Urinary tract obstruction

Lesson for clinical clerk

 Learning objtectives
• You should
– Recall urinary tract structure and function in
understanding the effects of obstruction at different
levels in the urinary tract
– Understand how the rate of onset of obstruction
influences symptoms and outcomes
– Appreciate the impotance of benign prostatic
hyperplasia and urethral stricture as treatable causes
of urinary tract obstruction
– Be aware that insidious onset can result in
irreversible upper tract changes
 Upper urinary tract obstruction
• Occuring at point between the renal
medulla and the bladder lumen
• Is usually unilateral, except with extrinsic
cause, such as pelvic tumers,
retroperitonium fibroblasis et al.
• The renal pelvis and ureter above the level
of the obstruction become distended
( hydronephrosis and hydroureter).
 The cause of obstuction
• Intraluminal cause
• Intramural cause
• Extrinsic cause
• Intraluminal cause
– Calculus: by far the most common
– Clot
– Renal papillary necrosis
• Intraluminal cause
• Intramural cause
• Extrinsic cause
• Intramural cause
– Urothelial tumour of ureter / of bladder
– Congenital pelviureteric junction obstruction
– Ureteric stricture
– ureterocele
• Intraluminal cause
• Intramural cause
• Extrinsic cause
• Extrinsic causes
– Ureteric injury, most often iatrogenic
– Direct invasion from carcinoma of cervix,
uterus, prostate or bladder
– Retroperitoneal fibrosis, which may be
malignant, inflammation or idiopathic
– pregnancy
• Acute obstruction usually cause loin pain
but chronic obstruction can be silent
• If bilateral may present with sign of renal
failure (Uremia)
• Pain in the flank radiating along the
course of the ureter
• Gross total hematuria
• Gastrointestinal symptoms
• Chills, fever, burning on urination, and
cloudy urine
• Uremia: nausea, vomiting, loss of weight
and strength, and pallor
• An enlarged kidney
• Renal tenderness
• Cancer of the cervix
• A large pelvic mass( tumor or
• pregnancy)
• Ascites :
• Laboratory findings
• X-Ray findings
• CT sonography MRI
• Isotope scaning
• Insrumental examination
 Treatment
• Depends on the cause,but the dialated collecting
system proximal to the obstruciton can be
drained with a percutaneous cannula under
ulrasound or radiographic control, to provide
temporary relief of the obstruction
• This protects renal function while the level and
cause of the obstruction is determined and
definitive treatment planned.
• It also permits antegrade urography, which
may be very useful in diagnosis.
• If the cause is known to be untreatable
pelvic malignancy, the decision to relieve
obstruction needs to be taken with care, to
avoid compromising best palliation.
 Lower urinary tract obstruction
• Obstruction occuring distal to the bladder
(intravesical obstruction) causes voiding
difficulty initially.
• Such bladder outflow obstruction is very
common and of great impotance in urology.
 Causes
• Acquired causes in adult may be structural:
– Urethral stricture
– Benign prostatic hyperplasia
– Carcinoma of the prostate
– Other pelvic tumour
– Bladder neck hypertrophy
• Or functional:
– Bladder neck and sphincter dysynergia
 Prostate: benign hyperplasia
• Benign prostatic hyperplasia (BPH) is detectable in nearly all men
over the age of 40 years, and in later years some degree of bladder
outflow obstruction will often develop as a result.
• Is the most common cause of bladder outflow obstruction in men.
• Currently only one in 10 men come to require surgical treatment, but
with the advent of potentially effective drug therapies, both
symptomatic presentation and treatment rates are rising
 Clinical features
• The clinical presentation of bladder outflow
obstruction is very variable.
• Early symptoms.
– Frequecy, nocturia, hesitancy and poor
stream, or of secondary urinary infection
– Such symptoms may be tolerated for many
years, and patients may not complain at all
untill retention of urine occurs
• Induration about a stricure
• Rectal examination:
• atony of the anal sphincter
• Enlargement of the prostate
• Urinary stream (force and caliber)
• Retention of urine
• Acute retention: with a apparently sudden and
distressing inability to pass urine. The bladder
is tender and tensely distended, and the patient
is well aware of a desperate urege to pass urine
• Alternatively, the bladder may undergo gradual
progressive dialation and this results in painless
chronic retention and eventually overflow
incontinence.
• The stretched and weakened detrusor
gives way in places to form diverticulae,
which come to contain stagnant infected
urine and often urinary stones.
• This insidious presentation is more serious
since bladder function may not recover
completely.
• Neglected obstruction
• More importantly though, untreated obstruction
can lead eventually to bilateral upper tract
obstruction and consequent renal impairment
(obstructive uropathy).
• Patients may then present for the first time with
signs of established chronic renal failure with
polyuria, anorexia, vomitting, hypertension and
impaired consciousness.
 Investigation
• This depends on the stage at which the
patient presents
• Patient presenting with early outflow
symptoms require careful assessment to
exclude other causes of similar symptoms,
especially bladder cancer and prostate
cancer:
• Urinalysis and digital rectal examinaltion
are essential
• Uroflowmetry gives an objective measure
of poor flow
• Ultrasound can be measure incomplete
bladder emptying sensitively
• A plain film is useful to exclude stones
• If there is incomplete bladder emptying,
serum creatinine should be checked and
an upper tract ultrasound examination
performed since consevative management
may be contraindicated.
 Treatment

