Pediatric PUVs may be linked to adult infertility

Posterior urethral valves occur during male embryogenesis, when the primitive folds in the posterior urethra just distal to the verumontanum insert high and fuse, resulting in bladder outlet obstruction. Today, in the age of gestational ultrasonography, these are usually recognized and treated postnatally with endoscopic ablation.

Some children then go on without urinary tract problems, but about 30% go into renal failure, and many have trouble emptying the bladder in adolescence and adulthood, Dr. Schober explained.

"With PUVs, we focus so hard on what happens to the bladder and the kidney, we sometimes forget that there is more in the urinary tract that could be modified or problematic, other than just the bladder or the kidney," Dr. Schober told Urology Times.

In addition, she said, the effects on the bladder, ureters, and kidneys are obvious on sonography, but the effects on the prostate, ejaculatory ducts, and seminal vesicles are not.

Dr. Schober and collaborator Christopher Woodhouse, MB, urology consultant at North Middlesex University Hospital, Great Ormond Street Hospital for Children in London, have followed the medical history of these patients. After many years of examining semen samples from these patients, they recognized that something was wrong. These patients have slow, dry, retrograde ejaculation, viscous semen, and high semen pH.

Significant conditions found

Recently, Dr. Schober, Lori Dulabon, DO, and Dr. Woodhouse performed a methodical study of a subset of these 29 PUV patients, aged 17 to 51 years (mean, 21.5 years), with ongoing bladder instability to find out what is atypical and how that can affect the boys' fertility as adults.

Other than bladder symptoms, epididymitis was common, occurring in 62% of the 29 patients. Likewise, urethritis was seen in 66% of patients, and 41% reported a history of UTIs.

Seven of the 29 men with intractable symptoms of frequency, urgency, and enuresis were examined using additional radiologic studies, urine and semen analysis, and urine and semen cultures. One patient had a history of vasectomy, and his semen specimen was not included in this evaluation. Five of six of these patients (83%) revealed significant bacterial growth in semen/pyospermia, leukocytospermia was seen in five, and profoundly decreased sperm motility was detected in three.

Sperm counts were low, sometimes profoundly, in all five patients, and three had only 15% normal forms. Organisms cultured from semen were generally moderate in levels of staphylococci and streptococci, instead of the Escherichia coli that one might expect in a UTI.

While semen-culture-specific antibiotic therapy brought relief of urinary symptoms to 71% of these patients (five of seven), none experienced concomitant improvement in semen parameters.

Dr. Schober doesn't think those are contaminants, but real infections. These bacteria, she said, "might not necessarily cause a symptomatic bladder infection, but they appear to do something different in the seminal vesicles or in the sex accessory glands."

Infection, she pointed out, is the primary cause of infertility. She cautioned urologists to carefully follow male patients who have a history of PUVs for bladder infection and sex accessory gland infections and problems such as epididymitis and abnormal semen. Sometimes these adolescents and men do not have positive urine cultures, but they do have positive semen cultures.

Even high levels of leukocytes in semen without apparent infection should send up a red flag for adult urologists who see these patients, Dr. Schober said. High leukocyte counts in semen are associated with male infertility, and some leukocyte products affect sperm motility and fertilizing ability in vitro.