eMedicine Specialties > Emergency Medicine > Genitourinary

Urinary Obstruction: Follow-up

Author: Michael A Policastro, MD, Assistant Professor of Emergency Medicine, Fellow in Medical Toxicology, Department of Emergency Medicine, University of Cincinnati; Consulting Staff, Department of Emergency Medicine, Jewish Hospital, Health Alliance
Coauthor(s): Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center; Pilar Guerrero, MD, Assistant Professor, Department of Emergency Medicine, John H Stroger Jr Hospital, Cook County Hospital
Contributor Information and Disclosures

Updated: Jan 29, 2009

Follow-up

Further Inpatient Care

  • Decision to admit the patient depends on the need for invasive surgical drainage procedures and complications of obstruction.
  • Replacement of electrolyte disturbances should be treated accordingly.

Further Outpatient Care

  • Depending on specific complications of obstruction, relief of bladder neck obstruction by urethral catheterization requires prompt (within 1 wk) follow-up care with a urologist for definitive therapy.

Transfer

  • Patients with indications for acute hemodialysis may need to be transferred if a facility is not available at the presenting institution.

Complications

  • Postobstructive diuresis is an uncommon but clinically significant complication following the release of urinary obstruction.
    • It is characterized by a marked natruresis and diuresis with excretion of large amounts of sodium and water.
    • In addition to the potential for severe volume depletion, electrolyte disorders such as hypokalemia, hyponatremia, hypernatremia, and hypomagnesemia may occur.
    • Etiology of this massive diuresis and electrolyte loss is multifactorial. It is related to fluid and urea overloads during obstruction and acquired tubular resistance to antidiuretic hormone and aldosterone.
    • Treatment of postobstructive diuresis consists of judicious fluid replacement with 0.45% saline (at a rate slightly less than urine output) and replacement of electrolytes.
    • Urinary tract infections may occur due to urinary stasis. Additionally, instrumentation may also introduce contamination. Antibiotic selection depends on the age, sex, and comorbid conditions of the patient. Additionally, minimizing drug interactions, such as patients on anticoagulation, should also guide antibiotic selection.

Prognosis

  • The longer the duration of obstruction, the lower the probability of recovery of any renal function and the lower the resultant GFR.
    • In humans, partial recovery of function frequently is observed after less than 3 weeks of obstruction; however, case reports have noted some return of function after 5 months of obstruction.
    • UTIs complicating obstruction further decrease the probability of recovery.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • The greatest risk in treating patients with high-grade urinary obstruction is missing the initial diagnosis. This disease is slowly progressive over many years, allowing the patient to acclimatize to symptoms of prostatism. Just asking if the patient has any problems passing urine frequently results in a negative response even in patients with significant obstruction.
    • Does the patient have nocturia? Increasing nocturia is often an early sign of obstruction.
    • How many times a day is the patient passing urine? Increasing urinary frequency is the result of incomplete bladder emptying.
    • Is the patient often wetting himself before he reaches the bathroom? In high-grade obstruction, the degree of urethral narrowing is the main control for micturition, not the patient's urethral sphincters.
    • In public restrooms, does the patient prefer using the urinal or does he wait for the toilet even when he only has to pass urine? Most men will prefer to use the urinal in this situation. Obstructed patients use the toilet from performance anxiety because starting the urinary stream takes so long (ie, hesitancy).
  • Once the bladder is decompressed, do not remove the catheter until the obstruction is relieved surgically or medically. Refer the patient to a urologist with the catheter in place attached to a leg bag.
  • Send urine analysis, electrolytes, and CBC to the laboratory. UTIs and hyperkalemia are frequent complications of urinary obstruction that should be diagnosed and treated prior to discharge.
  • After obstruction is relieved, observe the patient in the ED for 2-3 hours to ensure the patient is not experiencing postobstructive diuresis.
  • In the absence of physical obstruction, review the patient's medication to evaluate for possible etiologies of the obstruction. Over-the-counter medications and herbal supplementations should also be reviewed because many patients do not include these among their medication regimen.
 


More on Urinary Obstruction

Overview: Urinary Obstruction
Differential Diagnoses & Workup: Urinary Obstruction
Treatment & Medication: Urinary Obstruction
Follow-up: Urinary Obstruction
References
[ CLOSE WINDOW ]

References

  1. de la Rosette JJ, Witjes WP, Schafer W, et al. Relationships between lower urinary tract symptoms and bladder outlet obstruction: results from the ICS-"BPH" study. Neurourol Urodyn. 1998;17(2):99-108. [Medline].

