泌尿系梗阻（全英文）

1、UNILATERAL OBSTRUCTION 1.Upper urinary tract obstruction: Glomerular filtration rate, Kidney blood flow, Pellet pressure, with increased renal pelvis pressure,GFR decreased, kidney blood flow decreased.The impact of renal tubular function:Renal unit sodium transport capacity decreased. Renal concent

2、ration and secretion decreased. Pathophysiology Basic pathology of dilatation of urinary tract lesion of hydronephrosis is above obstruction. Normal pelvis pressure is 10cm H2O,obstruction lead to pressure continue to increase,When the pressure come to the 25cm H2O,glomerolar filtration stopped. Saf

3、ety valve in kidney open. Urine doesnt enter ureter and enter renal parenchyma.Vein and lymphatic vessel back flow.Pathological pelvic dilatation. With the pressure continue to increase,renal tussue ischemia occurred due to vascular near the tubules oppressed,resulting in renal dysfunction. Pelvic w

4、all becomes thin; renal papilla becomes atrophy and flat, renal parenchyma becomes atrophy and thin. Pelvic capacity increase. All kidney forms a dysfunctional huge water sac. The bacterial enter blood is very dangerous.Pathophysiology 2.Lower urinary tract obstruction: To overcome the detrusor obst

5、ruction,detrusor become thickened.When decompensated detrusor appeared,the main manifestation is chronic urinary retention. Incomplete emptying.Postvoid residual(PVR)残余尿残余尿,loss of detrusor contractility,bladder trabeculation小梁形成小梁形成,lead to detrusor instability逼尿肌不稳定逼尿肌不稳定. overflowing incontinence

6、充盈性尿充盈性尿失禁失禁. Impaired renal functionPathophysiology Hydronephrosis: Urination from the kidneys is blocked. The urine from kidney calyx and pelvic exceeds the normal capacity,hydronephrosis occurred. Section II Diagnosis and treatment of upper urinary tract obstruction Clinical manifestation The obs

7、truction that results in pressure increases in kidney, dilatation of calyx and pelvic and atrophy of renal parenchyma happened next. Mild hydronephrosis: asymptomatic Moderate or severehydronephrosis: back pain, Abdominal massClinical manifestation Symptoms and physical sign of primitive diseases. M

8、anifestation of hydronephrosis is lump in abdomen pain. Sometimes shows intermittent attack called intermittent hydronephrosis. Clinical manifestation Long time obstruction which produces hydronephrosis results in renal function decrease. If bilateral of separated kidney is obstructed , renal functi

9、on failure. Urine routine and urine culture can help the diagnosis of primitive diseases Clinical manifestation1.Image examination 1.1 ultrasonography IVP will provide definitive information about structural changes. demonstrate the anatomic form and divided renal function. Abdomen CT: Non-enhanced

10、CT scan become the preferred imaging examination for acute obstruction caused by ureteral stones. enhanced CT:tumor-induced obstruction.CTU:Ureteral stenosis.Auxiliary examination1.3 MRU:patients with contrast agent allergy. Not suitable for diagnosis of ureteral stones.2. Other Auxiliary examinatio

11、n. diagnostic tests may include visual examinations with the aid of endoscopy and a blood chemistry profile.3. Diuretic renogram or SPECT renal scintigraphy. Renal function Renal scan and renal pictures of radioactive isotope.Urodynamic:BPH, Neurogenic bladder, Bladder dysfunction, Bladder outlet ob

12、struction(BOO)Auxiliary examination An X ray of a blocked ureter. The ureters are muscular tubes that carry urine from the renal pelvis in each kidney to the urinary bladder. 1. Treatment on the causes：The basic therapeutic purposes are, removing the causes,protection of renal function. Before obstr

13、uction has not been caused severe renal funtion impairment,Which could obtain good therapeutic results. Use the appropriate method of treatment according to the causes, urinary tract malformations plasty成形术成形术, urolithiasis lithotomy尿尿路结石碎石术路结石碎石术.Treatment2. Symptomatic treatment: Percutaneous Neph

14、rostomy(PCN)经皮肾穿刺造经皮肾穿刺造瘘瘘:Hydronephrosis with severe infection,poor renal function, causes are temporarily unable to handle.In these cases,temporary or permanent nephrostomy should be used.Ureteral stent implantation输尿管支架植入输尿管支架植入Indwelling catheter留置尿管留置尿管Suprapubic cystostomy耻骨上膀胱造瘘术耻骨上膀胱造瘘术Nephr

