INTRODUCTION

Hydronephrosis is a condition where urine overfills, or backs up, into the kidney, which causes the kidney to stretch (dilate), much like a balloon when it is filled with water (1). Hydronephrosis is defined as aseptic distension of the renal calyces and pelvis with urine as a result of partial obstruction of the outflow of urine (2). It is a clinical condition which is caused by dilatation of the renal collecting system most frequently caused by incomplete or complete obstruction. There could be a number of underlying causes of hydronephrosis including congenital blockage (present at birth, scarring of tissue (from injuries or previous surgery), calculus, tumours or cancer, vesical mass, urinary tract infection (UTI) and benign prostatic hypertension (BPH) and pregnancy (3- 4). Hypertrophy Secondary to ureteropelvic junction obstruction may present as acute severe flank pain radiating to the inguinal and genital area (5). Hydronephrosis was first studied in 1824 by Fiorep. Since that time, several investigators have studied this association and the prevalence of hydronephrosis with uterine prolapse has varied from 0% to 100%(6-7). This variation can probably be accounted for by differences in the severity of prolapse and by small patient numbers (8). Although this condition is quite common yet its incidence and prevalence, aetiology, diagnosis and management is less commonly reported in literature especially in context with adults and non-pregnant women (9). Most of the literature available is related with hydronephrosis in foetuses, neonates and children and pregnant women (10). Most of the studies in adults are case-reports or

concerned only with diagnostic aspect and as such there is no comprehensive study highlighting the clinical profile, aetiology and management of hydronephrosis in adults only (11-12). In view of this void in literature, the present study was planned in which in order to maintain the exclusiveness, paediatric age group and pregnant women were excluded. It was also kept in mind that hydronephrosis in severely ill patients there might be multiple underlying aetiologies which may confound in exact evaluation of aetiologies and their diagnosis as proposed in present study; hence it was decided to exclude very sick patients with renal failure and patients with associated severe co morbid diseases (13). Patients were selected consecutively as and when they present during the study period considering the inclusion and exclusion criteria. Data for the study was collected from patients attending the Emergency/Surgery OPD in the Department of General Surgery at Era's Lucknow Medical College and Hospital, Lucknow. The outcome of results was assessed upon cases of Hydronephrosis diagnosed by USG findings. Careful history taking was done to determine any etiological factors.

∙Complete physical examination

∙Blood Investigations (CBC, RFT), LFT if required.

∙Urine Investigations (Urine R/M and C/S).

∙Radiological investigations including X-ray abdomen/KUB, IVP, Ultrasound KUB, RGU and MCU if needed.

∙Procedures performed on each admitted patient were noted.

Patients were followed up for upto 3 months after discharge and any complications noted were carefully followed.The statistical analysis was done using SPSS (Statistical Package for Social Sciences) Version 15.0 statistical Analysis Software. The values were represented in Number (%) and Mean ±SD.(14).

MATERIALSAND METHODS

Study Design

Prospective Study

Place of Study

Department of General Surgery, ERA'S

Lucknow Medical College & Hospital,

Lucknow.

Duration of Study

18 months.

Inclusion Criteria

Patients were included on following basis:

∙All patients admitted in General Surgery with Ultrasonographical evidence suggestive of Hydronephrosis.

∙Age more than >12 yrs.

Exclusion Criteria

∙Patients less than 12 years of age

∙Pregnant women

∙Very sick patients with renal failure, patients with associated severe co morbid diseases, patients not willing to participate in study.

RESULTS

The present study was conducted in the Department of Surgery, Era's Lucknow Medical College & Hospitals, Lucknow to evaluate the etiology, classify causes of hydronephrosis and to study common clinical presentation of hydronephrosis. A total of 105 patients of hydronephrosis attending the Emergency, OPD of Department of Surgery during the study period, fulfilling the inclusion criteria were included in the study. The outcome of results was assessed upon cases of Hydronephrosis diagnosed by USG findings.

Age Group	Number	Percentage
(years)
12-25	25	23.81
26-50	50	47.62
>50	30	28.57

Table 1: Distribution of Cases according to Age (N=105)

Min-Max: 12-79 years (Median: 41.00 years);

Mean±SD: 42.17+18.10

>50	12-25
28.57%	23.81%
	26-50
	47.62%

Minimum age of patients enrolled in the study was 12 years while maximum age was 79 years, median age in the study population was 41 years. Mean age of the patients was 42.17+18.10 years. Most common age group in 105 patients of hydronephrosis in our study was 26-50 years (47.62%) followed by >50 years (28.57%). Approximately three-fourth of the patients were aged >25 years. Only 23.81% patients were aged <25 years.

