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Urinary Tract Obstruction

Obstructive Uropathy

Urinary tract obstruction can occur due to both congenital and acquired disorders of different etiologies, which may ultimately lead to hydronephrosis, significant obstruction of urine passage, and even acute or chronic kidney disease. Signs and symptoms depend on the underlying cause, but an intense pain is one of the prominent features. Clinical assessment and imaging studies of the urinary tract are necessary steps in order to make the diagnosis.


Presentation

Urinary tract obstruction can be induced by a myriad of conditions and is defined as a renal disease that causes hydronephrosis and leads to significant changes in normal kidney function [1] [2] [3] [4]. Narrowing or complete obstruction of the ureteropelvic or ureterovesical junctions, ureterocele, phimosis, and the presence of posterior urethral valves are common causes of congenital urinary tract obstruction, whereas nephrolithiasis, urinary tract infections (UTIs), benign prostatic hyperplasia (BPH), malignant tumors (both primary and metastatic), diabetic neuropathy, trauma, and use of several drugs (anticholinergics and alpha-adrenergic antagonists) are important acquired etiologies [1] [2] [4] [5] [6]. Depending on the degree of obstruction (unilateral vs. bilateral) and the rate at which hydronephrosis develops, symptoms are either abrupt or slowly progressive. In the acute setting, a sudden onset of sharp and often severe abdominal pain (known as renal colic) is the hallmark of urinary tract obstruction and is often accompanied by diminished urine output (ranging from oliguria to anuria) in complete obstruction [5] [6]. Pain might project into the genitalia if the lower urinary tract is the site of obstruction [6]. In slowly progressive forms, pain may be mild or even absent, while dysuria, nocturia, increased frequency and urgency, as well as a sensation of incomplete bladder emptying, are often reported [2] [6].

Abdominal Pain
  • A 58-year-old man complained of right lower abdominal pain with hematuria for 3 hours after flexible ureteroscopy, combined with holmium laser lithotripsy of right renal calculi was performed 1 month ago.[ncbi.nlm.nih.gov]
  • Signs and symptoms include: Inability to pass urine (urinary retention) Weak stream of urine Interrupted stream Blood in the urine Pain in either flank (side) or in the back Abdominal pain and/or swelling Prostate enlargement (in men), which may be benign[gmcdhcc.com]
  • Symptoms of a stricture include pain with urination, slow urination, decreased bladder emptying, spraying of the urinary stream, blood in the urine, abdominal pain from a full bladder, urethral discharge, and bladder infections.[urology.ucsf.edu]
  • pain that may be triggered or worsened during states of increased diuresis (e.g., after caffeine or alcohol consumption).[amboss.com]
  • Most patients present with nonspecific symptoms, including dull abdominal pain, of less than 12 months' duration but patients can present with the complications of the fibrosis.[patient.info]
Hypertension
  • Evidence exists of an association with metabolic syndrome, obesity, diabetes and hypertension, and of enhanced risk of chronic kidney disease and metabolic bone disease.[ncbi.nlm.nih.gov]
  • The remaining twelve sections cover various types of diseases, including hypertension, urological problems, and urinary tract concerns.[books.google.de]
  • Angiotensin inhibitors have not been effective in slowing progression, although avoidance of nephrotoxins and timely treatment of hypertension are important.[ncbi.nlm.nih.gov]
  • Intrarenal varices in portal hypertension: demonstration by color Doppler imaging. Abdom Imaging 1996;21:549–50. CrossRef PubMed Google Scholar 9. Kember PG, Peck RJ. Renal arteriovenous malformation mimicking hydronephrosis.[link.springer.com]
  • For instance, it has been shown that protein released by the kidneys in diabetes mellitus sensitises the kidney to the damaging effects of hypertension . [1] Diabetes also can have a direct effect on urination due to peripheral neuropathies , which occur[en.wikipedia.org]
Neglect
  • Various hypotheses have been advanced in the literature to account for this neglected syndrome. A trial was carried out to assess whether all patients presenting with uterine prolapse should be screened to exclude urinary tract obstruction.[ncbi.nlm.nih.gov]
Urinary Retention
  • A 41-year-old man presented in urinary retention 36 hours after self-injecting his urethra with the foam sealant, which could be palpated throughout his entire urethra.[ncbi.nlm.nih.gov]
  • Although most paediatric pelvic fractures are managed non-operatively, we postulate that significant ring deformity contributing to urinary retention be considered an indication for open surgical treatment.[ncbi.nlm.nih.gov]
  • We present a series of infants who presented with urinary retention secondary to large primary bladder diverticulum. Seven infants were evaluated for symptoms of lower urinary tract obstruction. All seven were infant boys; three were neonates.[ncbi.nlm.nih.gov]
  • It is a cause of urinary retention . Causes [ edit ] Causes of urinary tract obstruction include: Bladder stone and renal stone Benign prostatic hyperplasia Obstruction as a congenital disorder .[en.wikipedia.org]
  • Urinary retention may be due to outflow obstruction or to weakness of the detrusor muscle.[bcm.edu]
Uremia
  • We report on a 52-year-old female patient hospitalized because of uremia due to bilateral urinary tract obstruction caused by bilateral sarcomatoid renal cell carcinoma (SRCC).[ncbi.nlm.nih.gov]
  • .  Nausea, vomiting, loss of weight and strength, and pallor are due to uremia secondary to bilateral hydronephrosis. 10.  SIGNS  Lower and midtract  Palpation of the urethra  induration about a stricture.  Rectal examination  atony of the anal[slideshare.net]
  • Urine constituents are reabsorbed by the renal veins, tubes, and lymphatic channels, leading to uremia . Because complete urinary tract obstruction can lead to renal failure , treatment must be prompt.[britannica.com]
  • When bilateral obstruction or unilateral obstruction in a solitary kidney is severe and renal failure has occurred, uremia can be present. Uremia symptoms include weakness, peripheral edema, mental status changes, and pallor.[emedicine.medscape.com]
Oliguria
  • Patients range from having oliguria / anuria to only having asymptomatic hydronephrosis that is incidentally identified through imaging or elevated creatinine levels.[amboss.com]

