The urinary system is made up of ducts.
Scope: starting from the renal tubules to the external urethral opening (to the external prepuce in circumcised patients).
Normal condition: renal tubules → renal papillae → renal pelvis → ureter → ureteral bladder junction (live flap action) → bladder → urethra → excretion.
Morbidity characteristics: 1, infants and children with congenital malformations: a, urethral valve; b, obstruction of the renal pelvis-ureter junction; c, forced flow of the vesicoureter.
2, Adults: a, stones, injury c, pregnancy; b, pelvic tumor.
3, Older adults: a, prostate hyperplasia; b, prostate cancer; c, bladder neck orifice sclerosis.
Etiological classification.
Intraductal lesions of the urinary tract: uric acid, sulfonamide crystalline deposits, stones, necrotic
renal papillae, blood clots, mycoballs.
Mechanical obstruction
Lesions of the duct wall itself Tumors, infections, tuberculosis, trauma, stenosis, and congenital valvular disease. Lesions outside the urinary tract Females: pregnancy [mechanical (right-sided) + endocrine factors], germline tumors, cervical cancer, ureteral misligation.
Males: prostatic hyperplasia, prostate cancer ;
Young and female: ectopic vessels, aneurysm, retroperitoneal inflammation, tumor and fibrosis.
Functional obstruction: 1, pelvic ureter and ureterobladder junction dysfunction (nerve and muscle disorders);
2, bladder dysfunction.
Departmental classification: upper urinary tract obstruction: obstruction above the opening of the ureteral bladder.
Lower urinary tract obstruction: obstruction below the opening of the ureter and bladder.
Pathophysiology: When the unilateral ureter is completely obstructed, there are three stages in the order of renal blood flow and ureteral pressure changes: the first stage (congestion stage): ureteral pressure ↑ renal blood flow ↑; the second stage (vasoconstriction stage): ureteral pressure ↑, renal blood flow ↓; the third stage (renal failure stage): ureteral pressure ↓, renal blood flow ↓ urine concentration capacity ↓, urine acidification capacity ↓, urine dilution capacity unchanged. Safety valve” in the kidney: glomerular filtration pressure = intrapelvic pressure.
Urine → Rung overflows intrapelvic pressure ↓ → glomerular filtration pressure – intrapelvic pressure > 0 Secretion of urine
Favorable factors: protects renal tissue in acute short term obstruction.
Risk factors: bacteria can enter the blood circulation directly.
Hydronephrosis: obstruction of urine drainage from the renal pelvis, resulting in increased intrarenal pressure, dilatation of the renal calyces and renal pelvis, and atrophy of the renal parenchyma. It is the final result of urinary tract obstruction.
Congenital lesions: (renal pelvis junction stenosis, ectopic vessels in the lower pole of the kidney, etc.) progress slowly and the fluid accumulation is huge forming an abdominal mass.
Secondary lesions: (stones, tumors, inflammation, tuberculosis) Signs and symptoms of the primary disease are predominant and are found in complete obstruction and when the onset is contended with urgency. Intermittent hydronephrosis may occur in the case of ureteral obstruction.
Clinical manifestations: 1, pain and swelling ;
2.Decreased renal function without obvious cause;
3, recurrent urinary tract infections;
4, hypertension (30% of patients with unilateral acute obstruction develop hypertension due to excess renin);
5, erythropoietic hyperplasia (the kidney produces a large amount of erythropoietin after obstruction);
6. renal tubular dysfunction (hypoconcentration of urine)
7. Intermittent obstruction may alternate between oliguria and polyuria.
Diagnosis: 1. The presence of hydronephrosis is clear;
2.The etiology of hydronephrosis, lesion site, degree of obstruction, presence of infection and renal function impairment.
Examination: blood: azotemia, acidosis, electrolytic disorders.
Urine: routine examination and culture, Mycobacterium tuberculosis, exfoliative cell examination. Excretory urography: prolonged renal parenchymal visualization time; thick renal shadow is characteristic of acute obstruction.
Retrograde angiography.
Renal pelvic puncture angiography.
MRI water imaging: ultrasound, CT to identify renal parenchymal masses.
Treatment: Comprehensive treatment according to etiology, urgency of onset, presence or absence of infection and degree of renal impairment, and comprehensive condition of the patient.
1.Cause treatment: remove the cause of hydronephrosis and preserve the affected kidney: a. pyelolithotomy; b. pyeloplasty; c. endoscopic surgery.
2.Nephrostomy: critical conditions and preparation before certain endoscopic procedures.
3, nephrectomy: high dose ivp does not show, contralateral renal function exists; ultrasound shows: thin and corrugated cortex.
Benign prostatic hyperplasia (BPH)
Basis of BPH pathogenesis: 1, functional testes 2, old age
Etiology: various hypotheses, the endocrine theory is more widely recognized testosterone → 5 a dihydrotestosterone 5-reduction ketone + prolactin Prostatic hyperplasia. 1987 story isolated prostate growth factor.
Prostate veins: migratory zone (5%) ← central zone of prostatic hyperplasia (23%) external homologous zone (73%) ← prostate cancer
Etiology of urinary obstruction due to BPH: 1. smooth muscle 2. adenoma 3. forced urinary muscle
Clinical manifestations.
Frequent urination: the first symptom to appear;
Difficulty in urination: the most important symptom;
Urinary retention: a serious consequence.
Other symptoms: symptoms of cystitis, hematuria, inguinal hernia, prolapse or internal oxygenation.
Diagnosis: men over 50 years of age, symptoms, anamnesis, ultrasound (volumetric residual urine), urinary flow rate
examination (Max<15ml/s. dyspareunia, Max<10ml/s, severe obstruction), PSA (differentiation from prostate vein cancer)
Differential diagnosis: 1, bladder neck infarction: cystoscopy, ultrasound;
2.Prostate cancer: ultrasound, MRI, PSA, biopsy;
3.Bladder cancer: ultrasound, cystoscopy;
4.Neurogenic bladder dysfunction (forced urinary muscle, urethral sphincter, muscle, instability).
Urodynamic examination.
5, urethral stricture: history, cystoscopy.
Treatment: receptor blockers: Terazosin
Hormone: Paulette
1.Medication: Lipid-lowering steroid drugs: lipid-lowering tablets, ursodeoxycholic acid
Botanicals: Pernod, herbal medicine
Surgical treatment: prostatectomy, urethral resection, TURP, TVP, etc.
Prostatectomy, TURP, TVP, isoelectric prostatectomy.
Palliative care: laser, dilation, thermotherapy, ultrasound, stent mesh.
Acute urinary retention
Etiology: 1. Mechanical obstruction: prostatic hyperplasia, urethral injury, urethral stricture.
2. Dynamic obstruction: anesthesia, central and peripheral nervous system injury, inflammation, tumor, drugs, low potassium, habit.
Treatment: Principle: Relieve the cause and restore urination
1.If the cause is clear and conditions are available for immediate removal, the cause should be removed immediately and urination should be restored;
2.Urinary retention after lumbar anesthesia, anal canal and rectal surgery can be treated with acupuncture and acupuncture point injection;
3.Urethral catheterization: aseptic operation;
4.Cystostomy.
Clinical focus: 1, the pathogenesis of urinary tract obstruction characteristics, intrarenal “safety valve”;
2.The examination of hydronephrosis;
3.Diagnosis and treatment of BPH;
4.Treatment of acute urinary retention.