Contents

HISTORY.................................................................................................................................. 1
PHYSICAL EXAM....................................................................................................................... 3
SALIENT FEATURES.................................................................................................................. 5
INITIAL IMPRESSION................................................................................................................ 5
DIFFERENTIAL DIAGNOSIS....................................................................................................... 5
Parapelvic cyst..................................................................................................................... 5
Hydronephrosis of pregnancy.............................................................................................. 5
Abdominal aortic aneurysm................................................................................................. 5
Appendicitis......................................................................................................................... 6
Gynaecological disorders (e.g., ovarian torsion, cyst)..........................................................6
Ectopic pregnancy............................................................................................................... 6
Renal failure......................................................................................................................... 6
Bowel obstruction................................................................................................................ 6
FINAL DIAGNOSIS:................................................................................................................... 6
ETIOLOGY................................................................................................................................ 7
EPIDEMIOLOGY........................................................................................................................ 7
PATHOPHYSIOLOGY.................................................................................................................. 8
CLINICAL COURSE................................................................................................................... 9
STEP-BY-STEP DIAGNOSTIC APPROACH..................................................................................10
Laboratory Studies............................................................................................................. 10
Urinalysis........................................................................................................................ 10
Basic metabolic panel.................................................................................................... 10
Complete blood cell count..............................................................................................10
Imaging Studies................................................................................................................. 11
Ultrasonography............................................................................................................. 11
Computerized tomography scan....................................................................................11
Intravenous pyelography................................................................................................ 11
Radionucleotide studies.................................................................................................12
Magnetic resonance imaging.......................................................................................... 12
Retrograde urethrography..............................................................................................12
Retrograde pyelography.................................................................................................12
Nephrostography............................................................................................................ 12
Diagnostic Procedures....................................................................................................... 12
Cystoscopy..................................................................................................................... 12
Cystoscopy with retrograde pyelography.......................................................................13
Histologic Findings............................................................................................................. 13
Staging.............................................................................................................................. 13

PROGNOSIS........................................................................................................................... 13
PLAN OF MANAGEMENT......................................................................................................... 13
Medical Therapy................................................................................................................ 13
Surgical Therapy................................................................................................................ 14
Preoperative Details........................................................................................................... 15
Intraoperative Details........................................................................................................ 15
Postoperative Details......................................................................................................... 15
COMPLICATIONS.................................................................................................................... 15
RECOMMENDATION............................................................................................................... 16
Follow up........................................................................................................................... 16
Monitoring......................................................................................................................... 16
Patient Instructions............................................................................................................ 16
REFERENCES:........................................................................................................................ 17

Case Report: Obstructive Uropathy 1

December 11, 2012

HISTORY
Date of interview: December 4, 2012
Time of Interview: 1:30 PM
Place of Interview: AUF MC
Identifying Data:
Patient TC is a 53 years old, female, Filipino, Born again, housewife and a resident of
Pandacaqui resettlement. She was admitted for the 2nd time at AUFMC.
Date of Admission: November 29, 2012
Chief complaint: Difficulty urinating
History of Present Illness:
3 days prior to admission the patient experienced vomiting accompanied by fever
and chills. The vomiting had occurred during nighttime for 3 days. It is described to
be continues and the vomitus is watery and moderate in amount. She took 1 tablet
of omeprazole but provided no relief. Fever occurred intermittently with the highest
temperature reading of 38c. It was managed by intake of 1 tablet paracetamol and
provided temporary relief.
1 day prior to admission above signs and symptoms still persisted with
accompanying symptom of dysuria with weak and interrupted stream. The patient
described the pain to be 4/10 where in 10 is the most painful. Persistence of the
above symptoms prompted the patient to consult at the ER of AUFMC and thus was
admitted on the same day.
Past Medical History:
Immunizations: complete.
Allergies: none
Childhood illnesses: unrecalled
Adult illnesses: endometrial cancer
Hospitalizations:
- 1999, patient was admitted at A. Garcia hospital due to urinary tract
infection.
- November 22, 2012, patient was admitted at AUFMC due to fever,
chills and vomiting.
Previous surgeries:
- September 2012, patient was admitted at a private hospital in the US for
hysterectomy

