OBSTRUCTIVE

UROPATHY
&
URINARY TRACT
CALCULI

 Important functions of the renal system

Create, store and eliminates
urine

Eliminate urea and uric acid

Allow body to adjust salt

concentration by diluting or
concentrate the urine

Regulates acid base balance

LEARNING OBJECTIVES
A review of the anatomy and physiology of the urinary
system, and pathophysiology of obstructive uropathy and
urinary calculi formation.
Definition of obstructive uropathy.
The clinical presentation of obstructive uropathy.
The clinical presentation of patients with urinary calculi.
The investigation of a patient with obstructive uropathy
and/or urinary calculi.
The principles of management of obstructive uropathy and
urinary calculi.

OBSTRUCTIVE
UROPATHY

KIDNEYS
Separate urea, mineral salts,
toxins and other waste products
from blood
Filter out wastes to be excreted in
the urine
Regulates blood pressure
Regulates acidbase balance
Stimulates RBC production
Normal adult size:
Length: 10-12 cm
Width: 5-7cm

URETERS
Transports urine from renal pelvis of
kidney to bladder
Pass beneath the urinary bladder
which results the bladder compressing
the ureters
This prevents backflow of urine when
pressure in bladder is high during
urination
Has 3 constrictions:
Pelviureteric junction (at the origin)
Pelvic brim (when it crosses external iliac
artery)
Vesicoureteric junction (just before
entering bladder)

BLADDER
Hollow, distensible
muscular organ.
Located in the pelvic
cavity
Posterior to pubic
symphysis.
When full, become
ovoid shape
Function:
store urine
expels urine into the

URETHRA
Extends from the base of the
bladder to the external part of
body.
Length of urethra:
Male: 14cm long
Female: 4cm long

Function:
A passageway through which urine
is discharged from the body, and
also played as a reproductive organ
in male.

PHYSIOLOGY OF MICTURITION
As the urinary bladder gets filled
with urine, the bladder will stretch.
In response ,the stretch receptors
on the walls of the bladder send
signals to the CNS.
The CNS passes on motor
messages to initiate the
contraction of smooth muscles of
the bladder.
The simultaneous relaxation of the
urethral sphincter causing the
release of urine (micturition)

OBSTRUCTIVE
UROPATHY

DEFINITION
Obstructive uropathy occurs when a defect
(structural or functional) occurs in the
urinary tract leading to impaired urinary flow.
Long duration and severe obstructive
uropathy can impairs renal function, which
later leads to renal dysfunction (obstructive
nephropathy)
The obstruction may be in upper or lower
urinary tracts and will have corresponding
signs and symptoms based on the site,
degree of obstruction and duration

ETIOLOGY
Mechanical

Lumen of
urethra /
overlying
internal
urethral orifice
Wall of
bladder /
urethra
Outside the
wall

Etiology
Neurogenic

Functional

Medications

Myogenic

MECHANICAL CAUSES
In urethral lumen
or overlying
internal urethral
orifice
Congenital valves
Foreign bodies
Tumour
Blood clot
Stones

In wall of bladder
or urethra
Phimosis
Trauma (rupture of
urethra)
Urethral stricture
Urethritis
Meatal ulcer
Tumour
Prostatic
enlargement
(benign and
malignant)

Outside the wall

Pregnancy
(retroverted gravid
uterus)
Fibroids
Ovarian cysts
Faecal impaction
Paraphimosis

FUNCTIONAL CAUSES
Neurogenic
Stroke
Spinal cord
injuries or
diseases
Diabetes
Mellitus

Medications

Myogenic

Anticholinerg
ics
Antihistamin
es
Smooth
muscle
relaxants

Myasthenia
Gravis

CLINICAL FEATURES
Features depends on:
Site affected
Degree of obstruction (partial / complete)
Duration of pathology (acute / chronic)

History and Physical examination principles

Find risk factors for obstruction
Find evidence of obstruction
Find complications of obstruction

HISTORY TAKING
Pain
Pain can be secondary to
stretching of the urinary
collecting system
Obstruction of the ureter by a
calculus commonly results in an
excruciating renal colic pain.
Pain is described as unrelenting,
radiating from the flank to lower
abdomen and testicles or labia
on the affected side.
By contrast, pathological
processes that slowly obstruct,
such as retroperitoneal tumors

Micturition pattern
alterations
Can present as early symptoms
but often missed
Bladder outlet obstruction leads
to the symptoms of prostatism
(frequency, urgency, hesitancy,
dribbling, decrease in voiding
stream, the need to double
void)

HISTORY TAKING
Hematuria
Often associated
with renal calculi,
papillary necrosis,
and tumors
These conditions
can later develop
into obstruction

Recurrent UTI
More towards
complications of
obstruction
Bacteria can
become trapped in
urine that pools
above a blockage.