15、ectomy肾切除术肾切除术,serious hydronephrosis or pyonephrosis脓肾脓肾, contralateral renal function is normal.Aim and method of medical managementTo establish urine drainage and relieve discomfortConservative measures include insertion of an indwelling catheter, analgesic (usually opioid), and an anticholinergi

16、c agent (Atropine) to decrease smooth muscle motilityTo establish urine drainage, inserting a catheter directly into the bladder through the abdominal wall (suprapubic cystostomyInto a ureter (ureterostomy), or into the kidney (nephrostomy).A stent is a tube, use for surgical correction of an obstru

17、ction in the urinary systemA mesh-like tube or coil-shaped device is inserted through an endoscope into the ureterStent holds the tubular structure open to facilitate drainage.3. Pain Management: collective system pressure increases causes renal colic. Analgesia Antispasmodic drugs should be used.No

18、nsteroidal anti-inflammatory drug(NSAIDs)非非甾体抗炎药甾体抗炎药 BPH is one of the most common disease of Urology,Which mostly occurred in aged men 50ys. BPH is a nonmalignant enlargement of the prostate gland caused by cellular hyperplasia of both glandular and stromal elements that leads to troublesome.Secti

19、on III Benign Prostatic Hyperplasia(BPH) General considerationThe size of prostate enlarged microscopically since the age of 40.Half of all men over the age of 60 will develop an enlarged prostateBy the time men reach their 70s and 80s, 80% will experience urinary symptomsBut only 25% of men aged 80

20、 will be receiving BPH treatment.BPH is one of the most common diseases in aging men and the main clinical manifestation is lower urinary tract symptoms (LUTS)下尿路症状下尿路症状General considerationPeripheral zoneTransition zoneUrethraWhat is Benign Prostatic Hyperplasia?Peripheral zoneTransition zoneUrethr

21、a The etiology of benign prostatic hyperplasia is not clear.Ageing and functional testes may be the basic of BPH,Both are indispensable.Etiology Prevalence of BPH Pathophysiology 20% of men age 41-50 50% of men age 51-60 65% of men age 61-70 80% of men age 71-80 90% of men age 81-90EtiologyWhat caus

22、es BPH?BPH is part of the natural aging process, like getting gray hair or wearing glassesBPH cannot be preventedBPH can be treatedAccepted hypothesis:1. Male hormones and their receptors:Dihydrotestosterone, DHT 2. Cell proliferation and apoptosis imbalance theory：Cell proliferation and apoptosis i

23、mbalance. 3. Growth factor neurotransmitter:FGF,VEGF,EGF,TGF- 4. Interstitial prostate epithelial interactions 5.Inflammation FactorsEtiology Prostate tissues composed by Peripheral zone,central zone，transitionnal zone and surroundding the urethral zone. BPH originated in transitionnal zone. While p

24、rostatic cancer in peripheral zone.Pathology Normal transition zone accounts for about 5% of the prostate tissue, The peripheral zone and the central region accounted for 95% of the prostate tissue. The prostate is composed of gland and stroma. Pathology change of BHP is stromal hyperplasia.Patholog

25、y BPH cause urinary obstruction,the performance is of the following three factors: 1.Mechanical obstruction due to glandular enlargement,squeezing the urethra,enlarged tissues protruding to the bladder,causing bladder outlet obstrution(BOO). 2.Dynamic obstruction secondary to contraction of the smoo

26、th muscle of the prostate, urethra and bladder neck. This dynamic obstruction is a result of sympathetic nervous system mediated stimulation of alpha-1 adrenoceptors 肾上腺素能肾上腺素能受体受体Pathophysiology 3.Secondary bladder dysfunction. Irritative symptoms,detrusor instability related to detrusor muscle cha

27、nges in response to obstruction, such as bladder wall hypertrophy and collagen deposition in the bladder,proliferation of smooth muscle fibers. 3.1 Compensatory period:Detrusor instability, Increased pressure within the bladder, urge incontinence occurs. After the obstruction is removed,unstable det

28、rusor contraction can disappear.Pathophysiology 3.2 Decompensated period: Unable to relieve the obstruction, further structural and functional changes into the decompensated period, Inability to empty the bladder, Residual urine appears. Bladder eventually lose tension and contractility, Bladder bec

29、ome a urinary sac. Overflowing incontinence occurs at this stage. Ureteral valve loss of function,vesicoureteral urinary reflux occurred.Pathophysiology BPH leading to lower urinary tract symptoms,Which related to obstruction degree,disease development rate,and Whether there is stones,infection, ren

