Updated: 9/3/2020

Hydronephrosis

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Snapshot
  • A 48-year-old woman presents to the emergency department due to severe back pain. Her symptoms began approximately 3 hours ago and says the pain is in her left mid-back. She describes the pain as sharp and 9/10. The pain radiates to her left groin. On physical exam, there is left-sided costovertebral angle tenderness. A non-contrast computerized tomography (CT) scan of the abdomen demonstrates left-sided urolithiasis and hydronephrosis. She is started on a nonsteroidal antiinflammatory drug (NSAID) and intravenous normal saline. (Nephrolithiasis resulting in hydronephrosis)
Introduction
  • Clinical definition
    • renal calyx and pelvis distension secondary to an obstruction in urine flow distal to the renal pelvis
      • dilation of the ureter describes hydroureter
  • Epidemiology
    • demographics
      • age
        • calculi is the most common cause of hydronephrosis and hydroureter in young adults
      • sex
        • pregnancy and gynecologic causes are more common causes in women
        • prostatic hyperplasia and cancer are a major cause of hydronephrosis in men
  • Etiology
    • pregnancy
      • normal finding
      • there may be a more prominent dilation on the right ureter and renal pelvis than the left
    • benign prostatic hyperplasia
    • calculi
    • ureteral narrowing secondary to surgery
    • malignancy
      • e.g., ureteral, cervical, and prostate
      • e.g., transitional cell carcinoma of the bladder can cause uni- or bi-lateral ureteral obstruction
    • congenital defects between the kidney, ureter, and bladder junction
    • ureteropelvic junction obstruction
    • retroperitoneal fibrosis
  • Pathogenesis
    • pathologic or anatomic processes interupt urine flow which leads to
      • an increase in the hydrostatic pressure in Bowman's space 
      • a decline in glomerular filtration rate
      • impaired ability to concentrate, dilute, and transport sodium, potassium, and hydrogen ions
    • chronic hydronephrosis results in gross changes to the kidney such as
      • renal papillae compression
      • renal septa and calyx coalescence
      • peri-calyx renal parenchymal thinning
  • Prognosis
    • variable as it is dependent on the underlying cause
Presentation
  • Symptoms
    • depends on whether the obstruction is acute or chronic
      • asymptomatic
      • pain secondary to bladder, collecting system, or renal capsule distention
      • anuria
  • Physical exam
    • palpable kidney in severe cases
    • costovertebral angle tenderness
    • distended bladder in lower urinary tract obstruction (e.g., benign prostatic hyperplasia)
Imaging
  • Renal ultrasonography
    • indication
      • imaging test of choice for evaluating urinary tract obstruction
  • Computerized tomography (CT) scan of the abdomen
    • indication
      • used when results are equivocal on renal ultrasound
Studies
  • Labs
    • urinalysis
      • to evaluate for infection, stone, or tumor
    • serum chemistry
      • ↑ BUN and creatinine
        • In cases of unilateral ureteral obstruction, the contralateral kidney usually compensates to maintain a normal GFR and serum creatinine; if the contralateral kidney is diseased or if the obstruction is bilateral, then GFR decreases and serum creatinine rises 
Differential
  • Pyelonephritis
  • Peripelvic cyst
  • Calyceal diverticula
Treatment
  • Conservative 
    • bladder catheterization
      • indication
        • performed initially if the clinical presentation is suggestive of a bladder neck obstruction such as
          • suprapubic pain
          • palpable bladder
  • Treatment ultimately depends on the underlying cause of hydronephrosis
    • e.g., oral alkalinization therapy for patients with uric acid stones
Complications
  • Postobstructive diuresis

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Questions (5)
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(M1.RL.13.18) A 45-year-old man presents with a 3-day history of right-sided flank pain due to a lodged ureteral stone. What changes would be expected to be seen at the level of glomerular filtration?


QID: 100972
1

Increase in glomerular capillary oncotic pressure

7%

(4/54)

2

Increase in Bowman's space capillary oncotic pressure

7%

(4/54)

3

Increase in Bowman's space hydrostatic pressure

67%

(36/54)

4

Increase in filtration fraction

4%

(2/54)

5

No change in filtration fraction

11%

(6/54)

M 1 E

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(M1.RL.13.78) A 72-year-old male presents to his primary care physician with urinary hesitancy and urinary dribbling that began 6 weeks ago and has gradually worsened. Rectal exam reveals a markedly enlarged prostate. CT scan, shown in Figure A, demonstrates dilated ureters and renal pelvises. Which of the following likely accounts for the CT scan results:

QID: 101032
FIGURES:
1

Urethral obstruction

84%

(32/38)

2

Autosomal dominant polycystic kidney disease

0%

(0/38)

3

Prerenal azotemia

3%

(1/38)

4

Elevated serum PSA

13%

(5/38)

5

Multiple endocrine neoplasia type 1

0%

(0/38)

M 2 E

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Evidence (6)
EXPERT COMMENTS (7)
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