History
The clinical presentation of urinary tract obstruction varies with the location, duration, and degree of obstruction. Thus, a thorough history and physical examination are key in the patient evaluation.
Upper urinary tract obstruction (kidney, ureter) can manifest as pain in the flank, ipsilateral back, and ipsilateral groin. Nausea and vomiting are also common and usually occur in acute obstruction. Chronic obstruction is usually indolent and may be asymptomatic. When infection is present, the patient may have fever, chills, and dysuria. Hematuria may also be present.
When bilateral obstruction or unilateral obstruction in a solitary kidney is severe and renal failure has occurred, uremia can be present. Uremia symptoms include weakness, peripheral edema, mental status changes, and pallor.
Lower urinary tract obstruction (bladder, urethra) can manifest as voiding dysfunction such as urgency, frequency, nocturia, incontinence, decreased stream, hesitancy, postvoid dribbling, and a sensation of inadequate emptying. Suprapubic pain or a palpable bladder indicates urinary retention. Infection may be present, and patients may experience dysuria. Hematuria may be present with or without infection.
Patients with urethral stricture may report a history of trauma, instrumentation, or sexually transmitted diseases; lower urinary tract pain is common. [12] They may also experience a split urinary stream.
Physical Examination
If hydronephrosis is severe, the kidney may be palpable on physical examination, especially in children. However, obstructive nephropathy without hydronephrosis has been reported. [13] In cases that involve an infectious process, costovertebral angle tenderness can indicate pyelonephritis.
Digital rectal examination is indicated in men, as it can reveal prostatic enlargement, decreased rectal tone, or prostatitis. [14] Urethral stricture often requires cytoscopy for diagnosis. Meatal stenosis is usually apparent on physical examination. In women, uterine or bladder prolapse can be identified on a pelvic examination. A urethral diverticulum can also be palpated on pelvic examination.
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Longitudinal image of right kidney displaying moderate hydronephrosis.
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A noncontrast, axial CT image showing right-sided hydronephrosis. In this particular case, the patient had a distal ureteral stricture secondary to prior ureterolithiasis.
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Flexible cystoscope; Gyrus ACMI ICN-2.
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Axial CT images with intravenous contrast, revealing right-sided hydronephrosis (left image) and an obstructing right ureteropelvic junction stone (right image).
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Coronal CT image with intravenous contrast, displaying (left) delayed contrast excretion and bilateral hydronephrosis secondary to (right) bladder outlet obstruction from benign prostatic hyperplasia, and an extremely distended bladder.
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Intravenous pyelogram, 1-hour delayed image showing left-sided hydroureteronephrosis secondary to distal ureteral obstruction.
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Intravenous pyelogram displaying right-sided ureteropelvic junction obstruction and normal excretory image of the left collecting system.
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T2-weighted MRI, coronal image, displaying a right-sided duplicated system with obstruction of the lower pole moiety.
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T2-weighted MRI, coronal image, displaying left-sided ureteropelvic junction obstruction.
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Mercaptoacetyltriglycine (MAG3) renal scan with furosemide (Lasix); delayed emptying of left-sided collecting system consistent with obstructive hydronephrosis.
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Mercaptoacetyltriglycine (MAG3) renal scan with furosemide (Lasix); , delayed emptying of left-sided collecting system consistent with obstructive hydronephrosis.
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Retrograde urethrogram displaying complete obstruction of prostatic urethra.
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Cystoscopic image of vapor-resection of an obstructing prostate. Obstructing lateral lobes can be seen proximal to the verumontanum.
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Kidney-ureter-bladder (KUB) image displaying a large right-sided renal stone and an indwelling ureteral stent.
