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Hydronephrosis and Upper Urinary Tract

Definition of Hydronephrosis
Hydronephrosis is caused by an obstruction of the urine flow from the kidney.
Hydronephrosis means literally "water inside the kidney" and refers to the distension and
dilation of the pyelocaliceal system.

Differential diagnosis of Hydronephrosis

Urinary retention:

Prostate diseases: benign prostatic hyperplasia, prostate cancer, prostatic cyst.

Bladder diseases: bladder tumors, bladder stones, bladder neck sclerosis, detrusor
sphincter dyssynergia (DSD).

Diseases of the urethra: urethral stricture, carcinoma, foreign bodies, phimosis,

urethral valves.

Medication, alcohol, postoperative urinary retention, diabetes mellitus.

Ureter diseases causing hydronephrosis (intrinsic causes):

Ureteral stone

Ureteral clot due to hematuria

Congenital diseases: ureteropelvic-junction obstruction, vesicoureteral reflux,

megaureter, ureterocele.

Benign ureteral stricture: after ureteral stone therapy, infection (tuberculosis,

schistosomiasis), idiopathic.

Ureteral cancer

Iatrogenic Causes of Hydronephrosis:

Intraoperative injuries: ureteroscopy, rectal surgery, hysterectomy, vascular surgery.

The spectrum of injury ranges from ischemic strictures due to coagulation to complete
transection and ligature.

Irradiation, radiation injury of the bladder trigone

Hydronephrosis due to Vascular Diseases:

Aortic aneurysm

Renal artery aneurysm

Aneurysm of the iliac vessels

Retrocaval ureter or retroiliac ureter

Puerperal ovarian vein thrombophlebitis: 1/3000 pregnancies. Hydronephrosis most

common on the right side, spontaneous healing is common.

After vascular surgery: hydronephrosis triggered by a periureteral fibrosis or by

intraoperative injury.

Gynecological Diseases Causing Hydronephrosis:

During pregnancy, the enlarged uterus can compress the ureter (right more than left)
and may cause pyelonephritis during pregnancy.

Puerperal ovarian vein thrombophlebitis: 1/3000 pregnancies. Hydronephrosis most

common on the right side, spontaneous healing is common.

Endometriosis: recurrent flank pain, dysuria, hematuria

Extra-uterine pregnancy

Tuboovarial abscess

Pelvic floor insufficiency with organ prolapse

Tumors: cervical cancer, ovarian cysts, ovarian cancer, uterine leiomyoma ...

Hydronephrosis caused by Diseases of the Retroperitoneum:

Retroperitoneal tumors: lymphoma, retroperitoneal sarcoma, retroperitoneal germ cell


Lymph node or distant metastases: prostate cancer, cervical cancer, breast cancer,
colon cancer, stomach cancer, bladder cancer, ....

Retroperitoneal fibrosis

Pelvic lipomatosis : rare disease with pelvic fat accumulation and cranial
displacement of bladder and ureters.

Diseases with Upper Urinary Tract Dilatation without Obstruction:

Ureteropelvic-junction obstruction


Caliceal diverticula

Renal scintigraphy is necessary to judge the significance of the upper urinary tract

Diagnostic Work-Up in Hydronephrosis

Classification of hydronephrosis in grade IIV (Beetz and others, 2001).

Hydronephrosis grade I: dilatation of the renal pelvis without dilatation of the calices.
Prominent reflex of the renal sinus without signs of parenchymal atrophy.
Hydronephrosis grade II: dilatation of the renal pelvis and calices. Attenuated sinus reflex.
No signs of parenchymal atrophy.

Hydronephrosis grade III: Missing or marginal sinus reflex. Minor signs of organ atrophy
present (flat papillae and blunt fornices).
Hydronephrosis grade IV: massive dilatation of the renal pelvis and calices. Borders between
renal pelvis and calyces are missing. Significant signs of renal atrophy (thin parenchyma).

