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CASE REPORT
Bladder Outlet Obstruction in a 5 Years Boy
Badar Murtaza, Muhammad Akmal, Arshad Mahmood, Waqar Azim Niaz and Hussain Ahmad
ABSTRACT
We report a 5 years old boy with bladder outlet obstruction secondary to a fibroepithelial polyp of prostatic urethra. The
micturating cystourethrogram showed a filling defect in the posterior urethra. Cystourethroscopy revealed a polyp in the
prostatic urethra proximal to the verumontanum. Transurethral resection was done and histopathology confirmed
fibroepithelial polyp of the urethra.
Key words:
Prostatic urethra. Polyp. Transurethral resection. Micturating cystourethrogram.
INTRODUCTION
Bladder outlet obstruction in children may result from a
variety of causes. The common causes are posterior
urethral valves, meatal stenosis, phimosis, prolapsing
ureterocele or urethral diverticulum. Urethral polyps as a
cause of bladder outlet obstruction are rare.1
Genitourinary tract polyps can occur anywhere from the
renal pelvis to the urethra.2 These polyps are mostly
found in the ureter and renal pelvis, rarely in the urethra.
In children, the urethral polyps are mostly found in the
first decade of life and histologically they are usually
benign fibroepithelial polyps with no malignant transformation.3 These urethral fibroepithelial polyps are
found more often in children than adults. Approximately
161 cases have been documented in the medical
literature, this highlights the rarity of this condition.4
Fibroepithelial polyps of the urethra have often been
described in boys while the occurrence in girls is
exceptional. Ultrasonography and micturating cystourethrogram are useful in the diagnosis; however,
cystourethroscopy remains the diagnostic procedure.1
The main aim of reporting this case was to emphasize it
in the differential diagnosis for all children especially
males presenting with bladder outlet obstruction.
CASE REPORT
pain, past history of trauma or any urethral intervention.
On examination, he was a healthy boy with stable vital
signs. He was neither pale nor jaundiced. The systemic
examination did not reveal any abnormality.
The complete blood count, urinalysis, serum urea/
creatinine and serum electrolytes were within normal
limits. The ultrasound of the abdomen/KUB revealed
normal sized kidneys with no hydronephrosis. The
urinary bladder was also normal. He had a micturating
cystourethrogram (MCUG) which showed a filling defect
in the prostatic urethra (Figure 1). However, the patient
was able to void with opacification of the anterior urethra
as well. Accordingly, cystourethroscopy was planned
under general anaesthesia. A 7.5 Fr cystoscope was
used. This revealed a pedunculated polyp in the
prostatic urethra, just proximal to the verumontanum, at
the 6 O'clock position. Endoscopically the urethral polyp
was excised with the help of the fulgration of the base of
the polyp (transurethral resection). The specimen was
removed, preserved in formalin and sent for
histopathology (Figure 2). Foley catheter was retained.
Postoperative course was uneventful. The catheter was
removed the next morning and he passed urine without
difficulty. The histopathology report confirmed a
fibroepithelial polyp. On 3 months follow-up he was
found asymptomatic with good urinary stream.
A 5 years old boy reported with a 6 months history of
difficulty in passing urine. According to the mother the
child was asymptomatic about 6 months ago, when she
noticed that the child had to strain in order to pass urine.
The symptoms aggravated progressively, he started
taking longer to forcibly empty the bladder. However,
there was no episode of acute urinary retention. There
was no history of fever, burning micturition, haematuria,
Department of Urology, Armed Forces Institute of Urology
(AFIU), Rawalpindi.
Correspondence: Dr. Badar Murtaza, 614-C, Harley Street,
Rawalpindi.
E-mail: [email protected]
Received February 01, 2011; accepted October 12, 2011.
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Figure 1: Filling defect seen in the
posterior urethra on micturating
cystourethrogram.
Figure 2: Excised specimen of
fibroepithelial urethral polyp.
