OBSTRUCTIVE

UROPATHY
NITHA. K
2ND YEAR MSC NURSING
Introduction

 The structural or functional disorder leading to impaired

urinary flow.
 The obstruction may be in the upper or lower urinary
tracts.
 Will have corresponding signs and symptoms based on
the site, degree of obstruction and duration.
Definition

 The structural or functional disorder leading to impaired

urinary flow. The obstruction may be in the upper or
lower urinary tracts and will have corresponding signs
and symptoms based on the site, degree of obstruction
and duration.
Etiology

Mechanical

Functionalal
 Mechanical
 Common anatomical sites: the PUJ, the crossing of the
ureter at the pelvic brim and the UVJ. These sites have a
tendency to be involved either by kinks or intraluminal
blocks.
 Congenital anomalies like ureteroceles, ectopic ureters,
megaureters and PUVs
 Inflammations : post surgical, infective(TB,
Schistosomiasis) or idiopathic like RPF.
 Intraluminal blocks: clots, stones ,papillary slough or
fungal balls.
 Neoplasms : Intrinsic and extrinsic. Particularly
gynaecological (uterine, cervical and ovarian
malignancies) and GI e.g. colorectal.
 Functional causes
 Seen in line with the neural and myogenic anomalies that
impair the contractile or propulsive capacity of the
urinary tract.
 Neurogenic conditions like stroke, parkinsonism, SCI,
Diabetes Mellitus, MS
 Medications anticholinergics and antihistamines.
 Myogenic conditions like mysthenia gravis and altered
muscular functions due to chronic obstruction.
 CALYX  URETER
 Hydrocalycosis  Ureterocele
 Myocalycosis  Retrocolic ureter or
 Calyceal diverticulum  aberrant
 PELVIC URETERIC  vessel obstruction
JUNCTION  Ureteric strictures
OBSTRUCTION  Ureteric valve
 Diverticulum
 Distal ureteral atresia
 BLADDER  URETHRA
 Urolithiasis  Posterior urethral valve
 Neurogenic bladder  Posterior urethral cyst
 Congenital hypertrophy of
verumontanum
 Anterior urethral valve
Urethral stricture
 Meatal stenosis)
 OTHERS
 Tumours
 Phimosis
 Damage to sacral roots
S2,S4(myelomeningocele
Clinical features

 PRESENTATION WILL DEPEND ON THE SITE, THE

DEGREE OF OBSTRUCTION AND THE DURATION.
  UPPER URINARY TRACT:
Colicky pains
Proximal dilation: Hydronephrosis requires at least 3 days.
Effects of pressure and stasis: renal failure, infection
,haematuria

 LOWER TRACT:
The effects of the obstruction will manifest in the urinary
tract
Apart from dilatation proximal to the site of obstruction, the
bladder will show the effects of continued pressure. This will
show as trabeculation,sacculation and diverticulation. There
may also be VUR.
Diagnosis

 Urinalysis
 Urinalysis can provide useful information in evaluating for
infection or hematuria.
 WBCs in the urine can indicate infection or inflammation.
 Nitrite- or leukocyte esterase–positive urine indicates
infection.
 All urine that contains WBCs or is positive for nitrite or
leukocyte esterase should be sent for culture analysis and
antibiotic susceptibility.
 RBCs in the urine can be present in infection, stones, or tumor.
Urine pH is useful in the evaluation and workup of stones.
  Basic metabolic panel
 Renal insufficiency is detected on a basic metabolic panel
based on elevated BUN and creatinine levels. This can
result from bilateral renal obstructive processes or
obstruction in a solitary kidney.
 Other metabolic abnormalities can also be present in renal
insufficiency. Hyperkalemia and acidosis may be present.
 Complete blood cell count
 Leukocytosis indicates infection.
 Anemia can be due to chronic renal insufficiency or
malignancy.
 Imaging Studies
 Ultrasonography
 Ultrasonography of the kidneys and bladder is a useful
imaging modality as an initial study. It is a noninvasive
inexpensive study that does not involve radiation
exposure or depend on renal function. It is the initial
study of choice in pregnant women.
 In patients with intravenous pyelography (IVP) dye
allergies or elevated creatinine levels, ultrasonography is
a very useful source of imaging.
 Ultrasonography is sensitive in revealing renal
parenchymal masses, hydronephrosis, a distended
bladder, and renal calculi.
 The accuracy of this imaging modality depends heavily
on the experience of the ultrasonographer and has 25%
false positives.
 In adults, if the ultrasonography findings are abnormal in
any way, additional imaging is usually recommended
 Intravenous pyelography
 It provides both anatomical and functional information. 
Delayed calyceal filling, delayed contrast excretion,
prolonged nephrography results, and dilatation of the
urinary tract proximal to the point of obstruction
characterize obstruction.
 IVP is superior to CT scan in revealing small urothelial
upper tract lesions.  If IVP is inadequate, retrograde
pyelography can be performed to completely visualize
the renal pelvis or ureter or in those with contrast allergy.
 Retrograde urethrography: Radiographic dye is injected
into the urethral meatus via Foley catheter at the distal
urethra. Fluoroscopy is used to visualize the entire
urethra for stricture or any abnormalities. This test can be
particularly useful in working up lower urinary tract
trauma.
 Nephrostography: This can be performed in patients
who have a nephrostomy tube in place. Radiographic dye
is injected antegrade through the nephrostomy tube.
With fluoroscopy, any abnormalities or filling defects in
the renal pelvis or ureter are visible. This can be safely
performed even in patients with IVP contrast allergies.
 Computerized tomography scan
 A CT scan is very useful in providing anatomic detail and
is often a first-line test in the evaluation of a patient. 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
  Radionucleotide studies: A renal scan can be performed
to determine the differential function of the kidneys, as
well as to demonstrate the concentrating ability,
excretion, and drainage of the urinary tract.
  Magnetic resonance imaging
 MRI is not a first-line test used to evaluate the urinary tract.
 In patients who cannot tolerate a CT scan with contrast, an
MRI with gadolinium can be performed to reveal any
enhancing renal lesions.
 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 well so is not often used
as a first-line test.
 Diagnostic Procedures
 Cystoscopy:
 Cystoscopy is the placement of a small camera called a
cystoscope through the urethral meatus and passing
through the urethra into the bladder. Any abnormalities
in the urethra, prostate, bladder neck.
Antenatally detected hydronephrosis