Case Report: Obstructive Uropathy 2

December 11, 2012

Family History:
Patients parents are both dead, age and reason of death were unrecalled. She has
4 children who are all alive and apparently well.
Personal and Social History:
Patient lives in Pandakati, Mexico, Pampanga right now. She works in US as a baby
sitter since 2004 and comeback twice a year to visit family. Her husband is a tourist
bus driver, carpenter, and polister and does swinging. The patient had studied up to
high school. There is misunderstanding among sons which she explains as the
source of stress. When she is stressed, she shouts to other family members to leave
her alone.
Diet and Environment History
She eats 3 times a day. The most common is rice and consumes mostly vegetables
and sometimes beef or chicken. The source of the food is from market. The source
of the water is from refilling. She is nonsmoker, non-alcoholic, she has sedentary life
style.
She lives in 2 room bungalow type house with her husband, one daughter, and 3
grandchildren. The house is well ventilated, lightened, with 1 bathroom. The
garbage is collected by truck three times a week. There are no industries near the
house. She has one dog in her home.
Review of Systems:
General: Confirms presence of weight loss. No weakness, fatigue, fever & chills.
Skin: Presence of pallor. No changes in the hair or nails. No rashes, pruritus, lumps,
dryness and sores.
Head: No headache, injury, dizziness and lightheadedness
Eyes: Confirms wearing of eyeglasses. No redness, pain, irritation, excessive
tearing, double vision, spots, glaucoma, cataracts & sensitivity to light.
Ears: No abnormal hearing, pain, tinnitus, vertigo, infection, discharge and hearing
aids.

Case Report: Obstructive Uropathy 3

December 11, 2012
Nose and sinuses: No colds, nasal stuffiness, discharge, itching, hay fever,
nosebleed, sore throat, and hoarseness.
Throat: No sore tongue, gum bleeding, dry mouth and difficulty swallowing.
Neck: No lumps, swollen glands, goiter, pain and neck stiffness.
Breast: No lumps pain and discharge.
Respiratory: No cough, hemoptysis, wheezing, and difficulty of breathing.
Cardiovascular: No palpitations, rheumatic fever, hypertension, murmurs, chest
pain, dyspnea, orthopnea and edema.
Gastrointestinal: Bowel movement: 3 times a day, stool semi solid, no trouble in
swallowing, no heart burn. No belching, flatulence, jaundice and gall bladder
problem. No nausea, no vomiting, no changes in bowel habit, no hemorrhoids, no
constipation, no diarrhea, no abdominal pain, no food intolerance.
Urinary: Has burning sensation after voiding. Light yellow color urine. No nocturia,
no frequency, no pain, no urgency, no UTI, no incontinence. No reduced force in
urination, no hesitancy, no dribbling.
Genital: No hernias, no sores, no discharge, no pain, no masses, no STD. Peripheral
Vascular: No leg cramps, no varicose veins, no intermittent claudication.
Musculoskeletal: No muscle or joint pains, no stiffness, no arthritis, no gout, no
backache
Hematologic: No anemia, no easy bruising or bleeding, no transfusion reactions
Endocrine: No thyroid problems, no heat or cold intolerance, no excessive
sweating, no excessive thirst or hunger, no polyuria, no change in glove or shoe size
Psychiatric: No nervousness, no depression, no memory loss, no suicidal attempts
Neurologic: No fainting, no weakness, no seizures, no numbness, no tingling, no
tremors

PHYSICAL EXAM
General Survey: conscious, coherent to time place and person, stays in a sitting
position, no effort when speaking, well kempt, and aptly groomed.

Case Report: Obstructive Uropathy 4

December 11, 2012
Vital Signs:
Temperature: 36.5
Pulse rate: 84 bpm
Respiratory Rate: 12 cpm
BP: 160/90 mm Hg
Height: 5'3"
Weight: 110 lbs
BMI: 19.48 kg/ m2 (Normal)
Skin: no discoloration, no cyanosis, with a longitudinal incision scar from umbilicus
to symphysis pubis, dry and warm to touch.
Nails: no clubbing, capillary refill count of 2 seconds
Eyes: pale palpebral conjunctiva, anicteric, pupils equally round and reactive to
light and accommodation.
Ears: no ear deformities, with cerumen of minimal amount, non-tender, no
discharges, tympanic membrane not inflamed
Nose and sinuses: symmetric with contiguous structures, no discharges, nontender
Mouth: pinkish-moist oral mucosa, moist lips, no sores, tongue in midline.
Neck: no masses, no scars, no lesions, no neck vein distention, thyroid gland barely
palpable, visible carotid artery pulsations, non-tender, no palpable nodes
Thorax: symmetric chest expansion, resonant on lung fields, clear breath sounds,
normal tactile fremitus.
Cardiovascular: PMI on 5th intercostal space Left MCL, distinct S1 and S2, no
murmurs, brisk carotid upstrokes.
Abdominal: Slightly globular, no pulsations, (+) colostomy drainage on left lower
quadrant no effluent seen on bag, moist viscera with pinkish color, skin surrounding
the bag is of good condition, no discoloration, redness nor ulcerations. Normoactive
bowel sounds 5/ minute, tympanitic on the remaining quadrants, non-tender.
Extremities: (+) grade 2, pitting edema on lower extremities, full equal pulses, full
ranges of motion, and no joint pains.
Neurologic:

