6 obstructive uropathy,acute urinary retention,hematuria
DESCRIPTION
TRANSCRIPT
WINTER IN ALEXANDRIA
Acute Urinary Retention Chronic Urinary Retention
Definition
Causes according to age & sex
Diagnosis (history, exam. Investigations)
AUR VS Anuria
Treatment
Hydronephrosis……… Pyonephrosis Infected hydronephrosis
Definition, Causes, Clinical picture
Imaging
D.D. of a renal Mass?
Treatment of
Hydronephrosis Infected hydronephrosis Pyonephrosis
Hematuria (symptom & sign)
Painless, Painful
Upper UTLower UT
Causes Congenital, Acquired
Diagnosis
Treatment (General, Specific)
Evaluation of Renal Function
LabImaging
Overall renal function Split renal Function
Acute renal Failure Pre renal Renal Post renal (Obstructive)
Management
Renal CalculiPrimary, SecondaryStone compositionRadio opaque , Lucent
Evaluation
Imaging
D.D. in KUB
Treatment Medical ….. Dissolution Interventional SWL…PNL…Open Surgery
Ureteric Calculi
Treatment Options Depend on:
LevelSizeDegree of obstructionPresence of UTIPain severity & Tolerance
Medical Interventional: SWL Ureteroscopy Surgery
Bladder StonesPrimarySecondary
Imaging
DD
Treatment No medical Treatment Interventional: Endoscopic crushing Surgery ? SWL RX of the cause
BPHClinical picture (symptoms, signs…complications)Is it BPH or Ca Prostate?DRE….PSA…..TRUS Biopsy
ImagingKUB? IVU? U/S? Others?
Associated pathology
DD: other causes of bladder Outlet obstruction
Treatment:Reassurance?Medical…(non specific… specific)Surgical….indicationsTURP Open Laser
Prostate Cancer
Disease of old ageClinical picture LUTS … non specificSymptoms of metastasis: Bony pains,..LL edema,… Fatigue, loss of WT
(DRE…PSA… TRUS biopsy)Spread (local, lymphatic, blood borne)StagingGradingImaging (KUB,IVU,U/S)Metastatic Survey: Bone scan ….Chest X-Ray
Treatment Depends on stage
Organ confined disease: (Potentially curable) R. Prostatectomy….R. Radiotherapy
Locally advanced Disease (extra-prostatic): Radiotherapy
Metastatic Disease: Hormonal (endocrine) Treatment
Orchiectomy LHRH agonists Anti-androgens Oestrogen
Bladder Cancer
Epidemiology: Incidence, age, sex, …Etiological factorsGross Pathology (papillary, solid)Histopathology Staging .. (TNM): Superficial (Tis, Ta, T1) Infiltrating (T2..T3) Locally advanced ….T4 Metastatic (N, M)GradingSpread
Clinical Picture: Symptoms LUTS …Hematuria…..Necroturia S.P.pain Symptoms of metastasis
Signs:BEUA…No mass…or .mass (mobile or fixed)S.P. mass?
Lab: urine cytology
Imaging: KUB, IVU, U/S..,CTCystoscopy & Biopsy (corner stone in diagnosis)
Treatment
Depends on stage
Superficial Bl Ca TUR….Intravesical adjuvant therapy …. Follow up
Infiltrating Bl Ca….. R. Cystectomy with urinary diversion
Locally advanced or metastatic …Palliative treatment Palliative surgery…..Radio-chemotherapy
Renal Pelvic Tumor ( 10% of R. Trs)
(Urothelial)HistologyPresentationLab: (Cytology)Imaging: Filling defect within contrast in the renal pelvis For D.D, Confirmation by U/S…CT.
