Paediatrics and child health

1. HYDRONEPHROSIS FAITH CHERONO

2. INTRODUCTION
DEFINITION
Hydronephrosis is the term used for dilatation
of renal pelvis and calyces due to partial or
intermittent obstruction to the outflow of
urine.
Can also be defined as condition that occurs
when the kidney swell due to failure of normal
[this swelling usually affects one kidney]

3. OVERVIEW
It results in a blockage or obstruction in the
urinary tract.
Hydronephrosis is not a primary disease but
it’s a secondary condition that results from
other underlying cause.
It occurs at any age . In children it can be
diagnosed prenatal[ultrasound] or during
infancy
Incidence occur in 1:100 babies.

4. Hydronephrosis affects drainage of urine in the
urinary system-the kidneys,ureter,bladder and
urethra. When the urinary system is impared
this vcause the urine to back up and the kidney
swell.
Typically, hydronephrosis is caused by either
blockage of urine flow or leaking backward
through the urinary system that is reflux.

5. AETIOLOGY
Most common causes of
hydronephrosis in
Children are anatomical
abnormalities. i.e.
Vesicoureteric reflux
Ureteropelvic junction
obstruction
Non – obstructive , non
– refluxing
hydronephrosis
Ureterovesical junction
obstruction
Mega ureter
Ureterocele
Posterior urethral valves
Multicystic dysplastic
kidney
Ectopic ureter
Neurogenic bladder

6. Young adults
•Kidney stones
• Renal calculi
Older adults
•BPH
•Neoplasms : prostate cancer

7. CLASSIFICATION
Hydronephosis can be unilateral or bilateral.
Unilateral Hydronephrosis
It affects one kidney.
Occurs due to obstruction of ureterus at the level of
pelviureteric junction (PUJ).

8. CAUSES,
•Intraluminal-calculus in the ureter or renal
pelvis.
•Intramural-congenital pelviureteric junction
obstruction, atresia,of ureter, inflammatory
strictures, trauma, neoplasm of ureter or
bladder.
•Extramural-obstruction of the upper part of
the ureter by inferior renal artery or vein,
pressure on ureter from outside such as

9. Bilateral hydronephrosis
It Affects both kidneys.
Occurs due to urethral obstruction.
It may be of the following types;
•Congenital-atresia of the urethral meatus, congenital
posterior urethral valve.
•Acquired-Bladder tumour involving both ureteric orifices,
prostatic carcinoma and prostatitis,bladder,neck stenosis,
inflammatory or traumatic urethral strictures and
phimosis.

10. PATHOPHYSIOLOGY
Urine passes from renal pelvis into ureter by
anatomical continuity at the PUJ and peristaltic
contractions from pelvis to ureter.
Normal basal pressure in the renal pelvis varies
from 5 to 25 cm of water.
When urinary system is impaired or obstructed
causes urine backflow to kidney leading to
initial rise in pressure resulting to dilatation
thus hydronephrosis develops.

11. CLINICAL PRESENTATION
They vary depending on duration of obstruction
Some cases are asymptomatic
Mild symptoms include: Frequency and urgency
Severe symptoms : pain in the abdomen , Nausea , vomiting, pain
with urination, incomplete voiding and fever.

12. CLINICAL FEATURES
Patients with congenital hydronephrosis due to PUJ may remain
asymptomatic throughout their life. However, they may develop symptoms
at any stage depending on the degree and duration of obstruction.
Renal lump—unilateral/bilateral, tense cystic/soft, small/large
Pain in the abdomen —high pressure, acute obstruction, infection, stone
Infection, stone
Fever
Intermittent lump, nausea, vomiting(Dietl’s crisis)
Haematuria—rare, usually after trauma
Renal failure—usually in single kidney with PUJ
Failure to thrive, anaemia

13. DIAGNOSIS
Assessment ;
•History[ clinical presentation]
•family history,
•focus on urinary symptoms, assess kidney for
imaging enlargement by gently massaging the
abdomen and flank area.
Investigations

14. INVESTIGATIONS
Primary investigation
Renal ultrasound
 It is a good screening modality of first
choice,
Non-invasive
can detect ureteric dilatation/bladder or
urethra pathology
Other investigations

15. SOCIETY FOR FETAL UROLOGY
GRADING SYSTEM FOR
HYDRONEPHROSIS
GRADE CENTRAL COMPLEX RENAL PARENCYMAL
THICKNESS
0 INTACT NORMAL
1 SLIGHT SPLITTING NORMAL
2 EVIDENT SPLITTING, COMPLEX CONIFINED WITH RENAL
DISORDER
NORMAL
3 WIDE SPLITTING PELVIS DILATED OUTSIDE RENAL
BORDER, CALYCES UNIFORMLY DILATED
NORMAL
4 FURTHER DILATION OF PELVIS AND CALYCES(CALYCES
MAY APPEAR CONVEX)
THIN

16. LAB INVESTIGATIONS
Routine haemogram, UECs{ to check kidney
functioning}
Urine examination; microscopy and culture-To
check for signs of infections or urinary stones
that could cause blockage.
X-ray of urinary tract

17. IMAGING TECHNIQUES
Radioisotopes studies
•Renal scintigraphy can be used to assess renal anatomy and
function(clearance and GFR)
•It uses radiopharmaceuticals like Mercaptocetly triglcine(MAG-
3)
•Alternatively DPTA(diethylene tetrapentaacetic) can be used
Excretory urogram
•Rarely used but indicated in cases with inderminate upper
urinary indeterminate urinary tract obstruction or suspected
duplication anomaly
Magnetic resonance urography