Case Report: Obstructive Uropathy 5

December 11, 2012
Mental status: alert and cooperative, oriented, demonstrates good recall
Cranial nerves:
I - intact sense of smell
II - normal visual acuity, pupils equally round and reactive to light and
accommodation
III, IV, VI - (+) eye movements on all directions of gaze
V - Intact chewing/ jaw clenching
VII - symmetric facial expressions
VIII - good hearing on both ears
IX, X - gag reflex elicited, able to elevate soft palate, uvula at midline
XI - able to turn head to sides, can move shoulders against resistance
XII - no tongue deviation, ale to move freely
Sensory: no deficits
Motor: no deficits, 5/5 on all extremities
Cerebellar: can perform rapid alternating movements, and fingers to nose.

SALIENT FEATURES
53 years old, female
Vomiting accompanied by fever and chills
Intermittent fever
Dysuria with weak and interrupted stream
History of urinary tract infection.
Has burning sensation after voiding
BP: 160/90 mm Hg

INITIAL IMPRESSION
On the basis of history and PE our initial impression is Obstructive Uropathy

Case Report: Obstructive Uropathy 6

December 11, 2012

DIFFERENTIAL DIAGNOSIS
Condition
Parapelvic cyst

Hydronephrosis of
pregnancy

Abdominal aortic
aneurysm

Appendicitis

Gynaecological
disorders (e.g.,
ovarian torsion, cyst)

Differentiating
signs/symptoms
Usually
asymptomatic.
May
appear
similar
to
hydronephrosis
but
there
is
no
obstruction present.
Hydronephrosis
is
found in 43% to 100%
of pregnant women
and tends to progress
throughout gestation;
most
patients
are
clinically
asymptomatic.

Haemodynamic
instability, personal or
family
history
of
abdominal aneurysm,
bilateral loin pain;
pulsatile mass in the
abdomen.
Focal tenderness over
McBurney's
point.
Patient often prefers
to lie still to avoid
pain on movement.
Gradual
onset
of
symptoms.
No haematuria; pain
may be associated
with menses.

Differentiating tests
If a radiologist cannot differentiate
on
ultrasound,
a
nuclear
renography scan or CT scan with
intravenous contrast can rule out
obstruction.
If a patient is asymptomatic, no
further testing is indicated.
Renal ultrasonography is indicated
if a patient has flank pain,
pyelonephritis, or renal failure.
Hydronephrosis beyond the level of
the pelvic brim is a sign that
obstruction from another cause
may be present.
Magnetic resonance urography is
an emerging technique to evaluate
the level of obstruction.
CT abdomen/pelvis with contrast
will demonstrate aneurysm sac
and extravasation of contrast if
leaking.

Diagnosis usually clinical.

CT scan can identify an inflamed
appendix.
WBC and CRP often elevated.

Perform urine pregnancy test in all

females of reproductive age before
imaging.
CT scan of the abdomen and pelvis
may
demonstrate
ovarian
pathology.
Transvaginal ultrasound is first-

Case Report: Obstructive Uropathy 7

December 11, 2012

Ectopic pregnancy

Renal failure

Bowel obstruction

May
be
haemodynamically
unstable;
unilateral
abdominal pain more
pronounced than loin
pain;
may
have
features of peritonitis
(e.g., guarding and
rebound tenderness).
No lower abdominal
pain,
no
bladder
distention; may be
pruritic, have nausea
or
anorexia;
may
have other systemic
illness
or
recent
history of dehydration
or fluid loss (e.g.,
post-surgery).
Bilious
vomiting
typically
associated
with
small
bowel
obstruction;
severe
constipation; previous
abdominal surgery or
obstructed
hernia
present. May have
concurrent
dehydration
and
acute renal failure.

choice
investigation
if
a
gynaecological cause is more likely
than renal colic: may demonstrate
ovarian torsion.
Positive
pregnancy
test
and
gestation of about 6 weeks with
ectopic pregnancy.
Transvaginal ultrasound reveals
ectopic pregnancy, dilatation of
fallopian tube and free fluid if
present.

Catheterisation: minimal urine.

Urea and creatinine: elevated urea
and creatinine.

Abdominal x-ray may demonstrate

dilated bowel loops.
CT abdomen may show dilated
loops of bowel and transition point
if mechanical obstruction present.

