Obstruction and infection

Urinary tract obstruction

Classification of obstructive uropathy

Patrick H OReilly

Obstructive Uropathy

Menelaos Philippou

Upper Tract

Abstract

Acute

Urinary tract obstruction is a common problem. It may be acute or chronic,

affect the upper or lower urinary tract, or both, and often presents as
a urological emergency. In non-acute cases, appropriate management
is necessary to prevent irreversible nephron loss and renal failure. In
recent years, the techniques available to accurately diagnose the site
and extent of obstructive uropathy have become more sophisticated,
and many of the conditions responsible lend themselves to less invasive
and even laparoscopic keyhole techniques. This chapter examines the
various types of obstructive uropathy, their causes and diagnoses and
the current surgical techniques available for treatment.

Unequivocal

Non-Function

Equivocal

Interactive

Figure 1

Upper urinary tract obstruction

Acute obstruction
Acute obstruction to the upper urinary tract is usually caused
by a ureteric stone (see also pages 415419), which has passed
from the renal pelvis to become arrested at the pelvi-ureteric
junction (PUJ), the ureter or at the vesico-ureteric junction
(VUJ). Acute ureteric colic is usually extremely painful, often
the worst pain the patient has ever experienced. Traditionally,
the diagnostic tool has been the intravenous urogram (IVU)
where a series of radiographs are taken following the injection
of contrast medium. In acute obstruction, there will be a dense
nephrogram and delayed films will demonstrate a dilated ureter down to the level of the obstruction. Computed tomography
(CT) urogram is now the preferred diagnostic test as virtually all
stones are visible on a CT scan, whereas only 7080% of stones
are seen on a plain radiograph.2 The only exception to this rule
is indinavir calculi caused by the antiviral agent of the same
name used in the treatment of HIV which are radiolucent on
CT imaging. If the patients loin pain is not due to a stone, the
CT may well show up an alternative cause, which an IVU rarely
does. Rapid multiplanar CT scanners have considerably reduced
the radiation dose associated with CT scanning, and a quick
(seconds or minutes) unenhanced CT scan can demonstrate the
presence of a urinary calculus.
The IVU is still valuable where the radiologist or CT scanner
is not available. A single-shot IVU (full-length post-micturition
prone film 20 minutes after contrast injection) is a very valuable
quick test of function and drainage. Nuclear medicine studies are
unhelpful in acute obstruction.
The treatment of urinary tract calculi is with non-invasive treatments such as electrohydraulic shock wave lithotripsy (ESWL),
and ureteroscopy with lithoclast or laser shattering of the stones.
Follow-up includes dietary advice and periodic plain films.

Keywords obstructive uropathy; ureteric colic; urinary tract obstruction;

urological emergency

There are many causes of urinary tract obstruction. To ensure a

logical approach to the subject, it is useful to divide it into upper
tract obstruction (e.g. ureteric stone), or lower tract obstruction (e.g. prostatic hypertrophy). Upper tract obstruction may
be acute or chronic. Chronic obstruction can be subdivided into
three types:
unequivocal, where the cause and effect are established
beyond doubt
equivocal, where the upper tract is dilated but not necessarily
obstructed
end-stage, where there is a post-obstructive, non-functioning
kidney.
Lower tract obstruction may simply impede bladder emptying,
or can occasionally interact with the upper tract, for example, in
high-pressure chronic retention where the obstructed high pressure bladder causes slow but steady upper tract dilatation and
hydronephrosis.1 This classification is demonstrated in Figure 1.

Paddy OReilly FRCS is a Consultant Urologist at Stepping Hill Hospital,

Cheshire, UK. He qualified and trained in Urology in Manchester. His
research interests include obstructive uropathy, prostate diseases and
nuclear medicine. He is past President of the British Association of
Urological Surgeons. Competing interests: none declared.
Menelaos Philippou MBChB is Senior House Officer in Urology at
Stepping Hill Hospital, Cheshire, UK, and his ambition is to pursue
a career in that specialty. He was born in Cyprus and qualified in
Medicine at the University of Manchester, UK. Competing interests:
none declared.

