URINARY TRACT OBSTRUCTION

The urinary tract may be obstructed at any point between the kidney and the urethral meatus resulting in dilatation of the tract proximal to the obstruction. Dilatation of the renal pelvis is known as hydronephrosis. Eventually there is compression and thinning of the renal parenchyma with a decrease in size of the kidney.

Aetiology

In adults the common causes are prostatic obstruction (hypertrophy or tumour), gynaecological cancer and calculi (Table 9.9).

Clinical features

■ Upper urinary tract obstruction results in a dull ache in the flank or loin, which may be provoked by an increase in urine volume, e.g. high fluid intake or diuretics. Complete anuria is strongly suggestive of complete bilateral obstruction or complete obstruction of a single functioning kidney. Partial obstruction causes polyuria as a result of tubular damage and impairment of concentrating mechanisms.

■ Bladder outlet obstruction results in hesitancy, poor stream, terminal dribbling and a sense of incomplete emptying. Retention with overflow is characterized by the frequent passage of small quantities of urine. Infec-tion commonly occurs and may precipitate acute retention of urine.

Table 9.8 Common causes of nephrocalcinosis
Mainly medullary Mainly cortical (rare)
Hypercalcaemia Renal cortical necrosis
Renal tubular acidosis
Primary hyperoxaluria
Medullary sponge kidney
Tuberculosis
 
Table 9.9 Causes of urinary tract obstruction
Within the lumen
Calculus
Tumour of renal pelvis or ureter
Blood clot
Sloughed renal papillae (diabetes, NSAIDs, sickle cell disease or trait)
Within the wall
Congenital anomalies of the urinary tract (usually detected antenatally or in
infancy)
Stricture: ureteric or urethral
Neuropathic bladder
Pressure from outside the wall
Prostatic hypertrophy/tumour
Pelvic tumours
Diverticulitis
Aortic aneurysm
Retroperitoneal fibrosis (periaortitis)
Accidental surgical ligation of the ureter
Retrocaval ureter (right-sided obstruction)
Pelviureteric compression (bands; aberrant vessels)
Phimosis

Depending on the site of obstruction an enlarged bladder or hydronephrotic kidney may be felt on examination. Pelvic (for malignancy) and rectal exami-nation (for prostate enlargement) is essential in determining the cause of obstruction.

Investigations

Imaging studies are performed to identify the site and nature of the obstruc-tion and, together with serum creatinine, to assess function of the affected kidney.

■ Imaging: Ultrasonography is the initial investigation but helical/spiral CT scanning has a higher sensitivity for detecting calculi as well as details of the obstruction. Excretion urography identifies the site of obstruction and shows a characteristic appearance (a delayed nephrogram, which eventually becomes denser than the non-obstructed side).

■ Radionuclide studies (p. 362) are of no value in the investigation of acute obstruction but may help in longstanding obstruction, to differentiate true

obstructive uropathy from retention of tracer in a baggy low-pressure unobstructed pelvicalyceal system.

■ Subsequent investigations may include retrograde and antegrade pyelog-raphy (p. 362), cystoscopy and pressure-flow studies during bladder filling and voiding.

Management

Surgery is the usual treatment for persistent urinary tract obstruction. Elimination of the obstruction may be associated with a massive post-operative diuresis, resulting partly from a solute diuresis from salt and urea retained during obstruction and partly from the renal concentrating defect. In some cases definitive relief of obstruction is not possible and urinary diversion may be required. This may be simply an indwelling urethral catheter, a stent placed across the obstructing lesion, or the formation of an ileal conduit.

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1. Ethics and communication

Ethics and communication

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Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
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SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
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BUDD - CHIARI SYNDROME
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Malignant disease
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Renal disease
INVESTIGATION OF RENAL DISEASE
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URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
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ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
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CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
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MYOCARDIAL DISEASE
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ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
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15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
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COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
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