FINAL DIAGNOSIS:
On the basis of history and PE our initial impression is OBSTRUCTIVE UROPATHY.

ETIOLOGY

Case Report: Obstructive Uropathy 8

December 11, 2012
Causes of urinary obstruction include:

prostate enlargement (in men), which may be benign or malignant

stones (can be in the kidneys, ureter, or bladder)

tumor (can be anywhere in or outside the urinary tract, compressing it)

infection

blood clots

enlarged uterus in pregnant women

weak bladder that cannot push the urine out (due to certain medications or
neurologic conditions)

abnormal congenital structures (abnormal tissue that blocks the connection

between the kidney and the ureter, or within the urethra ), especially seen in
children

abnormal tissue that results from instrumentation of the urinary tract (also
called strictures)

foreign body

trauma with pelvic fracture

EPIDEMIOLOGY
United States
No data are available on incidence and prevalence of urinary obstruction in
unselected populations. Most epidemiologic studies of obstruction are in selected
populations or autopsy studies. In large surveys of elderly men for symptoms of
urinary obstruction, a prevalence of 20-35% has been estimated. Most (60%) of the
men surveyed with moderately severe to severe symptoms of prostatism did not
consult their physicians with these symptoms. Postmortem examinations have
found hydronephrosis in 3.8% of adults and 2.0% of children.
Mortality/Morbidity
Urinary tract obstruction may lead to acute or chronic renal insufficiency or overt
kidney failure. Obstruction may lead to a salt-losing nephropathy and urinary
concentrating defects. Renal tubular acidosis (RTA) type IV, hyperkalemia,
hypomagnesia, and hypophosphatemia are common sequelae of chronic
obstruction. Although acute or chronic obstruction may cause urinary tract infection
(UTI), other sequelae such as renal calculi, hypertension, and polycythemia are
associated with a chronic setting. Ascites is a common sequela of neonatal
obstruction syndrome. In cases of acute obstruction, a postobstructive diuresis
following relief of the problem is well described.
Sex

Case Report: Obstructive Uropathy 9

December 11, 2012
In adults, incidence and etiology of urinary obstruction vary significantly with the
age and sex of the patient.
In young and middle-aged men, renal calculi are the most common cause of
at least temporary urinary obstruction. Rare cases of obstructive uropathy
due to seminal vesicle cyst and appendiceal mucocele have been reported.
In young and middle-aged women, gynecologic surgery, pregnancy, and
cancers of pelvic organs are important etiologies of obstruction.
Age
Special considerations in pediatric patients include acquired or congential urethral
stricture, congenital ureteropelvic junction (UPJ) or ureterovesical junction (UVJ)
obstruction, vesicoureteral reflux, and urolithiasis.
After age 60 years, urinary obstruction is most common in men secondary to
prostatic hypertrophy; prostate cancer accounts for occasional cases.

PATHOPHYSIOLOGY
Normal urine production in an adult is about 1.5-2 L/day. Urine flow depends on 3
factorsa pressure gradient from the glomerulus to the Bowman capsule,
peristalsis of the renal pelvis and ureters, and the effects of gravity (ie, hydrostatic
pressure).
Obstruction of the urinary tract at any level eventually results in elevation of
intraluminal ureteral pressure. With prolonged obstruction, ureteral peristalsis is
overcome and increased hydrostatic pressures are transmitted directly to the
nephron tubules.
As pressures in the proximal tubule and Bowman space increase, glomerular
filtration rate (GFR) falls. After 12-24 hours of complete obstruction, intratubular
pressure decreases to preobstruction levels. If complete obstruction is not relieved,
a depressed GFR is maintained by decreases in renal blood flow mediated by
thromboxane A2 and angiotensin II (AII). With continued obstruction, renal blood
flow progressively falls, resulting in ischemia and incremental nephron loss. Thus,
obstructive uropathy may lead to obstructive nephropathy. Several phases of
obstructive nephropathy may be seen, including an early hyperemia and a late
vasoconstriction followed by regulation of GFR post obstruction. Recovery of GFR
depends on the duration and level of obstruction, preobstruction blood flow, and
coexisting medical illness or infection.

