Direct Visual Internal Urethrotomy in Supine Position in a Patient with Complex Deformities of Both Lower Limbs and Neurogenic Bladder: A Case Report

Direct visual internal urethrotomy (DVIU) is a minimally invasive treatment for urethral stricture and is usually done in lithotomy position. We presented a case of a 35-year-old man with complex deformities of both lower limbs from birth. The lower limbs were severely wasted with ankylosis of the hips, flexion of the knee joints and dorsiflexion at the ankle joints. He had a history of progressively worsening difficult in urination characterized by frequency, urgency, urgency incontinence, nocturia, poor urinary stream (improved by straining), intermittency and feeling of incomplete bladder emptying. He had occasional dysuria and total hematuria. He was not a known hypertensive or diabetic patient. No history of trauma, previous urethral instrumentation, and no history of purulent urethral discharge before the onset of problems. On presentation, his abdomen was full with slight suprapubic distention. The anal sphincter was spastic and the prostate was not enlarged. He had normal non-circumcised male external genitalia. There was no spinal deformity and the upper limbs were normal. White cell count was 14,000 cells/ mm3 with a differential neutrophil of 85.5% and urine culture showed moderate growth of coliforms. Abdominopelvic ultrasound showed a thickened bladder wall with mild hydronephrosis bilaterally and a retrograde urethrography and micturating cystourethrography showed 3 short segment bulbar urethral strictures. There was also a Christmas tree appearance of the bladder. A diagnosis of bladder outlet obstruction secondary to multiple short segment idiopathic bulbar urethral strictures on background neurogenic bladder was made. He had intravenous antibiotics for 48 hours and subsequently a DVIU under spinal anesthesia and in the supine position. Catheter was removed on the 7th day post procedure and he started clean intermittent catheterization (CIC) with 12 French catheters. Seven months post procedure, patient is still satisfied with the outcome of his treatment. We concluded that DVIU can be done safely in the supine position and CIC can help improve post procedure outcome and in managing comorbid neurogenic bladder.