Hydronephrosis & Nephrolithiasis

Hydronephrosis

• Abnormal dilation of the renal pelvis and calyces of one or both kidneys
• Characterized by excess fluid in the kidney due to urine backup
• Caused by stones, tumors, benign prostatic hyperplasia, strictures, stenosis, and congenital urologic defects
• Unilateral renal involvement often indicates a ureter obstruction
• Bilateral renal involvement often indicates a urethra obstruction

Hydronephrosis Signs and Symptoms

• Colicky flank pain or pressure
• Bloody, cloudy, or foul-smelling urine may be present
• Dysuria, decreased urine output, frequency, and urgency can occur
• Additional symptoms: nausea, vomiting, and abdominal distension
• Can lead to UTIs and kidney failure
• Diagnosis involves history, physical exam, urinalysis, renal ultrasound, and computed tomography
• Treatment options include ureteral stents, stone removal, or surgery

Nephrolithiasis

• Kidney stones are hard crystals made of minerals that kidneys normally excrete
• More prevalent in men and Caucasians
• Calculi can develop in the renal pelvis, ureters, and bladder
• Calcium-containing calculi combined with oxalate or phosphate are the most frequent
• Other types: struvite, uric acid, and cysteine stones

Nephrolithiasis Risk Factors and Manifestations

• Risk factors: excessive insoluble salt concentration in urine, urinary stasis, family history, obesity, hypertension, and diet
• Manifestations: colicky pain in the flank area radiating to the lower abdomen and groin
• Additional symptoms: bloody, cloudy, or foul-smelling urine, dysuria, frequency, genital discharge, nausea, vomiting, fever, and chills

Nephrolithiasis Diagnosis and Treatment

• Diagnosis: history, physical examination, urine examination, CT of kidneys, ultrasound, calculi analysis
• Treatment: straining urine, increasing fluids, shock wave lithotripsy, surgery, pain management, dietary changes, and physical activity

Neurogenic Bladder

• Bladder dysfunction from interrupted nerve innervation, causing incontinence
• Causes: brain or spinal cord injury, nervous system tumors, brain or spinal cord infections, dementia, diabetes mellitus, stroke, vaginal childbirth, multiple sclerosis, chronic alcoholism, SLE, and herpes zoster

Benign Prostatic Hyperplasia (BPH)

• A common, nonmalignant enlargement of the prostate gland in aging men
• Exact cause is unknown
• Prostate expansion presses against the urethra, obstructing urine flow

BPH Complications, Manifestations, Diagnosis, and Treatment

• Complications: urinary stasis, hydronephrosis, and UTIs
• Manifestations: frequency, urgency, retention, difficulty initiating urination, weak urinary stream, dribbling urine, nocturia, bladder distension, overflow incontinence, and erectile dysfunction
• Diagnosis: history, physical examination, urinalysis, prostate-specific antigen (PSA), and biopsy
• Treatment: medications to relax and/or shrink the prostate, surgery, and avoiding alcohol and smoking

Renal Cell Carcinoma

• The most frequently occurring kidney cancer in adults aged 50-70
• Primary tumor arises from the renal tubule
• Cause is unknown
• Risk factors: being male and smoking
• Metastasis to the liver, lungs, bone, or nervous system is common

Renal Cell Carcinoma Signs/Symptoms, Diagnosis, and Treatment

• Manifestations: asymptomatic, painless hematuria, dull, achy flank pain, urinary retention, palpable mass over the affected kidney, unexplained weight loss, and night sweats/fever
• Diagnosis: history, physical examination, urinalysis, computed tomography, cystoscopy, biopsy, and blood chemistry
• Treatment: surgery and chemotherapy

Bladder Cancer

• Cancer forms in the tissue of the bladder
• Common sites for metastasis are the pelvic lymph nodes, liver, and bone
• Risk factors: advancing age, being male or Caucasian, working with chemicals, smoking, excessive analgesic use, recurrent UTIs, long-term catheter placement, chemotherapy, and radiation
• Manifestations: painless hematuria, abnormal urine color, frequency, dysuria, UTIs, and back or abdominal pain
• Diagnosis: ultrasound, cystoscopy, and biopsy
• Treatment: surgical removal, radiation, and chemotherapy

Urinary Tract Infections (UTI)

• Extremely common, acute cystitis
• Lower tract is the most frequent site
• Escherichia coli is the most common cause
• Risk factors: being female, benign prostatic hypertrophy (BPH) in men, urinary stasis, poor hygiene, and being immunosuppressed

UTI Manifestations and Diagnosis

• Manifestations: asymptomatic, urgency, dysuria, frequency, hematuria, bacteriuria, cloudy and foul-smelling urine, and symptoms of infection
• Diagnosis: history, physical examination, urinalysis (WBCs, nitrites), urine culture, cystoscopy, and complete blood count

UTI Treatment

• Includes antibiotics, increasing hydration, avoiding irritants, performing proper perineal hygiene, wearing cotton underwear, not delaying urination, adequately emptying the bladder, and providing appropriate catheter care

Cystitis

• Chronic interstitial inflammation of the bladder
• Bladder and urethra walls become red and swollen
• Causes: infection, irritants, and idiopathic factors
• Manifestations: UTI symptoms, abdominal pain, and pelvic pressure
• Diagnosis and treatment follow those usually seen for UTIs

Pyelonephritis

• Infection that reaches one or both kidneys
• E. coli is the most common culprit
• Kidneys become grossly edematous and fill with exudate, compressing the renal artery
• Abscesses and necrosis can develop, impairing renal function and causing permanent damage
• May be acute or chronic
• Complications: renal failure, recurrent UTIs, and sepsis

Pyelonephritis Manifestations and Treatment

• Manifestations: severe UTI symptoms, flank pain, and fever
• Diagnosis: history, physical examination, urinalysis, urine and blood cultures, complete blood count, cystoscopy, intravenous pyelogram, and ultrasound
• Treatment: usual UTI treatments, but long-term antibiotics (4–6 weeks) usually required

Renal Failure

• Kidneys are unable to function adequately
• Classified as either acute or chronic

Acute Kidney Injury (AKI)

• Sudden loss of renal function that is generally reversible
• Most common in critically ill, hospitalized patients, especially with advanced age
• Manifestations: decreased urine output, electrolyte disturbances, azotemia, and metabolic acidosis
• Treatment: dialysis, managing electrolytes, HTN, anemia, and preventing infection

Causes of Acute Renal Failure

• Pre-renal: conditions with extremely low blood pressure or blood volume, and heart failure
• Intra-renal: reduced blood supply within the kidneys and toxic injury
• Post-renal: obstruction from stones, tumors, or BPH

Chronic Kidney Disease (CKD)

• Gradual loss of kidney function that is irreversible
• Scar tissue replaces injured nephrons
• Causes of the progressive destruction of nephrons: diabetes (leading cause), hypertension, urine obstructions, renal diseases, exposure to toxins, smoking, and aging

CKD Progression and Characteristics

• CKD progresses through 5 stages
• Clinical manifestations begin to appear slowly as renal function declines by 50%
• Kidneys can maintain relatively normal function, even with declining glomerular filtration rate (GFR)
• Over time, waste products begin to accumulate

CKD Diagnosis and Treatment

• Diagnoses through blood chemistry (BUN, creatinine)
• Treatment aims to stop progression, manage underlying causes, prevent complications, adjust medication dosages, and renal dialysis
• Without treatment, mortality is 100%