STUDENT : AMEER SATTAR ADNAN

UNIVERSITY OF : KUFA

COLLEGE OF : NURSING

STUDTY : NIGHT

STAGE : THREE

Urinary Tract Obstruction In Children

 URINARY TRACT OBSTRUCTION IN CHILDREN

Urinary tract infections (UTIs) are a common and important clinical problem in
childhood and may lead to systemic illness and renal injury in the short term; with
repeated infections, renal scarring, hypertension, and end-stage renal dysfunction
may develop. The overall prevalence of UTI is estimated at 5% in febrile infants but
varies widely by race and gender.1,2 The highest prevalence rates of childhood UTI
occur in uncircumcised male infants under 3 months of age (prevalence ∼20%),and
among females (prevalence ∼8%).Uncircumcised older male children have the
lowest prevalence of UTI (∼1%)

• .Blockage can be complete or partial

•Blockage can lead to kidney damage, kidney stones, and infection

Symptoms can include pain in the side, decreased or increased urine flow and•
urinating at night

• Symptoms are more common if the blockage is sudden and complete

Testing can include insertion of a urethral catheter, insertion of a viewing tube into•
the urethra, and imaging tests

Treatment can include measures to open up a blocked path and to treat the cause•
of the blockage

A blockage (obstruction) anywhere along the urinary tract from the kidneys, where
urine is produced, to the urethra, through which urine leaves the body can increase
pressure inside the urinary tract and slow the flow of urine. An obstruction may
occur suddenly or develop slowly over days, weeks, or even months. An obstruction
may completely or only partially block part of the urinary tract. Sometimes only one
.kidney is affected, but obstruction may affect both kidneys

The prevalence of urinary tract obstruction ranges from five in 10,000 to five in
1,000 depending on the cause. In children, obstruction is due mainly to birth defects
affecting the urinary tract of kidney and urinary tract birth defects. Men, particularly
those older than 60, are also more likely to be affected because, as men age, the
prostate gland tends to increase in size (a condition called benign prostatic
hyperplasia

Normally, urine flows out of the kidneys at extremely low pressure. If the flow of
urine is obstructed, urine backs up behind the point of blockage, eventually reaching
the small tubes of the kidney and its collecting area (renal pelvis), swelling
(distending) the kidney and increasing the pressure on its internal structures. Such
kidney distention is called hydronephrosis. The elevated pressure due to the
obstruction may ultimately damage the kidney and can result in loss of its function.
When the flow of urine is obstructed, stones (calculi) are more likely to form. An
infection may develop when the flow of urine is obstructed because bacteria that
enter the urinary tract are not flushed out. If both kidneys are obstructed, kidney
.failure may result

Long-standing distention of the renal pelvis and ureter can also inhibit the rhythmic
muscular contractions that normally move urine down the ureter from the kidney to
the bladder (peristalsis). Scar tissue may then replace the normal muscular tissue in
.the walls of the ureter, resulting in permanent damage

Partial and complete obstruction tend to cause similar problems, but most problems,
.and particularly kidney damage, are more severe when obstruction is complete

Causes
Blockage may be partial or complete, affect one side or both sides, and develop
rapidly (acutely) or slowly (chronically). The most common causes overall are

 In children: Structural abnormalities for example, birth defects such

as valves in the inside back part of the urethra (called posterior urethral valves—
see Urethra Defects) and other constrictions that narrow or block the ureter or
urethra

 In young adults: Stones in a kidney or ureter or elsewhere in the

urinary tract

 In older adults: Benign prostatic hyperplasia (BPH) or prostate

cancer, tumors, and stones
Because BPH is so common in older men, obstruction is more common among
men. Other common causes of obstruction include strictures (narrowing caused by
scar tissue) of the ureter or urethra that develop after radiation therapy, surgery, or
procedures done on the urinary tract.

The many other possible causes of urinary tract obstruction include

the following:
 Polyps in the ureter
 Blood clot in the ureter
 Tumors in or near the ureter
 Disorders of the muscles or nerves in the ureter or bladder (such as
due to drugs that have anticholinergic effects, birth defects, or spinal cord
injury)

 Formation of fibrous (scar) tissue in or around the ureter resulting

from surgery, radiation therapy, or drugs (especially methysergide)
 Bulging of the lower end of the ureter into the bladder (ureterocele)
 Tumor, abscesses, and cysts of the bladder, cervix, uterus, prostate,
or other pelvic organs
 A large mass of feces stuck in the rectum (rectal impaction)

Hydronephrosis of both kidneys can occur during pregnancy as the enlarging

uterus compresses the ureters. Hormonal changes during pregnancy may worsen
the problem by reducing the muscular contractions that normally move urine
down the ureters. This condition, commonly called hydronephrosis of
pregnancy, usually resolves when the pregnancy ends, although the renal pelvis
and ureters may remain somewhat distended afterward.

Symptoms
Symptoms depend on the cause, location, and duration of the obstruction. When
the obstruction begins quickly and distends the bladder, ureter, and/or the
kidney, it usually causes pain. If the kidney is distended, renal colic can develop.
Renal colic is an excruciating pain between the ribs and hip on the affected side
that comes and goes every few minutes. The pain may extend into a testis or the
vaginal area. People may have nausea and vomiting.
Obstruction of one ureter does not reduce how much people urinate. Obstruction
can stop or reduce urination if blockage affects the ureters from both kidneys or
if it affects the urethra. Obstruction of the urethra or bladder outlet may cause
pain, pressure, and distention of the bladder.

