2. Urinary Tract Obstruction Obstructive Uropathy : Obstructive Uropathy : Obstruction is one of the most important abnormalities of the urinary tract, it makes back pressure, and causes atrophy of renal parenchyma. It also invites infection and stone formation, which cause additional damage and can ultimately end in complete unilateral or bilateral destruction of the kidneys. Obstruction is one of the most important abnormalities of the urinary tract, it makes back pressure, and causes atrophy of renal parenchyma. It also invites infection and stone formation, which cause additional damage and can ultimately end in complete unilateral or bilateral destruction of the kidneys.

5. Etiology : Etiology : Acquired urinary tract obstruction may be due to inflammatory or traumatic urethral strictures, bladder outlet obstruction (benign prostatic hyperplasia or cancer of the prostate), vesical tumors, neuropathic bladder, extrinsic ureteral compression (tumor, retroperitoneal fibrosis, or enlarged lymph nodes), ureteral or pelvic stones, ureteral strictures, or ureteral or pelvic tumors. Acquired urinary tract obstruction may be due to inflammatory or traumatic urethral strictures, bladder outlet obstruction (benign prostatic hyperplasia or cancer of the prostate), vesical tumors, neuropathic bladder, extrinsic ureteral compression (tumor, retroperitoneal fibrosis, or enlarged lymph nodes), ureteral or pelvic stones, ureteral strictures, or ureteral or pelvic tumors.

9. Pathogenesis( Pathogenesis( 发病学, 发病机理 ) Regardless of its cause, acquired obstruction leads to similar changes in the urinary tract, which vary depending on the severity and duration of obstruction Regardless of its cause, acquired obstruction leads to similar changes in the urinary tract, which vary depending on the severity and duration of obstruction

10. A. Urethral Changes A. Urethral Changes Proximal to the obstruction, the urethra dilates and balloons. A urethral diverticulum diverticulum may develop, and dilation and gaping of the prostatic urethra and ejaculatory ducts may occur. Proximal to the obstruction, the urethra dilates and balloons. A urethral diverticulum diverticulum may develop, and dilation and gaping of the prostatic urethra and ejaculatory ducts may occur.

11. B. Vesical Changes B. Vesical Changes Early, detrusor and trigonal thickening and hypertrophy compensate for the outlet obstruction, allowing complete bladder emptying. This change leads to progressive development of bladder trabeculation(, finally, diverticula. Subsequently, bladder decompensation occurs. Early, detrusor and trigonal thickening and hypertrophy compensate for the outlet obstruction, allowing complete bladder emptying. This change leads to progressive development of bladder trabeculation( 小梁形 成 ), finally, diverticula. Subsequently, bladder decompensation occurs.

13. C. Ureteral Changes C. Ureteral Changes The first change noted is a gradual increase in ureteral distention. This increases ureteral caliber(and stimulates hyperactive ureteral contraction and ureteral muscular hypertrophy Because the ureteral musculature runs in an irregular helical pattern, stretching of its muscular elements leads to lengthening as well as widening, causing the dilated ureter. The first change noted is a gradual increase in ureteral distention. This increases ureteral caliber( 管径 )and stimulates hyperactive ureteral contraction and ureteral muscular hypertrophy Because the ureteral musculature runs in an irregular helical pattern, stretching of its muscular elements leads to lengthening as well as widening, causing the dilated ureter.

17. D. Pelvicaliceal Changes D. Pelvicaliceal Changes The renal pelvis and calices, subjected to increased volumes of retained urine, distend. First, the pelvis shows evidence of hyperactivity and hypertrophy, and then progressive dilation and atony The renal pelvis and calices, subjected to increased volumes of retained urine, distend. First, the pelvis shows evidence of hyperactivity and hypertrophy, and then progressive dilation and atony 无力

18. Hydronephrosis. Hydronephrosis. (ureteropelvic junction stenosis) (ureteropelvic junction stenosis)

22. E. Renal Parenchymal Changes E. Renal Parenchymal Changes With continued pelvicaliceal distention, there is parenchymal compression and causes atrophy. With increased intrapelvic pressure, there is progressive dilation of the collecting and distal tubules, with compression and atrophy of tubular cells With continued pelvicaliceal distention, there is parenchymal compression and causes atrophy. With increased intrapelvic pressure, there is progressive dilation of the collecting and distal tubules, with compression and atrophy of tubular cells

24. Clinical Findings Clinical Findings A. Symptoms and Signs A. Symptoms and Signs The findings vary according to the site of obstruction. The findings vary according to the site of obstruction. Infravesical(obstruction: due to urethral stricture, benign prostatic hypertrophy, bladder neck contracture leads to difficulty in initiation of voiding, a weak stream, and a diminished flow rate with terminal dribbling. Burning and frequency are common associated symptoms. Infravesical( 膀胱下的 ) obstruction: due to urethral stricture, benign prostatic hypertrophy, bladder neck contracture leads to difficulty in initiation of voiding, a weak stream, and a diminished flow rate with terminal dribbling. Burning and frequency are common associated symptoms.