Case Report: Obstructive Uropathy 10

December 11, 2012
Chronic urinary tract obstruction can lead to permanent damage to the
urinary tract. Infravesical obstruction can lead to
changes in the
bladder, such as trabeculation, cellule formation,
diverticula, bladder wall thickening, and, ultimately,
detrusor muscle decompensation. Progressive back
pressure on the ureters and kidneys can occur and
can cause hydroureter and hydronephrosis. The
ureter can then become dilated and
tortuous, with the inability to adequately propel urine
forward. Hydronephrosis can cause permanent
nephron
damage and renal failure. Urinary stasis along
any portion of the urinary tract increases the risk of stone
formation and infection, and, ultimately, upper
urinary
tract injury. Urinary tract obstruction can cause
longlasting effects to the physiology of the kidney, including its
ability to
concentrate urine.

CLINICAL COURSE
Pain secondary to stretching of the urinary collecting system is the most common
symptom in acute obstruction. Prevalence of pain is related more to acuity of
obstruction than degree of distention. Acute obstruction of the ureter by a calculus
commonly results in an excruciating pain, commonly referred to as renal colic. This
pain is described as unrelenting, radiating from the flank to lower abdomen and
testicles or labia on the affected side.
By contrast, pathological processes that slowly obstruct, such as retroperitoneal
tumors, are relatively pain free. Prostatic hypertrophy also may be associated with
an obstructive uropathy that is relatively painless. It usually is identified when a
superimposed acute obstruction occurs with the inability to void effectively; the
resultant painful, distended bladder prompts a visit to an emergency physician.
Alterations in patterns of micturition often associated with more distal obstructions
are early but frequently missed symptoms. Although anuria is dramatic and specific
for obstruction, nocturia and polyuria are much more common presenting symptoms
associated with renal concentrating defects due to partial obstruction. Bladder
outlet obstruction leads to the symptoms of prostatism (eg, frequency, urgency,
hesitancy, dribbling, decrease in voiding stream, the need to double void).
Acute and chronic renal failures are common complications of urinary obstruction.
Obstructive nephropathy should be considered especially in uremic patients without
a previous history of renal disease, hypertension, or diabetes.

Case Report: Obstructive Uropathy 11

December 11, 2012
Gross or microscopic hematuria often is associated with renal calculi, papillary
necrosis, and tumors, all of which can cause obstruction.
Recurrent UTIs should always lead to an investigation for urinary obstruction.
New-onset or poorly controlled hypertension secondary to obstruction and increased
renin-angiotensin has been reported.
Polycythemia secondary to increased erythropoietin
hydronephrotic kidney also has been reported.

production

in

the

History of recent gynecologic or abdominal surgery can give important clues to the
etiology of urinary obstruction.
Pediatric patients may present with recurrent infections. Symptoms of voiding
dysfunction such as enuresis, incontinence, or urgency should be sought.
A thorough medication history should be elicited. A variety of drugs and toxins
affect renal function. Bladder dysfunction is seen with a variety of xenobiotic drugs
with antimuscarinic anticholinergic activity such as antihistamines, antipsychotics,
and antidepressants. A variety of xenobiotics such as ethylene glycol, indinavir,
methotrexate, phenylbutazone, or sulfonamides will induce crystal deposition
throughout the tubulointerstium obstructing urine output. Additionally, drug-induced
retroperitoneal fibrosis may obstruct ureteral function such as methysergide or
other natural-occurring ergotamines.
In cases of both acute and chronic obstructive uropathy, occupational exposure
history may be beneficial. For example, in textile manufactures, shipyard workers,
roofers, or asbestos miners, retroperitoneal fibrosis due to asbestos-induced
mesothelioma should be considered. Bladder cancerinduced outlet obstruction may
occur in textile workers, rubber manufacturing workers, leather workers, painters,
hairdressers, or drill press workers exposed to alpha- or beta-naphthylamine, 4aminobiphenyl, benzidine, chlornaphazine, 4-chlor-o-toluidine, 2-chloroaniline,
phenacetin compounds, benzidine azo dyes, or methylenedianiline.

STEP-BY-STEP DIAGNOSTIC
APPROACH
Laboratory Studies

Urinalysis

Urinalysis can provide useful information in evaluating for infection or

hematuria.
WBCs in the urine can indicate infection or inflammation.

Case Report: Obstructive Uropathy 12

December 11, 2012

Nitrite- or leukocyte esterasepositive urine indicates infection.

All urine that contains WBCs or is positive for nitrite or leukocyte
esterase should be sent for culture analysis and antibiotic
susceptibility.
RBCs in the urine can be present in infection, stones, or tumor. A
urologist should evaluate all patients with microscopic or gross
hematuria to ensure that malignancy is not present. These patients
require urine cytology and a full hematuria workup (cystoscopy, upper
urinary tract imaging).
Urine pH is useful in the evaluation and workup of stones.