People who have slowly progressive obstruction that causes hydronephrosis may
have no symptoms, or they may have attacks of dull, aching discomfort in the
flank (the part of the back between the lower end of the ribs and the spine) on
the affected side. Sometimes, a kidney stone temporarily blocks the ureter and
causes pain that occurs intermittently.

Obstruction that leads to hydronephrosis may cause vague digestive tract

symptoms, such as nausea, vomiting, and abdominal pain. These symptoms
sometimes occur in children when hydronephrosis results from a birth defect in
which the junction of the ureter and renal pelvis is too narrow (ureteropelvic
junction obstruction).

People who have urinary tract infections (UTIs) may have pus or blood in the
urine, fever, and discomfort in the area of the bladder or kidneys .

Diagnosis
 Bladder catheterization
 Imaging

Early diagnosis is important, because most cases of obstruction can be corrected

and because a delay in treatment can lead to irreversible kidney damage. Doctors
may suspect obstruction because of a person’s symptoms, such as renal colic,
symptoms of bladder distention, or a decrease in the volume of urine. A
distended kidney can rarely be felt in the flank, usually if the kidney is greatly
enlarged in an infant or a child or a thin adult. A distended bladder can
sometimes be felt in the lower part of the abdomen just above the pubic bone.
Doctors depend on testing to make the diagnosis.

Bladder catheterization

insertion of a hollow, soft tube through the urethra) is often the first diagnostic
test done in people with symptoms that suggest the bladder is distended, such as
pelvic pressure or distention. If the catheter drains a large amount of urine from
the bladder, then either the bladder outlet or the urethra is obstructed. Many
doctors do ultrasonography to determine whether the bladder is filled with a
large amount of urine before doing bladder catheterization.

Imaging tests
Imaging tests can be done to identify evidence of obstruction, such as
hydronephrosis or a site of blockage, when the presence or site of obstruction is
in doubt. For example, ultrasonography is a very useful test in most people
(particularly children and pregnant women) because it is fairly accurate and does
not expose the person to any radiation. However, ultrasonography is not always
accurate in its ability to localize the site of obstruction.

Computed tomography (CT)

is an alternative. It is rapid and highly accurate, particularly at identifying

stones. CT has traditionally involved exposure to significant doses of radiation.
However, with newer CT scanners and new ways of using them, CT images can
be obtained with much smaller doses of radiation. Magnetic resonance imaging
(MRI) is not as accurate as ultrasonography or CT, but MRI may be used if it is
important to avoid exposing the person to radiation and if the site of obstruction
cannot be seen with ultrasonography.

Other imaging tests, such as voiding cystourethrography (VCUG), may be done

to identify the site of obstruction, most often in children who have obstruction of
the bladder or urethra. This imaging test can identify blockages in those
structures (for example, caused by birth defects). It can also identify when urine
flows backward from the bladder into the ureters (called vesicoureteral reflux)
and causes urinary tract infections (UTIs) as well as obstruction. In VCUG,

x-rays are taken after a radiopaque agent (dye) is inserted through a catheter
inserted into the bladder.

Endoscopy
Endoscopy with a special rigid or flexible endoscope (a cystoscope) can be used
to examine the urethra, prostate, and bladder. A longer rigid or flexible
endoscope (ureteroscope) can be passed into the ureters or kidneys to identify
sites of obstruction. Sometimes the cystoscope, ureteroscope, or both can also be
used to remove objects causing obstruction .
Blood and urine tests

Blood tests and urine tests are done. Blood test results are usually normal
(particularly if obstruction is partial or acute), but tests may reveal high levels of
blood urea nitrogen (sometimes called BUN), creatinine, or both if obstruction
has completely blocked both kidneys for more than several hours. Results from
an analysis of urine (urinalysis) are usually normal, but white blood cells and red
blood cells may be present when a stone or a tumor is the cause of obstruction or
when the obstruction is complicated by an infection.

Prognosis
Blockage can usually be relieved, but if relief takes too long, the kidney can be
damaged permanently. However, because one normally functioning kidney is
enough to sustain the body, permanent kidney failure is unlikely to develop
unless both kidneys have been blocked for some time, usually at least a few
weeks. The prognosis also depends on the cause of obstruction. For example, an
untreated infection is more likely to cause kidney damage than a kidney stone.

Treatment
 Relief of obstruction

Treatment usually aims to relieve the cause of obstruction. For example, if the
urethra is blocked because of a benign enlarged or cancerous prostate, treatment
can include drugs, such as hormonal therapy for prostate cancer, surgery, or
enlargement of the urethra with dilators. Other treatments, such as lithotripsy or
endoscopic surgery, may be needed to remove stones that block the flow of urine
in the ureter or kidney.

If the cause of obstruction cannot be rapidly corrected, particularly if there is

infection, kidney failure, or severe pain, the urinary tract is drained. When acute
hydronephrosis is caused by an obstruction that is not easily relieved, urine that
has accumulated above the obstruction can be drained with a soft tube inserted
through the back into the kidney (nephrostomy tube) or by insertion of a soft
plastic tube that connects the bladder with the kidney (ureteral stent).
Complications of nephrostomy tubes or ureteral stents can include displacement
of the tube, infection, and discomfort. If the urethra is the site of an obstruction
that must be relieved rapidly, doctors insert a soft rubber catheter into the
bladder to drain urine.

Urgent relief of obstructions that causes chronic hydronephrosis is usually not

required. Complications of urinary tract obstruction, such as urinary tract
infections and kidney failure, if present, are treated promptly.