Urinary Outflow Obstruction


Published on

Published in: Health & Medicine
1 Comment
  • Fioricet is often prescribed for tension headaches caused by contractions of the muscles in the neck and shoulder area. Buy now from http://www.fioricetsupply.com and make a deal for you.
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Urinary Outflow Obstruction

  1. 2. Bladder outflow obstruction Harim Mohsin
  2. 3. Case study <ul><li>A 62 year old man presented with moderate lower urinary tract symptoms (LUTS)-hesitancy, urgency, feeling of retention & decreased stream. </li></ul><ul><li>Examination : Small benign prostate </li></ul><ul><li>Investigation : PSA of 1.7 and microscopic haematuria. (-4.5) </li></ul><ul><li>Uroflowmetr y - flow rate of 5.4 ml/sec (M-20-25, F-25-30) </li></ul><ul><li>Post void residual of 328 cc suggestive of bladder outflow obstruction. </li></ul><ul><li>Cystoscopy and an ultrasound scan , showed no urethral stricture but the bladder neck was occlusive by an extrinsic mass The ultrasound scan, revealed mild right ureterohydronephrosis and a heterogeneous mass arising behind the bladder. </li></ul><ul><li>CT was suggestive of bladder diverticulum arising from the fundus. </li></ul>
  3. 5. <ul><li>Diagnosis: </li></ul><ul><li>Neoplastic mucocele of the appendix </li></ul>
  4. 6. Introduction <ul><li>Urinary outflow obstruction & stasis is of immense importance in urological disorders because of their effects on renal function; leading to hydronephrosis, infections or even failure. </li></ul>
  5. 7. Approach to patient
  6. 8. Clinical features <ul><li>Hesitancy in starting urination </li></ul><ul><li>Lessened force & stream </li></ul><ul><li>Terminal dribbling </li></ul><ul><li>Urgency /incontinence </li></ul><ul><li>Feeling of incomplete emptying </li></ul><ul><li>Acute urinary retention </li></ul><ul><li>Chronic urinary retention </li></ul><ul><li>Interruption of stream </li></ul><ul><li>Hematuria (partial-stricture, complete-tumor/prostatic obstruction) </li></ul><ul><li>Cloudy urine (due to complicating infection) </li></ul>
  7. 9. Examination <ul><li>GPE </li></ul><ul><li>Abdominal examination </li></ul><ul><li>-Pelvic Mass </li></ul><ul><li>-Palpation of bladder </li></ul><ul><li>-DRE (prostate) </li></ul>
  8. 10. Investigations <ul><li>Ultrasound to locate the blockage of urine is, and find out completely the bladder is emptied </li></ul><ul><li>IVP to locate the blockage is </li></ul><ul><li>Urinalysis to look for blood or infection </li></ul><ul><li>Urine culture to show an infection </li></ul><ul><li>Uroflowmetry-determine how fast the urine flows out </li></ul><ul><li>Urodynamic testing -- see how much urine flow is blocked and how well the bladder contracts </li></ul><ul><li>Cystoscopy and retrograde urethrogram (x-ray to look for urethral narrowing) </li></ul><ul><li>Serum chemistries to reveal kidney damage </li></ul>
  9. 12. Classification <ul><li>Cause </li></ul><ul><li>Congenital </li></ul><ul><li>Acquired </li></ul><ul><li>Duration </li></ul><ul><li>Acute </li></ul><ul><li>Chronic </li></ul><ul><li>Degree </li></ul><ul><li>Partial </li></ul><ul><li>Complete </li></ul><ul><li>Level </li></ul><ul><li>Upper urinary tract </li></ul><ul><li>Lower urinary tract </li></ul>
  10. 13. Anatomy
  11. 14. Etiology <ul><li>Urinary outflow obstruction is more common in males. </li></ul><ul><li>The causes in males are generally intrinsic while in women they are extrinsic. </li></ul><ul><li>Congenital anomalies of the urinary tract are generally obstructive. </li></ul><ul><li>In adults acquired obstruction can occur. </li></ul><ul><li>The causes maybe different in children, males & females. </li></ul>
