Urinary tract obstruction Flashcards
(34 cards)
what comprises the upper urinary tract (i.e. supra-vesical)
- PUJ - pelvo-ureteric junction
- ureter
- VUJ - vesico-ureteric junction
what comprises the lower urinary tract (i.e. bladder outflow obstruction)
- bladder neck
- prostate
- urethra
- urethral meatus
- foreskin (eg phimosis)
what are the two types of causes of UPPER tract obstructions
intrinsic and extrinsic
what are the PUJ INTRINSIC obstructions
- PUJ obstruction (physiological)
- Stone
- Ureteric tumour (TCC)
- Blood clot from e.g. renal tumours
- Fungal ball- more common in the elderly
what are the PUJ EXTRINSIC obstructions
- PUJ obstruction (crossing vessel)
- Lymph nodes (tumour
- Abdominal mass (tumour)
what are the ureter INTRINSIC obstructions
- Stone
- Ureteric tumour (TCC)
- Scar tissue
- Blood clot
- Fungal ball
what are the ureter EXTRINSIC obstructions
- Lymph nodes (tumour, retroperitoneal fibrosis)
- Iatrogenic - usually from surgery
- Abdominal/pelvic mass (tumour, pregnant uterus)
what are the VUJ INTRINSIC obstructions
- stone
- bladder tumour
- ureteric tumour
what are the VUJ EXTRINSIC obstructions
- cervical cancer
2. prostate cancer
where are abdominal masses most likely to cause obstructions
in mid-lower thirds of the ureters
what are the symptoms for Upper tract obstructions
- can be asymptomatic - picked up in e.g. ante natal scanning
- pain - usually with acute obstruction
- frank haematuria
- symptoms of complications - e.g. symptoms of renal failure, primary tumour, etc
what are the signs of Upper tract obstruction
- palpable mass - more common in neonates and the elderly
- microscopic haematuria
- signs of complications - e.g. signs of renal failure, primary tumour, etc
what are complications of Upper tract obstruction
infection and sepsis, renal failure
CASE: 50yr old man - left sided colicky loin pain, nausea, vomiting, no PMH, no medications
On examination - 40C temp, 100BPM pulse, BP 90/60, RR 20 bpm, O2 sat 89% on air
what should the first step in his management be and what investigations should be organised
- fluids - to sort BP
- antibiotics - for infection
- analgesia - for pain
order urine sample
order CT
- must be NON-CONTRASTED
- don’t know his renal function yet
CASE: CT showed
- stone in right upper ureter
- perinephric stranding on right kidney (kidney looks hazy with puddle in the centre (urine)
what does this indicate the man has
PYELONEPHROSIS
- infection of the kidneys WITH obstruction
**pyelonephritis - infection of the kidneys WITHOUT obstruction
what are the resuscitation treatments of Upper tract obstruction
- ABCs
- IV access, ABG, urine, and blood cultures, fluid balance monitoring
- IV fluids, borad-spectrum antibiotics (if appropriate)
- Analgesia
- HDU care +/-renal replacement therapy (if appropriate)
what are the emergency treatments of Upper tract obstruction
- percutaneous nephrostomy insertion
2. retrograde stent insertion
what are the definitive treatments of Upper tract obstruction
TREAT UNDERLYING CAUSE
- e.g. stone - uteroscopy and laser lithotripsy
- e.g. ureteric tumour - radial nephropureterectomy
- e.g. PUJ obstruction - laparoscopic pyeloplasty
CASE: considering all the available treatments - what one would be best suited for our patient and why
percutaneous nephrostomy insertion - i.e. it is something to de-obstruct the kidney as fast as possible
percutaneous puncture - usually done under LA and sedation - US or Xray guidance
CASE: why would the other emergency treatment not be suitable
Ureteric stent - due to its position it may not get past stone into kidney - may accuse hole in delicate ureter
CASE: why must you never give shock therapy to break up stones if a patient is infected
if the stone is infected and breaks up - can cause sepsis as bacteria spreads through blood
- only use shock to break it up once infection has settled
how does a Lower tract obstruction present
- LUTS - including incontinence
- acute urinary retention
- chronic urinary retention
- recurrent urianry tract infection and sepsis
- frank haematuria
- formation of bladder stones
- renal failure
If a patient presents with retention what is the immediate treatment needed
catheterisation (foley catheter - ballon end)
- urethral catheter 14/16F*
- record residual
- 2 attempts (then introducer if GA experience)
- 16F SPC if urethra impassable
*16F = 16 French = 16mm diameter
CASE: two people arrive in hospital
- 65yrs acute retention
- can’t pass urine
- in agony
- creatinine 70 - 65yrs chronic retention
- can pass urine fine
- been wearing bigger trousers due to bloating
- pain free
- creatinine 170
WHO GETS THE BED??
Chronic retention gets the bed due to high creatinine - may need more monitoring
acute can be catheterised and sent home as creatinine levels normal
