The document discusses obstructive uropathy, which is the obstruction of the urinary tract. It can be caused by congenital defects like posterior urethral valves or acquired conditions like prostate cancer. This leads to renal impairment over time. Early on, bladder filling pressure is normal but voiding pressure rises. Later, the kidneys decompensate due to back pressure, causing hydronephrosis and hydroureter. The ureters thicken initially to compensate but eventually dilate severely and lose contractile power.
The document discusses obstructive uropathy, which is the obstruction of the urinary tract. It can be caused by congenital defects like posterior urethral valves or acquired conditions like prostate cancer. This leads to renal impairment over time. Early on, bladder filling pressure is normal but voiding pressure rises. Later, the kidneys decompensate due to back pressure, causing hydronephrosis and hydroureter. The ureters thicken initially to compensate but eventually dilate severely and lose contractile power.
The document discusses obstructive uropathy, which is the obstruction of the urinary tract. It can be caused by congenital defects like posterior urethral valves or acquired conditions like prostate cancer. This leads to renal impairment over time. Early on, bladder filling pressure is normal but voiding pressure rises. Later, the kidneys decompensate due to back pressure, causing hydronephrosis and hydroureter. The ureters thicken initially to compensate but eventually dilate severely and lose contractile power.
The document discusses obstructive uropathy, which is the obstruction of the urinary tract. It can be caused by congenital defects like posterior urethral valves or acquired conditions like prostate cancer. This leads to renal impairment over time. Early on, bladder filling pressure is normal but voiding pressure rises. Later, the kidneys decompensate due to back pressure, causing hydronephrosis and hydroureter. The ureters thicken initially to compensate but eventually dilate severely and lose contractile power.
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jslum.
com | Medicine Obstructive Uropathy
Definition Aetiology (Causes)
Obstruction of Urinary Tract Congenital Acquired Lead to Renal Impairment Congenital Narrowing Urethral stricture (Infection, Injury) Meatal stenosis Benign Prostatic Hyperplasia (BPH) Classification Distal urethral stenosis Prostate Cancer Causes – Congenital, Acquired Posterior urethral valve (PUV) Bladder Tumour Duration – Acute, Chronic Ectopic ureters (Bladder neck, Ureteral orifices) Degree – Partial, Complete Ureterocoeles CaP, Cervical cancer (CaCx) Level – Upper Urinary Tract, Lower Urinary Tract Ureterovesical (VUJ) (extension into base of bladder Ureteropelvic Junctions (PUJ) Stenosis occluding ureters) Anatomy S2-S4 Sacral Root Damage Compression of Ureters at Pelvic Brim Spina Bifida by metastatic nodes from CaP, CaCx Myelomeningocoele Ureteral Stones Vesicoureteric Reflux (VUR) Retroperitoneal Fibrosis Malignant Tumour Pregnancy Neurogenic Bladder
Pelvi-Ureteric Junction (PUJ) Obstr.
Stones
VUR
Bilateral VUR due to PUV
Staghorn Calculi
Bladder Outlet Obstruction (BOO)
Bilateral VUR 2° to Prune Belly Syndrome
Tumours
Stricture jslum.com | Medicine
Pathophysiol ogy Upper Tract Changes
Obstruction, Neuropathic Bladder Dysfun ction Hydroureter (HU) have same effects on GUT Hydronephrosis (HN) Upper Tract Ureter Lower Tract (Ureter, Kidney) Early Stages Late Stages Distal to Bladder Neck BPH Intravesical Pressure is Normal when Decompensation + Residual Urine Severe external urinary Bladder fills ↓ Pressure ↑ only in Voiding Added Stretch Effec t meatal stricture ↓ Pressure is not Transmitted to Incompetence of VUJ valves Bladder Ureters, Renal Pelves because ↓ BPH competence of VUJ valves VUR Trigonal Hypertrophy ↓ Lower Tract Changes (Bladder) ↓ Further Hyd roureteronephrosis ↑ Resistance Urine Flow 2° to Back Pressure Obstruction ↓ (due to reflux, obstruction) ↓ Progressive Back Pressure on ↓ ↑ Hydrostatic Pressure Ureter, Kidney Ureteral Musculature Thickens ↓ ↓ (push urine downward by peristaltic Hydroureter, Hydronephrosis activity – Compensation Stage) Dilation of Urethra ↓ ↙ ↓ ↘ Elongation, Tortousity of Ureter Diverticulum Prostatic Duct Dilation Infected Urine Fibrous tissue band formation ↓ ↓
Extravasation Further Angulate Ureter
(during contraction) ↓ ↓ Periurethral Abscess 2° Ureteral Obstruction At this stage, removal of obstruction below may not prevent Kidney from undergoing progressive obstruction Ureteral Wall Attenuated (due to ↑ Pressure) ↓ Contractile Power is Lost (Decompensation stage) ↓ Severe Ureteral Dilatation (like Bowel Loops) Kidney Normal Kidney Pressure ≈ 0 When Pressure ↑ - Pelvis, Calyces Dilate 2 Stages (depend on d uration, degree, site)(the higher, the greater effect on Kidney) Compensation Decompensation If Intrarenal Pelvis - Parenchyma affected (compared to extrarenal) Bladder musculature Hypertrophy Decompensation of Early Stage Later Stage (to balance ↑ urethral resistance) Detrusor Muscle results in Pelvic musculature Hypertrophy Muscle become Stretched Trabeculation of Bladder Wall presence of Resid ual Urine (RU) (to force urine past obstruction) ↑ Atonic (Decompe nsated) Cellules