Sonography of kidney and ureter (see above).

Intravenous urography or computed tomography of the abdomen (with or without

contrast media) or MRI abdomen.

Renal scintigraphy: to differentiate between relevant obstruction or dilatation of the

caliceal system without obstruction. Renal scintigraphy can determine renal function
and the need for surgical interventions.

Retrograde pyelography and ureterorenoscopy: necessary for diagnosis and treatment

of upper urinary tract obstruction (ureteral stenting, ureterotomy).

Hydronephrosis is commonly divided into four grades according to dilation of the

pelvicalyceal system and cortical thinning that can be visualised on ultrasound, CT and MRI.



dilation of the renal pelvis without dilatation of the calices
Grade dilation of the renal pevis and calices, that become convex; no signs of
cortical thinning
presence of cortical thinning
massive dilation of the real pelvis and calices, severe cortical thinning

1. Beetz R, Bkenkamp A, Brandis M, Hoyer P, John U, Kemper MJ, et al. [Diagnosis of

congenital dilatation of the urinary tract. Consensus Group of the Pediatric Nephrology
Working Society in cooperation with the Pediatric Urology Working Group of the German
Society of Urology and with the Pediatric Urology Working Society in the Germany Society
of Pediatric Surgery]. Urologe A. 2001 Nov;40(6):495507; quiz 508509
2. Quaia E. Radiological Imaging of the Kidney. Springer; 2011:354
3. Kim S-Y, Kim M-J, Yoon CS, Lee MS, Han KH, Lee M-J. Comparison of the reliability of

two hydronephrosis grading systems: the Society for Foetal Urology grading system vs. the
Onen grading system. Clin Radiol. 2013 Sep;68(9):e484490.

What is an intravenous pyelogram (IVP)?

An IVP is an imaging test used to look at the kidneys and ureters. The ureters are the narrow
tubes that carry urine from the kidneys to the bladder.
During the test, the radiologist injects a contrast dye into one of your veins. He or she uses Xray images to watch the contrast dye as it moves from the kidney into the ureter and then to
the bladder.
Dye that moves too slowly or not at all may mean that you have a blockage in the blood flow
through a kidney. It may also mean that the kidney, ureter, or bladder is not working as well
as it should.
This test is usually one of the first tests ordered when your healthcare provider thinks you
may have kidney disease or a urinary tract problem.
X-rays use a small amount of radiation to create images of your bones and internal organs. An
IVP is one type of X-ray.
This test may be done at the same time as a CT scan of the kidneys (nephrotomography). The
CT scan also uses contrast dye. It makes images that show layers or slices of the kidney.

Why might I need an intravenous pyelogram?

An IVP can show your healthcare provider the size, shape, and structure of your kidneys,
ureters, and bladder. You may need this test if your provider suspects that you have:

Kidney disease

Ureter or bladder stones

Enlarged prostate

Trauma or injury to the urinary tract


Your provider may also use this test to find the cause of flank pain or pain spasms in the
kidney area.

A CT scan of the kidneys will make a more accurate diagnosis of kidney tumors or kidney
problems caused by trauma.
Your healthcare provider may have other reasons to recommend an IVP.

What are the risks of an intravenous pyelogram?

You may want to ask your healthcare provider about the amount of radiation used during the
test. Also ask about the risks as they apply to you.
Consider writing down all X-rays you get, including past scans and X-rays for other health
reasons. Show this list to your provider. The risks of radiation exposure may be tied to the
number of X-rays you have and the X-ray treatments you have over time.
Tell your healthcare provider if you:

Are pregnant or think you may be pregnant. Radiation exposure during pregnancy
may lead to birth defects.

Are allergic to or sensitive to any medicines, contrast dye, or iodine. Because contrast
dye is used, there is a risk for allergic reaction to the dye.