25. Supravesical(obstruction: Renal pain or renal colic and gastrointestinal symptoms are commonly associated Supravesical obstruction (eg, due to ureteral stone, ureteropelvic junction obstruction) may be completely asymptomatic when it develops gradually over a period of months. An enlarged kidney may he palpable. Costovertebral angle tenderness may be present. Supravesical( 膀胱上的 )obstruction: Renal pain or renal colic and gastrointestinal symptoms are commonly associated Supravesical obstruction (eg, due to ureteral stone, ureteropelvic junction obstruction) may be completely asymptomatic when it develops gradually over a period of months. An enlarged kidney may he palpable. Costovertebral angle tenderness may be present.

26. B. Laboratory Findings B. Laboratory Findings Evidence of urinary tract infection, hematuria, or crystalluria may be seen. Impaired renal function may be noted in cases of bilateral obstruction. Postrenal azotemia (serum changes reflecting impaired renal function due primarily to obstruction) is suggested by elevation of serum urea nitrogen and serum creatinine with a ratio greater than 10: 1. Evidence of urinary tract infection, hematuria, or crystalluria may be seen. Impaired renal function may be noted in cases of bilateral obstruction. Postrenal azotemia (serum changes reflecting impaired renal function due primarily to obstruction) is suggested by elevation of serum urea nitrogen and serum creatinine with a ratio greater than 10: 1.

27. C. lmaging Studies C. lmaging Studies Radiologic examination(IVU, Antegrade urography), Ultrasonography, Isotope studies, CT scan. Radiologic examination(IVU, Antegrade urography), Ultrasonography, Isotope studies, CT scan.

28. Complications: Complications: The most important complication of urinary tract obstruction is renal parenchymal atrophy as a result of back pressure. Obstruction also predisposes to infection and stone formation, and infection occurring with obstruction leads to rapid kidney destruction. The most important complication of urinary tract obstruction is renal parenchymal atrophy as a result of back pressure. Obstruction also predisposes to infection and stone formation, and infection occurring with obstruction leads to rapid kidney destruction.

29. Treatment: Treatment: The first goal of therapy is relief of the obstruction ( eg, catheterization for relief of acute urinary retention). Definitive therapy often requires surgery, but minimally invasive techniques are becoming utilized more often. The first goal of therapy is relief of the obstruction ( eg, catheterization for relief of acute urinary retention). Definitive therapy often requires surgery, but minimally invasive techniques are becoming utilized more often.

30. Prognosis Prognosis The prognosis 'depends on the cause, site, duration, and degree of kidney damage and renal decompensation. In general, relief of obstruction leads to improvement in kidney fumction except in seriously damaged kidneys, especially those destroyed by inflammatory scarring. The prognosis 'depends on the cause, site, duration, and degree of kidney damage and renal decompensation. In general, relief of obstruction leads to improvement in kidney fumction except in seriously damaged kidneys, especially those destroyed by inflammatory scarring.

32. HYDRONEPHROSIS Clinical Findings Clinical Findings A. Symptoms and signs A. Symptoms and signs Symptoms of obstruction are typified by the symptoms of ureteral stricture or ureteral or renal stone. Nausea, vomiting, loss of weight and strength, and pallor are due to uremia secondary to bilateral hydronephrosis. Symptoms of obstruction are typified by the symptoms of ureteral stricture or ureteral or renal stone. Nausea, vomiting, loss of weight and strength, and pallor are due to uremia secondary to bilateral hydronephrosis. An enlarged kidney may be discovered by palpation or percussion. A large pelvic mass (tumor, pregnancy) can displace and compress the ureters An enlarged kidney may be discovered by palpation or percussion. A large pelvic mass (tumor, pregnancy) can displace and compress the ureters

35. B. Laboratory Findings B. Laboratory Findings Leukocytosis is to be expected in the acute stage of infection. Little if any. elevation of the white blood count accompanies the chronic stage. Leukocytosis is to be expected in the acute stage of infection. Little if any. elevation of the white blood count accompanies the chronic stage. In the presence of significant bilateral hydronephrosis, urine flow through the renal tubules is slowed. Thus, urea is significantly reabsorbed but creatinine is not In the presence of significant bilateral hydronephrosis, urine flow through the renal tubules is slowed. Thus, urea is significantly reabsorbed but creatinine is not

36. C. imaging study C. imaging study

37. KUB: may show enlargement of renal shadows KUB: may show enlargement of renal shadows IVU:demonstrate the degree of dilatation of the pelves, calyces, and ureters. IVU:demonstrate the degree of dilatation of the pelves, calyces, and ureters. Isotope Scanning Isotope Scanning CT scan CT scan lnstrumental Examination:cystoscopy,ureteroscopy. lnstrumental Examination:cystoscopy,ureteroscopy.

