HYDRONEPHROSIS

OVERVIEW

Hydronephrosis is swelling of one or both kidneys. Kidney swelling happens when urine can't drain from a kidney and builds up in the kidney as a result. This can occur from a blockage in the tubes that drain urine from the kidneys (ureters) or from an anatomical defect that doesn't allow urine to drain properly.  It can occur anywhere along the urinary tract from the opening of the kidneys to the ureters (draining the kidneys to the bladder), the bladder, and the urethra (draining the bladder). Problems with any of these structures may cause impaired emptying of the urinary system and back up of fluid and pressure.

If only one of the kidneys is affected, the condition is called unilateral hydronephrosis. If both kidneys are affected, it is called bilateral hydronephrosis.

Hydronephrosis may result in decreased kidney function. If not treated right away, permanent damage to the kidney or kidneys may occur, resulting in kidney failure.

DEFINITION

Hydronephrosis is defined as distention of the renal calyces and pelvis with urine as a result of obstruction of the outflow of urine distal to the renal pelvis. Hydronephrosis is defined as distention of the renal calyces and pelvis with urine as a result of obstruction of the outflow of urine distal to the renal pelvis. 

ETIOLOGY OF HYDRONEPHROSIS

The etiology and presentation of hydronephrosis in adults differ from that in neonates and children. 

• Anatomic abnormalities (including urethral valves or stricture, and stenosis at the ureterovesical or ureteropelvic junction) account for the majority of cases in children. 

• In comparison, kidney calculi are most common in young adults

In adults, the conditions that most often cause hydronephrosis include:

• Kidney stones: Stones that may become lodged in the kidneys or urinary tract.

• Cancer: Tumors in the bladder, prostate gland, uterus or other organs that are part of or near the urinary tract may cause blockages that disrupt the flow of urine.

• Benign prostatic hyperplasia (BPH): Enlargement of the prostate gland in men can cause pressure on the urethra, the tube that urine passes through before it leaves the body.

• Having blood clots: Blood clots can develop in the kidney or ureter.

• Narrowing or stricture of the urinary tract: This narrowing can be due to injury, infection, birth defects or surgery.

• Nerve or muscle problems: These problems can affect the kidneys or ureters, such as from diabetes mellitus.

• Urinary retention: Urine may be held inside the body due to an inability to empty the bladder.

• Vesicoureteral reflux: This is a condition when urine flows backward from the bladder to the kidneys.

• Uterocele: This is a condition where the lower part of the ureter may protrude into the bladder.

In women, hydronephrosis may occur as a result of:

• Pregnancy: As the uterus expands, it can press on the ureters and block the flow of urine.

• Uterine prolapse: A condition in which a woman's uterus (womb) sags or slips out of its normal position.

• Cystocele (fallen bladder): A condition that occurs when the wall between a woman's bladder and her vagina weakens and allows the bladder to droop into the vagina

RISK FACTORS

• Renal calculi

• Pregnancy

• Trauma

• Urinary tract infection

• Primary bladder neck obstruction

PATHOPHYSIOLOGY

Hydronephrosis can result from anatomic or functional processes interrupting the flow of urine. The interruption can occur anywhere along the urinary tract from the kidney to the urinary meatus. The rise in urethral pressure leads to marked changes in glomerular filtration, tubular function and renal blood flow. The glomerular filtration rate declines significantly within hours following acute obstruction. This significant decline of the glomerular filtration rate can persist for weeks after release of obstruction. In addition renal tubular ability to transport sodium, potassium, and protons and concentrate and dilute the urine is severely impaired.

 The extent and persistence of this insult is directly related to the duration and extent of the obstruction. Brief disruptions are limited to reversible functional disturbances with little associated anatomic changes. More chronic disruptions lead to profound atrophy and permanent nephron loss.

CLINICAL MANIFESTION

Symptoms of hydronephrosis usually depend on the cause. Often there are no symptoms. When symptoms occur, they can include:

• Sudden or intense pain in the back or side known as flank pain

• Pain is felt in the renal area

• Nausea

• Vomiting

• Frequent or painful urination

• Hematuria

• Cloudy urine

• Fever due to a urinary tract infection

• Failure to thrive, in infants

• Bladder pain

• Urinary tract infection

• Azotemia

DIAGNOSTIC EVALUATION:

Laboratory Test

• Urinalysis is used to assess for signs of infection. Pyuria suggests the presence of infection. Microscopic hematuria may indicate the presence of a stone or tumor.

• Complete blood cell count may reveal leukocytosis, which may indicate acute infection.

• Serum analysis can reveal an elevation of blood urea nitrogen (BUN) and creatinine levels, which may be the result of bilateral hydronephrosis.

IMAGING

• An ultrasound imaging exam, during which your doctor can view the kidneys, bladder and other urinary structures to identify potential problems.