HISTORY TAKING
History of past surgery
Obtain history of recent
gynecologic or abdominal
surgery
Scarring from
instrumentation
Previous bladder or
prostate surgeries can
lead to the formation of
strictures due to scar
tissue

Medication history
Remember to obtain
medication history
A variety of drugs and
toxins affect renal
function.
Bladder dysfunction
common with usage of
antihistamines,
antipsychotics, and
antidepressants

HISTORY TAKING
Occupational History
Equally important history to obtain
Consider retroperitoneal fibrosis due to
asbestos-induced mesothelioma in case of
textile manufactures, shipyard workers, roofers,
or asbestos miners
Bladder cancerinduced outlet obstruction may
occur in textile workers, rubber manufacturing
workers, leather workers, painters, hairdressers,

Physical Examination

Suprapubic tenderness

Bladder enlarged (palpable), tense, dull, rounded

mass arising out from pelvis
Dull to percussion, fluctuate and have fluid thrill
if patient is thin enough

Rectal examination

prostate or uterus pushed backward and downward

* cannot asses the size of prostate gland when

bladder is full

INVESTIGATIONS (BASELINE)
Urinalysis
WBCs in the urine = infection or inflammation.
Nitrite- or leukocyte esterasepositive urine = infection.
RBCs in the urine = infection, stones, or tumor.

Blood Urea & Serum Electrolyte

Provide information of renal insufficiency
Hyperkalemia and acidosis may be present.

Complete Blood Count

Leukocytosis = indicates infection.
Anemia can be acute (eg, blood loss) or due to chronic processes (eg, chronic
renal insufficiency, malignancy).

INVESTIGATIONS (IMAGING)
Ultrasonography
Sensitive in revealing renal parenchymal masses, hydronephrosis, distended
bladder, and renal calculi.

Intravenous Pyelography
It provides both anatomical and functional information.
Delayed calyceal filling, delayed contrast excretion, prolonged nephrogram
results, and dilation of the urinary tract proximal to the point of obstruction
characterize obstruction.
Retrograde pyelography can be performed to completely visualize the renal
pelvis or ureter.

INVESTIGATIONS (IMAGING)
Computerized Tomography Scan
A CT scan is very useful in providing anatomic detail.
A CT scan provides information regarding the urinary
tract, as well as any possible retroperitoneal or pelvic
pathologic condition that can affect the urinary tract via
direct extension or external compression.
A noncontrast CT scan should be obtained to assess for
calculi.
A contrasted CT scan is needed to provide information
on renal pathology.

INVESTIGATIONS (IMAGING)
Magnetic Resonance Imaging
MRI is useful in delineating specific tissue planes for surgical planning,
as well as in evaluating the presence or extent of a renal vein or
inferior vena cava thrombus in cases of renal tumors.
MRI does not reveal urinary stones so is not often used as a first-line
test.

Cystoscopy
Any abnormalities in the urethra, prostatic urethra, bladder neck, and
bladder can be visualized.

MANAGEMENT
Medical therapy
Antibiotics
Given for prophylaxis and should cover common urinary tract
pathogens.
Commonly used antibiotics: trimethoprim- sulfamethoxazole,
nitrofurantoin, cephalosporins, and fluoroquinolones.

Pain secondary to urinary tract obstruction:

Oxycodone, hydrocodone, acetaminophen, and nonsteroidal
anti-inflammatory medications.

MANAGEMENT
Surgical therapy
The goal of surgical intervention is to completely relieve the
urinary tract obstruction.
Lower urinary tract obstruction (bladder, urethra) can be
relieved with the following:
Urethral catheter
Suprapubic tube or catheter

Upper urinary tract obstruction (ureter, kidney) can be

relieved with the following:
Ureteral stent
Nephrostomy tube

MANAGEMENT
Urologic emergencies that require immediate attention
and intervention:

Complete urinary tract obstruction

Any type of obstruction in a solitary kidney
Obstruction with fever, infection, or both
Renal failure
Pain that is uncontrolled with oral medications
Nausea and vomiting that causes dehydration

COMPLICATIONS
Bladder diverticulum
Detrusor muscles hypertrophies to
overcome obstruction; trabeculated bladder
wall, out-pouches of bladder mucosa, form
saccule between muscle bands

Urinary retention
Due to urinary stagnation

Infection
Including cystitis, pyelonephritis, abscess
formation, and urosepsis

COMPLICATIONS
Bladder stones
Infection and stasis

Hydronephrosis
Back pressure on ureters (reflux)
Incompetent valves

Renal failure
Due to progressive hydronephrosis
Resulting in anaemia, uraemia
(obstructive uropathy)

Atonic bladder
Chronic retention : bladder is vastly
distended and atonic
Leading to overflow incontinence

Urinary tract calculi

(Urolithiasis)

Introduction
Renal calculi common
50% of patients present between ages of 30 to 50
years
Male-female ratio is 4:3

Aetiology
a)
b)
c)
d)
e)
f)
g)

Dietetic
Altered urinary solutes and colloids
Decreased urinary citrate
Renal infection
Inadequate urinary drainage and urinary stasis
Prolonged immobilisation
Hyperparathyroidism

Types of stones
1.
2.
3.
4.
5.