38. Complications: Complications: Stagnation( of urine leads to infection. Which then may spread throughout the entire urinary system. Once established, infection is difficult and at times impossible to eradicate even after the obstruction has been relieved. If both kidneys affected, the result may be renal insufficiency. Stagnation( 滞留 ) of urine leads to infection. Which then may spread throughout the entire urinary system. Once established, infection is difficult and at times impossible to eradicate even after the obstruction has been relieved. If both kidneys affected, the result may be renal insufficiency.

39. Treatment Treatment A. Relief of Obstruction A. Relief of Obstruction B. Eradication of Infection B. Eradication of Infection

40. Prognosis Prognosis The outcome depends on the cause, site, degree, and duration of the obstruction. The prognosis is also definitely influenced by complicating infection, particularly if the infection has been present for a long time. The outcome depends on the cause, site, degree, and duration of the obstruction. The prognosis is also definitely influenced by complicating infection, particularly if the infection has been present for a long time.

41. BENIGN PROSTATIC HYPERPLASIA(BPH) Androgen and aging is main cause of BPH. Androgen and aging is main cause of BPH. Clinical Findings Clinical Findings Symptoms and signs:Typically, the patient notices hesitancy and loss of force and caliber of the stream. He may also be awakened by the urge to void several times at night (nocturia). Postvoid dribbling ( “ terminal dribbling ” ) is particularly disturbing. Symptoms and signs:Typically, the patient notices hesitancy and loss of force and caliber of the stream. He may also be awakened by the urge to void several times at night (nocturia). Postvoid dribbling ( “ terminal dribbling ” ) is particularly disturbing.

42. ④排尿困难 ④排尿困难 Difficulty of urination 1 、与排尿有关的症状：

43. The complication of infection increases the degree of obstructive symptoms and is often associated with burning on urination. Acute urinary retention may supervene. The complication of infection increases the degree of obstructive symptoms and is often associated with burning on urination. Acute urinary retention may supervene.

44. The ducts from the paired bulbourethral glands empty directly into the urethra. The unpaired prostate gland is a multilobed structure within a strong capsule and has many separate and coalesced ducts (close to 100 in most men) entering along the prostatic urethra (pictured in next slide). The paired seminal vesicle ducts join with the vas deferens on its respective side to become the ejaculatory ducts that also enter into the prostatic urethra.

45. there is a poor correlation between the size of the gland and the degree of symptoms and amount of residual urine. there is a poor correlation between the size of the gland and the degree of symptoms and amount of residual urine.

46. Frank H. Netter. The CIBA Collection of Medical Illustrations Volume 2: Reproductive System, CIBA, New York (1954) p-2. When looking from the dorsal side, the relationship of the three glands and the vas deferens to the urinary bladder can easily be seen. The next slides show these relationships in pictures from cadavers. (vas)

48. Rectum Pouch of Douglas where sperm “hang out” Urinary bladder Prostate

49. B. Laboratory Findings B. Laboratory Findings Urinalysis may reveal evidence of infection. Residual urine is commonly increased, and a timed urinary flow rate will be decreased. The serum creatinine may be elevated in cases with prolonged severe obstruction (In late-stage ) Urinalysis may reveal evidence of infection. Residual urine is commonly increased, and a timed urinary flow rate will be decreased. The serum creatinine may be elevated in cases with prolonged severe obstruction (In late-stage )

50. C. Imaging Studies : Excretory urograms are often normal and are thus not required. In late- stage eases, the study may show hydroureteronephrosis if severe obstruction is present. C. Imaging Studies : Excretory urograms are often normal and are thus not required. In late- stage eases, the study may show hydroureteronephrosis if severe obstruction is present. D. Endoscopic Examination : Endoscopy will reveal secondary vesical changes (eg, trabeculation) and enlargement of the periurethral prostatic glands. D. Endoscopic Examination : Endoscopy will reveal secondary vesical changes (eg, trabeculation) and enlargement of the periurethral prostatic glands.

51. E. Urodynamic Studies: Simultaneous physiologic monitoring of bladder filling anti emptying, urethral sphincter activity, abdominal pressure, and pelvic floor muscle (electromyography) can be extremely useful in documenting whether bladder outlet obstruction, poor bladder function, or other causes are responsible for lower urinary tract symptoms. E. Urodynamic Studies: Simultaneous physiologic monitoring of bladder filling anti emptying, urethral sphincter activity, abdominal pressure, and pelvic floor muscle (electromyography) can be extremely useful in documenting whether bladder outlet obstruction, poor bladder function, or other causes are responsible for lower urinary tract symptoms.