Gender	Number	Percentage
Male	100	95.24
Female	5	4.76
Total	105	100.00

Table 2: Distribution of Cases according to Gender (N=105)

Female 4.76%

Male 95.24%

Majority of the patients in our study were males

(95.24%) only 5 (4.76%) were females.

S.No.	Chief Complaints	No. of	Percentage
	at presentation	patients
1.	Follow up cases of Acute retention	6	5.71
2.	Burning micturition with fever	16	15.24
3.	Difculty in micturition	17	16.19
4.	Diminished ow	10	9.52
5.	Dribbling of urine	6	5.71
6.	Flank Pain (Intermittent)	39	37.14
7.	Hesitancy	2	1.90
8.	Iliac fossa pain	6	5.71
9.	Nocturia	3	2.86

Table 3: Distribution of Study Population according

' to Chief Complaints at presentation

			Follow up cases of Acute retention			Buming micturation with fever
			Difculty in Micturation			Diminished ow
			Dribbling of urine			Flank Pain (Intermittent)
			Hesitency			lliac fossa pain
			Nocturia
5.71%				2.86%	5.71%
1.90%

15.24%

included in the study was tobacco chewer/consumer or

habitual of drug intake.

S.No. Clinical History/		Number	Percentage
	Personal History	of patients
1.	Trauma	8	7.62
2.	Tuberculosis	11	10.48
3.	Diabetes mellitus	3	2.86
4.	Hypertension	5	4.76
5.	Bronchial asthma	4	3.81

]

16.19%

37.14%

09.52%

05.71%

Chief complaint of most of the patients was intermittent flank pain (37.14%), followed by difficulty in micturition (16.19%), burning micturition with fever (15.24%). Diminished flow was observed in 9.52%, 5.71% each for follow up cases of acute retention, dribbling of urine and iliac fossa pain. Hesitancy was the least common chief complaint (1.9

0%) followed by Nocturia (2.86%).

S.No.	Personal History			Number		Percentage
				of patients
1.	Smoking			13		12.38
2.	Alcohol			18		17.14
3.	Tobacco chewing/			0		0.00
	consumption
4.	Drug intake			0		0.00
Table 4: Incidence of Personal Habits in Study Population
18
16
14
12
Percentage
10
8
6
4
2
0	Smoking		Alcohol	Tobacco	Drug intake

chewing/

consumption

Only 12.38% of patients had habit of smoking and

17.14%were habitual of alcohol. None of the patients

6.

Previous Surgery

4

3.81

Table 5: Incidence of Clinical/Personal History in

Study Population

		12
		10
	Percentage	8
		6
		4
		2
		0

Trauma	Tuberculosis Diabetes Hypertension	Bronchial	Previous
	mellitus	asthma	Surgery

Only 10.48% were suffering from tuberculosis, 7.62% had experienced a traumatic event, 2.86% had diabetes, 4.76% were suffering from hypertension, 3.81% had bronchial asthma and 3.81% had undergone surgery previously.

S.No.	Clinical Signs	Number	Percentage
		of patients
1.	pallor	16	15.24
2.	icterus	0	0.0
3.	cyanosis	0	0.0
4.	clubbing	0	0.0
5.	lymph node	0	0.0
6.	oedema	3	2.86
7.	fever	9	8.57

Table 6: Incidence of Clinical Signs in Study Population

		16
		14
		12
	Percentage	10
		8
		6

4

2

0

Pollor

Lcterus

Cyanosis Clubbing Lymph node Edema

Fever

Most common clinical signs was Pallor (15.24%), followed by Fever (8.57%), Oedema (2.86%). In none of the patient icterus, cyanosis, clubbing, lymphadenopathy was found.

	Variable			No. of				Min.			Max.		Median	Mean		SD
				patients
	Pulse rate				105			60			110		88	87.66	11.49
	(per min)
	SBP				105			110			150		120	122.55	9.33
	(mm Hg)
	DBP				105			70			90		80	81.31	6.26
	(mm Hg)
	RR				105			16			80		20	22.48	10.29
	(beats/min)
	Table 7: Hemodynamic Variables in Study Population
	Variable		No.of			Min.			Max.			Median		Mean		SD
		patients
	Haemo-		96				7			16			10.70	10.73		2.12
	globin
	TLC		100			3000			14000				7000	7031.0		2492.4
	DLC
	(Neutro-		100				55			84			76	74.67		6.13
	phils)
	DLC
	(Lymph-		100				15			38			25	24.95		6.25
	ocytes)
	DLC
	(Eosino-		96				0			15			0	2.06		3.57
	phils)
	S. Urea		100				1			102			35	47.55		27.25
	S. Creati		100				0.60			6.10			1.50	1.57		1.06
	nine
	RBS		105				109			141			125	126.34		10.73
	S. Na+		105				135			144			138	139.01		2.65
	S. K+		105				3.2			5.1			4.2	4.34		0.62

Table 8: Haematological/Biochemical Variables in the Study

Hemodynamic variables and haematological variables

of the study population have been tabulated in Table 7

and Table 8.