  12. 15. Etiology <ul><li>In children congenital anomalies are more common with the most </li></ul><ul><li>usual sites of narrowing/obstruction : </li></ul><ul><li>External meatus (meatal stenosis) </li></ul><ul><li>Distal urethra (stenosis) </li></ul><ul><li>Posterior urethral valves </li></ul><ul><li>Bladder neck </li></ul><ul><li>Ectopic ureters </li></ul><ul><li>Ureteroceles </li></ul><ul><li>Ureterovesical junction </li></ul><ul><li>Ureteropelvic junction </li></ul><ul><li>Severe vesicouretric reflux </li></ul>
  13. 16. Etiology <ul><li>In the adults the causes are Acquired: </li></ul><ul><li>Maybe primary in the UT or secondary to retroperitoneal lesions invading or compressing the urinary passages. </li></ul><ul><li>Urethral stricture following infection/injury </li></ul><ul><li>Urolithiasis (stone formation) </li></ul><ul><li>Inflammation such as ureteritis or urethritis. </li></ul><ul><li>Vesical tumor involving neck or both ureteral orifices </li></ul><ul><li>Compression at the pelvic brim by metastatic lymph nodes from ca prostate or cervix </li></ul><ul><li>Pelvic mass </li></ul><ul><li>Sloughed papillae or blood clot. </li></ul><ul><li>Neurogenic bladder </li></ul>
  14. 17. Etiology <ul><li>Males: </li></ul><ul><li>BPH or prostatic cancer </li></ul><ul><li>Inflammatory condition- prostatitis </li></ul>
  15. 18. Etiology <ul><li>Females: </li></ul><ul><li>Normal pregnancy. </li></ul><ul><li>Uterine prolapse and cystocele. </li></ul><ul><li>Local extension of cancer of cervix </li></ul>
  16. 19. Embryology <ul><li>The kidney develops from 3 set of excretory organs: </li></ul><ul><li>Pronephros </li></ul><ul><li>Mesonephros </li></ul><ul><li>Metanephros </li></ul><ul><li>Urinary bladder- during 4 th & 7 th week urorectal divides the cloaca into the anorectal canal & primitive urogenital sinus. </li></ul><ul><li>The urogenital sinus is divided into 3 parts: </li></ul><ul><li>Vesical part –forms larger part of urinary bladder </li></ul><ul><li>Pelvic part –forms the prosthetic & membranous part of urethra </li></ul><ul><li>Phallic part- form the genitals. </li></ul>
  17. 20. Embryology <ul><li>Urethra- </li></ul><ul><li>In males the prosthetic urethra is formed from mesonephric duct & urogenital sinus. </li></ul><ul><li>Penile urethra is formed from urogenital sinus & surface ectoderm. </li></ul><ul><li>In females the urethra is derived from the mesonephric duct & urogenital sinus. </li></ul>
  18. 21. Embryology
  19. 22. Urethral meatal stenosis <ul><li>It is narrowing (stenosis) of the opening of the urethra at the external meatus. </li></ul><ul><li>Males: </li></ul><ul><li>More common in circumscribed males. When the meatus is not covered by the foreskin, it can rub against urine soaked diapers resulting in inflammation and mechanical trauma= scarring. </li></ul><ul><li>Damage to the frenular artery during circumcision. </li></ul><ul><li>It may also be caused by lichen sclerosus. </li></ul><ul><li>Females </li></ul><ul><li>This condition is a congenital abnormality which can cause urinary tract infections and bed-wetting (enuresis). </li></ul>
  20. 23. Meatal stenosis <ul><li>Signs & symptoms in males </li></ul><ul><li>Visible narrow opening at the meatus in boys </li></ul><ul><li>Abnormal strength and direction of urinary stream </li></ul><ul><li>Discomfort with urination (dysuria and frequency) </li></ul><ul><li>Incontinence (day or night) </li></ul><ul><li>Hematuria at end of urination </li></ul><ul><li>Urinary tract infections </li></ul><ul><li>Diagnosis : males- history/exam </li></ul><ul><li>Females -VCUG (voiding cystourethrogram) </li></ul>
  21. 24. Distal urethral stenosis <ul><li>It is present congenitally & could be due to fibrosis. </li></ul><ul><li>Girls present with recurrent UTIs. </li></ul><ul><li>Diagnosed by VCUG. </li></ul>
  22. 25. Distal urethral stenosis