MEDICINE 35:8

Chronic

Lower Tract

Unequivocal chronic obstruction

Unequivocal chronic obstruction (Table 1) refers to the finding
of a dilated upper urinary tract with a demonstrable non-acute
420

2007 Published by Elsevier Ltd.

Obstruction and infection

Equivocal chronic obstruction

Dilatation does not necessarily mean obstruction as several
conditions can mimick obstruction on scans and IVUs, and
the dilated upper tract is, in fact, working perfectly well and
is completely unobstructed. Dilated renal pelves mimicking
pelvi-ureteric junction obstruction (for example, in pregnancy
and in renal transplantation), dilated ureters from primary nonobstructive megaureter, or previous vesicoureteric reflux, and
other conditions were clarified mainly by the development of
diuresis renography.4,5 In this test, a 99mTc-MAG-3 renogram
is performed giving intravenous frusemide 15 minutes before or
20 minutes into the test. If there is dilatation without obstruction, the radionuclide washes out. If genuine obstruction exists,
the curve remains obstructed. The diuresis renogram is now
the standard test to distinguish between obstructed and nonobstructed dilatation.

Causes of unequivocal chronic obstruction

Primary megaureter
Retrocaval ureter
Retroperitoneal fibrosis
Urothelial tumours
Ureteric stones
Ureteric strictures
Congenital
Tuberculous
Bilharzial
Iatrogenic
Radiation
Retroiliac ureter
Ovarian vein syndrome
Endometriosis
Extrinsic obstruction
Bowel malignancy (e.g. colon)
Pelvic malignancy (e.g. ovary; cervix)
Pregnancy
Ureterocoele
Bladder cancer
Malacoplakia
Benign prostatic hyperplasia (high-pressure chronic retention)
Prostate cancer
Procidentia
Pelvic lipomatosis
Urethral stricture
Phimosis

Lower urinary tract obstruction

Lower urinary tract obstruction can be caused by a variety of
conditions including bladder cancer, bladder neck obstruction,
benign or malignant prostatic hypertrophy, procidentia, urethral
stricture and phimosis. The principal complaint that patients
with lower urinary tract obstruction present with can be divided
into voiding and storage symptoms. Voiding symptoms include
hesitancy, poor flow, dribbling, haematuria and dysuria.
Storage symptoms include frequency, urgency and nocturia.
Symptoms may eventually become so severe as to cause complete outflow obstruction resulting in retention of urine. This
may be acute or chronic.
Acute retention
Acute retention is characterized by the painful inability to pass
urine. Most patients will display symptoms prior to this although
occasionally it presents out of the blue, often after delayed micturition and overdistension of the bladder. Catheterization will provide
prompt relief of the extreme pain. Investigation is geared towards
finding the actual cause of the retention. Careful history-taking,
urinalysis, digital rectal examination, and measurement of serum
urea and creatinine are mandatory.6 In the case of benign prostatic
hypertrophy (BPH), oral alpha-blockers followed by a trial without catheter 48 hours later results in resumption of micturition
in over half the cases.7 Further investigation including symptom
review, urinary flow rates and residual urine estimation will identify which patients require transurethral resection of the prostate
(TURP) rather than out-patient follow-up. Prostate specific antigen
(PSA) estimation should be delayed for 34 weeks since it often
rises during retention/catheterization even in benign cases.