S.No.	Urine Culture		Number	Percentage
			of patients
1.		Contaminated	8	7.62
2.		E. coli	21	20.00
3.		Klebsiella	8	7.62
4.		Sterile	68	64.76
Table 9: Urine Culture Findings of Study Population
			Contaminated
			7.62%	E.coli
				20.00%
Sterile				Kleibsella
64.7%				7.62%

Out of 105 Urine culture specimens, 68 (64.76%) were found to be sterile, 8 (7.62%) specimens contaminated.

E. coli and Klebsiella were isolated from 20.0% and 7.62% urine culture specimens respectively.

	Total	Normal Temp.		Fever
		(n=34)		(n=3)
		No.	%	No.	%
Contaminated	8	8	23.53	0	0.00
E. coli	21	18	52.94	3	100.00
Klebsiella	8	8	23.53	0	0.00
		χ²=2.487 (df=2); p=0.288

Table 10: Association of Positive Urine Culture with Fever

Normal body temp. Fever

100

90

80

70

60

50

40

30

20

10

0

Contaminated

E. coli

Kleibsella

Of 37 patients with positive Urine Culture, only 3 (8.11%) were found to be suffering of fever and rest 34 had normal body temperature. All the patients suffering from fever were isolated for E. coli. Proportion of patients with normal body temperature was higher as compared to suffering from fever, with contaminated urine culture (23.53% vs. 0.0%) and isolated for Klebsiella (23.53% vs. 0.0%) while proportion of patients suffering from fever was higher as compared to normal body temperature in whom E. coli was isolated from urine specimens. Association of isolate of Urine culture with fever was not found to be statistically significant.

	S.No.	X-ray	Number	Percentage
		Findings	of patients
		Anterior/
	1.	Middle/	13	12.38
		Post. urethral
		stricture
	2.	B/L renal	18	17.14
		calculi
	3.	Dil ureters	1	0.95
		with VUR
	4.	Dilated calyx	1	0.95
		with VUR
	5.	Left renal	17	16.19
		calculus
	6.	Lt multiple	2	1.90
		renal cal
	7.	Lt PUJ/ureteric	10	9.52
		obstruction
	8.	Rt PUJ	4	3.81
		obstruction
	9.	Rt renal cal	15	14.29
	10.	rt ureteric	1	0.95
		calculi
	11.	urethral	1	0.95
		calculus
		Vesicle
	12.	calculus	2	1.90
		positive
	13.	Ureteric	2	1.90
		strictures
	14.	WNL/NAD	18	17.14

Table 11a: X-ray Findings of Study Population

X-ray of 17.14% patients were found to be within- normal limits or without any abnormality. Bilateral renal calculi (17.14%) was found to be the most common X-ray finding, followed by Left renal

calculus (16.19%), Right renal calculi (14.29%).

	S.No.	Urine Culture	Number	Percentage
			of patients
	1.	Bilateral	19	18.1
		hydronephrosis
		Bilateral renal
	2.	calculi with	18	17.1
		hydronephrosis
		Unilateral renal
	3.	calculi with	34	32.4
		hydronephrosis
	4.	BPH	9	8..6
	5.	Dilated calyx	12	11.4
		with PUJ
		obstruction
	6.	Dilated calyx	1	0.95
		with VUR
		Unilateral ureteric
	7.	calculus with	9	8.6
		hydronephrosis
	8.	Genitourinary	1	0.95
		Tuberculosis
	9.	Severe UTI	1	0.95
		with BOO
	10.	Vesicureteric	1	0.95
		reux with
		dilated ureters

Table 11b USG Findings of Study Population

Unilateral renal calculi with hydronephrosis was the most common USG findings (n=34; 32.38%). Bilateral hydronephrosis was reported in 19 (18.1%) while bilateral renal calculi with hydronephrosis were

	S.No.	Diagnosis	Number	Percentage
			of patients
	1.	Calculus	64	61.90
	2.	VUR	2	1.90
	3.	Stricture	14	13.33
		Urethra
	4.	PUJ	12	11.43
	5.	Chronic UTI	1	0.95
	6.	BPH	11	10.48
	7.	Ureteric	1	0.95
		stricture

