continuation on the urinary tract disorders. congenital and acquired disorders well covered. pyelonephritis also forms part of the text. thanks for reading. remeber to like and follow

1. UPPER URINARY TRACT
DISORDERS
HABAKUK LARRY OMONDI

2. Definition
• Disorders of the kidneys and ureters.
• Disorders can either be congenital or acquired.
• Acquired disorders of urinary tract-
A)urinary Tract infections- pyelonephritis,
B)urological Obstructions- calculi
C) neoplasms- benign and malignant(kidney,ureter tumors)

4. Congenital disorders of kidney
• Renal agenesis
• Renal ectopia
•Horseshoe kidney
•Crossed dystopia
•Infantile polycystic disease
• Unilateral multicystic dysplastic kidney
• Aberrant renal vessels - Multiple renal arteries and
veins
• Duplex kidney
• Duplex renal pelvis

5. Renal agenesis
Bilateral renal agenesis
• both mesonephric ducts fail to develop.
• Incompatible with life.
Unilateral renal agenesis
• the mesonephric duct fails to develop.
• Usually there is absent ureter, trigone, kidney and
(in boys) vas deferens.
• Prevalence of unilateral renal agenesis is about
1:1400 and it
is usually discovered incidentally

6. Horseshoe kidney
• two distinct functioning kidneys on each side
of the midline, connected at the lower poles by
an isthmus of functioning renal parenchyma or
fibrous tissue that crosses the midline of the
body.
• occurs in 1 per 400-800 live births
• hydronephrosis, stone formation, infection are
common

8. Congenital cystic kidneys (synonym:
polycystic kidneys)
• Are hereditary and potentially lethal
• transmitted by either parent as an autosomal
dominant trait. Thus, the risk of an offspring
inheriting the condition can be high
• The disease is not usually detectable on
standard imaging until the second and third
decades of life and does not usually manifest
itself clinically before the age of 30 years.
• Types- adult and infantile

10. Duplication of a ureter
• a congenital condition in which the ureteric
bud splits (or arises twice), resulting in two
ureters draining a single kidney.
• occurrs in approximately 1% of the
population.
• Can be : partial and complete.

12. Ureterocele
• the distal ureter balloons at its opening into the bladder.
• Treatment should be avoided unless there are symptoms
arising from infection and/or stone formation.
• Ureterocele is most common in women; occasionally, the
cyst may cause obstruction to the bladder outflow by
prolapsing into the internal urethral opening.
• Endoscopic diathermy incision is usually all that is required
for treatment of a symptomatic ureterocele, although a
micturating cystogram is advisable to detect postoperative
urinary reflux.
• In advanced unilateral cases with hydronephrosis or
pyonephrosis, nephrectomy may be appropriate.

14. Pelvicureteric junction obstruction
• obstruction of the flow of urine from the renal pelvis to the proximal
ureter.
• Etiology-aperistaltic segment of ureter due to absent muscles or
crossing vessels over UPJ.
Clinical features-may present at any time (before birth, in childhood, or
in adulthood) by:
• abdominal mass.
• abdominal pain.
• Haematuria after fairly minor abdominal trauma.
Diagnostic evaluation-
• IVU - shows delay in appearance of contrast and dilated renal pelvis
and calices.
• Renal scan -shows differential renal function and confirms
obstruction

15. Management-
• Surgery is indicated for:
1. obstructive symptoms,
2. stone formation,
3. recurrent urinary infection,
4. progressive renal impairment.
• Pyeloplasty is the treatment of choice
• Nephrectomy is performed if the affected kidney is
<10% of total renal function.

16. Vesicoureteric junction reflux
• retrograde flow of urine into upper urinary
tract.
• Ureters run obliquely and run submucosally
for some distance. plus ureter's muscular
attachments.

18. • Micturating cystourethrography is the gold standard for
diagnosis and evaluation of VUR grade.
•Diuretic Renal scan (DMSA) is used to visualize scarring
and quantify differential renal function
Management
•antibiotic prophylaxis is recommended for children with
reflux of grades I-II.
•Surgery (uretero - vesical reimplantation or endoscopic
injection) is recommended in reflux of grades III-V and
persistent reflux despite a trial of antibiotics.

19. Pyelonephritis
• Pyelonephritis is inflammation of the kidney,
typically due to a bacterial infection.
• Common organisms are E. coli (70–80%)
and Enterococcus faecalis.
• Risk factors …….

20. Clinical features
• Fever
• Costovertebral angle pain
• Nausea and/or vomiting
• Mental status change
• Decompensation in another organ system
• Generalized deterioration
• hematuria

21. investigations
Definative
Urinalysis - Urine specimens may be obtained by
midstream clean catch, suprapubic aspiration,
or catheterization
Dipstick testing - glucose, protein, blood, nitrite,
and leukocyte esterase
Leukocyte esterase 57-96% sensitive and 94-
98% specific for identifying pyuria

22. Nitrite tests are sensitivity and specificity of 22% and 94-100%,
respectively.
Microscopic examination:
• Pyuria : Most truly infected patients have > 10 WBCs/μL. The
presence of bacteria in the absence of pyuria:due to contamination
during sampling.
• Microscopic hematuria occurs in up to 50% of patients, but gross
hematuria is uncommon.
• WBC casts: pyelonephritis, glomerulonephritis, and noninfective
tubulointerstitial nephritis.
• Pyuria in the absence of bacteriuria and of UTI is possible, for
example, if patients have nephrolithiasis, a uroepithelial tumor,
appendicitis, or inflammatory bowel disease or if the sample is
contaminated by vaginal WBCs

23. • Complete blood count.
• HIV test
• VDRL
• Erythrocyte sedimentation rate
• U/E/C

24. imaging
Ultrasonography
a. Abdominal - hydronephtosis pyonephrosis,
perirenal abcess.
Ct scan of the abdomen.