Have kidney failure or other kidney problems. In some cases, the contrast dye can
cause kidney failure. You are at higher risk for this if you take certain diabetes

Possible complications of this test also include problems urinating and urinary tract
You may have other risks depending on your specific health condition. Be sure to talk with
your provider about any concerns you have before the procedure.
Certain things can make this test less accurate. These include:

You have feces or gas in your colon

You have poor blood flow to the kidneys

You have barium in your intestines from a recent barium test

How do I get ready for an intravenous pyelogram?

Your healthcare provider will explain the procedure to you. Ask him or her any
questions you have about the procedure.

You may be asked to sign a consent form that gives permission to do the procedure.
Read the form carefully and ask questions if anything is not clear.

You'll be asked to not eat or drink liquids (fast) before the procedure. Your healthcare
provider will tell you how long to fast. It might be several hours or overnight.

Tell your healthcare provider if you are pregnant or think you may be pregnant.

Tell your healthcare provider if you are allergic to contrast dye or iodine.

Tell your healthcare provider if you are sensitive to or are allergic to any medicines,
latex, tape, or anesthetic drugs (local and general).

Tell your healthcare provider about all medicines you are taking. This includes
prescriptions, over-the-counter medicines, and herbal supplements. If you have
diabetes and take metformin, you may need to stop taking this medicine several days
before the exam.

Tell your healthcare provider if you have had a bleeding disorder. Also tell your
provider if you are taking blood-thinning medicine (anticoagulant), aspirin, or other
medicines that affect blood clotting. You may need to stop these medicines before the

You need to take a laxative the night before the test and have a cleansing enema or
suppository a few hours before the test.

You may need to have a blood test to see how well your kidneys will react to the
contrast dye.

Follow any other instructions your healthcare provider gives you to get ready.

What happens during an intravenous pyelogram?

You may have an IVP as an outpatient or as part of your stay in a hospital. The way the test is
done may vary depending on your condition and your healthcare provider's practices.
Generally, an IVP follows this process:
1. You will be asked to remove any jewelry or other objects that may get in the way of
the test.
2. You may be asked to remove clothing. If so, you will be given a gown to wear.
3. An intravenous (IV) line will be inserted in your hand or arm.
4. You will be asked to lie face up on an X-ray table.
5. The radiologist will take an X-ray of your kidneys, ureters, and bladder.

6. The radiologist will inject the contrast dye into the IV. You may feel a flushing
sensation, a salty or metallic taste in your mouth, a brief headache, itching, or nausea
or vomiting. These effects usually last for a few moments.
7. The radiologist will take a series of X-rays as the dye travels through the kidneys and
urinary tract. This usually lasts about 30 minutes. You may be asked to change
positions while the X-rays are taken.
8. You will be asked to empty your bladder. You may be given a bedpan or urinal. Or
you may be allowed to use the restroom.
9. After you have emptied your bladder, the radiologist will take a final X-ray to see
how much contrast dye remains in the bladder.

What happens after an intravenous pyelogram?

You do not need any special care after an IVP. You may go back to your usual diet and
activities, unless your healthcare provider tells you differently.
You should keep track of how much fluid you are drinking and how much urine you pass
over the next day (24 hours). You may be told to drink more fluids to help flush the contrast
dye from your body.
Call your healthcare provider right away if any of these happen:

Fever or chills

Redness, swelling, or bleeding or other drainage from the IV site

Blood in your urine

Nausea, hives, itching, or sneezing

Your healthcare provider may give you other instructions, depending on your situation.

Next steps
Before you agree to the test or the procedure make sure you know:

The name of the test or procedure

The reason you are having the test or procedure

What results to expect and what they mean

The risks and benefits of the test or procedure

What the possible side effects or complications are

When and where you are to have the test or procedure

Who will do the test or procedure and what that persons qualifications are

What would happen if you did not have the test or procedure

Any alternative tests or procedures to think about

When and how will you get the results

Who to call after the test or procedure if you have questions or problems

How much will you have to pay for the test or procedure