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6 obstructive uropathy,acute urinary retention,hematuria


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6 obstructive uropathy,acute urinary retention,hematuria

  2. 2. Acute Urinary Retention Chronic Urinary RetentionDefinitionCauses according to age & sexDiagnosis (history, exam. Investigations)AUR VS AnuriaTreatment
  3. 3. Hydronephrosis………PyonephrosisInfected hydronephrosisDefinition, Causes,Clinical pictureImagingD.D. of a renal Mass?Treatment ofHydronephrosisInfected hydronephrosisPyonephrosis
  4. 4. Hematuria (symptom & sign)Painless, PainfulUpper UTLower UTCausesCongenital,AcquiredDiagnosisTreatment (General, Specific)
  5. 5. Evaluation of Renal FunctionLabImagingOverall renal functionSplit renal FunctionAcute renal FailurePre renalRenalPost renal (Obstructive)Management
  6. 6. Renal CalculiPrimary, SecondaryStone compositionRadio opaque , LucentEvaluationImagingD.D. in KUBTreatmentMedical ….. DissolutionInterventionalSWL…PNL…Open Surgery
  7. 7. Ureteric CalculiTreatment Options Depend on:LevelSizeDegree of obstructionPresence of UTIPain severity & ToleranceMedicalInterventional:SWLUreteroscopySurgery
  8. 8. Bladder StonesPrimarySecondaryImagingDDTreatmentNo medical TreatmentInterventional:Endoscopic crushingSurgery? SWLRX of the cause
  9. 9. 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
  10. 10. 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
  11. 11. TreatmentDepends on stageOrgan confined disease: (Potentially curable)R. Prostatectomy….R. RadiotherapyLocally advanced Disease (extra-prostatic):RadiotherapyMetastatic Disease:Hormonal (endocrine) TreatmentOrchiectomyLHRH agonistsAnti-androgensOestrogen
  12. 12. 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
  13. 13. 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)
  14. 14. 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
  15. 15. 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
  16. 16. Renal Cell Carcinoma85% of all renal tumorsAge & sexClinical Picture:Asymptomatic....accidentally discoveredPain , Mass, HematuriaParaneoplastic SyndromeMetastasisSignsGross pathologyHistopathologySpreadVenous extension
  17. 17. Treatment:The only effective treatment is surgery:R. Nephrectomy for localized diseaseMetastatic disease:? Palliative nephrectomy….ImmunotherapyImaging:KUB, IVU, U/SCT (gold standard)Metastatic survey
  19. 19. 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
  20. 20. 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.)
  21. 21. Drugs:Parasympatholytics …detrusor hypotoniaAlpha-adrenergic agonists.. increasedtone of BN& proximal urethraBeta-adrenergic agonists…detrusorhypotoniaPost-operative:Following….ano-rectal, pelvic & obstetricinterventionsAetiology of AUR (cont.)
  22. 22. 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
  23. 23. AUR in middle aged males:-Stone impaction in B.N. orurethra- Urethral stricture with oedema- Urethral trauma (rupture)Other causes…extravasationstricture
  24. 24. AUR in young boys:Posterior urethral valve( AUR on top of chronic)Meatal stenosis(with infection/encrustation)valve
  25. 25. AUR in females:Generally uncommon- Neurogenic- Urethral & vulvaltumors- Hysterical
  26. 26. Chronic Urinary RetentionA condition characterized by persistent failure ofcomplete bladder evacuation at the time of voidingCausesweak detrusor contractility(usually neurogenic)Chronic bladder outlet obstruction
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. Acute Retention versus AnuriaDefinitionSymptoms &recent historyAbdominal examinationImaging (ultrasound)Urethral catheterRenal function tests
  31. 31. 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
  32. 32. Further evaluation is done to revealthe cause of AUR:- Lab- Imaging- Endoscopic.Definitive treatment will be that of theunderlying causeDefinitive treatment