An 8-year-old Caucasian male with no significant past medical history presented to the pediatric emergency department (ED) with complaints of three days of abdominal pain and dysuria, accompanied by nausea, vomiting, and poor oral intake. The patient had previously presented to his pediatrician, where he was found to have microscopic hematuria and subsequently sent to the ED. Microscopic hematuria and increased abdominal pain in the ED prompted a point of care ultrasound (POCUS).
The most likely site of abnormality in this patient is the urethra. Image 1 shows massive bilateral hydronephrosis while image 2 shows hydroureter and bladder wall thickening. This presentation in a male, together with the lab findings suggestive of a UTI, should raise concerns for posterior urethral valves (PUV). PUV, a congenital obstruction of the urethra, is one of the most common causes of lower urinary tract obstruction in males. 
The next step in management for patients with probable PUV is a referral to a urologist for a voiding cystourethrogram (VCUG) and cystoscopy to assess for vesicoureteral reflux and valvular obstruction. Patients who are found to have PUV can then undergo incision and correction of the urethral valve. PUV typically presents in the newborn period in males with a poor urinary stream, urinary tract infections, and other voiding complaints and can be corrected with bladder catheterization or valvular ablation [1,2].
While rare, PUV should be considered in the differential for any pediatric patient presenting with urinary tract-related complaints, abdominal pain, and unexplained nausea or vomiting, particularly in school-aged males.
A school-aged male without an underlying diagnosis presenting to the hospital with a UTI should prompt clinicians to look for underlying predisposing conditions, such as PUV – an undertaking in which bedside ultrasound can be extremely useful.
Point of care ultrasound (POCUS) is a tool used in real time by emergency physicians to provide evidence for hydronephrosis, which can lead to the diagnosis of PUV.
Hodges SJ, Patel B, McLorie G, Atala A. Posterior urethral valves. ScientificWorldJournal. 2009 Oct 14;9:1119-26. doi: 10.1100/tsw.2009.127. PMID: 19838598; PMCID: PMC5823193.
Shields LBE, White JT, Mohamed AZ, Peppas DS, Rosenberg E. Delayed Presentation of Urethral Valves: A Diagnosis That Should Be Suspected Despite a Normal Prenatal Ultrasound. Glob Pediatr Health. 2020 Oct 15;7:2333794X20958918. doi: 10.1177/2333794X20958918. PMID: 33117862; PMCID: PMC7570289.