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URINARY > Urinary tract obstruction > Flashcards

Urinary tract obstruction Flashcards

1
Q

what comprises the upper urinary tract (i.e. supra-vesical)

A
  1. PUJ - pelvo-ureteric junction
  2. ureter
  3. VUJ - vesico-ureteric junction
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2
Q

what comprises the lower urinary tract (i.e. bladder outflow obstruction)

A
  1. bladder neck
  2. prostate
  3. urethra
  4. urethral meatus
  5. foreskin (eg phimosis)
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3
Q

what are the two types of causes of UPPER tract obstructions

A

intrinsic and extrinsic

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4
Q

what are the PUJ INTRINSIC obstructions

A
  1. PUJ obstruction (physiological)
  2. Stone
  3. Ureteric tumour (TCC)
  4. Blood clot from e.g. renal tumours
  5. Fungal ball- more common in the elderly
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5
Q

what are the PUJ EXTRINSIC obstructions

A
  1. PUJ obstruction (crossing vessel)
  2. Lymph nodes (tumour
  3. Abdominal mass (tumour)
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6
Q

what are the ureter INTRINSIC obstructions

A
  1. Stone
  2. Ureteric tumour (TCC)
  3. Scar tissue
  4. Blood clot
  5. Fungal ball
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7
Q

what are the ureter EXTRINSIC obstructions

A
  1. Lymph nodes (tumour, retroperitoneal fibrosis)
  2. Iatrogenic - usually from surgery
  3. Abdominal/pelvic mass (tumour, pregnant uterus)
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8
Q

what are the VUJ INTRINSIC obstructions

A
  1. stone
  2. bladder tumour
  3. ureteric tumour
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9
Q

what are the VUJ EXTRINSIC obstructions

A
  1. cervical cancer

2. prostate cancer

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10
Q

where are abdominal masses most likely to cause obstructions

A

in mid-lower thirds of the ureters

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11
Q

what are the symptoms for Upper tract obstructions

A
  1. can be asymptomatic - picked up in e.g. ante natal scanning
  2. pain - usually with acute obstruction
  3. frank haematuria
  4. symptoms of complications - e.g. symptoms of renal failure, primary tumour, etc
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12
Q

what are the signs of Upper tract obstruction

A
  1. palpable mass - more common in neonates and the elderly
  2. microscopic haematuria
  3. signs of complications - e.g. signs of renal failure, primary tumour, etc
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13
Q

what are complications of Upper tract obstruction

A

infection and sepsis, renal failure

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14
Q

CASE: 50yr old man - left sided colicky loin pain, nausea, vomiting, no PMH, no medications

On examination - 40C temp, 100BPM pulse, BP 90/60, RR 20 bpm, O2 sat 89% on air

what should the first step in his management be and what investigations should be organised

A
  1. fluids - to sort BP
  2. antibiotics - for infection
  3. analgesia - for pain

order urine sample

order CT

  • must be NON-CONTRASTED
  • don’t know his renal function yet
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15
Q

CASE: CT showed

  • stone in right upper ureter
  • perinephric stranding on right kidney (kidney looks hazy with puddle in the centre (urine)

what does this indicate the man has

A

PYELONEPHROSIS
- infection of the kidneys WITH obstruction

**pyelonephritis - infection of the kidneys WITHOUT obstruction

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16
Q

what are the resuscitation treatments of Upper tract obstruction

A
  1. ABCs
  2. IV access, ABG, urine, and blood cultures, fluid balance monitoring
  3. IV fluids, borad-spectrum antibiotics (if appropriate)
  4. Analgesia
  5. HDU care +/-renal replacement therapy (if appropriate)
17
Q

what are the emergency treatments of Upper tract obstruction

A
  1. percutaneous nephrostomy insertion

2. retrograde stent insertion

18
Q

what are the definitive treatments of Upper tract obstruction

A

TREAT UNDERLYING CAUSE

  1. e.g. stone - uteroscopy and laser lithotripsy
  2. e.g. ureteric tumour - radial nephropureterectomy
  3. e.g. PUJ obstruction - laparoscopic pyeloplasty
19
Q

CASE: considering all the available treatments - what one would be best suited for our patient and why

A

percutaneous nephrostomy insertion - i.e. it is something to de-obstruct the kidney as fast as possible

percutaneous puncture - usually done under LA and sedation - US or Xray guidance

20
Q

CASE: why would the other emergency treatment not be suitable

A

Ureteric stent - due to its position it may not get past stone into kidney - may accuse hole in delicate ureter

21
Q

CASE: why must you never give shock therapy to break up stones if a patient is infected

A

if the stone is infected and breaks up - can cause sepsis as bacteria spreads through blood

  • only use shock to break it up once infection has settled
22
Q

how does a Lower tract obstruction present

A
  1. LUTS - including incontinence
  2. acute urinary retention
  3. chronic urinary retention
  4. recurrent urianry tract infection and sepsis
  5. frank haematuria
  6. formation of bladder stones
  7. renal failure
23
Q

If a patient presents with retention what is the immediate treatment needed

A

catheterisation (foley catheter - ballon end)

  • urethral catheter 14/16F*
  • record residual
  • 2 attempts (then introducer if GA experience)
  • 16F SPC if urethra impassable

*16F = 16 French = 16mm diameter

24
Q

CASE: two people arrive in hospital

  1. 65yrs acute retention
    - can’t pass urine
    - in agony
    - creatinine 70
  2. 65yrs chronic retention
    - can pass urine fine
    - been wearing bigger trousers due to bloating
    - pain free
    - creatinine 170

WHO GETS THE BED??

A

Chronic retention gets the bed due to high creatinine - may need more monitoring

acute can be catheterised and sent home as creatinine levels normal

25
Q

what are the resuscitation treatments for Lower tract obstruction

A
  1. ABCs
  2. IV access, bloods, ABG, urine and blood cultures, fluid balance monitoring
  3. IV fluids, broad-spectrum antibiotics (if appropriate)
  4. Analgesia
  5. HDU care +/- renal replacement therapy (if appropriate)
26
Q

what are the emergency treatments for Lower tract obstructions (for unremitting pain or complications)

A
  1. Urethral catheterisation 2. Suprapubic catheterisation
27
Q

what are the definitive treatments for Lower tract obstructions

A

TREAT UNDERLYING CAUSE

  1. e.g. BPE – TURP
  2. e.g. Urethral stricture – Optical urethrotomy
  3. e.g. Meatal stenosis – Meatal dilatation
  4. e.g. Phimosis – Circumcision
28
Q

what are the two types of chronic retention

A

high pressure and low pressure

29
Q

what are the indicators for high pressure chronic retention

A

painless
incontinent
raised cr
bilateral hydronephrosis

30
Q

what are the indicators for low pressure chronic retention

A

painless
dry
normal cr
normal kidneys

31
Q

what are complications of Lower tract obstruction

A
  1. decompression haematuria

2. post obstructive diuresis

32
Q

what happens in decompression haematuria

A

shearing of small vessels as decompression occurs due to differing compliance of tissue layers - usually self limiting

33
Q

what is post obstructive diuresis

A

diuresis brought on when disrupting an obstruction in the upper or lower tract

  • the passing of more than 150-200ml/hr urine
  • osmotic diuresis secondary to urea, ADH, altered tubular function
  • can lead to life threatening Na and water depletion
34
Q

how is post obstructive diuresis managed

A

saline

input = output-30ml/hr

URINARY (27 decks)

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