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UROPATHY
&
URINARY TRACT
CALCULI
LEARNING OBJECTIVES
A review of the anatomy and physiology of the urinary
system, and pathophysiology of obstructive uropathy and
urinary calculi formation.
Definition of obstructive uropathy.
The clinical presentation of obstructive uropathy.
The clinical presentation of patients with urinary calculi.
The investigation of a patient with obstructive uropathy
and/or urinary calculi.
The principles of management of obstructive uropathy and
urinary calculi.
OBSTRUCTIVE
UROPATHY
KIDNEYS
Separate urea, mineral salts,
toxins and other waste products
from blood
Filter out wastes to be excreted in
the urine
Regulates blood pressure
Regulates acidbase balance
Stimulates RBC production
Normal adult size:
Length: 10-12 cm
Width: 5-7cm
URETERS
Transports urine from renal pelvis of
kidney to bladder
Pass beneath the urinary bladder
which results the bladder compressing
the ureters
This prevents backflow of urine when
pressure in bladder is high during
urination
Has 3 constrictions:
Pelviureteric junction (at the origin)
Pelvic brim (when it crosses external iliac
artery)
Vesicoureteric junction (just before
entering bladder)
BLADDER
Hollow, distensible
muscular organ.
Located in the pelvic
cavity
Posterior to pubic
symphysis.
When full, become
ovoid shape
Function:
store urine
expels urine into the
URETHRA
Extends from the base of the
bladder to the external part of
body.
Length of urethra:
Male: 14cm long
Female: 4cm long
Function:
A passageway through which urine
is discharged from the body, and
also played as a reproductive organ
in male.
PHYSIOLOGY OF MICTURITION
As the urinary bladder gets filled
with urine, the bladder will stretch.
In response ,the stretch receptors
on the walls of the bladder send
signals to the CNS.
The CNS passes on motor
messages to initiate the
contraction of smooth muscles of
the bladder.
The simultaneous relaxation of the
urethral sphincter causing the
release of urine (micturition)
OBSTRUCTIVE
UROPATHY
DEFINITION
Obstructive uropathy occurs when a defect
(structural or functional) occurs in the
urinary tract leading to impaired urinary flow.
Long duration and severe obstructive
uropathy can impairs renal function, which
later leads to renal dysfunction (obstructive
nephropathy)
The obstruction may be in upper or lower
urinary tracts and will have corresponding
signs and symptoms based on the site,
degree of obstruction and duration
ETIOLOGY
Mechanical
Lumen of
urethra /
overlying
internal
urethral orifice
Wall of
bladder /
urethra
Outside the
wall
Etiology
Neurogenic
Functional
Medications
Myogenic
MECHANICAL CAUSES
In urethral lumen
or overlying
internal urethral
orifice
Congenital valves
Foreign bodies
Tumour
Blood clot
Stones
In wall of bladder
or urethra
Phimosis
Trauma (rupture of
urethra)
Urethral stricture
Urethritis
Meatal ulcer
Tumour
Prostatic
enlargement
(benign and
malignant)
FUNCTIONAL CAUSES
Neurogenic
Stroke
Spinal cord
injuries or
diseases
Diabetes
Mellitus
Medications
Myogenic
Anticholinerg
ics
Antihistamin
es
Smooth
muscle
relaxants
Myasthenia
Gravis
CLINICAL FEATURES
Features depends on:
Site affected
Degree of obstruction (partial / complete)
Duration of pathology (acute / chronic)
HISTORY TAKING
Pain
Pain can be secondary to
stretching of the urinary
collecting system
Obstruction of the ureter by a
calculus commonly results in an
excruciating renal colic pain.
Pain is described as unrelenting,
radiating from the flank to lower
abdomen and testicles or labia
on the affected side.
By contrast, pathological
processes that slowly obstruct,
such as retroperitoneal tumors
Micturition pattern
alterations
Can present as early symptoms
but often missed
Bladder outlet obstruction leads
to the symptoms of prostatism
(frequency, urgency, hesitancy,
dribbling, decrease in voiding
stream, the need to double
void)
HISTORY TAKING
Hematuria
Often associated
with renal calculi,
papillary necrosis,
and tumors
These conditions
can later develop
into obstruction
Recurrent UTI
More towards
complications of
obstruction
Bacteria can
become trapped in
urine that pools
above a blockage.
