6 obstructive uropathy,acute urinary retention,hematuria
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6 obstructive uropathy,acute urinary retention,hematuria

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6 obstructive uropathy,acute urinary retention,hematuria 6 obstructive uropathy,acute urinary retention,hematuria Presentation Transcript

  • WINTER IN ALEXANDRIA
  • Acute Urinary Retention Chronic Urinary RetentionDefinitionCauses according to age & sexDiagnosis (history, exam. Investigations)AUR VS AnuriaTreatment
  • Hydronephrosis………PyonephrosisInfected hydronephrosisDefinition, Causes,Clinical pictureImagingD.D. of a renal Mass?Treatment ofHydronephrosisInfected hydronephrosisPyonephrosis
  • Hematuria (symptom & sign)Painless, PainfulUpper UTLower UTCausesCongenital,AcquiredDiagnosisTreatment (General, Specific)
  • Evaluation of Renal FunctionLabImagingOverall renal functionSplit renal FunctionAcute renal FailurePre renalRenalPost renal (Obstructive)Management
  • Renal CalculiPrimary, SecondaryStone compositionRadio opaque , LucentEvaluationImagingD.D. in KUBTreatmentMedical ….. DissolutionInterventionalSWL…PNL…Open Surgery
  • Ureteric CalculiTreatment Options Depend on:LevelSizeDegree of obstructionPresence of UTIPain severity & ToleranceMedicalInterventional:SWLUreteroscopySurgery
  • Bladder StonesPrimarySecondaryImagingDDTreatmentNo medical TreatmentInterventional:Endoscopic crushingSurgery? SWLRX of the cause
  • BPHClinical picture(symptoms, signs…complications)Is it BPH or Ca Prostate?DRE….PSA…..TRUS BiopsyImagingKUB? IVU? U/S? Others?Associated pathologyDD: other causes of bladderOutlet obstructionTreatment:Reassurance?Medical…(non specific… specific)Surgical….indicationsTURPOpenLaser
  • Prostate CancerDisease of old ageClinical pictureLUTS … 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
  • TreatmentDepends on stageOrgan confined disease: (Potentially curable)R. Prostatectomy….R. RadiotherapyLocally advanced Disease (extra-prostatic):RadiotherapyMetastatic Disease:Hormonal (endocrine) TreatmentOrchiectomyLHRH agonistsAnti-androgensOestrogen
  • Bladder CancerEpidemiology:Incidence, age, sex, …Etiological factorsGross Pathology (papillary,solid)HistopathologyStaging .. (TNM):Superficial (Tis, Ta, T1)Infiltrating (T2..T3)Locally advanced ….T4Metastatic (N, M)GradingSpread
  • Clinical Picture:SymptomsLUTS …Hematuria…..NecroturiaS.P.painSymptoms of metastasisSigns:BEUA…No mass…or .mass (mobile or fixed)S.P. mass?Lab: urine cytologyImaging:KUB, IVU, U/S..,CTCystoscopy & Biopsy (corner stone in diagnosis)
  • TreatmentDepends on stageSuperficial Bl CaTUR….Intravesical adjuvant therapy …. Follow upInfiltrating Bl Ca…..R. Cystectomy with urinary diversionLocally advanced or metastatic…Palliative treatmentPalliative surgery…..Radio-chemotherapy
  • Renal Pelvic Tumor ( 10% of R. Trs)(Urothelial)HistologyPresentationLab: (Cytology)Imaging:Filling defect within contrast in the renal pelvisFor D.D,Confirmation by U/S…CT.Uretero-RenoscopyTreatment:R.Nephro-ureterectomy with removal of cuffOf the bladder mucosa around the homolateral UO
  • Renal Cell Carcinoma85% of all renal tumorsAge & sexClinical Picture:Asymptomatic....accidentally discoveredPain , Mass, HematuriaParaneoplastic SyndromeMetastasisSignsGross pathologyHistopathologySpreadVenous extension
  • Treatment:The only effective treatment is surgery:R. Nephrectomy for localized diseaseMetastatic disease:? Palliative nephrectomy….ImmunotherapyImaging:KUB, IVU, U/SCT (gold standard)Metastatic survey
  • URINARY RETENTION
  • ACUTE URINARY RETENTION (AUR)One of the common clinical emergenciesCan present to any practicing physicianDefinition:Inability to void in spite of the presenceof a full bladderAetiology:Disturbance of the evacuationfunction of the bladder:*Failure of effective detrusorcontraction*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 equinalesions)TraumaticVascularNeoplasticBladder outlet obstruction (infra-vesical obstruction)Anatomy PathologyBladder 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.. increasedtone of BN& proximal urethraBeta-adrenergic agonists…detrusorhypotoniaPost-operative:Following….ano-rectal, pelvic & obstetricinterventionsAetiology of AUR (cont.)
  • Aetiology of AUR correlated to age & sex:AUR in males over 50 :Benign Prostatic Hyperplasia (BPH)Prostate CancerOther causes…Predisposing factors of AUR related to BPH:*Infection:BPH complicated by prostatitis*Congestion:prolonged inhibition of voiding desireexposure to coldsustained sexual arousal*Prostatic infarction*Bladder decompensationBPH
  • AUR in middle aged males:-Stone impaction in B.N. orurethra- 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 & vulvaltumors- Hysterical
  • Chronic Urinary RetentionA condition characterized by persistent failure ofcomplete bladder evacuation at the time of voidingCausesweak detrusor contractility(usually neurogenic)Chronic bladder outlet obstruction
  • Pathology of chronic URSame causes of AURGradual building up of residual urine over timeIs it significant PV residual?How to assess?The result will be pathologically increasing bladderCapacityNormal Bladder Capacity= 300 -500 mlIn 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 residualurine with stasisIncreased susceptibility to Rec. UTI &bladder LithiasisAUR on top… may occurOver-flow incontinenceBil. 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 fullBladder (inspection, palpation & percussion)However, in obese or muscular individuals,clinical examination may be equivocalTo confirm:*Insert a urethral catheter*Abdominal sonographyFurther evaluation & investigation to revealthe under-lying cause are done after bladderevacuation
  • Acute Retention versus AnuriaDefinitionSymptoms &recent historyAbdominal examinationImaging (ultrasound)Urethral catheterRenal function tests
  • Treatment of AURImmediate treatment:Insert a urethral catheter to evacuate the bladderRules 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 urethratill urine comes out.- Never push against resistanceFailure of catheterization?!A suprapubic cystostomy is done under localanalgesia
  • Further evaluation is done to revealthe cause of AUR:- Lab- Imaging- Endoscopic.Definitive treatment will be that of theunderlying causeDefinitive treatment