  23. 26. Urolithiasis <ul><li>Urolithiasis is calculus formation at any level in the urnary collection system. </li></ul><ul><li>The commonest types of stones present are calcium oxalate, calcium phosphate, magnesium ammonium phosphate struvite, uric acid or cystine stones. </li></ul><ul><li>The cause maybe unknown or linked to specific problems like hypercalciuria linked or linked with hypercalcemia(due to hyperparathyroidism, vitamin D intoxication, sarcoidosis). </li></ul><ul><li>Magnesium ammonium phosphate (struvite) stones almost always occur in patients with a persistently alkaline urine, owing to urinary tract infections. </li></ul><ul><li>Gout and diseases involving rapid cell turnover,such as the leukemias, lead to high uric acid levels in the urine and the possibility of uric acid stones </li></ul>
  24. 27. Urolithiasis <ul><li>Stone formation is more common in males. </li></ul><ul><li>The major source of urethral stones is the bladder & lesser upper tract. The stones pass through the urethra spontaneously. </li></ul><ul><li>Urethral stones maybe formed secondary to urinary stasis, urethral diverticulum, near strictures or at a site of previous surgery. </li></ul><ul><li>Males also develop prostatic & seminal vesical stones. </li></ul><ul><li>In females stones are rare but maybe present due to urethral diverticula. </li></ul>
  25. 29. Posterior urethral valves <ul><li>During embryogenesis, the most caudal end of the Wolffian duct is absorbed into the primitive cloaca at the site in the posterior urethra. In healthy males, the remnants are the posterior urethral folds, called plicae colliculi. Posterior urethral valves occur when the primitive folds in the posterior urethra just distal to the verumontanum insert high and fuse, resulting in bladder outlet obstruction. </li></ul>
  26. 30. PUV <ul><li>Posterior urethral valves, which occur only in males, consist of mucosal folds that can obstruct the urethra and cause obstructive uropathy. Dilatation of the urinary bladder and proximal urethra are associated with a characteristic &quot;keyhole&quot; deformity at the bladder base and thickening of the bladder wall. </li></ul><ul><li>Urethral obstruction in females may be associated with caudal regression syndrome & urethral atresia. </li></ul>
  27. 31. Posterior urethral valves
  28. 32. Ureterocele <ul><li>It’s the sacculation of the terminal portion of the ureter. It can be intravesical or ectopic. </li></ul><ul><li>Most commonly associated with single ureters & ectopic ureters. </li></ul><ul><li>Its because of late canalization of the ureteral bud leading to a prenatal obstruction & expansion of the uretral bud prior to its absorption into a urogenital sinus. </li></ul><ul><li>Mostly associated with dysplastic upper pole of kidney that becomes prone to neoplasia. </li></ul><ul><li>Excretory urography will show a filling defect in the bladder or cystic dilatation. It may also show hydronephrosis of kidney. </li></ul>
  29. 33. Ureterocele
  30. 34. Uretrocele
  31. 35. Bladder diverticulum <ul><li>Outpouching of the bladder mucosa into the muscle layer. </li></ul><ul><li>Maybe congenital or acquired (infection or inflammation) </li></ul><ul><li>Features: recurrent UTI, VUR, retention. </li></ul><ul><li>Treatment :surgical. </li></ul>
  32. 36. Bladder diverticulum
  33. 37. Ureteropelvic junction obstruction <ul><li>Commonly the ureterovesical or ureteropelvic junction is obstructed, the latter is the most common congenital. </li></ul><ul><li>Its more common in boys than girls. </li></ul><ul><li>Exact cause is unknown but uretral valves & polyps have been reported. There is nearly always the presence of kinking & angulation at the junction of the renal pelvis & ureter which maybe the primary or secondary cause. </li></ul><ul><li>True stenosis rare but a thin walled hypoplastic ureter is frequently observed leading to abnormal peristalsis. </li></ul><ul><li>2 other findings maybe found during operation. 1-high origin of ureter from renal pelvis & 2-abnormal relationship of proximal ureter with lower pole renal artery causing it to become entrapped & leading to obstruction. </li></ul><ul><li>Diagnosis is made on ultrasound. </li></ul>
  34. 38. Ureteropelvic junction obstruction