HISTORY TAKING
History of past surgery
Obtain history of recent
gynecologic or abdominal
surgery
Scarring from
instrumentation
Previous bladder or
prostate surgeries can
lead to the formation of
strictures due to scar
tissue
Medication history
Remember to obtain
medication history
A variety of drugs and
toxins affect renal
function.
Bladder dysfunction
common with usage of
antihistamines,
antipsychotics, and
antidepressants
HISTORY TAKING
Occupational History
Equally important history to obtain
Consider retroperitoneal fibrosis due to
asbestos-induced mesothelioma in case of
textile manufactures, shipyard workers, roofers,
or asbestos miners
Bladder cancerinduced outlet obstruction may
occur in textile workers, rubber manufacturing
workers, leather workers, painters, hairdressers,
Physical Examination
Suprapubic tenderness
Rectal examination
INVESTIGATIONS (BASELINE)
Urinalysis
WBCs in the urine = infection or inflammation.
Nitrite- or leukocyte esterasepositive urine = infection.
RBCs in the urine = infection, stones, or tumor.
INVESTIGATIONS (IMAGING)
Ultrasonography
Sensitive in revealing renal parenchymal masses, hydronephrosis, distended
bladder, and renal calculi.
Intravenous Pyelography
It provides both anatomical and functional information.
Delayed calyceal filling, delayed contrast excretion, prolonged nephrogram
results, and dilation of the urinary tract proximal to the point of obstruction
characterize obstruction.
Retrograde pyelography can be performed to completely visualize the renal
pelvis or ureter.
INVESTIGATIONS (IMAGING)
Computerized Tomography Scan
A CT scan is very useful in providing anatomic detail.
A CT scan provides information regarding the urinary
tract, as well as any possible retroperitoneal or pelvic
pathologic condition that can affect the urinary tract via
direct extension or external compression.
A noncontrast CT scan should be obtained to assess for
calculi.
A contrasted CT scan is needed to provide information
on renal pathology.
INVESTIGATIONS (IMAGING)
Magnetic Resonance Imaging
MRI is useful in delineating specific tissue planes for surgical planning,
as well as in evaluating the presence or extent of a renal vein or
inferior vena cava thrombus in cases of renal tumors.
MRI does not reveal urinary stones so is not often used as a first-line
test.
Cystoscopy
Any abnormalities in the urethra, prostatic urethra, bladder neck, and
bladder can be visualized.
MANAGEMENT
Medical therapy
Antibiotics
Given for prophylaxis and should cover common urinary tract
pathogens.
Commonly used antibiotics: trimethoprim- sulfamethoxazole,
nitrofurantoin, cephalosporins, and fluoroquinolones.
MANAGEMENT
Surgical therapy
The goal of surgical intervention is to completely relieve the
urinary tract obstruction.
Lower urinary tract obstruction (bladder, urethra) can be
relieved with the following:
Urethral catheter
Suprapubic tube or catheter
MANAGEMENT
Urologic emergencies that require immediate attention
and intervention:
COMPLICATIONS
Bladder diverticulum
Detrusor muscles hypertrophies to
overcome obstruction; trabeculated bladder
wall, out-pouches of bladder mucosa, form
saccule between muscle bands
Urinary retention
Due to urinary stagnation
Infection
Including cystitis, pyelonephritis, abscess
formation, and urosepsis
COMPLICATIONS
Bladder stones
Infection and stasis
Hydronephrosis
Back pressure on ureters (reflux)
Incompetent valves
Renal failure
Due to progressive hydronephrosis
Resulting in anaemia, uraemia
(obstructive uropathy)
Atonic bladder
Chronic retention : bladder is vastly
distended and atonic
Leading to overflow incontinence
Introduction
Renal calculi common
50% of patients present between ages of 30 to 50
years
Male-female ratio is 4:3
Aetiology
a)
b)
c)
d)
e)
f)
g)
Dietetic
Altered urinary solutes and colloids
Decreased urinary citrate
Renal infection
Inadequate urinary drainage and urinary stasis
Prolonged immobilisation
Hyperparathyroidism
Types of stones
1.