Uretero-Renoscopy
Treatment:R.Nephro-ureterectomy with removal of cuffOf the bladder mucosa around the homolateral UO
Renal Cell Carcinoma
85% of all renal tumorsAge & sex
Clinical Picture: Asymptomatic....accidentally discovered Pain , Mass, Hematuria Paraneoplastic Syndrome Metastasis Signs Gross pathology Histopathology Spread Venous extension
Treatment:The only effective treatment is surgery: R. Nephrectomy for localized disease
Metastatic disease: ? Palliative nephrectomy….Immunotherapy
Imaging:
KUB, IVU, U/S CT (gold standard)Metastatic survey
URINARY RETENTION
ACUTE URINARY RETENTION (AUR)
One of the common clinical emergenciesCan present to any practicing physician
Definition:Inability to void in spite of the presence of a full bladder
Aetiology:Disturbance of the evacuation function of the bladder:
*Failure of effective detrusor contraction *Bladder outlet obstruction
Failure of effective detrusor contraction:
Neurological lesion interrupting detrusor innervation, the micturition reflex or its higher control :(cortical, brain stem, spinal cord or cauda equina lesions)
Traumatic Vascular Neoplastic
Bladder outlet obstruction (infra-vesical obstruction)
Anatomy Pathology
Bladder neck …………………… (stone, tumor,.)Prostate …………………………. (BPH,.. PCa,…)Urethra……………………… (stone, Stricture, valve...)External meatus …………………. Meatal stenosis (encrustation)
Aetiology of AUR (cont.)
Drugs:
Parasympatholytics …detrusor hypotoniaAlpha-adrenergic agonists.. increased tone of BN& proximal urethraBeta-adrenergic agonists…detrusor hypotonia
Post-operative:
Following….ano-rectal, pelvic & obstetric interventions
Aetiology of AUR (cont.)
Aetiology of AUR correlated to age & sex:
AUR in males over 50 : Benign Prostatic Hyperplasia (BPH) Prostate Cancer Other causes…
Predisposing factors of AUR related to BPH: *Infection: BPH complicated by prostatitis
*Congestion: prolonged inhibition of voiding desire exposure to cold sustained sexual arousal
*Prostatic infarction
*Bladder decompensationBPH
AUR in middle aged males:
-Stone impaction in B.N. or urethra- Urethral stricture with oedema- Urethral trauma (rupture) Other causes…
extravasationstricture
AUR in young boys:
Posterior urethral valve ( AUR on top of chronic) Meatal stenosis (with infection/encrustation)
valve
AUR in females:
Generally uncommon
- Neurogenic
- Urethral & vulval tumors
- Hysterical
Chronic Urinary Retention
A condition characterized by persistent failure ofcomplete bladder evacuation at the time of voiding
Causes
weak detrusor contractility (usually neurogenic)
Chronic bladder outlet obstruction
Pathology of chronic UR
Same causes of AUR
Gradual building up of residual urine over time Is it significant PV residual? How to assess?
The result will be pathologically increasing bladder Capacity
Normal Bladder Capacity= 300 -500 ml In ch. UR may reach 1-2 or litres more
Eventually the picture will be:
Large UB with thinned out wall… (poor contractility) Large amount of post-void residual urine with stasis
Increased susceptibility to Rec. UTI & bladder Lithiasis
AUR on top… may occur
Over-flow incontinence
Bil. hydro-uretero- nephrosis…. Renal insufficiency
Diagnosis of AURClinical picture:
*Recent onset of inability to void*Suprapubic & urethral pains (?misleading complaint)
Examination: reveals evidence of a full Bladder (inspection, palpation & percussion) However, in obese or muscular individuals, clinical examination may be equivocal
To confirm:*Insert a urethral catheter*Abdominal sonography
Further evaluation & investigation to revealthe under-lying cause are done after bladder evacuation
Acute Retention versus Anuria
Definition
Symptoms &recent history
Abdominal examination
Imaging (ultrasound)
Urethral catheter
Renal function tests
Treatment of AUR
Immediate treatment:Insert a urethral catheter to evacuate the bladder
Rules of proper catheterization- Use a sterile packed catheter of appropriate size- Use sterile gloves- Paint the ext. genitals with an antiseptic solution - Inject a lubricant (with local anaesthetic gel ) into the urethra- Gently advance the catheter into the urethra till urine comes out. - Never push against resistance
Failure of catheterization?! A suprapubic cystostomy is done under local analgesia
Further evaluation is done to reveal the cause of AUR:
- Lab - Imaging - Endoscopic.
Definitive treatment will be that of the underlying cause
Definitive treatment