 With in the more frequent use of routine USG Screening

In the incidence of antenatally detected hydronephrosis
has increased.
 Majority of the babies are asymptamatic.
 Posterior Urethral Valve

  Posterior Urethral Valves are mucosal folds at the distal

prostatic urethra that cause varying degrees of
obstruction.
 Most common cause of obstruction of bladder outflow in
male neonates and infants
 Epidemiology
 PUV affects exclusively in male infants
 Occurs in about 1 : 8,000 births
 Elevated incidence in African-Americans and children
with Down’s syndrome
 10% of cases of prenatally diagnosed hydronephrosis
overall
 Types
 Type I valves (95%) – Represents sail-like folds from the
verumontanum distally along the urethra – They are
thought to arise owing to the mesonephric ducts
inserting abnormally into the cloaca.
 Type II valves – Extend proximally from the
verumontanum to the bladder neck. – Likely have only
historical significance and are not considered to be a
clinical entity, but rather hypertrophied urethral folds
 Type III valve (5%) – Circular diaphragm distal to the
verumontanum at the level of the membranous urethra.
 Represent a cannulated septum thought by some to
represent an incomplete dissolution of the urogenital
membrane
Pathophysiology

Urethral obstruction

Alteration in urinary bladder function

Renal dysplasia

Stasis in the uppertract

 Clinical features
 Poor urinary stream
 Recurrent urinary tract infection
 Dehydration
 Electrolyte imbalance
 Diagnosis
 MCU
 USG
 MRU
 DTPA
 DMSA
Management
 Initial resuscitation
 catheterization
 correction of dehydration and electrolyte
balance
 Obstruction
 Cystoscopy and fulguration
 Vesiculostomy
 Urinary bladder function
 Keeping empty
 Night time continuous drainage
 Oxybutin
 Tamosulin
 Renal function
 Avoid dehydration
 Blood pressure monitoring
 Uroprophylaxis
 Shohl ‘ s solution
Uretero pelvic Junction Obstruction

 A uretero pelvic junction (UPJ) obstruction can be

considered a restriction to flow of urine from the renal
pelvis to the ureter, which if left uncorrected, will lead to
progressive renal deterioration.
 Epidemiology
 UPJ obstruction is the most common cause of significant
dilation of the collecting system in the fetal kidney (48%)
 Estimated at 1 in 5,000 live births.
 More commonly in boys than in girls.
 Especially in the newborn period, where the ratio
exceeds 2 : 1
 Left-sided lesions pre- dominate, particularly in the
neonate (approximately 67%). Bilateral UPJ obstruction
in 10% to 40% of cases.
 Noted in 21% of children with the VATER (Vertebral
defects, imperforate Anus, Tracheoesophageal fistula,
and Radial and Renal dysplasia) association.
Etiology

Intrinsic Extrinsic Intraluminal

Adynamic Mechanical Intra luminal
segment obstruction causes
Grading

Grade 3: Grade 4
Grade 1 : Grade 2: Wide :Wide
Slight Evident spitting spitting
spitting spitting pelvis dilated
dilated calices
Symptoms & Signs