Table 1

cause for that dilatation, indicating genuine obstruction (see

also pages 415419). Imaging studies, especially CT scanning or
magnetic resonance (MR) imaging, demonstrate the anatomical
problem and its effect on the upper urinary tract (it is important to
note, however, the absence of dilation does not rule out obstruction particularly when a tumour causes encasement).3 Nuclear
medicine is useful in this situation. 99mTc-MAG3 scanning will
determine the degree of obstruction, as well as the effect the
obstructing lesion has had on underlying renal function. This is
important since it will guide the clinician towards the vital decision regarding renal conservation after removal of the obstructing
lesion, or nephrectomy if the residual renal function is seriously
and irreversibly reduced. If the kidney would be incapable of
sustaining dialysis-free life should anything destroy the contralateral organ, nephrectomy is preferred. However, in current urological practice, there are other considerations. In many cases, if time
allows it, a glomerular filtration rate (GFR) should be obtained
to get a proper estimate of single kidney GFR before making the
decision regarding nephrectomy. There is also a need to address
the role of decompression by intraureteric stents or percutaneous
nephrostomy drainage of the obstructed kidney for a period of
time to assess recoverability of function before deciding between
nephrectomy and conservation. Thus, a two-stage approach to
the situation is often the best course of action, first to deal with
the primary pathology, and thereafter to assess the renal status.

MEDICINE 35:8

Chronic retention
Chronic retention is characterized by the incomplete emptying of
the bladder following voiding. A persistent post void residual
of over 300 ml is diagnostic. Chronic retention can be divided
into low pressure and high pressure according to the detrusor
pressure at the end of micturition.
In the case of high-pressure chronic retention (HPCR), the
pressure increases even more during micturition and eventually
upper tract dilatation and impaired renal function result.8,9 The
process is slow and silent and patients often have few symptoms
421

2007 Published by Elsevier Ltd.

Obstruction and infection

but eventually present with hypertension, oedema, renal failure

and a tense, palpable, painless bladder. Nocturnal enuresis is
a cardinal symptom. Catheterization results in a high residual
volume usually greater than a litre followed by a post-obstructive
diuresis sometimes comprising several litres per day. The patients
have to be monitored to avoid volume depletion and circulatory
collapse. Ultrasound imaging usually confirms hydronephrosis
and hydroureter. Patients are usually discharged with a longterm catheter to await maximum renal recovery before TURP.
The post-operative outcome is usually extremely good.

7 Kirby RS, Pool IL. Alpha adrenoceptor blockade in the treatment of

BPH: past, present and future. Br J Urol 1997; 80: 52132.
8 George NJR, OReilly PH, Barnard RJ, et al. High pressure chronic
retention. BMJ 1983; 286: 178083.
9 George NJR, OReilly PH, Barnard RJ, et al. Practical management of
patients with dilated upper tracts and chronic retention of urine.
Br J Urol 1984; 56: 912.

Further reading
OReilly PH, ed. Obstructive uropathy. Berlin: Springer-Verlag, 1986.
Prigent QA, Piepz A. Functional imaging in nephrourology. Oxford:
Taylor and Francis, 2006.
Weiss RM, George NJR, OReilly PH. Comprehensive urology. London:
Mosby, 2001.

References
1 Jones DA, George NJR. Interactive obstructive uropathy in man:
a review. Br J Urol 1992; 69: 33745.
2 Smith RC, Levine J, Dalrymple NC, et al. Acute flank pain: a modern
approach to diagnosis and management. Semin Ultrasound CT MR
1999; 20: 10835.
3 Claudon M, Mandry D, Dacher J-N. The contribution of radiology
in functional imaging in nephrourology. In: Prigent A, Piepz A,
Functional imaging in nephrourology. New York, NY: Taylor and
Francis, 2006.
4 OReilly PH, Testa HJ, Lawson RS, et al. Diuresis renography in
equivocal urinary tract obstruction. Br J Urol 1978; 50: 7680.
5 OReilly PH. Standardisation of the renogram technique for
investigating the dilated upper tract and assessing the results of
surgery. BJU Int 2003; 91: 23943.
6 Murray K, Massey A, Feneley RCL. Acute urinary retention a
urodynamic assessment. Br J Urol 1984; 56: 46873.

MEDICINE 35:8

Practice points
Obstructive uropathy can affect the upper urinary tract, or the
lower urinary tract
Upper tract obstruction may be unequivocal or equivocal
Upper tract assessment may include ultrasound scanning, CT
urography and diuresis renography. Intravenous urography is
still available but used less than in the past
Lower tract obstruction may be acute or chronic
Acute obstruction rarely affects the upper tract, but chronic
obstruction does. This distinction dictates the methods of
assessment

422

2007 Published by Elsevier Ltd.