Table 12: Final Findings of Study Population

reported in 18 (17.14%) cases. Dilated calyx with PUJ obstruction, BPH, unilateral ureteric calculi with hydronephrosis were seen in 11.4%, 8.6% and 8.6% patients respectively. There was 1 case each with USG findings suggestive of dilated calyx with VUR, Genitourinary Tuberculosis, Severe UTI with BOO and Vesicureteric reflux with dilated ureters respectively.

years for VUR (8.00% vs. 0.0% & 0.0%), PUJ (32.00% vs. 8.0% & 0.0%). Proportion of patients aged 26-50 years was higher as compared to 12-25 years and >50 years for Calculus (70.00% vs. 52.00%

& 56.67%). Proportion of patients aged >50 years was

higher as compared to 12-25 years and 26-50 years for

Stricture urethra (20.0% Vs. 8.0% and 12.0%) and

BPH (23.33% vs. 0.0% & 8.0%). Difference in Final

Chronic UTI

BPH

diagnosis in different age groups was found to be

0.95%

PUJ 11.43%

10.48%

statistically significant (p<0.001).

	Total	Males		Females
		(n=100)		(n=5)
		No.	%	No.	%
Calculus	65	60	60.00	5	100.00

Structure
Urethra	VUR
13.33%
	1.90%	Calculus
		61.90%

Most common diagnosis was Calculus (61.90%) followed by Stricture (13.33%), PUJ (11.43%), BPH (10.48%), VUR (1.90%), and Chronic UTI (0.95%).

		T	12-25 yrs		26-50 yrs		>50 yrs
		O	(n=25)		(n=50)		(n=30)
		T
		A
			No.	%	No.	%	No.	%
		L
	Calculus	65	13	52.00	35	70.00	17	56.67
	VUR	2	2	8.00	0	0.00	0	0.00
	Stricture	14	2	8.00	6	12.00	6	20.00
	Urethra
	PUJ	12	8	32.00	4	8.00	0	0.00
	Chronic	1	0	0.00	1	2.00	0	0.00
	UTI
	BPH	11	0	0.00	4	8.00	7	23.33

Table 13: Association of Age with Final Diagnosis

Upto 25 26-50 yrs >50 yrs

70

60

50

40

30

20

10

0

Calculus	VUR	Stricture	PUJ	Chronic	BPH
		Urethra		UTI

Calculus was diagnosed in majority of the patients of each age group., Proportion of patients aged 12-25 years was higher as compared to 26-50 years and >50

VUR	2	2	2.00	0	0.00
StrictureUrethra	14	14	14.00	0	0.00
PUJ	12	12	12.00	0	0.00
Chronic UTI	1	1	1.00	0	0.00
BPH	11	11	11.00	0	0.00
		χ²=3.231 (df=5); p=0.664

Table 14: Association of Gender with Final Diagnosis

100

90

80

70

Percentage 60

50

40

30

20

10

0

Calculus VUR Stricture PUJ Chronic BPH

UrethraUTI

Only 5 patients were female and all were diagnosed as

Calculus. No statistically significant association in

gender and Final diagnosis was found.

		T	2-25 yrs		26-50 yrs		>50 yrs
		O
		T	(n=9)		(n=18)		(n=18)
		A
		L
			No.	%	No.	%	No.	%
	BLRenal	18	5	55.56	8	44.44	5	27.78
	calculi
	BPH	11	0	0.00	4	22.22	7	38.89
	Stricture	14	2	22.22	6	33.33	6	33.33
	VUR	2	2	22.22	0	0.00	0	0.00
				χ	²=13.364(df=6);		p=0.038

Table 13: Association of Bilateral Hydronephrosis

(n=45) with Age

Upto 25 26-50 yrs >50 yrs

	60
	50
Percentage	40
	30

20

10

0

BL Renal Calculi

BPH

Stricture

VUR

Only 45 patients were found to be suffering from Bilateral hydronephrosis. For of patients aged 12-25 was found to be higher as compared to 26-50 years and >50 years for Bilateral renal calculi (55.56% vs. 44.44% & 27.78%) and VUR (22.22% vs. 0.0% & 0.0%) while proportion of patients aged >50 years and 26-50 years was higher for BPH (38.89% & 22.22% vs. 0.0%) and Stricture (33.33% & 33.33% vs. 22.22%).