• Patients presenting with acute retention require

relief with urethral (or percutaneous suprapubic
catheterisation
• Most will subsequently require surgical
treatment, but if there is no good preceding
history of out flow symptoms then a trial removal
of catheter may be followed by a return to
voiding, allowing elective assessment of the
bladder outflow.
 Medical treatment
• Alpha-adrenergic blockers inhibit
contraction of the prostate capsule and
bladder neck, which can improve mild
symptoms.
• 5α-Reductase inhibitors can cause gradual
shrinkage of the prostate, but their place in
treatment is not established
 Surgery

• Transurethral prostatic resection (TURP)

remains the current standard treatment
• Retropubic (open) prostatectomy is reserved
for very large glands
• Alternative “minimally invasive” treatments:
– Tranurethral laser coagulation/resection
– Transurethral microwave thermotherapy/TUMT
– Prostate stents
– Balloon dilatation
Urethra stricture
 Causes
• Stricture results from contraction and fibrosis
occurring during healing of a urethral injury or
after an episode of inflammation
• Traumatic
– Major pelvic fracture:urethral rupture
– Perieal trauma: a fall astride
– Iatrogenic: insrumentation or catheterisation
• Infective and inflammatory
– Gonococcal urethritis
– Non- specific urethritis
 Diagnosis
• Urethral stricture should be suspected in a
young man with poor urine flow.
• The urine flow rate has a characteristic
plateau appearance
• The diagnosis is confirmed by
urethroscopy and further assessed by
contrast urethrography.
 Complications of urethral
stricture
• Complications are generally those of long-
term bladder outflow obstruction:
• Commom
– Urine infection
– Epididymitis
• Rare
– squmous carcinoma
 Treatment
• Urethral dialation has been in used for centuries
but provides temporary relief only and has to be
repeated at intervals
• Endoscopic incision (optical urethrotomy) may
be curative but often has to be supplemented by
intermittent self- catheterisation by the patietnt.
• Formal urethroplasty (open urethral repair) is
required for long, recurrent or dense strictures
 Case 1
• A man aged 74 years presents with a
history of passing no urine for 12 hours.
He denies previous urinary symptoms but
on direct questioning admits that he has
needed to get out of bed two or three
times each night to pass urine for several
years. He is now very restless and
uncomfortable, with a constant urge to
pass urine:
Is it true???Why?
• Catheterisation should be deferred until renal
function has been assessed by urgent blood
biochemistry
• The bladder should be decompressed slowly to
avoid causing heavy heamaturia
• The retention may have been precipitated by
antidepressant medication
• The most likely cause is benign prostatic
enlargenmen
• Blood should be taken for PSA assay within 24
hours
 Answers
• False. This presentation is of acute retention and
early relief by catheteration takes priority over
investigation
• Controversial . Although bleeding can occur
from the bladder after decompression by
catheterisation, this is more common after
chronic retention and furthernore, is not
prevented by slow decompres-sion. But in
clinical practice we are warmed to do in this way.
• Yes Any drug with anticholinergic action
can precipitate retention
• True.
• False. The PSA level may be spuriously
elevated soon after retention or
catheterisation.
 About prostate cancer. True or
false??why?
• Prostate cancer is present in most men over 80
years age
• A serum PSA greater than 100ug/litre suggests
skeletal metastases
• A serum PSA of 15ug/litre is diagnositic of
prostate cancer
• Early disease can often be cured by bilateral
orchiectomy
• Abnormal uptake on bone scan can be
disregarded if radiographs of the same area are
quiet normal
 Answers
• Ture. But men have an asymptomatic
microscopic focus
• True. 80% will have a positive bone scan
• False. A PSA at this level is probably
caused by benign hyperplasia only.
• False.Orchiectomy and other types of
