Unilateral Upper Urinary Tract Obstruction

One of the most common forms of failed drainage in the upper urinary tract is acute unilateral ureteral ob-

Table 10.1. Etiology of upper urinary tract obstruction Intrinsic

Urothelial carcinoma Fibroepithelial polyp UPJ obstruction

Ureterovesical junction obstruction

Acquired stricture

Congenital stricture

Urinary stones

Tuberculosis

Papillary necrosis

Trauma

Extrinsic

Renal cell carcinoma Wilms tumor Cystic renal diseases Parapelvic cysts Renal artery aneurysm

Retroperitoneal malignancy (primary or metastatic)

Adnexal mass

Endometriosis

UPJ obstruction

Retrocaval ureter

Abscess

Appendicitis

Inflammatory bowel disease Trauma (ureteral ligation) Radiation therapy Lymphocele Urinoma

Retroperitoneal fibrosis Pelvic lipomatosis Aortic aneurysm Pregnancy struction. The underlying etiology is often urinary calculi, but the diagnostic possibilities are extensive (Ko-bayashi et al. 2003). In general, acute obstruction is most commonly associated with intermittent, severe flank pain that can radiate into the groin, external genitalia, and/or ipsilateral thigh (i.e., classic renal colic). Gross hematuria can also be associated with the colicky symptoms. Not uncommonly, gastrointestinal complaints including nausea and vomiting will also accompany the symptoms. In addition, patients can also experience fever and chills, especially if the obstruction is associated with infection (Nickel 2002). In some instances, patients can present with partial unilateral obstruction in the absence of flank pain. In this scenario, an urgent evaluation is often prompted by other associated symptoms including nausea and vomiting, abdominal pain, new onset of irritative voiding symptoms, or gross hematuria. In other instances, the finding of a partial obstructing stone can be an entirely incidental finding. In the setting of acute unilateral urinary obstruction, the development of gross hematuria in the presence or absence of pain also may suggest an etiology of blockage unrelated to stone disease.

The development of chronic unilateral upper urinary obstruction often occurs over extended periods of time and frequently is not associated with presenting symptoms. Unless the patient is to develop concurrent symptoms (i.e., hematuria, recurrent urinary tract infections, etc.), the obstruction is typically an incidental finding. In some instances such as unilateral uretero-pelvic junction (UPJ) obstruction or ureterovesical obstruction, pain-related symptoms may occur only after increased fluid intake. A classic example of this would be the development of flank pain following the ingestion of alcohol in a patient with UPJ obstruction. More commonly, chronic unilateral obstruction is related to an extrinsic process that has developed slowly over time. In most cases, the obstruction will be evaluated as an incidental finding in the ambulatory care setting.

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