The classic presentation of bilateral upper urinary tract obstruction often differs clinically when compared to unilateral obstruction. Bilateral upper urinary obstruction most commonly occurs on a more chronic basis, related to an extrinsic process that progresses slowly over time. In this scenario, signs and symptoms directly related to the extrinsic process often prompt the workup which ultimately leads to the diagnosis of bilateral obstruction. When bilateral chronic upper urinary tract obstruction progresses to the point of causing symptoms, manifestations of renal failure are also commonplace. A common presentation for acute bilateral upper urinary obstruction is related to bilateral obstructing ureteral or UPJ stones. The tip-off to this diagnosis can be the development of bilateral flank pain in the setting of anuria; however, more commonly the bilateral stones will be only partially obstructing and the patient will maintain an adequate urine output. Urgent management of chronic bilateral upper urinary obstruction is frequently not related to pain or hematu-ria, but rather the development of renal failure or the sequelae of fluid overload. For example, patients with chronic bilateral upper urinary obstruction may report nonspecific symptoms including pedal edema, weight gain, fatigue, shortness of breath, increased waist size, and vague gastrointestinal complaints (Gulmi et al. 2002). In the urgent setting, ultimately the development of these signs or the frank symptoms of uremia may prompt the initial evaluation and treatment.
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