Hydronephrosis Disease

BASICS

DESCRIPTION

Unilateral or bilateral dilatation of the urinary tract at any level secondary to intrinsic and/or extrinsic obstruction to urine flow. May also be functional.

System(s) affected: Renal/Urologic
Genetics: Unknown
Incidence/Prevalence in USA:
- Children 2 in 100
- Adults 3.8 in 100
Predominant age: All ages. Bimodal peaks: congenital and over age 60.
Predominant sex:
- Age 0 - 20 years: Male = Female
- Age 20 to 60 years: Female > Male
- Age greater than 60 years: Male > Female

SIGNS AND SYMPTOMS

Varies with acute or chronic presentation
Chronic hydronephrosis may be completely asymptomatic
"Colic" referred to vulva or to testicle (lithiasis) with acute obstruction
Change in urine output (anuria, polyuria, intermittent variation in urine volume)
Hesitancy
Dribbling
Urinary tract infections
Decreased force of urine or interrupted stream
Nocturia
Abdominal mass
Frequency and urgency
Thirst
Hypertension (may be accelerated)
Edema
After relief - post obstructive diuresis
Epididymitis
Acute or chronic urinary retention

CAUSES

Intrinsic, congenital
- Stenosis (ureteral, urethral and meatal)
- Adynamic ureter
- Spinal cord defects, e.g., spina bifida
- Duplication of the ureter
- Ureterocele
Intrinsic, acquired
- Renal lithiasis (most common)
- Neoplasm (renal, ureteral or bladder)
- Papillary necrosis with sloughed papilla
- Ureterocele
- Trauma
- Blood clot
- Fungus ball
- Granuloma (tuberculosis)
- Neurogenic bladder
- Other nervous system diseases - tabes dorsalis, multiple sclerosis, diabetes mellitus, traumatic spinal cord injury
- Anticholinergics
- Phimosis, Ureteral valve, Polyp or stricture
- Schistosomiasis (hematobium)
- Wegener's granulomatosis
- Psychogenic polydipsia
- Imperforate hymen
Extrinsic
- Retroperitoneal - neoplasm, blood, abscess, fibrosis, aneurysm
- Crohn's disease
- Lymphocele, hydrocele
- Gynecologic - gravid uterus, endometriosis, pelvic inflammatory disease, abscess, cyst, iatrogenic-ureteral injury during surgery, gynecologic malignancy, uterine prolapse
- Sjögren's syndrome (pseudolymphoma)
Functional or non-mechanical - congenital
- Mega-ureter
- Prune belly syndrome
- Extra renal pelvis
Functional or non-mechanical - other
- Diabetes insipidus
- Diuretics
- Pregnancy
- Vesicoureteral reflux
- Postobstructive residual
- Postsurgical: post ureteral anastomosis
- Progestational agents

RISK FACTORS

Radiation
Prostatic hypertrophy and/or malignancy
Renal lithiasis
Methysergide
Analgesic abuse (papillary necrosis, transitional cell carcinoma)
Sickle cell anemia (papillary necrosis)
Diabetes mellitus (papillary necrosis)
Bleeding diathesis
Anticholinergics
See Causes

DIAGNOSIS

LABORATORY

May be completely normal
Azotemia
Hyperkalemia
Metabolic acidosis (with and without anion gap)
Hypernatremia (nephrogenic diabetes insipidus)
Urine analysis - hematuria, crystals, bacteriuria
Decreased urine concentrating ability
Polycythemia (rare)
Anemia of chronic renal disease

Drugs that may alter lab results: Nephrotoxins may aggravate azotemia (nonsteroidal anti-inflammatory drugs, immunosuppressants, aminoglycosides, iodinated contrast, anticholinergics)
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Thin renal cortex
Renal tubular atrophy
Medullary destruction

