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Management of the valve–bladder syndrome and congenital bladder obstruction: the role of nocturnal bladder drainage


Valve–bladder syndrome often develops after the resolution of posterior urethral valves, but is also found after the resolution of congenital bladder obstruction. The features of this syndrome include the persistent dilation of the upper urinary tracts, a thick-walled, noncompliant urinary bladder, urinary incontinence, and polyuria secondary to nephrogenic diabetes insipidus. Nocturnal bladder management, which involves timed emptying of the bladder or continuous drainage, has been recommended in conjunction with diurnal timed voiding therapy as an adjunct to the treatment of valve–bladder syndrome. This treatment is derived from the hypothesis that valve–bladder syndrome is caused by congenital obstruction, and that the resultant changes in detrusor muscle are associated with a persistent bladder dysfunction characterized by chronic overdistention of the urinary bladder. Such overdistention is exacerbated by polyuria, and can be a cause of secondary hydronephrosis. Bladder dysfunction and overdistention is usually treated during waking time, but occasionally this is not effective on its own, and nocturnal therapy is used as well. To date, there are a few sets of data that suggest overnight bladder drainage can bring about profound improvements in the degree of upper-tract hydronephrosis, renal function, or bladder function. Nocturnal bladder drainage seems, in these initial reports, to be a simple and safe therapeutic maneuver. This review discusses the etiology of valve–bladder syndrome and examines each of the studies which have investigated nocturnal bladder drainage in its treatment.

Key Points

  • Transurethral valve ablation is the initial treatment for obstruction caused by PUV, and the vast majority of patients have resolution of hydroureteronephrosis following treatment; however, a small proportion of patients experience persistent hydroureteronephrosis, with some progressing to end-stage renal disease

  • Treatment of valve–bladder syndrome includes anticholinergic drug therapy in combination with timed voiding, utilizing (if needed) intermittent catheterization to empty the bladder

  • Boys with PUV can have a renal concentration defect that leads to large volumes of dilute urine; this arises from obstruction during fetal medullary development that causes a paucity of collecting-duct formation

  • Chronic bladder overdistention at night that is caused by large urine volumes with less frequent bladder emptying is thought to be the cause of persistent upper-tract dilation, despite daytime therapy

  • Despite following a strict daytime regimen of timed voiding and anticholinergic therapy, some boys with valve–bladder syndrome have persistent hydroureteronephrosis, which can be alleviated by a strict nocturnal voiding regimen

  • Nocturnal bladder drainage by timed voiding or either intermittent or indwelling catheterization has been shown to alleviate the symptoms of valve–bladder syndrome and might slow down the progression to renal failure

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Correspondence to Gordon A McLorie.

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Fumo, M., McLorie, G. Management of the valve–bladder syndrome and congenital bladder obstruction: the role of nocturnal bladder drainage. Nat Rev Urol 3, 323–326 (2006).

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