Urinary Tract Obstruction Flashcards
What types of obstruction can occur?
Upper tract (supra-vesicle)
- PUJ
- Ureter
- VUJ
Lower tract (bladder outflow obstruction)
- Bladder neck
- Prostate
- Urethra
- Urethral meatus
- Foreskin (phimosis)
What intrinsic causes of obstruction are there are the PUJ?
- PUJ obstruction (physiological)
- Stone
- Ureteric tumour (TCC)
- Blood clot
- Fungal ball
What extrinsic causes of obstruction are there at the PUJ?
- PUJ obstruction (crossing vessel)
- Lymph nodes (tumour)
- Abdominal mass (tumour)
What intrinsic causes of obstruction are there at the ureter?
- Stone
- Ureteric tumour (TCC)
- Scar tissue
- Blood clot
- Fungal ball
What extrinsic causes of obstruction are there at the ureter?
- Lymph nodes (tumour, retroperitoneal fibrosis)
- Iatrogenic
- Abdominal/pelvic mass (tumour, pregnant uterus)
What intrinsic causes of obstructions are there are at the VUJ?
- Stone
- Bladder tumour
- Ureteric tumour
What extrinsic causes of obstructions are thee at the VUJ?
- Cervical tumour
- Prostate cancer
How may someone with an upper tract obstruction present?
Symptoms
- Pain
- Frank haematuria
- Symptoms of complications
Signs
- Palpable mass
- Microscopic haematuria
- Signs of complications
Complications
- Infection and sepsis
- Renal failure
What resuscitation is important in the management of upper tract obstruction?
- ABCs
- IV access, bloods, ABG, urine and blood cultures, fluid balance monitoring
- IV fluids, broad spectrum antibiotics (if appropriate)
- Analgesia
- HDU care +/- renal replacement therapy (if appropriate)
What emergency treatment can be carried out for upper tract obstruction?
- Percutaneous nephrostomy insertion
- Retrograde stent insertion
What definitve treatment is there for upper tract obstruction?
Treat the underlying cause
- Stone: urteroscopy and laser lithotripsy +/- basketing or ESWL
- Ureteric tumour: radical nephron-ureterectomy
- PUJ obstruction: laparoscopic pyeloplasty
How is nephrostomy carried out?
Percutaneous puncture usually under LA and sedation using US or x-ray guidance
What must you be careful of in nephrostomy procedures?
- Bleeding
- Possible damage to adjacent organs
What type of ureteric stent are there?
- Silicone
- Polyurethane
- Nickel titanium (usually for malignant obstruction)
How can lower urinary tract obstruction present?
- Lower urinary tract symptoms (including urinary incontinence)
- Acute urinary retention
- Chronic urinary retention
- Recurrent urinary tract infection and sepsis
- Frank haematuria
- Formation of bladder stones
- Renal failure
How should catheterisation be carried out in urinary retention?
- Immediately
- Using urethral catheter 14/16F
- Residual volume recorded
- Take 2 attempts (then introducer if GA experience)
- Use 16F SPC if urethra impassable
What resuscitation is important in the management of lower tract obstruction?
- ABCs
- IV access, bloods, ABG, urine and blood cultures, fluid balance monitoring
- IV fluids, broad-spectrum antibiotics (if appropriate)
- Analgesia
- HDU care +/- renal replacement therapy (if appropriate)
What investigations can be carried out for lower tract obstruction?
Imaging
- Bladder scan
- USS renal tract
What emergency treatment is there for lower tract obstruction?
-Urethral catheterisation
OR
-Suprapubic catheterisation
What is the definitive treatment for lower tract obstruction?
Treat underlying cause
- BPE: TURP
- Urethral stricture: Optical urethrotomy
- Meatal stenosis: meatal dilatation
- Phimosis: circumcision
What features of chronic retention should you worry about?
- High pressure
- Painless
- Incontinent
- Raised creatinine
- Bilateral hydronephrosis
What are the possible complications of lower tract obstruction leading to CUR?
- Decompression haematuria
- Post obstructive diuresis
Why does decompression haematuria occur?
- Shearing of small vessels due to differing compliance of tissue layers
- Usually self limiting
When does post obstructive diuresis occur?
- Greater than 150-200ml/hr
- 0.5-50%