Basic metabolic panel

Renal insufficiency is detected on a basic metabolic panel based on

elevated BUN and creatinine levels. This can result from bilateral renal
obstructive processes or obstruction in a solitary kidney.
Other metabolic abnormalities can also be present in renal
insufficiency.Hyperkalemia and acidosis may be present.

Complete blood cell count

Leukocytosis indicates infection.
Anemia can be due to acute processes (eg, blood loss) or chronic
processes (eg, chronic renal insufficiency, malignancy).
Imaging Studies

Ultrasonography

Ultrasonography of the kidneys and bladder is a useful imaging

modality as an initial study. It is a noninvasive inexpensive study that
does not involve radiation exposure or depend on renal function. It is
the initial study of choice in pregnant women.
In patients with intravenous pyelography (IVP) dye allergies or elevated
creatinine levels, ultrasonography is a very useful source of imaging.
In children, this is often part of the initial workup for obstructive
processes.
Ultrasonography is sensitive in revealing renal parenchymal masses,
hydronephrosis, a distended bladder, and renal calculi.
The accuracy of this imaging modality depends heavily on the
experience of the ultrasonographer.
In adults, if the ultrasonography findings are abnormal in any way,
additional imaging is usually recommended. The combination of renal
ultrasonography with flat-plate radiography of the kidneys, ureters,
and bladder (KUB) is an inexpensive initial combination.

Computerized tomography scan

A CT scan is very useful in providing anatomic detail and is often a

first-line test in the evaluation of a patient.

Case Report: Obstructive Uropathy 13

December 11, 2012

A CT scan provides information regarding the urinary tract, as well as

any possible retroperitoneal or pelvic pathologic condition that can
affect the urinary tract via direct extension or external compression.
A noncontrast CT scan should be obtained to assess for calculi. If
calculi are found, flat-plate radiography of the abdomen (KUB) should
be obtained to help determine calcium content and stone shape and to
assist in monitoring the progress of the stone. Its progress can be
observed with periodic simple radiography.
A contrasted CT scan is needed to provide information on renal
pathology.
If delayed contrast images are obtained, CT urography with 3dimensional reconstruction can provide excellent visualization of the
entire upper urinary tracts. A CT scan can be used to identify or rule
out any other intra-abdominal processes that can cause presenting
symptoms (eg, appendicitis, cholecystitis, diverticulitis, abdominal
aneurysms, ovarian cysts).

Intravenous pyelography

IVP involves the injection of dye into the venous system and a series of
KUB radiographs over time.
It can be performed in patients with a normal creatinine value (< 1.5
mg/dL) for visualization of the upper urinary tract.
It provides both anatomical and functional information.
Delayed calyceal filling, delayed contrast excretion, prolonged
nephrography results, and dilatation of the urinary tract proximal to
the point of obstruction characterize obstruction.
IVP is superior to CT scan in revealing small urothelial upper tract
lesions.
If IVP is inadequate, retrograde pyelography can be performed to
completely visualize the renal pelvis or ureter.
Patients with IVP dye allergy cannot undergo this test.
A combination CT scans and IVP (CT/IVP) test is commonplace. With
this combined technique, both modalities can be used. CT urography,
as mentioned above (see Computerized tomography scan), is also an
excellent modality.
Radionucleotide studies: A renal scan can be performed to determine the
differential function of the kidneys, as well as to demonstrate the concentrating
ability, excretion, and drainage of the urinary tract. Lasix can be administered with
the renal scan to verify delayed excretion and the presence of obstruction.

Magnetic resonance imaging

MRI is not a first-line test used to evaluate the urinary tract.

In patients who cannot tolerate a CT scan with contrast, an MRI with
gadolinium can be performed to reveal any enhancing renal lesions.

Case Report: Obstructive Uropathy 14

December 11, 2012

MRI is useful in delineating specific tissue planes for surgical planning,

as well as in evaluating the presence or extent of a renal vein or
inferior vena cava thrombus in cases of renal tumors.
MRI does not reveal urinary stones well so is not often used as a firstline test.

Retrograde urethrography: Radiographic dye is injected into the urethral

meatus via Foley catheter at the distal urethra. Fluoroscopy is used to visualize the
entire urethra for stricture or any abnormalities. This test can be particularly useful
in working up lower urinary tract trauma.

Retrograde pyelography: similar to Cystoscopy with retrograde pyelography.

Nephrostography: This can be performed in patients who have a nephrostomy
tube in place. Radiographic dye is injected antegrade through the nephrostomy
tube. With fluoroscopy, any abnormalities or filling defects in the renal pelvis or
ureter are visible. This can be safely performed even in patients with IVP contrast
allergies.
Diagnostic Procedures

Cystoscopy: Cystoscopy is the placement of a small camera called a

cystoscope through the urethral meatus and passing through the urethra into
the bladder. Any abnormalities in the urethra, prostatic urethra, bladder neck,
and bladder can be visualized. This can be performed in the office or in the
operating room.