30、al function impairment. Symptoms and prostate volume size is not proportional, include urinary storage symptoms, voiding symptoms,after voiding symptoms.Clinical manifestation 1. Urinary storage symptoms,bladder irritative symptoms Frequent of urination,nocturia夜尿夜尿, Nocturia is the earliest symptom

31、s of BPH.Storage/Irritative symptoms: incontinence:Detrusor instability, Low compliance bladder, it may be associated with urgency and dysuria.Urgency (compelling need to void that can not be deferred)Clinical manifestation Overflowing incontinence : At decompensated period, high compliance bladder

32、appears, enable to empty bladder urine, residual urine is increasing, urinary frequency is more common.When the bladder is overfilled, the bladder pressure exceed urinary tract pressure, urine spontaneously overflow from the urethra.2. Voiding symptomsThe main symptoms include:Obstruction, dysuria C

33、ompensated period The most common symptoms is of dysuria.Progressive dysuria is the most important symptoms of BPH. MainVoiding/Obstructive symptoms: Hesitancy,shorter spray urine length. Intermittency Incomplete voiding,Weak urinary stream, straining to pass urine,prolonged micturition terminal dri

34、bbling. feeling of incomplete(尿不尽尿不尽感感),etc Clinical manifestation Decompensated period The main manifestation is chronic urinary retention. Incomplete emptying.Postvoid residual(PVR)残残余尿余尿,loss of detrusor contractility,bladder trabeculation小梁形成小梁形成,lead to detrusor instability逼尿肌不稳定逼尿肌不稳定. overflo

35、wing incontinence occurs充盈性尿失禁充盈性尿失禁.clinical manifestation 3. After voiding symptoms Endless dribbling after urinationclinical manifestationWhats LUTS? Storage (irritative orfilling) symptoms Urgency Frequency Nocturia Urge incontinence Voiding (obstructive) symptoms Hesitancy Weak stream Straining

36、 to pass urine Prolonged micturition Feeling of incompletebladder emptying Urinary retentionBladder trabeculation increases.Vesical calculi developedComplications Others： BPH with infection, bladder irritatitive syptom,such as frenquency,urgency,dysuria, Painless hematuria无痛性血尿无痛性血尿 Inguinal hernia腹

37、股沟疝腹股沟疝,hemorrhoids内内痔痔,anal prolapse secondary to high abdominal pressure due to dysuria. Acute urinary retention Complications Acute or chronic renal failure(慢性肾功能衰竭慢性肾功能衰竭) obstruction lead to vesicoureteral reflux, hydronephrosis,renal functional impairment, 病病patients symptom also include：anore

38、xia(食食欲减退欲减退),nausea,vomiting,anemia,anergyAUA Symptom Index ScoringSCORE INTERPRETATION0-7Mild8-19Moderate20-35SevereDiagnosis 1.1 Medical History: (LUTS, previous surgery in the urinary tract, urethral stricture尿道狭窄尿道狭窄). 1.2 Voiding charts(diaries)排尿日志排尿日志 LUTs in patients with nocturnal symptoms

39、 recording frequency of urination,time,volume,fluid intake,associated symptoms etc. 1.3 IPSS score: international prostate symptom score: mild 0-7,moderate 8-19 and severe 20-39. QOL: quality of life.Diagnosis2.Physical Examination 2.1 The external genitalia and local neurological examination:Anal m

40、alignancy and detect undiagnosed neurologic conditions by evaluating the sphincter tone and perianal sensation肛周感肛周感觉觉;Abdomianl exam: distended扩大的扩大的 bladder).2.2 Digital rectal examination(DRE) (Ca:nodules, asymmetry, hardened ridges, Prostatitis:tenderness, bogginess; digital rectal examination(D

41、RE)2.3. Urinalysis by dipstick and routine microscopy, urine culture and sensitivity to infections and hematuria. Serum (prostate-specific antigens)PSA optional to Prostate Ca. 2.4. Prostate ultrasonography,transrectal ultrasound(TRUS).measure the prostate size,degree of protruding to the bladder,PV

42、R.Diagnosis2.5 Upper urinary tract ultrasonography. imaging (IVP,CT, U/S) only in presence of concomitant urinary tract disease or complications-hematuria, UTI, renal insufficiency. 2.6 Urine flow rate尿流率尿流率:Qmax(Maximum urinary flow rate)15ml/s:bradyuria, Qmax10ml/s:severe obstruction.2.7 Urodynami

43、cs: Detrusor function assessment2.8 Urethral cystoscopeDiagnosis Cystoscopy: for patients who dont respond to medical examination to determine the need for surgical approachDiagnosis Cystometrograms and urodynamic profile for patients with suspected neurologic disease or those who failed prostate su

44、rgery Flow rate尿流率尿流率, post void residual volume残残余尿量余尿量 of urine determination and pressure flow studies Diagnosis With the liberal（大量）（大量） use of B type ultrasound,computer tomography (CT) scans and magnetic resonance imaging (MRI), benign prostatic hyperplasia are being detected more frequently.