2.
3.
4.
5.
Oxalate calculus
Phosphate calculus
Uric acid calculus
Cystine calculus
Xanthine calculus
Types of stones
Characteristics
Oxalate calculus
Phosphate calculus
Cystine calculus
Uncommon
Congenital error of metabolism that
leads to cystinuria
Hexagonal, translucent, white crystal
of cystine in acidic urine
Pink or yellow, but change to green
when exposed to air
Radio-opaque
Xanthine
Rare
Smooth and round
Brick red
Shows lamellation on cross section
Clinical features
Renal calculi
May be clinically silent even when large (silent
calculus)
renal failure may be the first indication of bilateral silent
calculi, although secondary infection usually produce
symptoms first
Pain
Occurs in 75% of people with urinary
stones
Fixed renal pain occurs in the renal
angle, the hypochondrium, or in both
May worsen on movement
Ureteric colic: agonising pain passing
from the loin to the groin.
Often caused by a stone entering the
ureter
Hematuria
Pyuria
Chronic cases can present with
anemia
During an attack of ureteric colic,
there is rigidity of lateral abdominal
muscles
Tenderness on deep palpation
Renal punch +ve
Percussion produces stab pain
Ureteric calculi
Small stones come from the kidney
Ureteric colic
As the stone progresses to the lower ureter, loin pain is
referred to groin, external genitalia and anterior surface
of the thigh
As the stone enters the bladder, the pain can be
referred to the tip of the penis
Ureteric calculi
clinical features
Impaction
Commonly at 5 sites of narrowing
An impacted stone causes a more consistent
dull pain, often in the iliac fossa
Increased by exercise and lessened by rest
Hematuria
Generally in pain and less systematically ill
Tenderness and some rigidity over course
of ureter
Bladder stones
Primary stones occur in sterile urine, usually
originate from kidney stones
Secondary stones can occur in bladder outflow
obstruction, infection, impaired bladder emptying
or foreign body
Ureteric stones
Suprapubic pain
dysuria
intermittency
frequency
hesitancy
nocturia
urinary retention
Investigations (Diagnostic)
Kidney-Ureter-Bladder (KUB) film
Diagnose radiopaque stones
Abdominal ultrasound
To determine stone locations
Spiral CT
Investigation of choice for diagnosing uric acid stones
Investigations (Others)
Urinalysis
Colour, volume, appearance, specific gravity
Urine dipstick
Centrifuge (microscopic)
Microhematuria, urine pH
Cast cells, tumour cells
Serum calcium
Hyperparathyroidism
Management
Hydration
Analgesic (NSAIDs, acetaminophen)
Antispasmodic (CCB- Nifedipine, alpha blocker- Doxazosin)
Antibiotic
Alkalinazation of urine (Potassium citrate) for uric acid
stone
Removal of stones
Calculi smaller than 5mm passes spontaneously unless
impacted
Stones removal
Indications
Symptomatic
Obstructing micturition process
Staghorn calculi
Failure to pass spontaneously
Infection
To prevent complication
Stones removal
Kidney
Ureter
Bladder
Percutaneous
nephrolithomy
(PCNL)
Endoscopic stone
removal with
dormia basket
Transurethral
litholapaxy
Extracorporeal
shock wave
lithotripsy (ESWL)
Uteroscopic stone
removal through
push bang
Percutaneous
suprapubic
litholapaxy/
Vesicolithotomy
Pyelolithotomy
Ureterolithotomy
Open suprapubic
cystolithotomy
Nephrolithotomy
Uteroscopy
Dormia stone-catching basket in use
1. Basket introduced pass stone
2. Opened
3. Enclosing stone, ready for withdrawal
Blind
lithothrite
used to
crush
bladder
stones
Prevention of recurrence
Drink plenty of water
Avoid purine rich food (red
meat, fish)
Eggs, meat and fish are high in
sulphur-containing protein and
should be restricted in
cystinuria
Urinate more than 2 litres per
day
Maintain ideal weight