  2. Christensen J, Ostri P, Frimodt-Moller C, Juul C. Intravesical pressure changes during bladder drainage in patients with acute urinary retention. Urol Int. 1987;42(3):181-4. [Medline].

  3. Gould F, Cheng CY, Lapides J. Comparison of rapid versus slow decompression of the distended urinary bladder. Investigative urology. Sep 1976;14 (2):156-8. [Medline].

  4. Bartosh SM. Medical management of pediatric stone disease. Urol Clin North Am. Aug 2004;31(3):575-87, x-xi. [Medline].

  5. Batlle DC, Arruda JA, Kurtzman NA. Hyperkalemic distal renal tubular acidosis associated with obstructive uropathy. N Engl J Med. Feb 12 1981;304(7):373-80. [Medline].

  6. Becker A, Baum M. Obstructive uropathy. Early Hum Dev. Jan 2006;82(1):15-22. [Medline].

  7. Belal M, Abrams P. Noninvasive methods of diagnosing bladder outlet obstruction in men. Part 1: Nonurodynamic approach. J Urol. Jul 2006;176(1):22-8. [Medline].

  8. Berrocal T, Lopez-Pereira P, Arjonilla A, Gutierrez J. Anomalies of the distal ureter, bladder, and urethra in children: embryologic, radiologic, and pathologic features. Radiographics. Sep-Oct 2002;22(5):1139-64. [Medline].

  9. Bosniak MA, Megibow AJ, Ambos MA, et al. Computed tomography of ureteral obstruction. AJR Am J Roentgenol. Jun 1982;138(6):1107-13. [Medline].

  10. Catalano C, Pavone P, Laghi A, et al. MR pyelography and conventional MR imaging in urinary tract obstruction. Acta Radiol. Mar 1999;40(2):198-202. [Medline].

  11. Chapple CR, Baert L, Thind P, et al. Tamsulosin 0.4 mg once daily: tolerability in older and younger patients with lower urinary tract symptoms suggestive of benign prostatic obstruction (symptomatic BPH). The European Tamsulosin Study Group. Eur Urol. 1997;32(4):462-70. [Medline].

  12. Chevalier RL. Pathogenesis of renal injury in obstructive uropathy. Curr Opin Pediatr. Apr 2006;18(2):153-60. [Medline].

  13. Chu J. Genitourinary principles. In: Goldfrank's Toxicologic Emergencies. 8th ed. 2006: 442-56.

  14. Dal Canton A, Corradi A, Stanziale R, et al. Glomerular hemodynamics before and after release of 24-hour bilateral ureteral obstruction. Kidney Int. Apr 1980;17(4):491-6. [Medline].

  15. Dalgic A, Boyvat F, Karakayali H, et al. Urologic complications in 1523 renal transplantations: The Baskent University experience. Transplant Proc. Mar 2006;38(2):543-7. [Medline].

  16. Decramer S, Wittke S, Mischak H, et al. Predicting the clinical outcome of congenital unilateral ureteropelvic junction obstruction in newborn by urinary proteome analysis. Nat Med. Apr 2006;12(4):398-400. [Medline].

  17. Djavan B, Marberger M. A meta-analysis on the efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction. Eur Urol. 1999;36(1):1-13. [Medline].

  18. Feinfeld DA, Anthony VL. Renal principles. In: Goldfrank's Toxicologic Emergencies. 8th ed. 2006: 427-42.

  19. Gustilo-Ashby AM, Jelovsek JE, Barber MD, et al. The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for pelvic organ prolapse. Am J Obstet Gynecol. May 2006;194(5):1478-85. [Medline].

  20. Hoffman LM, Suki WN. Obstructive uropathy mimicking volume depletion. JAMA. Nov 1 1976;236(18):2096-7. [Medline].

  21. Ilbeigi P, Lombardo S, Sadeghi-Nejad H. Unusual cause of obstructive uropathy. Int Urol Nephrol. 2005;37 (3):505-6. [Medline].

  22. Kessler TM, Gerber R, Burkhard FC, et al. Ultrasound assessment of detrusor thickness in men-can it predict bladder outlet obstruction and replace pressure flow study?. J Urol. Jun 2006;175(6):2170-3. [Medline].

