OBSTRUCTION OF URINARY TRACT

Soumya Ranjan ParidaBasic B.Sc. Nursing 4th year

Sum Nursing College

Obstruction of urinary tractEtiology – Renal dysplasia, infectionClinical features – FTT, vomiting, diarrhea Acute ureteral obstruction – abdominal pain, nausea, vomiting, Chronic ureteral obstruction – vague abdominal pain, increased fluid intakeDiagnosis – Neaonatal – palpable abdominal mass Infravasical – bladder palpable , patent urachus, urinary ascitis Antenatal USG – hydronephrosis, infection, sepsis Imaging studies – USG – hydronephrosis VCUGMercapto acetyl triglycine (MAG-3) – • Recheases renal parenchyma in 2-3 minutes • lasix after 20-30 min 10-15 min – ½ radionuclide 20 min delayed 15-20 min intermittent Limitation – Newborn kidney, dehydration

Urinary tract obstruction

IVP – infravasical obstruction, ureteral obstructionWhitaker test – 10 ml/min fluid infusion – pressure difference of more than 20 cm

H2O b/w renal pelvis and bladderHydrocalycosis – • localized dilatation of calyx caused by obstruction of infundibulumUPJ obstruction – • 60% left side• M:F - 2:1• 10% bilateral• Intrinsic obstruction • Extrinsic obstruction by artery• Type 3,4 hydronephrosis without dilatated ureterClinical features – • Fetal hydronephrosis• Palpable renal mass in newborn• Abdominal, flank, back pain in older children• Febrile UTI • Hematuria without minimal UTI

Antenatal hydronephrosis

Postnatal USG 3rd day

Grade 1,2 hydronephrosisNormal renal parenchyma

Antibiotic prophylaxis

Repeat USG at 1 months

Grade 3, 4 hydronephrosisAbnormal renal parenchyma

MAG-3 diuretic renogram

Upper tract drainageDifferential renal function

Poor

pyeloplasty

goodRepeat USG

No improvement in hydronephrosis

Repeat renogram 6-12 months

surgery

Grade 3, 4 hydronephrosisAbnormal renal parenchyma

pyeloplasty

Midureteral obstruction –

• Retrocaval ureter – Upper right ureter travels posterior to IVC

• IVP shows – right ureter deviated medially at the level of L3

• Surgical repair – only when obstruction is present.

• Acquired obstruction – retroperitonial tumors, fibrosis, inflammatory process, radiation therapy.

Ectopic ureter –

• Ureters that drain out side the bladder

• M:F 1:3

Females –

• Bladder neck – 35%

• Urethrovaginal septum – 35%

• Vagina – 25%

• Cervix , uterus, gartner duct, urethral diverticulum

• Manifests as UTI and continuous urinary incontinence

Urinary tract obstruction

Boys – • Posterior urethra – 47%• Seminal vesicval – 33%• Prostatic utrical – 10%• Ejaculatory duct – 5%• Vas deference – 55• Manifests as UTI and epididymitis• No continuous urinary incontinence.Ureterocele – • M : F 1:2• Ectopic – cystic swelling extends through bladder neck into the urethra• Orthotopic – ureterocele entirely within the bladder• Manifest as bladder neck obstruction, b/l hydronephrosis, ureterocele prolapse

through urethra• VCUG shows filling defect in bladder often shows reflux• ‘Drooping lily’ appearance of the kidney

Urinary tract obstruction

Treatment – • No function in upper pole, no reflux – excision of upper pole and

associated ureter• Function in upper pole, significant reflux, septic – transurethral

incision with catery to decompress the ureterocele

Orthotopic ureterocele – • Discovered during screening for antenatal hydronephrosis or UTI• USG – Sensitive• IVP – varying degrees of ureteral and calyceal dilation, and there is a

round filling defect in bladder• Treatment – transurethral incision

Urinary tract obstruction

Classification of megaureter

Refluxing Obstructed Nonrefluxing & nonobstructed

Primary Secondary Secondary SecondaryPrimary Primary

Primary refluxMegacystic- megauretersyndromeEctopic ureterPrune- belly syndrome

Neuropathic bladderHinman syndromePosterior urethral valveBladder diverticulumPost opertave

Primary obstructed megaureterUreteral valveEctopic ureterEctopic uretocele

Neuropathic bladderHinman syndromePosterior urethral valveBladder diverticulumPost opertave

Nonrefluxing & nonobstructed

Diabetes insipidusInfectionPersistent after relief of obstruction

Megaureter –

• The primary obstructed nonrefluxing megaureter results from abnormal development of the distal ureter, with collagenous tissue replacing the muscle layer

• There is a disruption of the normal ureteric peristalsis, and proximal ureter widens

• IVP – Distal ureter dilated and tapers abruptly at or above the junction of the bladder

Clinical manifestation –

• UTI, urinary stones, flank pain

Treatment –

• Nonobstructed megaureters diminish in size over time

• Obstructed megaureters – excision of narrowed segment, ureteral tapering, reimplantation of ureter