45、Differential Diagnosis 1.Bladder neck sclerosis(contracture) 2.Prostate cancer DRE:nodules, asymmetry,不不对称对称,hardened ridges, induration硬结硬结 3.Bladder tumors：cystoscopy 4.Neurogenic bladder or detrusor disfunction 5.Urethral strictureDifferential DiagnosisDecrease bladder outlet obstructionImprove b

46、ladder emptyingLower detrusor instabilityReverse renal insufficiencyPrevent future episodes of gross hematuria, UTI and urinary retentionQuality of life and sexualityManagement depends on severity. Treatment1.Watchful waiting:IPSS7 or patients IPSS7 but the patients quality of life was unaffected. R

47、egular supervised. Lifestyle modification Treatment options2.MedicationFirst line of defense against bothersome urinary symptomsTwo major types:2.1 -blockers relax the smooth muscle of prostate and provide a larger urethral opening2.2 5- reductase inhibitor - Shrink the prostate gland TreatmentDistr

48、ibution of 1-Adrenergic Receptors Adrenoceptors may be further sub-divided into alpha1A and alpha1D subtypes, with alpha1A predominant in the prostate and alpha 1D in the bladder. Thus blockade of alpha1A may be necessary for reduction of obstruction whereas the blockade of alpha1D may be required t

49、o relieve storage symptoms.Reduce outflow resistance.2.3 Phytotherapy (alternative)植物制剂植物制剂 普适泰普适泰2.4 -blockers with 5- reductase inhibitor 2.5 -blockers with M-receptor blockersTreatment3.Surgical treatment Absolute surgical indications: Recurrent attacks of acute urine retention,recurrent hematuri

50、a,Overflow incontinence, UTI(urinary tract infection), upper urinary tract obstruction results in hydronephrosis and renal impairment,gross hematuria,complicated by bladder stone. Relative indications for surgery:Conservative treatment or medical treatement,Which unable to relieve the LUTs. Increase

51、d residual urine volume. emptying.Postvoid residual(PVR)残余尿残余尿 50ml Transurethral resection of the prostate (TURP) is the gold-standard surgical treatment. Open prostatectomy is the procedure of choice for prostates larger than 80-100 g. Combined with vesical diverticulum or bladder stone. 4. Other

52、treatments: some elderly patients can not tolerate surgery, the relatively safe treatment options should be considered photoselective vaporization of the prostate, transurethral needle ablation(射频消融射频消融), transurethral microwave therapy, and holmium laser enucleation of the prostate. Balloon dilatat

53、ion,intraprostatic stents. The most promising results have been produced with the laser therapies, which achieve similar results to those of TURP, but with fewer complications and side effects. Data on long-term efficacy of these newer therapies are lacking.SummarySurgical: InvasiveTURP : Transureth

54、ral resection of theprostateOpen prostatectomy techniquesSuprapubicRetropubicTUIP : Transurethral incision of the prostateTULIP : Transurethral laser incision of theprostateSurgical:minimally invasiveBalloon dilatationMicrowave treatment : TUMTIntraprostatic stentsLaser therapyMedical:Alpha- adrenoc

55、eptor blockersAlpha-reductase inhibitorsPlant extractsWatchful Waiting: Acute retention of urine (AUR) is one of the most common emergency deseases of urologic disorders.Needing emergent treatment. retention of urinean is abnormal, involuntary accumulation of urine in the bladder as a result of a lo

56、ss of muscle tone in the bladder, neurologic dysfunction or damage to the bladder, obstruction of the urethra, or administration of a narcotic analgesic, especially morphine Acute urinary retention is a medical emergency. Section IV Acute urinary retention Obstructive and dynamic obstruction. If there is an obstruction (kidney stones), urine cannot flow freely through the urinary track. Dynamic (non-obstructive) causes include a weak bladder muscle and nerve problems that in