eMedicine Specialties > Radiology > Genitourinary

Obstructive Uropathy, Acute: Follow-up

Author: Sameet Rao, MD, Associate Radiologist, Department of Radiology, Radiology Associates of Burlington County
Contributor Information and Disclosures

Updated: Mar 10, 2008

Intervention

Most calculi smaller than 6 mm in diameter pass spontaneously. Pain control and hydration usually are all that is required in an uncomplicated situation. Larger stones as well as stones lodged in the proximal ureter are less likely to resolve on their own and require intervention. Treatment choice depends on the location and composition of the stone, presence of infection, preceding treatment, and anatomy of the urinary tract.

The placement of a ureteral stent by the urologist often is the primary intervention for ureteral calculi. If the obstruction is not relieved, endourologic procedures such as retrograde ureteroscopy and lithotripsy may be attempted. Extracorporeal shock wave lithotripsy (ESWL) commonly is performed on renal and ureteral calculi with success but is contraindicated in obstruction, unless a urinary diversion procedure allows for passage of the stone fragments.

In ureteral obstruction, the interventional radiologist performs US and/or fluoroscopic-guided percutaneous nephrostomy. As it provides access to the collecting system, nephroscopy, lithotripsy, and removal of large renal calculi are possible. It is the treatment of choice in patients with staghorn calculi, which are commonly infected and do not respond as well to other treatments. In patients with obstructions with evidence of infection and/or sepsis, emergent percutaneous nephrostomy tube placement serves to decompress the collecting system.25

For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Kidney Stones and Intravenous Pyelogram.

Medicolegal Pitfalls

  • Calculi may be missed and signs of obstruction may not be evident. Clinical and imaging follow-up care is warranted to prevent the loss of kidney function. The interpreting radiologist is responsible for all pathologic entities present on the imaging study, whether or not they may be the source of the present symptoms.

See also the Medscape topic Medical Malpractice and Legal Issues.

Special Concerns

  • The pregnant patient with acute flank pain from ureteral obstruction presents a unique diagnostic and therapeutic challenge. The incidence of an obstructing stone is approximately 1 in 1500 pregnancies. Compression from the gravid uterus also may result in an obstructive uropathy.
  • The diagnostic imaging approach to these patients begins with an abdominal US to demonstrate the presence of hydronephrosis. Remember that mild hydroureteronephrosis is observed in normal pregnant patients. Transvaginal and transrectal US may be used to detect distal ureteral calculi. Doppler sonography plays an important role, using the RI and ureteral jets to diagnose obstruction.
  • Where US does not provide a diagnosis, MRU or IVU may be the next step in imaging. MRU, if available, is preferred, as no ionizing radiation exposure occurs. One can make the diagnosis of an obstructing calculus by the presence of a filling defect with associated perinephric or periureteral edema. Alternatively, an extremely limited IVU may provide the necessary information. The limited IVU consists of a preliminary film followed by a single postcontrast exposure to demonstrate the point and cause of obstruction. However, the gravid uterus with the fetus can obscure a nonpregnancy cause of hydronephrosis.
  • As in other patients with ureteral calculi, management is conservative, as most stones will pass with hydration. In patients with persistent symptoms, placement of a ureteral stent or percutaneous nephrostomy is needed to relieve obstruction. This also may be necessary in patients with obstruction secondary to a gravid uterus, where conservative measures such as postural changes may be ineffective.
 
Acknowledgments

The authors and editors acknowledge Kevin Dickey, MD, for his contributions to this article. 



More on Obstructive Uropathy, Acute

Overview: Obstructive Uropathy, Acute
Imaging: Obstructive Uropathy, Acute
Follow-up: Obstructive Uropathy, Acute
Multimedia: Obstructive Uropathy, Acute
References
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References

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Further Reading

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Contributor Information and Disclosures

Author

Sameet Rao, MD, Associate Radiologist, Department of Radiology, Radiology Associates of Burlington County
Sameet Rao, MD is a member of the following medical societies: American College of Radiology and New England Roentgen Ray Society
Disclosure: Nothing to disclose.

Medical Editor

Steven Perlmutter, MD, FACR, Clinical Associate Professor, Radiology Residency Program Director, Radiology Medical Director, Department of Radiology, University Hospital at Stony Brook
Steven Perlmutter, MD, FACR is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, American Medical Association, American Roentgen Ray Society, Association of Program Directors in Radiology, Association of University Radiologists, Medical Society of the State of New York, Radiological Society of North America, Society of Breast Imaging, Society of Nuclear Medicine, and Society of Uroradiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Joshua A Becker, MD, Professor, Department of Radiology, New York University School of Medicine
Joshua A Becker, MD is a member of the following medical societies: Society of Uroradiology
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Consulting Staff, Department of Radiology, Virginia Mason Medical Center
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

 
 
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