52. Differential Diagnosis Differential Diagnosis Neuropathic bladder may produce a similar syndrome. A history" suggesting a neuropathic difficulty may be obtained. Neurologic deficit involving (sacral vertebrae) S2_4 is particularly significant. Neuropathic bladder may produce a similar syndrome. A history" suggesting a neuropathic difficulty may be obtained. Neurologic deficit involving (sacral vertebrae) S2_4 is particularly significant. Cancer of the prostate also causes symptoms of vesical neck obstruction. Typically, the cancerous gland is stony hard. If serum prostate-specific antigen is over 10 ng / ml, cancer should be suspected (normal is <4 ng/ml). Cancer of the prostate also causes symptoms of vesical neck obstruction. Typically, the cancerous gland is stony hard. If serum prostate-specific antigen is over 10 ng / ml, cancer should be suspected (normal is <4 ng/ml). Urethral stricture diminishes the caliber of the urinary stream. There is usually a history of gonorrhea or local trauma. Urethral stricture diminishes the caliber of the urinary stream. There is usually a history of gonorrhea or local trauma.

53. Complications Complications Obstruction and residual urine lead to vesical and prostatic infection and occasionally pyelonephritis; these may be difficult to eradicate. Obstruction and residual urine lead to vesical and prostatic infection and occasionally pyelonephritis; these may be difficult to eradicate. The obstruction may lead to the development of bladder diverticula, Infected residual urine may contribute to the formation of calculi. The obstruction may lead to the development of bladder diverticula, Infected residual urine may contribute to the formation of calculi. Functional obstruction of the intravesical ureter, caused by the hypertrophic trigone, may lead to hydroureteronephrosis,and damage of the renal function Functional obstruction of the intravesical ureter, caused by the hypertrophic trigone, may lead to hydroureteronephrosis,and damage of the renal function

54. Treatment: Treatment: Waiting and watching: Controversy surrounds choices in the treatment of benign prostatic hyperplasia. No treatment may be appropriate in patients who complain of mild to moderate symptoms. Waiting and watching: Controversy surrounds choices in the treatment of benign prostatic hyperplasia. No treatment may be appropriate in patients who complain of mild to moderate symptoms.

55. Medication: Alpha-adrenergic blocking agents relax the internal (bladder neck) sphincter and prostatic capsule. Selective agents that are longacting and preferentially work for this purpose include doxazosin( Cardura ) and tamsulosin. 5- reductase inhibitors( Proscar) block conversion of testosterone to dihydrotestosterone ( the androgen active in promoting prostate growth) and are particularly useful for large glands and in combination with an alpha-blocker. Medication: Alpha-adrenergic blocking agents relax the internal (bladder neck) sphincter and prostatic capsule. Selective agents that are longacting and preferentially work for this purpose include doxazosin( Cardura ) and tamsulosin. 5α- reductase inhibitors( Proscar) block conversion of testosterone to dihydrotestosterone ( the androgen active in promoting prostate growth) and are particularly useful for large glands and in combination with an alpha-blocker.

56. Catheterization is mandatory for acute urinary retention. Spontaneous voiding may return, but a catheter should be left indwelling for 3 days while detrusor tone returns. If this tails, treatment is indicated. Catheterization is mandatory for acute urinary retention. Spontaneous voiding may return, but a catheter should be left indwelling for 3 days while detrusor tone returns. If this tails, treatment is indicated.

57. B. Surgical Measures: B. Surgical Measures: There are four classic approaches used in prostatectomy: transurethral, retropubic, suprapuhic, and perineal. There are four classic approaches used in prostatectomy: transurethral, retropubic, suprapuhic, and perineal.

58. The transurethral route is preferred in patients with glands weighing under 50g, because morbidity rates are lower and the hospital stay is shoter. The transurethral route is preferred in patients with glands weighing under 50g, because morbidity rates are lower and the hospital stay is shoter.

59. Larger glands may require open surgery Larger glands may require open surgery An alternative approach to the treatment of benign prostatic hyperplasia is transurethral resection of the prostate (TURP). An alternative approach to the treatment of benign prostatic hyperplasia is transurethral resection of the prostate (TURP).

60. Prognosis Prognosis Most patients with marked symptoms receive considerable relief and substantial improvement in urine flow following surgical treatment; however, those with milder forms may benefit from drug therapy. Most patients with marked symptoms receive considerable relief and substantial improvement in urine flow following surgical treatment; however, those with milder forms may benefit from drug therapy.