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Updated: Sep 3 2020


  • 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
        • 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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