 Asymptomatic
 Insidious onset of pain
 Sensation of draggaing heavyness that worsen by
excessive fluid intake.
 Enlarged kidney may be palpable.
 Attacks of acute real colic may occur with no palpable
swelling.
 Symptoms of UTI and/or pyelonephritis .
 Post strain hematuria
Diagnosis

 Renal ultrasound
Management

 Renal function 35-45%

 Renal function 35-45%
 APD 20mm
 APD 20mm
 ANDERSON – HYNES PYELOPLASTY (Open
 ANDERSON – HYNES PYELOPLASTY (Open
 or laparoscopic)
 or laparoscopic)
 NEPHRECTOMY
 NEPHRECTOMY
 Vesicoureteric reflux

 VUR refers to the retrograde passage of urine from the

bladder into the ureter.
 38% of children with prenatal hydronephrosis .
 May presence normal postnatal ultrasound .
 Reflux may be present in up to 70% of infants who
present with UTI.
Causes

 Primary
 Secondary
 PUV, neurogenic bladder
 Reflux of infected urine
 Damage of kidney
 Embryological development
Diagnosis
 MCU
 DMSA
Management

 Medical management
 In sterile low grade VUR most cases are not harmful to
kidney

 Low dose antibiotic

 Parasymptholytic like Oxybutylin and bladder neck alpha
recepetor
 Surgical treatment
 Severe grade
 Failed medical treatment
 Significant anatomical abnormality
 Transvesical reimplanation
 Endoscopic treatment for VUR
Urethral stricture

 Exclusively in males

 Congenital
 Infections – secondary to urethritis by catheter
 Traumatic – non iatrogenic (20%) – iatrogenic (60%)
 Present with urinary retention
 Diagnosis
 Suspected from history and PE
 IVU, retrograde urethrography (helpful)
 Endoscopy : direct visualization
 Treatment
 Diversion (intubated or tubeless)
 Manipulation (intubation, dilation)
 Endoscopic urethrotomy (knife, electrical or laser)
 Repair (excision & re-anastomosis, single staged / multi
staged repair)
 Meatal stenosis

 Usually as a result of previous episodes of meatitis by

ammoniacal inflammation.
 Associated with balanitis xerotica obliterans.

 Treatment – ventral meatotomy. – diagnosis requires

instrumental calibration or observation of voided stream.
 Phimosis

 Inability to retract foreskin.

 Neonate – physiologic due to natural adhesions between
prepuce & the glans.
 > 3yr – 90% retractable
 at 17 yr - <1% phimosis
 Secondary phimosis : early forceful retraction –
recurrent adhesions & cicatrical preputial ring.
 circumcision or dorsal slit
Nursing diagnosis

 Impaired Urinary Elimination related to bladder neck

obstruction
 Acute pain related to increased frequency of urinary
contraction
 Fluid volume deficit related to
 Knowledge deficit related to condition, prognosis
treatment
Nursing intervention

 Monitor urinary elimination, including consistency, odor,

volume,
 and color.
 Help the client select appropriate incontinence garment or pad
 for short-term management while more definitive treatment is
 designed.
 Instruct Mr. Baker to limit fluids for 2 to 3 hours before bedtime.
 Instruct him to drink a minimum of 1,500 mL (six 8-ounce
 glasses) fluids per day.
 Limit ingestion of bladder irritants (e.g., colas, coffee, tea, and
 chocolate)
 Acute Pain related to surgery
 Anxiety related to change in health status
 Deficient knowledge related to lack of information
 Risk for injury related to catheter placement
 Risk for infection related to invasive postoperative
drainage tube
 The profile of patients with obstructive uropathy in Cameroon:
case of the Douala General Hospital
 Marie Patrice Halle,  Linda Njonkam Toukep,2 Samuel Ekane
Nzuobontane, Hermine Fouda Ebana,2,4 Gregory Halle Ekane,2,3 and 
Eugene Belley Priso2,4
  cross sectional study carried out in the urology unit of the Douala
General Hospital, including patients with a diagnosis of obstructive
uropathy seen from January 2004 to December 2013. Clinical profile,
treatment and outcome data were obtained from patients records.
 Of the 229 patients included 69% were men, mean age
50 ±18 years. Associated comorbidities were
hypertension, diabetes, and HIV. Mean haemoglobin
8,40±2,4g/dl, mean GFR 10,3 ±10ml/min, 94 (41%)
patients needed emergency dialysis.
 Patients with obstructive uropathy presented with
significant impaired renal function. Main causes were
urinary stones, prostatic hypertrophy, prostatic and
cervical cancers. Renal recovery was poor, loss to follow
up and mortality high. Specific strategies to target
improvement in renal recovery and patient's survival are
needed in this patient's group.