• IVU (intravenous urogram) is useful for assessing the position of the obstruction.

• A specialized X-ray of the urinary tract that uses a special dye to outline the kidneys, ureters, bladder and urethra, capturing images before and during urination.

MANAGEMENT:

MEDICAL MANAGEMENT:

GOAL: The aim of treatment is to remove obstruction, drainage of the urine that has accumulated behind obstruction and restore the flow of urine from the kidney.

 Treatment depends on the underlying condition that is the primary problem. 

If the hydronephrosis is acute or sudden, a stent or soft tube (nephrostomy tube) may be inserted through the skin into the kidney to drain off excess urine. A soft plastic tube called a ureteral stent may be placed between the kidney and bladder by a urologist during a cystoscopy to drain excess fluids. If hydronephrosis is caused by stones in the kidneys or ureters, treatment options may include:

• Shock wave lithotripsy: High-energy shock waves are emitted by a machine outside to break up the stones into dust or smaller fragments so they can pass out of the body..

SURGICAL MANAGEMENT:

Only in severe cases would surgery be needed. The goal of the operation is to reduce the swelling and pressure in the kidney by restoring the free flow of urine.

° Nephrostomy: acute obstruction of the upper urinary tract is usually treated by the insertion of a Nephrostomy ( an artificial opening created between the kidney an the skin which allows for the drainage of urine directly from the upper part of the urinary system) tube.

° Ureteric Stent: chronic upper tract obstruction is treated by the insertion of a ureteric stent (a thin tube inserted into the ureter to prevent or treat obstruction of the urine flow from the kidney).

° Pyeloplasty: is a surgical reconstruction of the renal pelvis to drain and decompress the kidney. Most commonly it is performed to treat an utero-pelvuc junction obstruction if residual renal function is adequate.

PHARMACOLOGICAL MANAGEMENT:

• Antibiotics may be administered to prevent or treat urinary tract infections.

• Analgesics may be used to relieve pain.

NURSING MANAGEMENT

ASSESSMENT

History Taking: 

• Elicit a careful history about urinary patterns to determine a history of burning sensations, abnormal colour, and frequent of urination.

• Determine any recent history of mild or sever renal pain or flank pain that radiate to the groin.

• Ask about vomiting, nausea or abdominal fullness. Ask a male patient if he has had prostrate difficulties or urinary difficulties. 

• Inspect the flank area for asymmetry, which indicate the presence of a renal mass.

• Inspect the male urethra for stenosis, injury, or phinosis. 

• Inspect and palpate for vaginal, uttering and rectal lesions in females. When flank area is palpated, you may feel a large fluctuating soft mass in the kidney area that represents the collection of urine in the renal pelvis.

• Palpate the abdomen to help identify tender areas.

• If the hydronephrosis is as a result of bladder obstruction, markedly distended urinary bladder may be felt.

• Gentle pressure on the urinary bladder may result in leaking urine from the urethra because of bladder overflow.

NURSING DIAGNOSES

i. Acute pain related to obstructing  urinary calculus evidence by patients verbalization 

ii. Anxiety related to unknown outcome of disease condition evidence restlessness or patient asking questions

iii. Impaired urinary elimination related to blockage of ureter or urethra evidence by decreased urinary output or bloody urine.

iv. Risk for urinary tract infection related to presence of urinary obstruction.

NURSING OBJECTIVES

i. Patient will be calm and cooperate with the therapy.

ii. Patient will be relief of pain after nursing intervention.

iii. Patient will be able to eliminate urine.

iv. Patient will be free from infection.

PLANNING AND IMPLENTATION

1. Assess the kidney status

2. Recognizing signs of Infection (elevated body temp, fever, flank pain, chills, fatigue, malaise).

3. Encourage adequate fluid intake.

4. Monitor input and output.

5. Monitor vital signs

6. Observe for signs and symptoms for inspection.

7. Administration of medications as ordered.

8. Assess for pain.

9. Catheter care if present.

10. Observe dressing if surgery was performed.

11. Provide emotional support to patient and family.

EVALUATIONS

• Patient verbalized relief of pain.

• Patient’s urinary output returned to normal volume and usual pattern.

• Patient was free from any sign of infection and demonstrated ability to perform hygienic measure.

PREVENTION OF HYDRONEPHROSIS

Since hydronephrosis is caused by an underlying condition, prevention depends on avoiding or promptly treating the cause. For instance, the chance of developing a kidney stone may be reduced by going to a stone clinic to find out what is causing the stones and start treatment to prevent recurrence (repeating). 

Teach the importance of adequate fluid.

Explain the importance of notifying the physician at the first signs of inability to void or urinary infection, such as burning or painful urination etc.

COMPLICATIONS

• Urinary tract infection

• Decreased renal failure