Chapter 14 OBSTRUCTIVE UROPATHY Introduction Normally, urine flow occurs in a stream & without effort.

. Obstruction results into stasis, dilatation and infection. If it is not diagnosed early, renal failure ensues. Obstruction manifests as i. dribbling ii. straining iii. dysuria iv. reflux of urine v. Distended bladder Urinary ascites

vi.Hydronephrosis in long standing cases resulting into renal impairment, failure to thrive, anorexia & vomiting. Note, Lower tract urinary tract obstruction is the most common cause of neonatal ascites which is due to rupture of dilated pelvis with extravsation of urine.

POSTERIOR URETHRAL VALVE Introduction It is the most common cause of severe subvesical

obstruction in the male infant. (Note, females do not have posterior urethra) Valves appear as mucosal folds in the posterior urethra Early obstruction during renal development may result in renal dysplasia Clinical Presentation i. Dribbling ii. Poor urinary streams in neonates & infants iii. Bladder All these form triads iv. Symptoms of uraemia v. Symptoms of infection

Complications The more severe the obstruction, the more the degree of complications. Later, in infancy i. Vomiting ii. Failure to thrive secondary to chronic renal failure iii. Dehydration secondary to diabetes insipidus Older children i. Enuresis may be the presenting complaint. Diagnosis o Can be made prenatally by ultrasound which reveals an

enlarged bladder & hydronephrosis. Investigation 1. Micturating Cystourethrogram is diagnostic. It shows o Dilated elongated posterior urethral valve o Trabeculated baldder o There may be urinoma or urinary ascites 2. Intravenous Urogram It is not routinely done. It may show extensive hydronephrosis and hydroureters. 3. Sepsis screen

Treatment

Immediate i. Fluid & Electrolyte correction i.e o Metabolic acidosis o Sodium Depletion o Dehydration ii. Establish bladder drainage by urethral (preferred) or suprapubic catheterization or vesicostomy(definitive treatment). In very ill patient, do urinary diversion by bilateral, ureterostomy. It is rarely done nowadays. iii. Give antibiotics

Definitive o Is surgery i.e excision of the valve o In the past, obliteration with diathermy used to be done. But, recently, what is done is Mohans valvotomy. Follow up o Is done because of the complications, to monitor for continence, stricture or development of chronic renal failure Prognosis o Depends on the severity of renal damage and

dysplasia at the time of diagnosis. Those who present late have poorer prognosis.