after voiding Progression of Hydronephrotic Atrophy Diverticula Earliest change – Calyceal Hydronephrosis Mucosal changes With ↑ Pressure, Normal Concave Calyx Trabeculation of Bladder Wall become Flattened then become Convex (clubbed) Normal Mucosa – Smooth Renal Parenchymal changes due to Hypertrophy • Compression atrophy (from ↑ Intrapelvis Pressure) ↓ • Ischaemic Atrophy (from Haemodynamic changes) Individual muscles bundle become taut (manifested in Arcuate vessels that run at base of Pyramids) → Spotty Atrophy ↓ Tubules become Dilated Coarse interwoven appearance Cells Atrophy from Ischaemia Trigonal muscle, Interureteric ridge Hypertrophy Hydronephrosis (un usual type of Pathologic change) ↓ Only in Unilateral Hydronephrosis ↑ Resistance urine flow in Intravesical ureteral segments Advanced stages of Hydronephrotic Atrophy is seen ↓ Eventually, Kidney become Functional obstruction of VUJ Completely Destroy ed ↓ Back Pressure on Kidney Appears as Thin-Walled Sac filled with Clear Fluid, Pus ↓ ↑ Intrarenal Pressure Hydroureter, Hydronephrosis Cause Suppression of Renal Function The Closer Intrapelvic Pressure approaches Glomerular Filtration Pressure Obstruction ↑ in the presence of Significant Residual Urine The ↓ Urine can be secreted Cellules GFR, RBF ↓ Mucosa between Superficial Muscle Bundles is Pushed Concentrating Power is Gradually Lost ↓ Urea/Creatinine Ratio ↓ (compared to Normal Kidney) Formation of Small Pockets (Cellules) Completely Obstructed Kidney Diverticula Continue to secrete Urine (which is reabsorbed via Tubules, Lymphatics) Cellules force through entirely the musculature of Bladder Wall (Normally – other secreting organs – cease sec reting when completely obstructed) ↓ Intrapelvic Pressure ↑ Rapidly Saccules ↓ ↓ Extravasation of Urine from Renal Pelvis into Parenchymal Interstitium Diverticula (reabsorbed by lymphatics) ↓ May be embedded in Perivesical Fat or covered by Peritoneum ↓ Intrapelvic Pressure (depending on location) (Allow Further Filtration) Unable to expel content efficiently into Bladder after 1° obstruction has been removed Compensation (No Muscle Wall) Markedly Hydronephrotic Kidney continue to Function Does not contain true urine (only H2O, Salts) As Unilateral Hydronephrosis Progress Normal Kidney undergo compensatory hypertrophy (Maintain Total Renal Function) Successful Anatomical Repair of Obstruction of Kidney Fail to Improve Powers of Elimination If Both Kidney Equally Hydronephrosis Strong Stimulus Continually Exerted on Both to Maintain Maximum Function jslum.com | Medicine
Clinical Features Recovery of Function
Loin Pain (due to Capsule Stretch, Presence of Calculu s, Infection ) Depend on Ureteric, Renal Colic Degree of Obstruction Complete Anuria Duration of Obstruction Complete Bilateral Obstruction Prevent Renal Impairment Complete Obstruction of Single Functioning Kidney Relief of Complete Urinary Obstruction should be achieved expediently Polyuria Decompress Urinary System Temporarily Partially Obstruction – impairment of Renal Tubular Concentrating Ability Temporary Drainage device Hematuria (Microscopic/ Occult) Until Management can be executed Urinary Stones Obstruction & Infection Malignancy Urological emergency Infection Require Uraemia • Immediate relief Bilateral Obstruction, Obstruction of a solitary Kidney (Foley Catheter, Ureteral Stent, Percutaenous Nephrostomy Tube) Results in • Broad spectrum Antibiotics (prevent Life-threatening Urosepsis) • Weakness • Pallor Relieve Obstruction (Decompress Upper Tract Obstruction) • Weight Loss Ureteral Stent Percutaenous Nephrostomy • Peripheral Edema Small tube Small Tube • Mental status change Renal Pelvis → Bladder Placed through Flank (placed endos copically, with Directly into Renal Pelvis Investigations Fluoroscopic guidance ) (percutaneously by Urologist, KUB X-Ray Performed in Operating Room (OR) Interventional Radiologist) Renal Function Test (RFT) Under Local Anaesthesia (LA) Require only Local Anaesthesia (LA) Urine Adequate Sedation Full Microscopic Examination (FEME) Culture, Sensitivity (C&S) Ultrasound KUB Urinary Tract Intravenous Urography (IVU) CT Urography/ CT Renal Protocol Retrograde Pyelography (RPG) Antegrade Pyelography (APG) DTPA DMSA Complications Treatment Pyelonephritis, Pyonephrosis Aims (eg. gross pus within obstructed renal pelvis of a funtionless kidney) Relieve Obstruction Abscess formation Treat Underlying Cause Urosepsis Prevent, Treat Infection Urinary Extravasation with Urinoma Formation Relief Symptoms Urinary Fistula Formation Preserve Renal Function Renal Parenchymal Loss Depend on (long term obstruction leading to renal insufficiency, failure) Degree of Obstruction Renal Impairment Infection Site of Obstruction Expeditious Intervention, Hos pitalization Complete Obstruction Obstruction of a Solitary Kidney Infection (Fever, Leukocytosis, Bacteriuria) Azotemia Pyonephrosis Uncontrolled Colic Pain Nausea, Vomiting, Dehydration Prognosis Depend on Medical Treatment Cause Analgesics Antibiotics Site Voltaren Bactrim Degree (partial, complete) Pethidine Trimethoprim Duration of Obstructive process Presence of Concomitant Infection Zinnat Favourable Prognosis Expected if Ciprobay Renal Function Good Obstruction Corrected Infection Eradicated
