Immediate Management of Posterior Urethral Valve in Obstructive Jeopardy
Catheterize the bladder immediately to decompress the urinary tract—this is the single most critical intervention to prevent irreversible renal damage and must be done at birth when PUV is suspected. 1
Initial Stabilization and Urinary Drainage
The priority is establishing urinary drainage as rapidly as possible to relieve the obstruction:
Place a urethral catheter immediately when PUV is suspected based on prenatal findings (bilateral hydronephrosis, oligohydramnios, bladder wall thickening, dilated posterior urethra on ultrasound). 1
Begin prophylactic antibiotics at the time of catheterization to prevent urinary tract infection in the obstructed system. 1
The catheter placed for initial bladder decompression can remain in place for subsequent diagnostic studies—there is no need to remove it. 1
Diagnostic Confirmation
Once the bladder is decompressed and the infant stabilized:
Perform voiding cystourethrography (VCUG) using the indwelling catheter to confirm the diagnosis of PUV and assess for associated vesicoureteral reflux (present in up to 93% of cases). 1, 2
The VCUG will demonstrate bladder wall thickening, dilated posterior urethra, and the characteristic valve leaflets. 1
Obtain baseline renal function studies including serum creatinine and renal ultrasound to assess the degree of hydronephrosis and renal parenchymal damage. 3
Definitive Management Algorithm
After initial stabilization and diagnostic confirmation:
Endoscopic valve ablation is the gold standard treatment and should be performed as soon as the infant is medically stable, typically within days to weeks of diagnosis. 3, 4
For neonates too small for safe endoscopy (typically <2.5-3 kg), temporary vesicostomy may be considered as a bridge to definitive valve ablation, though this should be reserved for cases where endoscopic equipment is inadequate or the infant is too unstable. 4
Suprapubic cystostomy is recommended in pediatric patients after surgical management rather than prolonged urethral catheterization. 1
Critical Pitfalls to Avoid
Never delay bladder catheterization while awaiting diagnostic studies—the obstruction must be relieved immediately to prevent progressive renal damage. 1
Avoid proximal urinary diversion (ureterostomy, pyelostomy) as initial management unless valve ablation repeatedly fails, as this can result in poor bladder compliance and worse long-term outcomes. 4
Do not assume normal renal function after valve ablation—30% of children with PUV will develop renal insufficiency before adolescence despite early intervention. 5
Post-Ablation Monitoring
Following valve ablation, aggressive surveillance is essential:
Monitor serum creatinine at 1,3,6, and 12 months, then every 6 months—nadir creatinine >1.0 mg/dL is the strongest predictor of progression to end-stage renal disease (OR 71). 2
Assess for bladder dysfunction requiring clean intermittent catheterization—severe bladder dysfunction is an independent risk factor for renal failure (OR 8.9). 2
Perform serial renal ultrasounds to monitor for persistent or worsening hydronephrosis, which may indicate incomplete valve ablation or secondary bladder dysfunction. 3
Follow-up VCUG at 1-3 months to confirm complete valve ablation and reassess vesicoureteral reflux. 1