18. IMAGING TECHNIQUES
Computed tomography
Indicated in children with a suspected ureteral calculus, non
contrast spiral CT of the abdomen and pelvis to demonstrate
calculus.
Ancillary studies
•Antegrade pyelogram: to assess the anatomy of upper urinary
tract
•Antegrade pressure-perfusion flow study to determine
obstruction( pressure differences exceeding 20cm H2O
suggest obstruction
Micturating cystourethrogram (MCU)- is indicated if the ureter

19. TREATMENT
Treatment depend on the underlying cause
Mild to moderate hydronephrosis-opt and see
if it will resolve by itself
Preventive measures-Give antibiotic therapy to
lower risk of UTI.The condition resolve over a
period of time.
Severe hydroneprosis-Surgery is recommended
to fix blockage or correct reflux.

20. TYPES OF URINARY TRACT
OBSTRUCTION AND THEIR
TREATMENT
Ureteropelvic junction obstruction(UPJ)
The most common lesion in childhood
Usually caused by intrinsic stenosis
Typical appearance on ultrasonography is
grade 3 or 4 hydronephrosis without dilated
ureter.

21. It commonly manifests on antenatal
ultrasonography revealing fetal hydronephrosis;
as a palpable mass in newborn or infant; as
abdominal, flank, or back pain; as a febrile UTI
or as hematuria after abdominal trauma
60% of cases occur on the left side
Male to female ratio 2:1
10% cases are unilateral

22. Kidney with UPJ obstruction may impaired renal
function due to pressure and atrophy
The anomaly can be corrected by pyeloplasty in
which stenotic segment is excised and normal
ureter and renal pelvis are reattatched.
Diagnosis can be difficult in asymptomatic child in
whom renal dilation is found incidentally on during
prenatal ultrasound.
After birth the sonographic study is repeated to
confirm prenatal finding

23. If no dilation on initial sonogram, repeat study
at one month of age though it is ideal to
perform 1st sonogram at day 3 of life.
Antibiotics are not indicated for children with
mild hydronephrosis(grade 1,2)
Grade 3 ,4 less likely to resolve on its own and
more likely to cause obstruction

24. At 4-6 wk perform renogram with MAG-3 if
ythere is poor upper tract drainage .
Pyeloplasty is recommended and continue with
observation with serial ultrasonograms
Then prompt surgical repair is indicated in
infants with an abdominal mass, bilateral severe
hydronephrosis, a solitary kidney or diminished
function in the involved kidney

25. Mid ureteral obstruction
Diagnosis can be confirmed by retrograde
pyelography
It is corrected by excision of strictured segment
and reanastomosis of the normal upper and
lower ureteral segments

26. Ectopic ureter
Ureter that drains outside the bladder.
It 3 times common in girls as compared to boys and usually detected
prenatally
It causes continuous urinary incontinence and UTI is common because of
urinary stasis in girls
In boys it causes UTI and epididymitis
Treatment depends on renal unit drained by ectopic ureter
Ureteral reimplantation or ureterostomy indicated
Total or partial nephrectomy indicated if poor function

27. Ureterocele
Cystic dilatation of the terminal ureter and is obstructive
because of a pin point ureteral orifice.
Common in girls and boys
Treatment depends on whether there is upper pole
functions or whether there is reflux into lower pole ureter
if there is function of upper pole and significant reflux into
lower ureter
transurethral incision with cautery or the holmium
otherwise: laparoscopic, robotic or open excision of the
obstructed upper pole

28. Megaureter
Can be refluxing , obstructed and non refluxing non
obstructed
Asymptomatic patients put on serial ultrasonography
and diuretic renography
If there is grade 4 hydronephrosis give prophylactic
antimicrobial therapy
If renal function deteriorates ureteral implantation is
recommended

29. Posterior urethral valves
Most common cause of severe obstructive uropathy in children
Affects 1 in 8,000 boys
Vesicoureteric reflux occurs in 50% of patients
Treatment
Transurethral ablation or temporary vesicostomy
Antimicrobial prophylaxis and follow up

30. Non-neurogenic bladder
It involves failure of the external sphincter to
relax during voiding in children without
neurologic abnormalities.
Treatment is complex and involves
anticholinergic and alpha adrenergic blocker
therapy, timed voiding, treatment of
constipation, behavioral modification and
encouragement relaxation during voiding.

31. Urethral stricture : urethral dilation
Prune belly syndrome
Treatment of undescended testes by
orchidopexy and surgery
Reconstruction of abdominal wall defects
Prompt treatment of UTI because they occur
often

32. INDICATIONS FOR SURGERY
All children presenting with symptoms—lump, pain and
infection
PUJ is associated with horseshoe, pelvic and crossed fused
kidney
If the split renal function is less than 40% in the affected side,
supported by delayed excretion and an obstructive renogram
curve
Deterioration in renal function from normal to less than 40%
function
A fall of more than 10% of the original value on the affected
side at follow-up

33. COMPLICATIONS
Urinary tract infection [most common complication]
 symptoms include: cloudy urine, painful urination, burning sensation with urination,
weak stream, backpain, bladder pain, fever and chills.
Pyelonephritis
Kidney infection
Sepsis
Renal colic
Bleeding- common after nephrostomy drainage
Urine leak
Obstruction