DISCUSSION
Fibroepithelial polyps are rare; however, they are the
most common benign mesodermal tumours of the
Journal of the College of Physicians and Surgeons Pakistan 2011, Vol. 21 (12): 780-781
Bladder outlet obstruction in a 5 years boy
Multiple urethral polyps are however, a rare entity.1
These fibroepithelial polyps can be successfully excised
by transurethral resection.3 Due to the proximity of the
lesion to the verumontanum, care is required to avoid
damage to the external sphincter. Other cystoscopic
options are Bugbee fulguration of the polyp and laser
excision. In some cases, especially in children with large
polyps, transvesical approach is preferred.10
urinary tract. They are composed of a fibrous core
covered with normal urothelium.5 Most fibroepithelial
polyps occur in the ureter, then in renal pelvis and a
small number in posterior urethra and bladder.4
Fibroepithelial polyps do not show malignant
transformation. However, the urethral polyps having
prostatic glandular tissue can undergo transformation
and exhibit recurrence.6 Fibroepithelial polyps of the
upper urinary tract are usually mistaken for the
transitional cell carcinoma, frequently resulting in more
extensive surgery than would otherwise be required for
the diagnosis and treatment.
REFERENCES
The etiology of urethral fibroepithelial polyp remains
controversial. Some consider it as a congenital anomaly.
However, there are some patients who present in
adulthood, thus it seems to be less likely to be
congenital. There are various other hypotheses
regarding the origin of these lesions. Some consider
fibroepithelial urethral polyp as developmental error in
the invagination process of submucous glandular
material of the inner zone of the prostate gland, an
abnormal protrusion of the urethral wall or epithelial
changes secondary to the maternal estrogen. The
fibroepithelial polyps are covered with transitional
epithelium. This layer can show squamous, intestinal or
rarely gastric metaplasia as well.7
Fibroepithelial polyps predominantly develops in
childhood including the neonates, but may also occur in
adults.8 The commonest symptoms are of bladder outlet
obstruction, like urinary obstruction, urinary hesitancy or
even urinary retention. In this case, the most notable
symptoms were straining on micturition with prolonged
act of micturition. Other symptoms like dysuria,
haematuria, enuresis, urinary tract infection and flank
pain may also be seen.8 Dilatation of the upper urinary
tract, vesical calculus disease9 and even reflux has
been documented.
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1.
Jain P, Shah H, Parelkar SV, Borwankar SS. Posterior urethral
polyp and review of literature. Indian J Urol 2007; 23:206-7.
2.
Aita GA, Begliomini H, Mattos D. Fibroepithelial polyp of the
urethra. Int Braz J Urol 2005; 31:155-6.
3.
Issac J, Snow B, Lowichik A. Fibroepithelial polyp of the
prostatic urethra in an adolescent. J Pediatr Surg 2006; 41:29-31.
4.
William TR, Wagner BJ, Corse WR, Vestevich JC.
Fibroepithelial polyps of the urinary tract. Abdom Imaging 2002;
27:217-21.
5.
Brady JD, Korman HJ, Civantos F, Soloway MS. Fibroepithelial
polyp of the renal pelvis: nephron sparing surgery after false
positive biopsy for transitional cell carcinoma. Urology 1997;
49:460-4.
6.
Mustafa M. Capillary haemangioma of verumontanum: case
report and review of the literature. Inter Urol Nefrol 2006;
38:493-4.
7.
Jaidane M, Hidoussi A, Slama A, Hmida W, Sorba NB, Mosbah
F. Gastric metaplasia of posterior urethral polyp: a case report.
Cases J 2009; 2:9119.
8.
Tsuzuki T, Epstein JI. Fibroepithelial polyp of the lower urinary
tract in adults. Am J Surg Pathol 2005; 29:460-6.
9.
Kouranloo J. Congenital polyp of the posterior urethra and
bladder stone in a 21 months old boy. Pak Paed J 2002; 26:203-5.
10. Demicran M, Ceran C, Karaman A, Uguralp S, Mizrak B.
Urethral polyps in children: a review of the literature and report
of two cases. Int J Urol 2006; 13:841-3.
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