Rare association of the anterior and posterior urethral valves

Posterior urethral valves (PUV) are the most common cause of congenital lower urinary tract obstruction in male children, with an incidence between 1.6 and 2.1 per 10 000 births. Anterior urethral valves (AUV) are 25–30-fold less common than PUV. Associated AUV and PUV is an extremely rare congenital abnormality that results in poor urinary stream, incontinence, bladder dysfunction, vesicoureteral reflux (VUR), hydronephrosis and urinary tract infection (UTI). Severe cases have a risk of irreversible renal failure. A 10-year-old boy was examined at his previous hospital for urinary frequency and incontinence. He had no abnormalities on prenatal ultrasonography and no history of UTI. He had, however, had a poor urinary stream since infancy. Although voiding cystourethrography (VCUG) was planned to evaluate his lower urinary tract, he refused the examination due to fear of catheterization. On cystourethroscopy, he was diagnosed with type I PUV, and endoscopic cold knife ablation was performed at the 5, 7 and 12 o’clock positions (Fig. 1a). The urinary symptoms did not improve, however, and he was referred to the present hospital for further management at the age of 11. On physical examination there was neither a palpable abdominal mass nor lumbosacral abnormality, and he had normal external genitalia. Urinalysis was normal and the urine was sterile. Serum creatinine level was 0.55 mg/dL. Abdominal ultrasonography indicated bladder wall thickening and bladder diverticulum without hydronephrosis (Fig. 1c). On uroflowmetry, the maximum flow rate was only 3.0 mL/s and the residual urine volume was 230 mL. The lumbosacral spinal nerve was normal on magnetic resonance imaging. We encouraged the patient to undergo VCUG, which was performed using an 8 Fr urethral catheter, and natural instillation of contrast media and films with filling and oblique-position voiding phases. This showed bladder trabeculation, urachal remnant without VUR and urethral obstruction in the penile urethra with a dilated urethra proximal to the obstruction, which was suggestive of AUV (Fig. 1d). Cystourethroscopy under general anesthesia confirmed the incised PUV and ventrally located semi-lunar flap of the AUV in the penile urethra using Crede’s maneuver (Fig. 1b,e). The AUV was incised