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OBSTRUCTION OF URINARY TRACT Soumya Ranjan Parida Basic B.Sc. Nursing 4 th year Sum Nursing College.

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Presentation on theme: "OBSTRUCTION OF URINARY TRACT Soumya Ranjan Parida Basic B.Sc. Nursing 4 th year Sum Nursing College."— Presentation transcript:

1 OBSTRUCTION OF URINARY TRACT Soumya Ranjan Parida Basic B.Sc. Nursing 4 th year Sum Nursing College

2 Obstruction of urinary tract Etiology – Renal dysplasia, infection Clinical features – FTT, vomiting, diarrhea Acute ureteral obstruction – abdominal pain, nausea, vomiting, Chronic ureteral obstruction – vague abdominal pain, increased fluid intake Diagnosis – Neaonatal – palpable abdominal mass Infravasical – bladder palpable, patent urachus, urinary ascitis Antenatal USG – hydronephrosis, infection, sepsis Imaging studies – USG – hydronephrosis VCUG Mercapto acetyl triglycine (MAG-3) – Recheases renal parenchyma in 2-3 minutes lasix after 20-30 min  10-15 min – ½ radionuclide  20 min delayed  15-20 min intermittent  Limitation – Newborn kidney, dehydration

3 Urinary tract obstruction IVP – infravasical obstruction, ureteral obstruction Whitaker test – 10 ml/min fluid infusion – pressure difference of more than 20 cm H 2 O b/w renal pelvis and bladder Hydrocalycosis – localized dilatation of calyx caused by obstruction of infundibulum UPJ obstruction – 60% left side M:F - 2:1 10% bilateral Intrinsic obstruction Extrinsic obstruction by artery Type 3,4 hydronephrosis without dilatated ureter Clinical features – Fetal hydronephrosis Palpable renal mass in newborn Abdominal, flank, back pain in older children Febrile UTI Hematuria without minimal UTI

4 Antenatal hydronephrosis Postnatal USG 3 rd day Grade 1,2 hydronephrosis Normal renal parenchyma Antibiotic prophylaxis Repeat USG at 1 months Grade 3, 4 hydronephrosis Abnormal renal parenchyma MAG-3 diuretic renogram Upper tract drainage Differential renal function Poor pyeloplasty good Repeat USG No improvement in hydronephrosis Repeat renogram 6-12 months surgery Grade 3, 4 hydronephrosis Abnormal renal parenchyma pyeloplasty

5 Midureteral obstruction – Retrocaval ureter – Upper right ureter travels posterior to IVC IVP shows – right ureter deviated medially at the level of L3 Surgical repair – only when obstruction is present. Acquired obstruction – retroperitonial tumors, fibrosis, inflammatory process, radiation therapy. Ectopic ureter – Ureters that drain out side the bladder M:F 1:3 Females – Bladder neck – 35% Urethrovaginal septum – 35% Vagina – 25% Cervix, uterus, gartner duct, urethral diverticulum Manifests as UTI and continuous urinary incontinence Urinary tract obstruction

6 Boys – Posterior urethra – 47% Seminal vesicval – 33% Prostatic utrical – 10% Ejaculatory duct – 5% Vas deference – 55 Manifests as UTI and epididymitis No continuous urinary incontinence. Ureterocele – M : F 1:2 Ectopic – cystic swelling extends through bladder neck into the urethra Orthotopic – ureterocele entirely within the bladder Manifest as bladder neck obstruction, b/l hydronephrosis, ureterocele prolapse through urethra VCUG shows filling defect in bladder often shows reflux ‘Drooping lily’ appearance of the kidney Urinary tract obstruction

7 Treatment – No function in upper pole, no reflux – excision of upper pole and associated ureter Function in upper pole, significant reflux, septic – transurethral incision with catery to decompress the ureterocele Orthotopic ureterocele – Discovered during screening for antenatal hydronephrosis or UTI USG – Sensitive IVP – varying degrees of ureteral and calyceal dilation, and there is a round filling defect in bladder Treatment – transurethral incision Urinary tract obstruction

8 Classification of megaureter Refluxing Obstructed Nonrefluxing & nonobstructed Primary Secondary Primary Primary reflux Megacystic- megaureter syndrome Ectopic ureter Prune- belly syndrome Neuropathic bladder Hinman syndrome Posterior urethral valve Bladder diverticulum Post opertave Primary obstructed megaureter Ureteral valve Ectopic ureter Ectopic uretocele Neuropathic bladder Hinman syndrome Posterior urethral valve Bladder diverticulum Post opertave Nonrefluxing & nonobstructed Diabetes insipidus Infection Persistent after relief of obstruction

9 Megaureter – The primary obstructed nonrefluxing megaureter results from abnormal development of the distal ureter, with collagenous tissue replacing the muscle layer There is a disruption of the normal ureteric peristalsis, and proximal ureter widens IVP – Distal ureter dilated and tapers abruptly at or above the junction of the bladder Clinical manifestation – UTI, urinary stones, flank pain Treatment – Nonobstructed megaureters diminish in size over time Obstructed megaureters – excision of narrowed segment, ureteral tapering, reimplantation of ureter Urinary tract obstruction

10 Prune-Belly syndrome (Eagle- Barret syndrome) – Incidence – 1:49000 M: F – 9.5:1 Defficient abdominal muscles, undescended testes, urinary tract abnormality Pulmonary hypoplasia Oligohydromnios Malrotation of bowel Cardiac anomaly Abnormalities of musculoskeletal system Anomalies of the urethra, uterus and vagina Treatment – No obstruction – Antibiotic prophylaxis Obstruction – Vesicostomy Urinary tract obstruction