hormonal manipulation can produce useful
remission of advanced disease but are
never curative. Such treatment are not
indicated for early asumptomatic disease.
• False. Although bony secondaries are
usually sclerotic, this combination is also
diagnostic of metastasis
 Question about Ureteric
obstruciton: ture or false? Why?
• is most often caused by calculus
• If the plain KUB radiograph is normal, it
cannot be caused by calculus
• May be asymptomatic
• Usually causes an increase in blood urea
• Should always be relieved when
complicating advanced pelvic malignancy
 answers
• True. 90% of cases are caused by stone
• False. Not all urinary stones are radiopaque
• Ture. Especially when of gradual onset
• False. If the other kidney is normal and
unobstructed, as is usually the case, blood
biochemistry is unchanged.
• False. Each individual patient should be
considered carefully, but it is often considered
wrong to relieve a painless terminal complication
and then expose the patient to a painful death
from other cause in some country but not in
China.
 Case 2
• This 83-year-old man has started wetting
his bed at night, and has anorexia and
weight loss. You have his blood
biochemistry results, and the report of an
abdominal ultrasond examination.
• Look at the results, and then explain to the
patient what treatment you recommend
• Blood biochemistry: Na 135 K3.8 Urea 42
Creatinine 280
• Ultrasound report: Liver, gallbladder,
spleen unremarkable. There is gross
bilateral hydronephrosis and hydroureter.
The bladder is hugely distended, although
the patient has just voided, and the
bladder volume is established as 3500ml
 Discuss of case 2
• He has overflow incontinence secondary
to bladder outflow obstruction, complicated
by obstructive renal failure.
• You should explain the need for prompt
urethral catheterisation, both to relieve the
renal obstruction, and to treat the incontin-
ence
• You should explain the need for close
(probably in-paitient) monitoring of fluid
balance as an obligatory diuresis is likely
to occur, requiring fluid replacement. You
should consider explaining that the
bladder is unlikely to recover, and long-
term catheteration or intermittent self-
catheteration may be needed
 Case 3
• A man of 44 years present with a 3year history
of increasing frequency of micturation. For the
past year he has needed to wake about five
times each night to pass urine. He admits that
the stream of urine has become weaker and
prolonged. About 6years ago he was involved in
a fight and was kicked in the perineum.
• Examnation shows a mild phimosis, rectal
examination reveals a normal prostate. Urinary
flow rate is a maximum of 4ml per second, and it
takse 90 seconds for him to pass 200ml.
 Questions
• What is the most likely diagnosis?
• What other investigation should he have?
• How might he be treated initially?
• Should he have a circumcision and is so
why?
 Answers
• Symptomatic benign prostatic hyperplasia
is only occasionally seen at this age, with
funcitonal bladder neck obstruction being
rather more frequent. This history and
findings are, however, most suggestive of
obstruction caused by traumatic urethral
stricture.
• A midsteam urine specimen should be collected
for culture, since obstruction often complicated
by infection. The probable diagnosis is best
confirmed by cystoscopy (flexible or rigid),
although the actual length and position of any
urethral stricture may be better defined by
contrast urethrography. Urinary tract ultrasound
may be indicated if there is evidence of
incomplete bladder emptying, and plain
abdominal radiograph will exclude bladder
calculus.
• Urethral stricture can be mannaged initially
by dialation with urethral sounds, but
endoscopic incision of the stricture (optical
urethrotomy) has better long term results.
• Circumcision should be avoided if possible,
since long or recurrent stricture may come
to require urethroplaty and the preputial
skin may be required to form a urethral
patch