Cystoscopy with retrograde pyelography: Retrograde pyelography is

performed in the operating room with a cystoscope in the bladder.
Radiographic dye is injected into each ureteral orifice. Then, with the use of
fluoroscopy, any ureteral or renal pelvis filling defects or abnormalities can be
visualized. The contrast load does not interfere with renal function and can be
used in patients with elevated creatinine levels. It can also be used in
patients with an IVP dye allergy because the contrast remains extravascular.

Histologic Findings
When upper urinary tract obstruction occurs, the kidney undergoes interstitial
fibrosis, with the accumulation of collagens and other extracellular matrix
components.
Staging
No staging system exists for urinary tract obstruction.

Case Report: Obstructive Uropathy 15

December 11, 2012

PROGNOSIS
Obstructive uropathy can result in permanent renal damage, but the majority of
patients recover completely if the obstruction is relieved promptly. Although benign
prostatic hyperplasia (BPH) is a common cause of obstructive uropathy, most
patients with BPH do not go on to develop obstruction. In a study of over 3000 men,
18 (2.4%) of the 737 men in the placebo group went on to develop acute urinary
retention with a mean follow-up of 4.5 years. No men in the trial went on to develop
renal insufficiency due to BPH.

PLAN OF MANAGEMENT
Medical Therapy
Consultation with a urologist should be obtained in patients with urinary tract
obstruction, as in hydronephrosis or urinary retention. A patient with complete
urinary tract obstruction; any type of obstruction in a solitary kidney; obstruction
with fever or infection; or renal failure needs immediate attention by a urologist.
Patients with pain that is uncontrolled with oral medications or with persistent
nausea and vomiting that causes dehydration also need immediate urological
attention.
A partial urinary tract obstruction in the absence of infection can be initially
managed with analgesics and prophylactic antibiotics until a complete urologic
evaluation is performed and definitive management is completed.
Antibiotics are often given for prophylaxis and should cover common urinary tract
pathogens. Commonly used antibiotics include trimethoprim-sulfamethoxazole,
nitrofurantoin, cephalosporins, and fluoroquinolones.
Pain secondary to urinary tract obstruction is often managed with oxycodone,
hydrocodone, acetaminophen, and nonsteroidal anti-inflammatory medications.
Surgical Therapy
The goal of surgical intervention is to completely relieve the urinary tract
obstruction. This can be evaluated with reimaging to ensure that the obstruction is
resolved, as well as renal function monitoring with a creatinine laboratory test. The
recovery of renal function depends on the severity and duration of the obstruction.
Different interventions can be performed to temporarily relieve the point of
obstruction. Surgical intervention is usually obtained once the point of obstruction is
identified with radiographic imaging.

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Lower urinary tract obstruction (bladder, urethra) can be relieved with the following:

Urethral catheter
A urethral catheter (size 8F-24F) is a flexible external catheter that
extends from the bladder through the urethra.
o A physician or nurse can place it. If catheter placement is difficult, a
urologist may be needed to avoid urethral trauma. The urologist may
need to perform urethral dilation, cystoscopy, or both to pass the
catheter.
o The catheter can be left indwelling, or, as an alternative, the patient
can perform clean intermittent catheterization.
o If blood is present at the urethral meatus after pelvic trauma and
suspicion of urethral injury exists, a urologist should be consulted prior
to catheter placement. Retrograde urethrography needs to be
performed to rule out urethral injury.
Suprapubic tube or catheter: If a Foley catheter cannot be passed, a
suprapubic tube can be placed percutaneously (at the bedside) or in an open
fashion (in the operating room). A suprapubic tube is placed on the lower
anterior abdominal wall, approximately 2 finger-breadths above the pubic
symphysis. Ultrasound guidance should be used for bedside procedures to
ensure proper placement without injury to adjacent structures. In patients
with previous abdominal surgery, adhesions and scar tissue may have
changed the normal bowel location, so an open approach may be preferred.
o

Upper urinary tract obstruction (ureter, kidney) can be relieved with the following:
Ureteral stent: A ureteral stent is a flexible tube that extends from the renal
pelvis to the bladder. It can be placed during cystoscopy to relieve
obstruction along any point in the ureter. A ureteral stent generally needs to
be changed every 3 months.
Nephrostomy tube: A nephrostomy tube is a flexible tube that is placed
through the back directly into the renal pelvis. If a ureteral stent cannot be
placed cystoscopically in a retrograde fashion, a percutaneous nephrostomy
tube can be inserted for relief of hydronephrosis. If needed, a ureteral stent
can then be passed in an antegrade fashion through the nephrostomy tube
tract.
The following are urologic emergencies that require immediate attention and
intervention:

