From the Guidelines
The approach to hydronephrosis begins with prompt evaluation to determine the cause and severity of the urinary obstruction, with ultrasound as the first-line imaging modality, followed by CT scan if needed, as recommended by the most recent study 1. The initial assessment should include a comprehensive history, physical examination, laboratory tests (serum creatinine, BUN, urinalysis), and imaging studies.
- Key points to consider in the initial assessment include:
- Comprehensive history to identify potential causes of hydronephrosis
- Physical examination to assess for signs of infection or obstruction
- Laboratory tests to evaluate renal function and detect infection
- Imaging studies to confirm the diagnosis and determine the severity of hydronephrosis Management depends on the underlying cause, degree of obstruction, and presence of complications.
- For acute, severe hydronephrosis with infection or renal impairment, urgent decompression is necessary via percutaneous nephrostomy or ureteral stent placement, as supported by recent studies 1.
- For stone-related hydronephrosis, pain management with NSAIDs (ketorolac 30mg IV or ibuprofen 400-600mg orally every 6 hours) is recommended, along with alpha-blockers like tamsulosin 0.4mg daily to facilitate stone passage, as suggested by the evidence 1.
- Antibiotics are indicated if infection is present, typically with fluoroquinolones or third-generation cephalosporins, as recommended by the most recent study 1.
- For pregnancy-related hydronephrosis, conservative management with hydration and position changes is often sufficient, as supported by the evidence 1.
- Congenital hydronephrosis in children may require surgical correction if severe, as suggested by the studies 1. Long-term management focuses on treating the underlying cause, whether it's removing obstructing stones, correcting anatomical abnormalities, or managing malignancies.
- Regular follow-up imaging is essential to monitor resolution and prevent permanent renal damage, as prolonged obstruction can lead to irreversible kidney injury through increased intratubular pressure and subsequent inflammatory and fibrotic changes, as highlighted by the most recent study 1.
From the Research
Approach to Hydronephrosis
- The approach to hydronephrosis involves urinary diversion with percutaneous nephrostomy or ureteral stent, indicated by symptoms such as persistent colic, high temperature, and uremia, as seen in a study published in The Journal of Urology 2.
- Diagnosis of hydronephrosis can be made using various modalities, including sonography, radiography, magnetic resonance imaging, and nuclear medicine technology, as discussed in an article in Radiologic technology 3.
- The grading scale for hydronephrosis is used to assess the severity of the condition, and treatment options are explained in the same article 3.
- A study published in the British journal of hospital medicine (London, England : 2005) explores how to approach an adult patient with hydronephrosis, encompassing aetiology, clinical presentation, diagnosis, and management 4.
Treatment Options
- Percutaneous nephrostomy and ureteral stent are two treatment options for hydronephrosis, with percutaneous nephrostomy being superior to ureteral stents for diversion of hydronephrosis caused by stones, especially in patients with a high temperature, as well as in males and juveniles, as demonstrated in a study published in The Journal of Urology 2.
- Another study published in Urolithiasis found that percutaneous nephrostomy was associated with a higher rate of spontaneous stone passage when adjusted for stone size and location, and was better tolerated and associated with fewer urinary symptoms when compared with retrograde ureteral stent 5.
Prognosis and Management
- The severity of hydronephrosis can clarify prognosis and guide management for emergency department patients with acute ureteral colic, as seen in a study published in CJEM 6.
- The study found that absent or mild hydronephrosis identified a large subset of patients with low passage failure rates, who may be appropriate for trial of spontaneous passage without CT imaging, while severe hydronephrosis was an important finding that warranted definitive imaging and referral 6.