Urinary Obstruction 

  • Author: Michael A Policastro, MD; Chief Editor: Erik D Schraga, MD   more...
 
Updated: Apr 19, 2011
 

Background

Urinary obstruction is a common cause of acute and chronic renal failure. A wide variety of pathological processes, intrinsic and extrinsic to the urinary system, can cause obstruction. Symptoms and signs of obstruction are often mild, occurring over long periods of time and requiring a high index of suspicion for diagnosis.

Because the degree and duration of obstruction are the chief determinants of renal dysfunction, early recognition and treatment are the keys to preventing renal loss. Urinary obstruction should be viewed as a potentially curable form of kidney disease.

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Pathophysiology

Normal urine production in an adult is about 1.5-2 L/day. Urine flow depends on 3 factors—a pressure gradient from the glomerulus to the Bowman capsule, peristalsis of the renal pelvis and ureters, and the effects of gravity (ie, hydrostatic pressure).

Obstruction of the urinary tract at any level eventually results in elevation of intraluminal ureteral pressure. With prolonged obstruction, ureteral peristalsis is overcome and increased hydrostatic pressures are transmitted directly to the nephron tubules.

As pressures in the proximal tubule and Bowman space increase, glomerular filtration rate (GFR) falls. After 12-24 hours of complete obstruction, intratubular pressure decreases to preobstruction levels. If complete obstruction is not relieved, a depressed GFR is maintained by decreases in renal blood flow mediated by thromboxane A2 and angiotensin II (AII). With continued obstruction, renal blood flow progressively falls, resulting in ischemia and incremental nephron loss. Thus, obstructive uropathy may lead to obstructive nephropathy. Several phases of obstructive nephropathy may be seen, including an early hyperemia and a late vasoconstriction followed by regulation of GFR post obstruction. Recovery of GFR depends on the duration and level of obstruction, preobstruction blood flow, and coexisting medical illness or infection.

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Epidemiology

Frequency

United States

No data are available on incidence and prevalence of urinary obstruction in unselected populations. Most epidemiologic studies of obstruction are in selected populations or autopsy studies. In large surveys of elderly men for symptoms of urinary obstruction, a prevalence of 20-35% has been estimated. Most (60%) of the men surveyed with moderately severe to severe symptoms of prostatism did not consult their physicians with these symptoms. Postmortem examinations have found hydronephrosis in 3.8% of adults and 2.0% of children.

Mortality/Morbidity

Urinary tract obstruction may lead to acute or chronic renal insufficiency or overt kidney failure. Obstruction may lead to a salt-losing nephropathy and urinary concentrating defects. Renal tubular acidosis (RTA) type IV, hyperkalemia, hypomagnesia, and hypophosphatemia are common sequelae of chronic obstruction. Although acute or chronic obstruction may cause urinary tract infection (UTI), other sequelae such as renal calculi, hypertension, and polycythemia are associated with a chronic setting. Ascites is a common sequela of neonatal obstruction syndrome. In cases of acute obstruction, a postobstructive diuresis following relief of the problem is well described.

Sex

In adults, incidence and etiology of urinary obstruction vary significantly with the age and sex of the patient.

  • In young and middle-aged men, renal calculi are the most common cause of at least temporary urinary obstruction. Rare cases of obstructive uropathy due to seminal vesicle cyst and appendiceal mucocele have been reported.
  • In young and middle-aged women, gynecologic surgery, pregnancy, and cancers of pelvic organs are important etiologies of obstruction.

Age

  • Special considerations in pediatric patients include acquired or congential urethral stricture, congenital ureteropelvic junction (UPJ) or ureterovesical junction (UVJ) obstruction, vesicoureteral reflux, and urolithiasis.
  • After age 60 years, urinary obstruction is most common in men secondary to prostatic hypertrophy; prostate cancer accounts for occasional cases.
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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.

Specialty Editor Board

David S Howes, MD  Professor of Medicine and Pediatrics, Section Chief and Emergency Medicine Residency Program Director, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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.

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

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

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. De Luca GC, Wijdicks EF. Images in clinical medicine. Agitation associated with acute bladder obstruction. N Engl J Med. Oct 21 2010;363(17):1656. [Medline].

  17. 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].

  18. 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].

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

  20. 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].

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

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

  23. 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].

  24. 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].

  25. 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].

  26. 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].

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

  28. 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].

  29. 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].

  30. 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].

  31. 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].

  32. 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].

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

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

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

  36. 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].

  37. 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].

  38. 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].

  39. 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].

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

 
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