Oxalate calculus
Phosphate calculus
Uric acid calculus
Cystine calculus
Xanthine calculus

Types of stones

Characteristics

Oxalate calculus

Irregular, with sharp projection

Tend to bleed
Hard and radiodense

Phosphate calculus

Struvite, staghorn calculus

Smooth and dirty white
In alkaline urine with urea splitting
Proteus organism present

Uric acid calculus

Hard, smooth, multiple

Yellow to reddish brown
Radiolucent, filling defect on
excretion urogram, confirmed by CT
Most uric acid stones contain some
calcium , so they cast a faint
radiological shadow

Cystine calculus

Uncommon
Congenital error of metabolism that
leads to cystinuria
Hexagonal, translucent, white crystal
of cystine in acidic urine
Pink or yellow, but change to green
when exposed to air
Radio-opaque

Xanthine

Rare
Smooth and round
Brick red
Shows lamellation on cross section

Clinical features

Renal calculi
May be clinically silent even when large (silent
calculus)
renal failure may be the first indication of bilateral silent
calculi, although secondary infection usually produce
symptoms first

 Pain
Occurs in 75% of people with urinary
stones
Fixed renal pain occurs in the renal
angle, the hypochondrium, or in both
May worsen on movement
Ureteric colic: agonising pain passing
from the loin to the groin.
Often caused by a stone entering the
ureter

 Hematuria
Pyuria
Chronic cases can present with
anemia
During an attack of ureteric colic,
there is rigidity of lateral abdominal
muscles
Tenderness on deep palpation
Renal punch +ve
Percussion produces stab pain

Ureteric calculi
Small stones come from the kidney
Ureteric colic
As the stone progresses to the lower ureter, loin pain is
referred to groin, external genitalia and anterior surface
of the thigh
As the stone enters the bladder, the pain can be
referred to the tip of the penis

Ureteric calculi
clinical features
Impaction
Commonly at 5 sites of narrowing
An impacted stone causes a more consistent
dull pain, often in the iliac fossa
Increased by exercise and lessened by rest

Hematuria
Generally in pain and less systematically ill
Tenderness and some rigidity over course
of ureter

Bladder stones
Primary stones occur in sterile urine, usually
originate from kidney stones
Secondary stones can occur in bladder outflow
obstruction, infection, impaired bladder emptying
or foreign body

Ureteric stones

Suprapubic pain
dysuria
intermittency
frequency
hesitancy
nocturia
urinary retention

 Terminal gross hematuria

sudden termination of voiding with
some degree of associated dull/sharp
pain referred to the tip of the penis
or labia majora
Interruption of the urinary stream is
due to the stone blocking the internal
meatus
Urinary infection is a common
presenting symptom

Investigations (Diagnostic)
Kidney-Ureter-Bladder (KUB) film
Diagnose radiopaque stones

Intravenous urography (IVU)

Detect radiolucent stones
Can rule out hydronephrosis

Abdominal ultrasound
To determine stone locations

Spiral CT
Investigation of choice for diagnosing uric acid stones

Investigations (Others)
Urinalysis
Colour, volume, appearance, specific gravity
Urine dipstick
Centrifuge (microscopic)
Microhematuria, urine pH
Cast cells, tumour cells

Uric acid stone acidic

Phosphate stone alkali
Pyuria infection

Renal function test

Plasma urea, electrolytes, creatinine (RF)

Full blood count

Haemoglobin level, total white count

Serum calcium
Hyperparathyroidism

Management

Hydration
Analgesic (NSAIDs, acetaminophen)
Antispasmodic (CCB- Nifedipine, alpha blocker- Doxazosin)
Antibiotic
Alkalinazation of urine (Potassium citrate) for uric acid
stone
Removal of stones
Calculi smaller than 5mm passes spontaneously unless
impacted

Stones removal
Indications
Symptomatic
Obstructing micturition process
Staghorn calculi
Failure to pass spontaneously
Infection
To prevent complication

Stones removal
Kidney

Ureter

Bladder

Percutaneous
nephrolithomy
(PCNL)

Endoscopic stone
removal with
dormia basket

Transurethral
litholapaxy

Extracorporeal
shock wave
lithotripsy (ESWL)

Uteroscopic stone
removal through
push bang

Percutaneous
suprapubic
litholapaxy/
Vesicolithotomy

Pyelolithotomy

Ureterolithotomy

Open suprapubic
cystolithotomy

Nephrolithotomy

Uteroscopy
Dormia stone-catching basket in use
1. Basket introduced pass stone
2. Opened
3. Enclosing stone, ready for withdrawal

Blind
lithothrite
used to
crush
bladder
stones

Prevention of recurrence
Drink plenty of water
Avoid purine rich food (red
meat, fish)
Eggs, meat and fish are high in
sulphur-containing protein and
should be restricted in
cystinuria
Urinate more than 2 litres per
day
Maintain ideal weight

 Check for serum calcium to exclude

hyperparathyroidism
Serum uric acid
Urinary urate , calcium and
phosphate to screen from cystine
Analysis of stone passed