  23. Kilby MD, Daniels JP, Khan K. Congenital lower urinary tract obstruction: to shunt or not to shunt?. BJU Int. Jan 2006;97(1):6-8. [Medline].

  24. Levin RM, Longhurst PA, Whitbeck C, Korstanje C. The effect of tamsulosin on the response of the rabbit bladder to partial outlet obstruction. Neurourol Urodyn. 2006;25(1):89-94. [Medline].

  25. Louca G, Liberopoulos K, Fidas A, et al. MR urography in the diagnosis of urinary tract obstruction. Eur Urol. Feb 1999;35(2):102-8. [Medline].

  26. Matlaga BR, Assimos DG. Urologic manifestations of nonurologic disease urolithiasis. Urol Clin North Am. Feb 2003;30(1):91-9. [Medline].

  27. Misseri R, Rink RC, Meldrum DR, Meldrum KK. Inflammatory mediators and growth factors in obstructive renal injury. J Surg Res. Jun 15 2004;119(2):149-59. [Medline].

  28. Moudouni SM, Tligui M, Doublet JD, et al. Laparoscopic excision of seminal vesicle cyst revealed by obstruction urinary symptoms. Int J Urol. Mar 2006;13(3):311-4. [Medline].

  29. O'Reilly PH, Lawson RS, Shields RA, Testa HJ. Idiopathic hydronephrosis--the diuresis renogram: a new non-invasive method of assessing equivocal pelvioureteral junction obstruction. J Urol. Feb 1979;121(2):153-5. [Medline].

  30. Powers TA, Grove RB, Bauriedel JK, et al. Detection of obstructive uropathy using 99mtechnetium diethylenetriaminepentaacetic acid. J Urol. Nov 1980;124(5):588-92. [Medline].

  31. Reynard JM. Does anticholinergic medication have a role for men with lower urinary tract symptoms/benign prostatic hyperplasia either alone or in combination with other agents?. Curr Opin Urol. Jan 2004;14(1):13-6. [Medline].

  32. Rodriguez RA. Renal toxicology. In: Occupational & Environmental Medicine. 2nd ed. 1997: 355-67.

  33. Rose JG, Gillenwater JY. Pathophysiology of ureteral obstruction. Am J Physiol. Oct 1973;225(4):830-7. [Medline].

  34. Rugo HS, Fischman ML. Occupational cancer. In: Occupational & Environmental Medicine. 2nd ed. 1997: 235-70.

  35. Rule AD, Lieber MM, Jacobsen SJ. Is benign prostatic hyperplasia a risk factor for chronic renal failure?. J Urol. Mar 2005;173(3):691-6. [Medline].

  36. Tsai JD, Huang FY, Lin CC, et al. Intermittent hydronephrosis secondary to ureteropelvic junction obstruction: clinical and imaging features. Pediatrics. Jan 2006;117(1):139-46. [Medline].

  37. Wille-Gussenhoven MJ, de Bock GH, de Beer-Buijs MJ, et al. Prostate symptoms in general practice: seriousness and inconvenience. Scand J Prim Health Care. Mar 1997;15(1):39-42. [Medline].

  38. Woderich R, Fowler CJ. Management of lower urinary tract symptoms in men with progressive neurological disease. Curr Opin Urol. Jan 2006;16(1):30-6. [Medline].

  39. Zeidel ML, Pirtskhalaishvili G. Urinary tract obstruction. In: Brenner & Rector's The Kidney. 7th ed. 2004.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

urinary obstruction, obstruction of the urinary tract, blocked urine flow, renal failure, kidney failure, renal dysfunction, kidney dysfunction, renal insufficiency, renal calculi, urinary tract infection, UTI, renal tubular acidosis, RTA, hyperkalemia, hypomagnesia, hypophosphatemia

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Michael A Policastro, MD, Assistant Professor of Emergency Medicine, Fellow in Medical Toxicology, Department of Emergency Medicine, University of Cincinnati; Consulting Staff, Department of Emergency Medicine, Jewish Hospital, Health Alliance
Michael A Policastro, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pilar Guerrero, MD, Assistant Professor, Department of Emergency Medicine, John H Stroger Jr Hospital, Cook County Hospital
Disclosure: Nothing to disclose.

Medical Editor

David S Howes, MD, Residency Program Director, Professor of Medicine, Section of Emergency Medicine, University of Chicago/Pritzker School of Medicine
David S Howes, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.