CONCLUSIONS

From our study, we concluded that age of patients ranged from 12 to 79 years with a mean age of 42.12 years. Out of them, majority of patients were males (95.24%). There were only 4 (4.76%) females. Intermittent flank pain was the most common complaint at presentation (37.14%) followed by difficulty in micturition and burning micturition with fever (16.19% and 15.24% respectively). Diminished flow (9.52%), iliac fossa pain, h/o acute retention, dribbling of urine (5.71%), nocturia (2.86%) and hesitancy (1.9%) were some of the less common presenting complaints. History of smoking (12.38%) and alcohol use (17.14%) were reported as the personal habits with health risk. None of the patients reported of drug use / tobacco chewing habit. Evaluation of medical history revealed history of tuberculosis (10.48%) as the most common finding followed by trauma (7.62%), hypertension (4.76%), bronchial asthma and previous surgery (3.81% each) and diabetes mellitus respectively (2.86%). Most of the patients did not present with any particular clinical sign. Pallor (15.24%) and fever (8.57%) were the most common clinical signs. A total of 3 (2.86%) reported

w i t h o e d e m a . M e a n h e m o d y n a m i c a n d haematological parameters of patients were within normal range. Mean serum urea level was 47.55±27.55 mg/dl, thus indicating a high degree of derangement. Urine culture was sensitive in 29 (27.6%) cases. E. coli was isolated in 21 and Klebsiella in 8 cases. No significant association of microbial positivity with body temperature was observed. X-ray

findings did not show any abnormality in 18 (17.14%) cases. Most common X-ray abnormality was presence of renal calculi (18; 17.14% bilateral and 32; 30.5% unilateral; 2; 1.9% multiple). Urethral stricture in 13 (12.38%) cases and Unilateral obstruction in 14 (13.3%) cases. Ureteric calculi were seen in 3 (2.9%) cases. Vesicular calculi were seen in 2 (1.9%) cases. There was 1 (0.95%) case each with dilated uterers with VUR, dilated calyx with VUR; Urethral calculi were seen in 1 case each. USG findings were positive in all the cases. Unilateral renal calculi with hydronephrosis was the most common USG findings (n=34; 32.38%). Bilateral hydronephrosis was reported in 19 (18.1%) while bilateral renal calculi with hydronephrosis was reported in 18 (17.14%) cases were the most common findings. Dilated calyx with PUJ obstruction, BPH, unilateral ureteric calculi with hydronephrosis were seen in 11.4%, 8.6% and 8.6% patients respectively. There was 1 case each with USG findings suggestive of dilated calyx with VUR, Genitourinary Tuberculosis, Severe UTI with BOO and Vesicureteric reflux with dilated ureters respectively.

The aetiology of hydronephrosis was established as calculus in 64 (61.9%) cases followed by stricture urethra (13.33%), PUJ (11.43%), BPH (10.48%), VUR (1.9%), Chronic UTI (0.95%) and ureteric stricture (0.95%) respectively. Calculus was most common diagnosis in all age groups, however, in younger age group (12-25 yrs) PUJ was the second most common diagnosis whereas in age group >50 years, BPH was the second most common diagnosis. Statistically, a significant association was seen between age and aetiology of hydronephrosis. All the 5 females were diagnosed to have calculus as the aetiology of hydronephrosis as compared to 60% of males presenting with calculus as the aetiology. In cases with bilateral hydronephrosis, in younger age group (12-25 years) calculi were the most common aetiology (55.56%) followed by stricture and VUR (22.22% each), in age group 26-50 years renal calculi were the most common aetiology (44.44%) followed by stricture (33.33%) and BPH (22.22%) whereas in older age group >50 years, BPH was the most common aetiology (38.89%) followed by stricture (33.33%) and renal calculi (27.78%) respectively. Statistically, there was a significant difference in aetiology of hydronephrosis in different age groups. Management based on aetiology was successful in all the case with a significant reduction in renal size from the first month follow up itself. By third month follow up resolution of hydronephrosis was seen in all the cases. None of the cases showed recurrence.

DISCUSSION

The findings of present study suggested that the clinical signs and symptoms of hydronephrosis were non-specific to the aetiology which was dependent mainly on age and gender. After ruling out paediatric age group and pregnant women, hydronephrosis was seen as a highly male dominant disease with renal calculi as the major aetiology and BPH and VUR being age-associated risk factors. Aetiology based management of hydronephrosis yielded good outcome. The present study is perhaps the first detailed clinic pathological profile of hydronephrosis. In fact, there is tremendous life of large case series on hydronephrosis – though the present study has made to fill this gap, yet further studies on this entity are recommended to build a proper data base regarding epidemiology, pathogenesis, clinical presentation and management.

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