  35. 39. Pelvic junction obstruction
  36. 40. Ectopic ureters <ul><li>Mostly associated with ureterocele or duplication of ureters but singly effected ureters present. </li></ul><ul><li>Caused by delay or failure of separation of the ureteric bud from the mesonephric duct during embryologic development. Primarily because of the abnormally located ureteral bud. </li></ul><ul><li>The ureters may open in the vas deferens or seminal vesical. In girls it may open into the urethra, vagina or perinieum. </li></ul><ul><li>Clinical features vary with the gender & position of ureteral opening. </li></ul><ul><li>Ultrasound & voiding cystourethrography help delineate the problem. </li></ul>
  37. 41. Ectopic ureter
  38. 42. Ectopic ureter
  39. 43. Vesicoureteral reflux(VUR) <ul><li>Incompetence of the ureterovesical junction causing backflow of urine leading to hydronephrosis & pyelonephritis. </li></ul><ul><li>Most commonly affected is the intravesical ureter. </li></ul><ul><li>It may not be long enough to enable the ureter to close sufficiently to prevent urine reflux.(rare) </li></ul><ul><li>Most common cause is trigone weakness related to the uretric bud on the mesonephric duct. The deficiency in the trigone’s occulsive power leads the orifice to retract back into the uretral hiatus. </li></ul><ul><li>Uretral abnormalities like duplication, ectopic urethral orifice (shape/position) & ureterocele are the other common causes. </li></ul><ul><li>Common presentation maybe UTI or obstruction in severe cases. </li></ul><ul><li>Diagnosed on cystogram and a voiding cystourethrogram (VCUG). U/s will show hydronephrosis. </li></ul>
  40. 44. VUR
  41. 45. Urethral stricture <ul><li>Urethral stricture is fibrotic narrowing of the urethra. </li></ul><ul><li>Urethral stricture may be caused by inflammation or scar tissue from surgery, disease, or injury. It may also be rarely caused by external pressure from an enlarging tumor near the urethra. </li></ul><ul><li>Increased risk is associated with men who have a history of sexually transmitted disease (STD), repeated episodes of urethritis, or benign prostatic hyperplasia (BPH). There is also increased risk of urethral stricture after an injury or trauma to the pelvic region. Any instrument inserted into the urethra (such as a catheter or cystoscope). </li></ul><ul><li>Diagnosed by urine flowmetry, Post-void residual (PVR) & x-ray. </li></ul>
  42. 46. Urethral stricture
  43. 47. Contracture of bladder neck <ul><li>It’s the congenital narrowing of the bladder neck & the cause is debatable, proposed causes maybe presence of VUR, vesicular diverticula, bladder of large capacity & irritable bladder. </li></ul><ul><li>Diagnosis: VCUG </li></ul>
  44. 48. Contracture of bladder neck
  45. 49. Neurogenic bladder <ul><li>Neurogenic bladder is the loss of normal bladder function caused by damage to part of the nervous system. </li></ul><ul><li>Risk factors for neurogenic bladder include </li></ul><ul><li>Birth defects affecting the spinal cord and function of the bladder, including spina bifida. </li></ul><ul><li>Tumors within the spinal cord or pelvis may also disrupt normal nervous tissue function and place an individual at risk. </li></ul><ul><li>Traumatic spinal cord injury is also a major risk factor for development of neurogenic bladder.  </li></ul><ul><li>Diagnosis: CT of the skull and spine </li></ul><ul><li>Urodynamic studies: cystometry, uroflowmetery, EMG (electromyography) </li></ul>
  46. 50. Benign prostatic hyperplasia <ul><li>It’s the most common cause of obstruction in males. </li></ul><ul><li>BPH may occur because the higher amount of estrogen within the gland increases the activity of substances that promote cell growth. </li></ul><ul><li>Dihydrotestosterone (DHT), which is derived from testosterone in the prostate, may help control its growth. Older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage the growth of cells </li></ul>