Complete urinary tract obstruction

Any type of obstruction in a solitary kidney
Obstruction with fever, infection, or both
Renal failure
Pain that is uncontrolled with oral medications
Nausea and vomiting that causes dehydration

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December 11, 2012
Preoperative Details
Before any surgical intervention or any manipulation of the urinary tract, broadspectrum antibiotics should be initiated to prevent infection or urosepsis. Ideally,
before any manipulation is performed, the urine should be sterile. However, this
may not be possible in cases of emergent surgical intervention. Urine culture along
with the administration of broad-spectrum antibiotics is important.
If cystoscopy and stent are needed emergently, coagulation is not a concern. If
percutaneous drainage is necessary, coagulopathies should be corrected.
Intraoperative Details
Different interventions can be performed to temporarily relieve the point of
obstruction. If the planned procedure cannot be performed safely or is not adequate
in relieving urinary tract obstruction, other modes of urinary tract decompression
can be tried.
Postoperative Details

When a patient has long-standing urinary tract obstruction that has been
relieved, they may experience postobstructive diuresis. This physiologic
diuresis is usually self-limiting and can be managed conservatively with fluid
replacement and, if needed, electrolyte replacement. Postobstructive diuresis
is defined as diuresis of more than 200 mL/h for at least 2 hours. Patients
with severe diuresis should receive intravenous fluid replacement in the form
of half normal saline at 80% of the hourly urine volume for the first 24 hours,
then 50%. Postobstructive diuresis usually lasts 24-72 hours. Most cases are
not severe enough to require this level of attention.

COMPLICATIONS
A patient with urinary tract obstruction should see a urologist promptly because of
the serious complications that the obstruction can impose. The following are
complications of obstructive uropathy:

Infection, including cystitis (bladder infection), pyelonephritis

infection), abscess formation, and urosepsis
Urinary extravasation with urinoma formation
Urinary fistula formation
Renal insufficiency or failure
Bladder dysfunction secondary to a defunctionalized bladder
Pain

(kidney

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December 11, 2012

RECOMMENDATION
Follow up
Definitive treatment at the point of obstruction is needed after the acute obstruction
is resolved. Adults and children often have different etiologies of urinary tract
obstruction. Thus, various definitive surgical treatment options are available for
each condition. After definitive treatment is achieved, a final imaging study is
obtained to verify complete relief of the obstruction. The type of study performed,
as well as the timing of the study, is left to the discretion of the urologist.
For excellent patient education resources, visit eMedicine's Kidneys and Urinary
System Center. Also, see eMedicine's patient education articles Intravenous
Pyelogram, Cystoscopy, Magnetic Resonance Imaging (MRI), and CT scan.
Monitoring
The frequency and type of monitoring depends on the illness the patient has and
what has been done. In chronic illness (e.g., in a patient with obstructive uropathy
undergoing chemotherapy) routine stent or nephrostomy tube changes are needed
every few weeks or months.
Patients who have undergone definitive treatment such as a transurethral resection
of the prostate and whose renal function is normal may not require further follow-up
after an initial check.
For ureteric stones, follow-up is needed until the stone passes or is surgically
removed. A metabolic evaluation to look for an underlying reason for stone
formation is advised in certain patient groups (children and those who have a strong
family history of ureteric calculi or previous personal history). Follow-up for
unilateral obstruction not due to stones is focused on the underlying condition and
usually involves a multidisciplinary team approach.
Patient Instructions
Patients undergoing treatment of obstructive uropathy need to be alert to signs
such as worsening flank pain, fever, dysuria, increasing weakness, or decrease in
urine output. If patients have a catheter or nephrostomy tube, they will need to be
taught routine care of these appliances. It is critical that patients understand when
the condition has not been completely treated and that appropriate follow-up is
arranged

REFERENCES:

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December 11, 2012
Schwartz, S. I., & Brunicardi, F. C. (2010). Schwartz's principles of surgery (9th
ed.). New York: McGraw-Hill, Medical Pub. Division.
http://bestpractice.bmj.com/best-practice/monograph/643/followup/prognosis.html
http://emedicine.medscape.com/article/438890-overview
http://renux.dmed.ed.ac.uk/EdREN/EdRENINFObits/Obstruction.html