Urinary tract obstruction

Prune-Belly syndrome (Eagle- Barret syndrome) –

• Incidence – 1:49000

• M: F – 9.5:1

• Defficient abdominal muscles, undescended testes, urinary tract abnormality

• Pulmonary hypoplasia

• Oligohydromnios

• Malrotation of bowel

• Cardiac anomaly

• Abnormalities of musculoskeletal system

• Anomalies of the urethra, uterus and vagina

Treatment –

• No obstruction – Antibiotic prophylaxis

• Obstruction – Vesicostomy

Urinary tract obstruction

Posterior urethral valves – • Incidence – 1:8000 boys• Tissue leaflets fanning distally from the prostatic urethra to the external

urinary sphinctor• Dilatation of prostatic urethra, bladder muscles under go hypertrophy• VUR (50%), distal ureteral obstruction• Mild hydronephrosis to renal dysplasia• Oligohydromnios, pulmonary hypoplasia• Antenatally – b/l hydronephrosis, distended bladder, oligohydromnios• Postnatally – distended urinary bladder, weak urinary stream, FTT, sepsisTreatment – • NG tube is inserted in bladder and left for several days• Sreum creatinine normal – Tranurethral ablation of valve leaflets/vesicostomy• Sreum creatinine high – vesicostomy• Uremia without infection – medical management• Uremia with infection – life saving measures, antibiotics, percutaneous

nephrostome, and hemodialysis

Urinary tract obstruction

Urethral atresia –

• Distended bladder, b/l hydronephrosis, oligohydromnios

• Infants are still birth

• Patent urachus – oligohydromnios unlikely

Treatment –

• Continent urinary diversion

Urethral hypoplasia –

• Urethral lumen is very small

• B/L hydronephrosis , distended bladder

• Passage of NG tube is diffucult

Treatment –

• Urethral reconstruction,

• Gradual urethral dilation,

• Continent urinary diversion

Urinary tract obstruction

Urethral strictures –

Males –

• Urethral trauma either accidental or iatrogenic

• Decrease in urinary stream is seldom noted

• Bladder instability, hematuria, dysuria

• Catheterization imposible

Treatment -

• Endoscopic dilation of stricture

Females –

• True urethral stricture is rare b/c urethra is protected from trauma

• ‘Spinning top’ deformity on VCUG

Urinary tract obstruction

Anterior urethral valves –

• It is rare

• No obstructive valve leaflets

• It is a urethral diverticulum in penile urethra that expands during voiding

• Soft mass on the ventral surface of the penis at the penoscrotal junction

• Weak urinary stream

Treatment –

• Open excision of diverticulum

• Trans urethral excision of the distal urethral cusp

Urinary tract obstruction

Urolithiasis

Composition –

Calcium, oxalate, uric acid, cysteine, ammonium, phosphate

crystals or combination of these substances.

Classification –

• Ca oxalate and Ca phosphate• Cystine stones• Struvite stone• Uric acid stone• Indinavir stones• Nephrocalcinosis

Stone formation – • Matrix – Mixtures of proteins, non amino sugars, glucosamines, water, organic ash. 2-9 % of dry weight• Precipitation-crystallization – Supersaturation of the urine with specific ions comprising of crystals.• Epitaxy – Aggregation of crystals of different composition but similar lattice structer• Inhibitors – Citrate, diphosphonate, Mg++Clinical manifestation – • Renal pelvis and calyx – gross or microscopic hematuria, abdominal or flank pain.• Distal ureter – Dysuria, urgency, frequency.• Bladder – Asymptomatic• Urethra – Dysuria, difficult voiding

Urolithiasis

Diagnosis –

KUB x-ray – all are radiopaque except cystine and uric acid

USG abdomen – limitation ureteric calculi

Nonenhanced spiral CT

Metabolic evaluation –

• Serum –

Calcium, phosphorus, uric acid, electrolytes

and anion gap, creatinine, alkaline phosphatase

• Urine –

Urinolysis, urine culture,

Ca:Cr ratio,

Spot test for cystinuria

24 hr urine for – Ca, PO4, oxalate, uric acid,

Diabasic amino acids (COAL)

Urolithiasis

Ca oxalate and Ca phosphate – • Hypercalciuria without hypercalcemia – Absorption , renal, resorption• Hyperoxaluria – Primary - Increased production Glycolic aciduria, L-glyceric acidosis Secondary – Increased intake Pyridoxine deficiency, intestinal malabsorption Enteric hyperoxaluria - IBD, pancreatic insufficiency, biliary disease• Hyperuicosuria• Hypocitruria – Chronic diarrhea, malabsorption, RTA• Cystinuria• Hypomagnesuria• Hyperparathyroidism• RTA type 1

Urolithiasis

• Cystine stones –

Defective renal tubular absorption – cystinuria – low

osmolality, acidic urine – stone formation

• Struvite calculi –

Magnesium ammonium phosphate, staghorn configuration

UTI by urea splitting organism – urinary alkalinization – excess

NH3 production – precipitation of MAP and CaPO4 – stone

formation

• Uric acid calculi –

Hyperuricosuria with or without hyperuricemia

Acidic urine and urate crystalluria

Lesh Nyhan syndrome, G6PD, short bowel syndrome, chronic

diarrhea, acidosis, tumor, myeloproliferative disorders

Urolithiasis

• Indinavir calculi – Radiolucent Soluble at Ph < 5.5 Urinary acidification by NH4Cl and ascorbic acid• Nephrocalcinosis – Deposition of calcium in renal parenchymaTreatment – • Removal depends upon location, size, composition, obstruction, infection• Maintain high urine output• ESWL of bladder, ureter, small renal pelvisCalcium stones –• Decrease Ca and Na in diet.• Thiazide diuretics• Potassium citrate – 1-2 meq/kg/day• Lemon juice – 120 ml ( 84 meq citric acid )

Urolithiasis

Uric acid stone –

• Allopurinol

• Alkalinization of urine – Ph > 6.5

• NaHCO3 and Na citrate

Cystine stone –

• Alkalinization of urine – Ph > 6.5

• D-Penicillamine

• N-Acetyl cystein

Primary hyperoxaluria –

• Hepatic transplant

Urolithiasis

THANKS