  47. 51. BPH <ul><li>Digital Rectal Examination (DRE) </li></ul><ul><li>Prostate-Specific Antigen (PSA) </li></ul><ul><li>Urine Flow Study </li></ul><ul><li>Rectal Ultrasound and Prostate Biopsy </li></ul><ul><li>Cystoscopy </li></ul>
  48. 52. Benign prostatic hyperplasia
  49. 53. Benign prostatic hyperplasia <ul><li>Treatment Options </li></ul><ul><li>Medical </li></ul><ul><ul><li>Watchful waiting </li></ul></ul><ul><ul><li>Drugs ( alpha blockers-terazosin, doxazosin, finasteride) </li></ul></ul><ul><ul><li>Prostatic stents </li></ul></ul><ul><li>Minimally invasive treatments (thermotherapy) </li></ul><ul><ul><li>Laser (e.g., non-contact, contact, interstitial types) </li></ul></ul><ul><ul><li>Microwave (e.g., TUMT) </li></ul></ul><ul><ul><li>Other thermotherapies (e.g., Prostiva™ RF therapy [previously known as TUNA]) </li></ul></ul><ul><li>Surgical treatments </li></ul><ul><ul><li>Transurethral resection of the prostate (TURP) </li></ul></ul><ul><ul><li>Holmium laser enucleation of the prostate (HoLEP) </li></ul></ul><ul><ul><li>Prostatectomy </li></ul></ul><ul><ul><li>Transurethral incision of the prostate (TUIP) </li></ul></ul><ul><ul><li>Transurethral ultrasound-guided laser incision of the prostate (TULIP) </li></ul></ul>
  50. 54. Bladder carcinoma <ul><li>Most are transitional cell carcinomas </li></ul><ul><li>Of all bladder carcinomas: </li></ul><ul><li>90% are transitional cell carcinomas </li></ul><ul><li>5% are squamous carcinoma </li></ul><ul><li>2% are adenocarcinomas </li></ul><ul><li>Aetiological factors </li></ul><ul><li>Occupational exposure </li></ul><ul><li>Chemical implicated - aniline dyes, chlorinated hydrocarbons </li></ul><ul><li>Cigarette smoking </li></ul><ul><li>Analgesic abuse e.g. phenacitin </li></ul><ul><li>Pelvic irradiation - for carcinoma of the cervix </li></ul><ul><li>Commonest presentation : frank hematuria or microscopic hematuria. </li></ul>
  51. 55. Bladder carcinoma <ul><li>O-epithelium </li></ul><ul><li>A-lamina propria </li></ul><ul><li>B1-muscle </li></ul><ul><li>B2-deep muscle </li></ul><ul><li>C-peritoneum </li></ul><ul><li>D-pelvic wall /uterus/prostate. </li></ul>
  52. 56. Bladder carcinoma
  53. 57. Bladder carcinoma
  54. 58. Treatment options <ul><li>Depending on the staging: </li></ul><ul><li>Transurethral resection </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Immunotherapy </li></ul><ul><li>BCG </li></ul><ul><li>Radical cystectomy </li></ul><ul><li>Radiotherapy </li></ul>
  55. 59. Cystocele <ul><li>A cystocele occurs when the tough fibrous wall between a woman's bladder and vagina (the pubocervical fascia) is torn by childbirth, allowing the bladder to herniate into the vagina. </li></ul><ul><li>Presenting features maybe incontinence or urinary retention. </li></ul><ul><li>Grade 1-when the bladder droops only a short way into the vagina </li></ul><ul><li>Grade 2-cystocele, the bladder sinks far enough to reach the opening of the vagina. </li></ul><ul><li>Grade 3-bladder bulges out through the opening of the vagina </li></ul>
  56. 60. Cystocele
  57. 61. Other causes <ul><li>They may directly or indirectly effect the urinary tract & lead to obstruction. </li></ul><ul><li>Other tumors arising from prostate, seminal vesicle, urethra,cervix or vagina. </li></ul><ul><li>Urethral spasm </li></ul><ul><li>Foreign body </li></ul><ul><li>Pregnancy </li></ul><ul><li>Inflammation-urethritis </li></ul>
  58. 62. Complications of BOO <ul><li>Renal failure </li></ul><ul><li>Recurrent urinary tract infection </li></ul><ul><li>Urinary incontinence </li></ul><ul><li>Urinary retention </li></ul><ul><li>Bladder and renal calculi </li></ul>
  59. 63. Management <ul><li>Depends on the cause of the obstruction: </li></ul><ul><li>Relief of obstruction: </li></ul><ul><li>Temporary: cathertisation (foley’s/suprapubic) </li></ul><ul><li>Permanent: surgical repair </li></ul><ul><li>Eradication of infection </li></ul>
  60. 64. The End