11 Posterior urethral valves – Incidence – 1:8000 boys Tissue leaflets fanning distally from the prostatic urethra to the external urinary sphinctor Dilatation of prostatic urethra, bladder muscles under go hypertrophy VUR (50%), distal ureteral obstruction Mild hydronephrosis to renal dysplasia Oligohydromnios, pulmonary hypoplasia Antenatally – b/l hydronephrosis, distended bladder, oligohydromnios Postnatally – distended urinary bladder, weak urinary stream, FTT, sepsis Treatment – NG tube is inserted in bladder and left for several days Sreum creatinine normal – Tranurethral ablation of valve leaflets/vesicostomy Sreum creatinine high – vesicostomy Uremia without infection – medical management Uremia with infection – life saving measures, antibiotics, percutaneous nephrostome, and hemodialysis Urinary tract obstruction

12 Urethral atresia – Distended bladder, b/l hydronephrosis, oligohydromnios Infants are still birth Patent urachus – oligohydromnios unlikely Treatment – Continent urinary diversion Urethral hypoplasia – Urethral lumen is very small B/L hydronephrosis, distended bladder Passage of NG tube is diffucult Treatment – Urethral reconstruction, Gradual urethral dilation, Continent urinary diversion Urinary tract obstruction

13 Urethral strictures – Males – Urethral trauma either accidental or iatrogenic Decrease in urinary stream is seldom noted Bladder instability, hematuria, dysuria Catheterization imposible Treatment - Endoscopic dilation of stricture Females – True urethral stricture is rare b/c urethra is protected from trauma ‘Spinning top’ deformity on VCUG Urinary tract obstruction

14 Anterior urethral valves – It is rare No obstructive valve leaflets It is a urethral diverticulum in penile urethra that expands during voiding Soft mass on the ventral surface of the penis at the penoscrotal junction Weak urinary stream Treatment – Open excision of diverticulum Trans urethral excision of the distal urethral cusp Urinary tract obstruction

15 Urolithiasis Composition – Calcium, oxalate, uric acid, cysteine, ammonium, phosphate crystals or combination of these substances. Classification – Ca oxalate and Ca phosphate Cystine stones Struvite stone Uric acid stone Indinavir stones Nephrocalcinosis

16 Stone formation – Matrix – Mixtures of proteins, non amino sugars, glucosamines, water, organic ash. 2-9 % of dry weight Precipitation-crystallization – Supersaturation of the urine with specific ions comprising of crystals. Epitaxy – Aggregation of crystals of different composition but similar lattice structer Inhibitors – Citrate, diphosphonate, Mg++ Clinical manifestation – Renal pelvis and calyx – gross or microscopic hematuria, abdominal or flank pain. Distal ureter – Dysuria, urgency, frequency. Bladder – Asymptomatic Urethra – Dysuria, difficult voiding Urolithiasis

17 Diagnosis – KUB x-ray – all are radiopaque except cystine and uric acid USG abdomen – limitation ureteric calculi Nonenhanced spiral CT Metabolic evaluation – Serum – Calcium, phosphorus, uric acid, electrolytes and anion gap, creatinine, alkaline phosphatase Urine – Urinolysis, urine culture, Ca:Cr ratio, Spot test for cystinuria 24 hr urine for – Ca, PO 4, oxalate, uric acid, Diabasic amino acids (COAL) Urolithiasis

18 Ca oxalate and Ca phosphate – Hypercalciuria without hypercalcemia – Absorption, renal, resorption Hyperoxaluria – Primary - Increased production Glycolic aciduria, L-glyceric acidosis Secondary – Increased intake Pyridoxine deficiency, intestinal malabsorption Enteric hyperoxaluria - IBD, pancreatic insufficiency, biliary disease Hyperuicosuria Hypocitruria – Chronic diarrhea, malabsorption, RTA Cystinuria Hypomagnesuria Hyperparathyroidism RTA type 1 Urolithiasis

19 Cystine stones – Defective renal tubular absorption – cystinuria – low osmolality, acidic urine – stone formation Struvite calculi – Magnesium ammonium phosphate, staghorn configuration UTI by urea splitting organism – urinary alkalinization – excess NH 3 production – precipitation of MAP and CaPO 4 – stone formation Uric acid calculi – Hyperuricosuria with or without hyperuricemia Acidic urine and urate crystalluria Lesh Nyhan syndrome, G6PD, short bowel syndrome, chronic diarrhea, acidosis, tumor, myeloproliferative disorders Urolithiasis

20 Indinavir calculi – Radiolucent Soluble at Ph < 5.5 Urinary acidification by NH 4 Cl and ascorbic acid Nephrocalcinosis – Deposition of calcium in renal parenchyma Treatment – Removal depends upon location, size, composition, obstruction, infection Maintain high urine output ESWL of bladder, ureter, small renal pelvis Calcium stones – Decrease Ca and Na in diet. Thiazide diuretics Potassium citrate – 1-2 meq/kg/day Lemon juice – 120 ml ( 84 meq citric acid ) Urolithiasis

21 Uric acid stone – Allopurinol Alkalinization of urine – Ph > 6.5 NaHCO 3 and Na citrate Cystine stone – Alkalinization of urine – Ph > 6.5 D-Penicillamine N-Acetyl cystein Primary hyperoxaluria – Hepatic transplant Urolithiasis


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