SPECIAL TESTS

Kidney and urinary bladder (KUB)
Voiding cystourethrogram
Measurement post void residual
Ultrasound prostate with biopsy if nodule found
Prostatic specific antigen (malignancy); controversial - yes (American Cancer Society), no (National Cancer Institute)
Prenatal sonography
Rectal examination in males age > 50

IMAGING

Unenhanced helical CT for lithiasis
Ultrasound - abnormal renal function, cortical thinning, ureteral dilatation
IVP with tomograms (normal renal function): Renal pelvis dilatation
Renal flow scan, diuretic renogram
CT scan; MRI
Pulsed and color Doppler
Diuretic enhanced duplex Doppler sonography

DIAGNOSTIC PROCEDURES

To determine location and etiology:
- Cystoscopy/retrograde pyelography
- Antegrade pyelography
- Loopography (obstruction with ureteral diversion)

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient

GENERAL MEASURES

Females: Pelvic pap smear for potential gynecologic malignancy. Appropriate work-up for recurrent urinary tract infections.
Males: Anatomic study of the urinary tract for any urinary tract infection, appropriate review of systems and digital rectal exam for prostatic hypertrophy. Prostatic specific antigen, acid phosphatase, rectal transducer ultrasound of prostate for prostatic enlargement.
Relief of obstruction for preservation of renal function:
- Foley catheter for prostatic hypertrophy
- Transurethral resection of the prostate gland for prostatic hypertrophy
- Nephrostomy tube
- Pyeloplasty
- Surgical diversion of ureters
- Ureteral stents
- Urolithiasis - extra corporeal shock wave lithotripsy, percutaneous nephrolithotomy, ureteroscopic stone removal or surgical removal. Treatment depends on stone size.
- Nephrectomy
Neurogenic hydronephrosis:
- Frequent voiding
- Double voiding
- Suprapubic pressure
- Intermittent catheterization
- Cholinergics
- Surgical reimplantation of ureters
- Antibiotics, when needed for infection
Uremia:
- Dialysis
- Hyperkalemia (calcium, Kayexalate, insulin and glucose)
- Treat acidosis (1-2 teaspoons sodium bicarbonate tid or Shohl's solution)
- Treat hypocalcemia (calcium acetate tablets 1-3 with meals; vitamin D - dihydrotachysterol 0.2 mg po every day)

SURGICAL MEASURES

see General Measures

ACTIVITY

Fully active

DIET

If not uremic, no restriction
When uremic - protein, salt, potassium restriction as needed
For stone-formers, increased oral fluids

PATIENT EDUCATION

Printed material available from National Kidney Foundation, 30 East 33rd, St., Ste. 1100, New York, New York, 10016 (800)622-9010. "What Everyone Should Know About Kidneys and Kidney Disease" (Order #01-01 BP English, #01-02 BP Spanish); also Urinary Tract Obstructions. How they Can Affect You.

FOLLOW UP

PREVENTION/AVOIDANCE

Avoid anticholinergics when obstruction present
Avoid dehydration with lithiasis
Drug therapy appropriate to prevent future calculi (e.g., allopurinol for uric acid stones)

POSSIBLE COMPLICATIONS

Urinary tract infection from instrumentation
Fibrosis from radiation for pelvic malignancy
Obstruction from stone fragments on lithotripsy
Postoperative bleeding

EXPECTED COURSE AND PROGNOSIS

Contingent on relief of obstruction and residual renal function
Excellent course and prognosis with relief of obstruction and restoration of normal renal function
Nonmechanical ureteropelvic junction (UPJ) obstruction has a good prognosis
Reflux with pyelonephritis worsens prognosis significantly
Poor if obstruction secondary to advanced malignancy

MISCELLANEOUS

ASSOCIATED CONDITIONS

See causes

AGE-RELATED FACTORS

Pediatric: Hydronephrosis most often congenital
Geriatric: In males, most often due to prostatic enlargement
Others: N/A

PREGNANCY

Frequent temporary cause of hydronephrosis

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

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