Fall, 2014

Depending on the cause of hydronephrosis patients can be asymptomatic or patients can present with abdomen, back and flank pain. Patients can also present with dysuria, oliguria incontinence and nausea. Hydronephrosis and hydroureter can be unilateral or bilateral. Hydronephrosis occurs in 65-85% of pregnancies and has a greater incidence of occurrence on the right side. Bilateral symmetrical hydronephrosis usually suggests a cause that is related to the bladder, whereas unilateral hydronephrosis can be attributed to ureteral obstruction on just that side (Lusaya, 2013). The sonographic appearance of hydronephrosis is “splaying, spreading or ballooning of the central echo complex” (Kawamura & Lunsford, 2012). Hydronephrosis is graded based on its sonographic appearance. Grade I (mild) shows minimal separation of sinus echoes.  

Grade II (moderate) shows moderate dilatation of renal pelvis and calyces, with possible mild cortical thinning. Grade III (severe) shows extensive separation of central sinus and calyces with parenchymal thinning, giving the kidney a blown out “dumbbell” shape. (Kawamura & Lunsford, 2012) 




This case was performed at a local hospital. The patient was an 87 year old female presenting with abdomen and right flank pain and nausea. The patient was catheterized and a RUQ ultrasound was ordered as well as a CT and MRI. With the multiple imaging modalities used to evaluate this patient similar results were found. The ultrasound findings were severe right hydronephrosis and hydroureter and a gallstone within a normal size gallbladder (Figures 1-4). The MRI showed dilated intrahepatic and extrahepatic biliary ductal systems, with the common bile duct measuring up to 13.5 mm off the head of the pancreas (Figure 7), a 1.5 cm gallstone in the gallbladder (however the gallbladder had been displaced distal and lateral and resided next to the lateral border of the right kidney as seen in Figures 5 & 6) and severe right hydroureteronephrosis and tortuous dilated right ureter. CT imaging showed moderate right hydronephrosis with a markedly tortuous proximal ureter with severe hydroureter seen down to the level of the urinary bladder, as well as a gallstone within the gallbladder (Figure 8). There is suspected ectopic insertion of the right ureter into the bladder laterally.

The goal of treatment of hydronephrosis and hydroureter is to free the blocked urine and regain the free flow of urine from the kidney to the bladder. Initial treatment of patients is directed at decreasing pain levels and preventing any urinary tract infections by using antibiotics. Surgical intervention may be required but depends upon the cause of the hydronephrosis and hydroureter. Bladder catheterization may be all that is needed in some cases such as with urinary retention. A stent may be placed to bypass the obstruction and allow the urine to flow out of the kidney. A percutaneous nephrostomy tube can also be placed when a stent cannot be placed. (Wedro, 2013)

There are multiple other conditions that can mimic hydronephrosis such as a simple renal cyst, parapelvic cyst etc. Visualization of a dilated ureter can help make diagnosis of hydronephrosis and hydroureter. It is important to try to identify the cause of hydronephrosis and hydroureter and follow dilated ureter to bladder to try to determine the cause. An overfilled bladder can mimic hydronephrosis so it is important to image the kidneys pre-void and post-void to demonstrate whether the hydronephrosis persists after voiding.

References
Kawamura, D., & Lunsford, B. (2012). The Kidneys. In Diagnostic Medical Sonography: Abdomen and Superficial Structures (3rd ed., pp. 306-311). Baltimore: Lippincott, Williams and Wilkins. Lusaya, MD, D. (2013, February 14). Hydronephrosis and Hydroureter . Retrieved September 29, 2014, from http://emedicine.medscape.com/article/436259-overview Wedro, MD, FACEP, FAAEM, B. (2013, November 19). Hydronephrosis Index. Retrieved September 29, 2014, from http://www.medicinenet.com/hydronephrosis/article.htm