Workup

Urinary tract obstruction is a known risk factor for the development of both acute and chronic kidney disease, especially in children [4], which may have devastating long-term consequences in the absence of an early diagnosis. For this reason, physicians must conduct a thorough clinical workup, starting with a detailed patient history that will assess the presenting signs and symptoms and reveal preexisting disorders or events that might have caused obstruction [2]. In addition, a meticulous physical examination, with an emphasis on abdominal and genital inspection, palpation and percussion, is necessary to raise valid suspicion [2]. Urinalysis is one of the first laboratory studies that can be performed, and often shows hematuria and bacteriuria [5]. In addition, a full laboratory workup comprised of serum electrolytes, a complete blood count (CBC) and renal function tests must be carried out. Serum creatinine and blood urea nitrogen (BUN) are both high in acute obstruction, in which case imaging studies should be employed to identify the cause. If obstruction at the level of the urethra is suspected, either cystourethroscopy or voiding cystourethrography is recommended, whereas abdominal ultrasonography and computed tomography (CT) are used if hydronephrosis or ureteral obstruction might be present [5] [6]. If ultrasound and CT are not conclusive, urography or pyelography (anterograde or retrograde) is indicated [5] [6]. Several biochemical markers have been proposed as potentially useful indicators of obstructive uropathy and its severity (kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin, or KIM-1 and NGAL, but also several other), although further studies are required to solidify their place in general practice [4].

Abnormal Renal Function
  • Abnormal renal function was defined when serum creatinine higher than 50 micromol/L (2 Standard Deviation) or the necessity of dialysis or renal transplantation. Autopsy was always performed whenever fetal or neonatal deaths occurred.[ncbi.nlm.nih.gov]

Treatment

  • The patient underwent conservative treatment after the optimal treatment strategy was reviewed and discussed. Urinary system CT re-examination suggested complete absorption of the hematoma and urinary extravasation 3 months later.[ncbi.nlm.nih.gov]
  • Randomised research with long-term follow up is necessary to determine the role of antenatal treatment in clinical practice.[ncbi.nlm.nih.gov]
  • The rationale for in utero treatment for those cases is based on the possibility of relieving the obstruction, improving the amniotic fluid volume, and preventing renal and bladder damage.[ncbi.nlm.nih.gov]
  • A high proportion of LUTO may be visualised during routine second trimester (and first trimester) ultrasound giving rise to the possibility of determining individual fetal prognosis and treatments such as vesico-amniotic shunting, with a view to altering[ncbi.nlm.nih.gov]
  • We aimed to assess the effectiveness of vesicoamniotic shunting for treatment of LUTO.[ncbi.nlm.nih.gov]

Prognosis

  • Sensitivity and specificity in defining a poor renal prognosis were 80.6% and 89% for β-2-microglobulin, 61.3% and 100% for sodium and 64.5% and 100% for calcium, respectively.[ncbi.nlm.nih.gov]
  • A high proportion of LUTO may be visualised during routine second trimester (and first trimester) ultrasound giving rise to the possibility of determining individual fetal prognosis and treatments such as vesico-amniotic shunting, with a view to altering[ncbi.nlm.nih.gov]
  • Vesicoamniotic shunts and cystoscopy are the current methods utilized to treat LUTO; however, it remains difficult to determine whether fetal prognosis favors intervention and long-term outcome follow-up has been limited.[ncbi.nlm.nih.gov]
  • Fetal urine analysis may provide improvements in prenatal determination of renal prognosis, but the optimum criteria to be used remain unclear.[ncbi.nlm.nih.gov]
  • Our observations confirm the poor prognosis associated with fetal LUTO.[ncbi.nlm.nih.gov]

