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Year : 2002  |  Volume : 18  |  Issue : 2  |  Page : 140-142

Posterior urethral valves: Transperineal ultrasonography - a diagnostic tool: Pictorial essay

Department of Surgery and Radiology, North Bengal Medical College & Hospital, Siliguri, India

Correspondence Address:
Anup Kumar Kundu
4, P.C. Sarkar Sarani, Hakimpara, Siliguri (W.B.) - 734 401
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Posterior urethral valves (PUV) is a singular struc­ture, often incorrectly referred as plural, an obstructive uropathy in male infants and neonates. This congenital abnormnality is diagnosed by non-invasive investigation - perineal ultrasonography.

Keywords: PUV; MCU; USG; Transperineal.

How to cite this article:
Chowdhury DN, Kabiraj SP, Kundu AK. Posterior urethral valves: Transperineal ultrasonography - a diagnostic tool: Pictorial essay. Indian J Urol 2002;18:140-2

How to cite this URL:
Chowdhury DN, Kabiraj SP, Kundu AK. Posterior urethral valves: Transperineal ultrasonography - a diagnostic tool: Pictorial essay. Indian J Urol [serial online] 2002 [cited 2023 Mar 24];18:140-2. Available from:

   Introduction Top

Valvular obstruction of the posterior urethra is the most common cause of lower urinary tract obstruction in male infants. Males with PUV represent about 10% of neonates with a significant uropathy. [1] With the ad­vances in diagnosis and management the mortality of the sick and affected infants is reduced. Definitive con­firmation of the urethral obstruction is attained with a Micturating Cysto-Urethrogram (MCU). The use of ul­trasonography for the last 25 years in evaluation of neo­natal genitourinary tract, including the evaluation of posterior urethral valves has further enhanced the ability of the sonologist to make a timely and accurate diagno­sis. We took the help of transperineal ultrasonography (USG) to improve our diagnostic capability.

   Materials and Methods Top

19 male patients (aged between I day to 13 years), who were suspected to have posterior urethral valves were studied with routine renal tract ultrasonography, performed through fluid-filled bladder, as well as through the perineum in both transverse and longitudi­nal orientations. All these patients presented with void­ing urinary symptoms, urinary tract infections, dribbling of urine, enuresis, renal failure and abnormal urinary stream at birth. Clinically almost all of them had palpa­ble urinary bladder with or without palpable kidneys. Seven of them were already catheterised. The cases were examined with real-time sector and linear scanner using 7.5 mHz transducer. The kidney and bladder areas were first examined in both longitudinal and transverse planes to note the presence or absence of pelvic, calyceal or proximal ureteral dilatation or peritoneal fluid (urinary ascites). The ultrasound examination of full bladders were done to note distal ureteral dilatation and bladder wall (including the trig­one) hypertrophy (when the thickness is more than 4-5 mm). [1] An inferior angulation, through the fluid-filled bladder, was used to enhance the possibility of imaging a dilated poste­rior urethra. This was followed by transperineal scan by putting the transducer and coupling gel on the perineum between the scrotum and anus directed towards the bladder neck. The transperineal views were obtained in the trans­verse plane with cranio-caudal angulation and in the longi­tudinal plane in midline and with parasagittal angulation. The catheters were taken out during ultrasonography.

We sought to image the posterior urethra and note whether it was dilated and if a posterior urethral valves could be imaged within it. All the cases later had MCU, IVU followed by urethro-cystoscopy.

   Results Top

PUV was diagnosed in 14 of the 19 patients by transperi­neal ultrasonography. The transverse and longitudinal views showed dilated posterior urethra and areas of soft tissue echogenicity in the periphery of the dilatation. In 5 patients USG suggested a diagnosis of PUV by a thick walled uri­nary bladder and dilated posterior urethra [Figure - 1] and in 4 children only dilated posterior urethra [Figure - 2]a, b, c. In 5 cases, USG diagnosed PUV by demonstrating an area of linear echogenicity [Figure - 3], which is a valuable confirmatory evidence within the dilated posterior urethra at transperineal examination. [1] 9 of the 14 children had pelvicalyceal dilata­tion, bilaterally dilated ureters and large bladders [Figure - 4]. One patient had increased renal parenchymal echogenicity with loss of cortico-medullary differentiation, suggesting CRF.

In all these patients identified at USG as PUV, the diag­nosis was confirmed by MCU. The valves were endoscopi­cally confirmed and fulgurated in 10 cases. 1 patient died of chronic renal failure. One child of one-day age devel­oped severe septicemia following MCU. 2 patients at­tended with enuresis, refused operation and were lost to follow-up.

   Discussion Top

MCU is the "gold standard" for the diagnosis of PUV. It is an invasive investigation. PUV, the obstructive uropa­thy, is usually associated with urosepsis and we lost a baby due to septicemia following MCU. Non-invasive ultra­sound scanning of the perineum, urinary bladder and kid­neys (which will show hydronephrotic changes and/or increased renal cortical echogenicity [2] ) may demonstrate "dilated and elongated posterior urethra" [3] of PUV, allow­ing the differentiation of PUV from neurogenic bladder outlet obstruction or stricture urethra. Cremin and Aarason' described dilated posterior urethra for diagnosis of PUV by trans-perineal ultrasonography. Cohen et al [5] imaged a linear area of echogenicity within dilated posterior ure­thra by same method and believed it to be PUV which was also observed by others. [2],[6],[7] Antenatally PUV may also be diagnosed by USG. [6]

So we conclude that transperineal USG has not yet re­placed MCU for diagnosis of PUV but it is a practical proposition where urinary tract infection contradicts the performance of micturating cystourethrogram.

   References Top

1.Deubury KC, Meire HB, Bruyn RD. The paediatric renal tract. In Meire H, Cosgrove D, Dewbury K, Farrant P (eds.). Abdominal and general ultrasound. London, Churchill Livingstone, 2001; 1247. 1258-1260.  Back to cited text no. 1    
2.Sherman NH, Rosenberg HK. Paediatric Pelvis. In : Rumack CM, Wilson SR, Charboneau JW (eds.). Diagnostic Ultrasound. St. Louis, Mosby Yearbook, 1991; 1223.  Back to cited text no. 2    
3.Gilsanz V, Miller J, Reid B. Ultrasonographic characteristics of pos­terior urethral valves. Radiology 1982; 145: 143-145.  Back to cited text no. 3    
4.Cremin BJ, Aaronsan IA. Ultrasonic diagnosis of posterior urethral valves in neonates. Br J Radiol 1983: 56: 435-438.  Back to cited text no. 4    
5.Cohen HL, Susman M, Haller JO et al. Posterior urethral valve: Transperineal US for imaging and diagnosis in Male Infants. Radi­ology 1994; 192: 261-264.  Back to cited text no. 5    
6.Kundu AK, Sinha S, Shah BB, Mustafi MC. Posterior urethral valve- diagnosed by US scan. Ind J Radiol Imag 1993; 3: 183-184.  Back to cited text no. 6    
7.Joshi H, Patel V, Dave A. Transperineal US for imaging and diag­nosis of posterior urethral valve. Ind J Radiol Imag 1997; 7: 177­-179.  Back to cited text no. 7    


  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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