Hydronephrosis

Definition

Hydronephrosis is the swelling of the kidneys when urine flow is obstructed in any of part of the urinary tract. Swelling of the ureter, which always accompanies hydronephrosis, is called hydroureter. Hydronephrosis implies that a ureter and the renal pelvis (the connection of the ureter to the kidney) are overfilled with urine.

Description

The kidneys filter urine out of the blood as a waste product. It collects in the renal pelvis and flows down the ureters into the bladder. The ureters are not simple tubes, but muscular passages that actively propel urine into the bladder. At their lower end is a valve (the ureterovesical junction) that prevents urine from flowing backward into the ureter. The bladder stores urine. The prostate gland surrounds the bladder outlet in males. Urine then flows through the urethra and out of the body as a waste product.

Because the urinary tract is closed save for the one opening at the bottom, urine cannot escape. Instead, the parts distend. Rupture is rare unless there is violent trauma like an automobile accident.

Obstructed flow anywhere along the drainage route can cause swelling of the upper urinary tract, but if the obstruction is below the bladder, the ureterovesical valve will protect the upper tract to a certain extent. Even then, with no place to go, the urine will back up all the way to its source. Eventually, the back pressure causes kidney function to deteriorate.

Obstruction need not be complete for problems to arise. Intermittent or partial obstruction is far more common than complete blockage, allowing time for the parts to enlarge gradually. Furthermore, if a ureterovesical valve is absent or incompetent, the pressure generated by bladder emptying will force urine backward into the ureter and kidney, causing dilation even without mechanical obstruction.

Causes & symptoms

Causes are numerous. Various congenital deformities of the ureter may sooner or later produce back pressure. Kidney stones are a common cause. They form in the renal pelvis and become lodged in the kidney, usually at the ureterovesical junction. In older men, the continued growth of the prostate gland leads commonly to restricted urine flow out of the bladder. Prostate cancer, and cancer anywhere else along the urine pathways, can obstruct flow. Pregnancy normally causes ureteral obstruction from the pressure of the enlarged uterus (womb) on the ureters.

Symptoms relate to the passage of urine. Sometimes, urine may be difficult to pass, irregular, or uncontrolled. Pain from distension of the structures is present. Blood in the urine may be visible, but it is usually microscopic.

In all cases where bodily fluids cannot flow freely, infection is inevitable. Symptoms of urinary infection may include:

• Painful, burning urine.
• Cloudy urine
• Pain in the back, flank, or groin
• Fever, sweats, chills, and generalized discomfort.

Patients often mistake a serious urinary infection for the flu.

Diagnosis

If the bladder is significantly distended, it can be felt through the abdomen. An analysis of the urine may reveal blood (if there is a stone), infection, or chemical changes suggesting kidney damage. Blood tests may also detect a decrease in kidney function.

All urinary obstructions will undergo imaging of some sort. Beginning with standard x rays to look for stones, radiologists, physicians specializing in the use of radient energy for diagnostic purposes, will select from a wide array of tests. Ultrasound is simple, inexpensive, and very useful for these conditions. Standard x rays can be enhanced with contrast agents in several ways. If the kidneys are functioning, they will filter an x ray dye out of the blood and concentrate it in the urine, giving excellent pictures and also an assessment of kidney function. For better images of the lower urinary tract, contrast agents can be instilled from below. This is usually done with a cystoscope placed in the bladder. Through the cystoscope, a small tube can be threaded into the ureter through the ureterovesical valve, allowing dye to be injected all the way up to the kidney. CT and MRI scanning provide miraculous detail, more than is often needed for this condition.

Treatment

The obstruction must be relieved, even if it is partial or functional, as in the case of reflux from the bladder. If not, the kidney will ultimately be damaged, infection will appear, or both. The task may be as simple as placing a catheter through a restricting prostate or as complicated as removing a cancerous bladder and rebuilding a new one with a piece of bowel. In some cases, a badly damaged kidney may have to be removed.

Alternative treatment

Catheters or other urinary diversions may be better for weak or ill patients who cannot tolerate more extensive procedures. There is support using botanical medicine that can help the patient using a catheter avoid infections. Consultation with a trained health care practitioner is necessary.

Prognosis

After relief of the obstruction, a kidney may react with a brief flood of urine, but if the obstruction has been of short duration, normal kidney function will return. If one kidney is destroyed, the other will compensate for the lost organ.

Prevention

Kidney stones can be prevented by dietary changes and medication. Prompt evaluation of infections and urinary complaints will usually detect problems early enough to prevent long-term complications.

Key Terms

Catheter

A tube placed into the body that allows fluids to pass through it.

Contrast agent

Substances that cast shadows on x rays or other imaging methods.

CT and MRI

Two high technology methods of creating images of internal organs. Computerized axial tomography (CT or CAT) uses x rays, while magnetic resonance imaging (MRI) uses magnet fields and radio-frequency signals. Both construct images using a computer.

Cystoscope

A pencil-thin instrument that allows viewing and operating inside the urinary system.

Renal pelvis

The middle section of the kidney where urine first collects after filtration from the blood.

Further Reading

For Your Information

Books

• Gulmi, Frederick A. "Pathophysiology of urinary tract obstruction." In Campbell's Urology. Edited by Patrick C. Walsh, et al. Philadelphia: W. B. Saunders, 1998, pp. 342-380.
• Nelson, Waldo E., et al., ed. "Obstruction of the urinary tract." In Nelson Textbook of Pediatrics. Philadelphia: W. B. Saunders, 1996, pp. 1534-1542.
• Seifter, Julian L. and Barry M. Brenner. "Urinary tract obstruction." In Harrison's Principles of Internal Medicine. Edited by Kurt Isselbacher, et al. New York: McGraw-Hill, 1998.
• Tierney, Lawrence M., et al., ed. Current Medical Diagnosis and Treatment. Stamford, CT: Appleton & Lange, 1996.
• Weiss, Robert M. "Physiology and pharmacology of renal pelvis and ureters." In Campbell's Urology. Edited by Patrick C. Walsh, et al. Philadelphia: W. B. Saunders, 1998, pp. 855-858.

  Organizations

• American Association of Kidney Patients. 111 South Parker Street, Suite 405, Tampa, FL 33606. (800)749-2257.
• American Kidney Foundation. 6110 Executive Boulevard, #1010, Rockville, MD 20852. (800) 638-8299.
• The National Kidney Foundation. 30 East 33rd Street, New York, NY 10016. (800) 622-9010.

Gale Encyclopedia of Medicine. Gale Research, 1999.