Etiology

  • Fetal cystoscopy is accurate in the diagnosis of the etiology of LUTO and serves as a guide to the specific prenatal treatment.[ncbi.nlm.nih.gov]
  • Evaluation Lab tests: PSA in men, electrolytes, and kidney function Urine tests: urinalysis, urine culture and sensitivity, possible urine cytology if concern for a malignant etiology Imaging: Depending on concern for different etiologies (plain film[nuomed.com]
  • References: [7] [16] [17] [18] [19] [20] [21] [22] [23] [24] [3] [25] Complications Hydronephrosis Definition : dilation of the renal pelvis and calyces Etiology Urinary tract obstruction (see “Etiology” above) Vesicoureteral reflux Clinical features[amboss.com]
  • The prognosis of fetal lower urinary tract obstruction (LUTO) depends upon renal function and also upon the underlying etiology. Precise identification of the latter remains a challenge antenatally.[ncbi.nlm.nih.gov]

Epidemiology

  • Recruitment was hampered by logistical and regulatory difficulties, a lower incidence of LUTO and lower antenatal diagnosis rate [estimated to be 3.34 (95% CI 2.95 to 3.72) per 10,000 total births and 47%, respectively, in an associated epidemiological[ncbi.nlm.nih.gov]
  • Epidemiology Frequency In an autopsy series of 59,064 patients aged 0-80 years, the frequency of hydronephrosis was 3.1%.[emedicine.medscape.com]
  • Epidemiology Age Urinary tract obstruction occurs most commonly in the young and the old: In older men, this is a relatively common condition due to prostatic enlargement: Incidence of lower urinary tract symptoms (LUTs)/BPH averages 15 per 1,000 man-years[patient.info]
Sex distribution
Age distribution

Pathophysiology

  • Each disease-oriented section begins with an up-to-date review of pathophysiology and then focuses on specific diseases.[books.google.de]
  • Pathophysiology of urinary tract obstruction. In: Wein AJ, Kavoussi LR, Partin AW, Peters CA, eds. Campbell-Walsh Urology . 11th ed. Philadelphia, PA: Elsevier; 2016:chap 48. Zeidel ML. Obstructive uropathy. In: Goldman L, Schafer AI, eds.[nlm.nih.gov]
  • Pathophysiology of urinary tract obstruction. In: Wein J, ed. Campbell-Walsh Urology. Vol 2. 9th ed. Saunders; 2007:1195-226 7. Renal colic - acute, Clinical Knowledge Summaries (April 2009) 8. Chen MY, Zagoria RJ, Dyer RB.[degruyter.com]
  • Pathophysiology Chronic urinary tract obstruction can lead to permanent damage to the urinary tract.[emedicine.medscape.com]

Prevention

  • Current surgical procedures include removal of the obstructions to facilitate bladder emptying or prompt prenatal or postnatal spinal closure to prevent further neurogenic damage.[ncbi.nlm.nih.gov]
  • It is time to view nephrolithiasis as a condition predictive of chronic kidney disease and cardiovascular damage, which deserves full metabolic evaluation together with an early prevention care strategy, mainly consisting of dietary and lifestyle changes[ncbi.nlm.nih.gov]
  • Fetal urinary tract obstruction may prevent normal development of the lungs, be associated with other anomalies which cannot be diagnosed before delivery and retard infant development in survivors.[ncbi.nlm.nih.gov]
  • The rationale for in utero treatment for those cases is based on the possibility of relieving the obstruction, improving the amniotic fluid volume, and preventing renal and bladder damage.[ncbi.nlm.nih.gov]
  • The catheter was secured to prevent dislodgment and tunneled to a subcutaneous reservoir. The reservoir was accessed as necessary, infusing normal saline to maintain AFV. Pregnancy continued until term or indicated delivery.[ncbi.nlm.nih.gov]

References

Article

  1. Chevalier RL. Congenital Urinary Tract Obstruction: The Long View. Advances in chronic kidney disease. 2015;22(4):312-319.
  2. Dmochowski RR. Bladder Outlet Obstruction: Etiology and Evaluation. Reviews in Urology. 2005;7(Suppl 6):S3-S13.
  3. Bascands J-L, Schanstra JP. Obstructive nephropathy: insights from genetically engineered animals. Kidney International. 2005;68(3):925-937.
  4. Wasilewska A, Taranta-Janusz K, Dębek W, Zoch-Zwierz W, Kuroczycka-Saniutycz E. KIM-1 and NGAL: new markers of obstructive nephropathy. Pediatr Nephrol. 2011;26(4):579-586.
  5. Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2016.
  6. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.

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Last updated: 2018-06-21 22:07