These two papers give a very good summary of the long-term effects of posterior urethral valves (PUV) into adulthood and are worth a read. Pereira et al. It is well known that the consequences of posterior urethral valves extend well beyond the paediatric age and affect the rest of the boy’s / man’s life. Renal function deterioration appears to have two components – obstructive glomerulopathy (potentially reversible) and renal dysplasia (irreversible). About 25% of boys initially do well in terms of renal function but then have significant deterioration in the long term, especially in the second and third decades of life. Bladder dysfunction has a major role to play in the deterioration of renal function and so the ‘valve bladder’ term was coined in 1982 by Mitchell. A valve bladder may be overactive, poorly compliant or underactive (myogenic failure). More and more evidence is appearing that in the long term, many initially overactive bladders become underactive in late childhood requiring a Mitrofanoff for emptying. Appropriately managing overactivity, poor compliance and poor emptying reduces the progression of renal failure. This may include bladder augmentation to provide a low pressure, high volume compliant storage with a Mitrofanoff for emptying. Vesicoureteric reflux occurs between 50-70% of patients at diagnosis of PUVs. This often disappears after treatment or with time but if hydronephrosis and VUR persist then poor bladder outflow has to be considered and a secondary bladder neck procedure may need to be considered. Polyuria due to renal tubular damage occurs in up to 75% of patients and this is made worse by high pressure bladder storage. Hyperfiltration injury due to the increased metabolic demands of puberty is increasingly recognised and is recognised when proteinuria rises, risking glomerulosclerosis. Early use of angiotensin converting enzyme inhibitors may delay or even avoid chronic renal failure. Posterior urethral valves are still a major childhood cause of requiring a renal transplant with 15% of transplants due to this condition. The state of the bladder is vital to determine whether or not a transplant survives and urodynamic evaluation is mandatory pre-transplant. Information on sexual function and fertility is still developing for patients who have had PUVs in childhood. Most studies show normal sexual function (erections, orgasm, normal / slow ejaculation) but the quality of the seminal fluid is relatively poor with agglutination abnormalities, increased liquefaction time, increased viscosity and pH. The ability to father a child however, seems to be more dependent on renal failure than on the PUV. Jalkanen et al. The Helsinki group emailed questionnaires to 108 patients with PUV of whom 62% responded. They used three questionnaires (15D questionnaire, Life Satisfaction Score – LSS, RAND-36 score) and compared the results between those patients who had normal kidney function and those who had treatment for renal disease (transplant or medication). Patients generally had a good quality of life compared to reference values for the normal population. Patients treated for renal insufficiency had poorer quality of life than the rest. They were less content with themselves, more stressed and felt more hopeless about their future. Patients who had incontinence problems reported more sleeping problems, felt more mental pressure and regarded themselves as physically more disabled than those who were continent. 

Long –term consequences of posterior urethral valves.
Lopez-Pereira P, Martinez Urrutia MJ, Espinosa L, et al.
The impact of posterior urethral valves on adult quality of life.
Jalkanen J, Mattila A, Hikkilae J, et al.
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Henrik Steinbrecher

Southampton University Hospital NHS Trust

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