Differential diagnosis, investigations and treatment:
Basic laboratory tests showed abnormal renal function with urea levels at 60 g/dl and Creatinine levels at 2 g/dl. Full laboratory findings are available in (Table 1)
Abdominal ultrasound confirmed ascites and revealed second-degree hydronephrosis in the left kidney and first-degree hydronephrosis in the right kidney. The diameter of ureter was increased bilaterally with bilateral loss of corticomedullary differentiation. The bladder on ultrasound appeared full and enlarged, filling most of the abdomen. Its walls showed thickness and multiple diverticula along with a classified polyp. These findings are consistent with neurogenic bladder and lower urinary tract obstruction. MRI of the spine was performed to determine the cause but no abnormalities were observed. MCUG confirmed bilateral hydronephrosis with two large diverticula within the bladder wall (Unfortunately unavailable). Renogram revealed a glomerular filtration rate (GFR) of 40 ml/min for right kidney and 24 ml/min for left kidney which is consistent with insidiously progressive chronic renal failure. Initial management focused on protecting the kidneys from further damage by performing ureterocutaneostomy as it was believed that patient had neurogenic bladder.
After the surgery, urodynamics studies were conducted to rule out any neurological bladder issues. However, these studies did not find any evidence of a neurological bladder. As a result, the patient was referred for a urethroscopy procedure.
During the urethroscopy, it was discovered that the patient had a posterior urethral valve. The valve was treated by ablation during the procedure. Subsequently, another urethroscopy was performed to assess the condition of the urethra (video 1).