25. Treatment
Emphysematous pyelonephritis-emergent
nephrectomy
• IV analgesics &antipyretics & IV fluids
• Abx-levofloxacin 500mg/d IV then orally for
7-14 days or 750mg/day for 5 days
• Ciprofloxacin 500mg PO bd for 7d
2nd line-septrin

26. Renal calculi
• Incidence- The occurrence of urinary stones occurs predominantly in the
third to fifth decades of life and affects men more than women.
• About half of patients with a single renal stone have another episode within
5 years.
• Most stones contain calcium or magnesium in combination with
phosphorus or oxalate.
• Most stones are radiopaque and can be detected by x-ray studies
Types of stone-
• Calcium stone
• Oxalate stone
• Cystiene stone
• Struvite stone

27. Causes and predisposing factors of renal calculi:
• Chronic dehydration, poor fluid intake, and immobility
• Living in mountainous, desert, or tropical areas
• Infection, urinary stasis, and periods of immobility
• Inflammatory bowel disease and in patients with an ileostomy or
bowel resection because these patients absorb more oxalate.
• Medications- antacids, acetazolamide (Diamox), vitamin D,
laxatives, and high doses of aspirin
Location of stones-
• Kidney
• Ureter
• Bladder
• Urethra
• Prostate

28. Clinical features-
• Pain
• Hematuria
• Dysuria
• Oedema
• Pyuria
Associated symptoms-
• Nausea, vomiting, diarrhea, abdominal
discomfort
• Chills and fever (may)

29. Diagnostic evaluation
• Urinalysis-
hematuria and pyuria
pH < 5.5 indicates uric acid stone
pH > 7.5 indicates struvite stone
urine culture and drug sensitivity studies to detect
infection.
• 24-hour urine test for measurement of calcium,
uric acid, creatinine, sodium,citrate and oxalate

30. Blood studies-
• Hyperuracemia
• Hypercalcemia
• Neutrophilia
• Elevated serum parathyroid hormone
Stone chemistry-
• Collection of stone through a strainer is useful.
• Analyze the stone chemically to find out the
composition which helps in therapeutic
management.

31. Radiographic studies-
• Kidney, ureters, and bladder radiography may
show stone.
• Intra venous urogram (intravenous pyelogram) to
determine site and evaluate degree of obstruction
• Retrograde pyelography
• Ultrasound
• Helical or axial CT Scan

32. Management
General Principles
• If small stone (< 4 mm) and able to treat as
outpatient, 80% will pass stone spontaneously
with hydration, pain control, and reassurance.
• Hospitalized for intractable pain, persistent
vomiting, high-grade fever, obstruction with
infection, and solitary kidney with obstruction.
• Medical management
• Surgical management

33. Medical management
Goal-
Immediate goal- To relieve the pain until its
causes can be eliminated.
Long term goal (basic goal)-
• To eradicate the stone
• To determine the stone type
• To prevent nephron destruction
• To control infection
• To relieve any obstruction

34. Medical management
• Opioid analgesics or NSAIDs
• NSAIDs provide specific pain relief because
they inhibit the synthesis of prostaglandin E.
• Hot baths or moist heat to the flank areas may
also be useful.
• Fluids are encouraged. This increases the
hydrostatic pressure behind the stone, assisting
it in its downward passage.
• A high, around-the-clock fluid intake reduces
the concentration of urinary crystalloids, dilutes
the urine, and ensures a high urine output

35. Calcium stone-
• Cellulose sodium phosphate (Calcibind) may be effective
in preventing calcium stones.
• it binds calcium from food in the intestinal tract, reducing
the amount of calcium absorbed into the circulation.
• restrict calcium in diet
• Therapy with thiazide diuretics may be beneficial in
reducing the calcium loss in the urine
• The urine may be acidified by use of medications such as
ammonium chloride or acetohydroxamic acid
• Sodium and protein restriction diet

36. Uric acid stone-
• low-purine diet such as shellfish, anchovies, asparagus,
mushrooms, and organ meats are avoided
• Allopurinol may be prescribed to reduce serum uric acid
levels and urinary uric acid excretion.
• Proteins may be limited in diet
Cystine stone -
• Low-protein diet
• Penicillamine is administered to reduce the amount of
cystine in the urine
• urine is alkalinized.
Oxalate stone -
• Encourage the increased fluid intake
• Avoid the food contains oxalate such as- spinach,
strawberries, tea, peanuts, wheat bran

37. Non surgical management-
• Ureteroscopy
• ESWL (Extra Corporeal Shock wave lithotripsy)
• Endoscopic procedures
• Electrohydrolic lithotripsy
• Chemolysis
Surgical management-
• Nephrolithotomy - Incision into the kidney with removal of the
stone
• Nephrectomy – removal of kidney
• Pyelolithotomy - removal of stone from renal pelvis
• Ureterolithotomy - removal of stone from ureter
• Cystostomy – removal of stone from bladder
• Cystolitholapaxy - an instrument is inserted through the urethra
into the bladder, and the stone is crushed in the jaws of this
instrument