habit is normal.
H/O Present Illness (cont.)

6. Past medical history
•Antenatal- Mother was under irregular
antenatal check-up.
• Natal- Baby was delivered by C/S at term
due to oligohydramnios.
•Postnatal: Uneventful. No h/o respiratory
distress after birth.

7. Drug history: H/O having homeopathic
medication.
Feeding History: On breast feeding since
birth.
Immunization: As per as EPI schedule.
Past illness: Nothing significant.

8. Consanguinity: Absent
Family History:
His father, mother and rest of family
members are healthy.
Socio-economic History:
Father is businessman, mother is housewife.
Lived in pakka house.
Use safe drinking water and sanitation.

9. General Examination—
•Appearance: Ill looking
•Nutritional status: Well nourished
•Anaemia: Mild
•Dehydration: Absent
•Jaundice: Absent
•Edema: Absent
•Cyanosis: Absent
•Lymph node: Not enlarged

10. General Examination (cont.)
•Pulse: 110b/min
•Resp. Rate: 32/min
•Temperature: 100oF
•Weight: 6.5 kg

11. Abdominal Examination:
Inspection:
•Shape of the abdomen: Scaphoid
•Flanks - Not full
•Umbilicus: Centrally placed, inverted.
•Hernial Orifices: Intact
•Visible peristalsis: Absent

12. Abdominal Examination (cont.)
Palpation:
Abdomen soft.
Temperature normal.
Liver, Spleen & Kidneys: Not palpable
Urinary bladder is palpable.
Percussion: Dull over urinary bladder.
Auscultation: Bowel sound present.

13. Genito-urinary Examination
Inspection:
EUM: Drop of urine present at meatus.
Glans: Normal
Prepuce: Uncircumscribed
Scrotum: Well developed.
Suprapubic Area: No scar mark.
Hernial Orifices: Intact

14. Genito-urinary Examination (cont.)
Palpation:
EUM: Not stenosed.
Urethral Plate: Normal
Testis: Both present in scrotum.
Suprapubic Area: Full, Tender on palpation
Urinary bladder: Palpable.
Kidneys: Both kidneys are not palpable.

15. Other Systemic Examination
Respiratory system : NAD
Cardiovascular system : NAD
Central Nervous system : NAD

16. Salient Feature
Emam Hossain, 6 months old male baby
presented with the complaints of poor flow of
urine with straining since birth. He had
dribbling of urine after micturition but
remained dry between each episode. Emam
also had fever for last 5 days which was high
grade, continuous with a h/o 4-5 similar
episodes in the last 6 months. He was
delivered by C/S at term due to antenatal
oligohydramnios.

17. Salient Feature (cont.)
On examination he is ill looking, mildly
anemic and other vitals are within normal
limit. On systemic examination his urinary
bladder is palpable. There was drop of
urine found on his external urethral
meatus. Other systemic examination
reveals normal.

18. Provisional Diagnosis
Posterior Urethral Valve with UTI

19. Differential Diagnoses
• Neurogenic bladder
• Bladder neck hypertrophy

20. Investigations
•Hemoglobin - 10.2 g/dl
•WBC Count:
Total - 17,100/cmm
DC – N:58%, L:34%, M:5%, E:3%
•Serum Creatinine - 39.2 umol/l
•Serum Urea – 1.4 mmol/L
•Serum Electrolytes:
•Sodium - 141 mEq/L
•Potassium - 4.3 mEq/L
•Chloride - 97 mEq/L
•Blood Group - B Positive

21. Urine R/M/E:
• Physical:
Color: Straw
Appearance: Clear
S. Gravity: 1.020
• Chemical:
Urinary Protein: Absent
Nitrite: Positive
Ascorbic Acid: Negative
• Microscopic:
Pus Cell: 50-60/HPF
RBC: Nil/HPF
Epithelial Cell: 0-2/HPF
Investigations

22. Urine Culture:
Growth: Escherichia coli
Colony count - >10^5/ml
Investigations

23. Investigations
Ultrasonography of KUB:
•Kidney: Size of both kidneys are normal.
Pelvicalyceal system of both kidneys are
dilated. More marked on left side.
•Ureter: Both ureters are dilated.
•Urinary bladder: Wall is thick and irregular.
Comment:
•Bilateral hydroureteronephrosis.
•Cystitis.

24. Ultrasonography of KUB:

25. Micturating cystourethrogram(MCU)

26. Micturating cystourethrogram(MCU)
•Cystitis
•Diverticulum of urinary bladder
•Posterior urethral valve
•VUR on both side – Grade V

27. Management:
•Diet: Normal
•I/V Infusion: 10% Dextrose in 0.45% Normal
saline
•I/V Antibiotic: According to Urine C/S (inj.
Ciprofloxacin)
•Urethral catheterization initially with 6 Fr feeding
tube connected to a closed drainage system.
Later recatheterization was done with 8 Fr feeding
tube.
Planning for Cystoscopic Fulguration.

28. Thank You.