Urinary tract dilatation and oral contraceptives

Nonsurgical Management of Urolithiasis: An Overview of Expulsive Therapy

Although minimally invasive stone therapies such as shockwave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy are efficacious, these techniques are not free of risks and are relatively expensive. Watchful waiting may be appropriate in patients without infection whose pain can be controlled with oral medication but is associated with pain, uncertainty, potential risks to renal function, and time lost from work. Hydroxyprogesterone, prostaglandin synthetase inhibitors, calcium-channel blockers such as nifedipine, alpha-1 blockers such as tamsulosin, and corticosteroids may have some beneficial effect. Future studies are likely to provide additional data in support of their use.

Urinary tract infections in pregnancy

Although pregnancy does not increase the prevalence of ASB in women, it does enhance the progression rate from asymptomatic to symptomatic disease. Furthermore, ASB is associated with preterm delivery. Given the fact that identification and eradication of ASB in pregnant women can lower the likelihood of pyelonephritis and prevent preterm delivery, every gravida should be systematically screened for ASB and appropriately treated. In the authors' opinion, a first-trimester urine culture remains the screening test of choice; reliance on symptoms to prompt screening is inadequate because the state of pregnancy can provoke frequency and nocturia. Multiple antibiotic regimens for ASB are safe during pregnancy and effective.

Rigid ureteroscopy in pregnant women

OBJECTIVE

To report our experience with rigid ureteroscopy in pregnant women.

PATIENTS AND METHODS

Ten pregnant women (mean age 25 years, SD 4.5, range 22-33) with ureteric stones were treated by ureteroscopy. The mean (SD, range) gestation time was 24 (6.5, 19-33) weeks. A standard rigid ureteroscope of 11.5 F was used in eight patients and 9.5 F in two. The procedure was carried out with no ureteric dilatation in three patients and with easy dilatation in seven. Fluoroscopy was not used before or during ureteroscopy in any case. Ultrasonography was available throughout the procedures for constant renal and obstetric monitoring.

RESULTS

Mid and lower ureteric stones were extracted by basket or forceps in three patients and had to be disintegrated by ultrasound in two. Upper ureteric stones were displaced to the kidney, with placement of double-pigtail ureteric stents, in three patients who were subsequently treated after delivery. Ureteric oedema was seen in one patient and the endoscopic findings were normal in the remaining patient. There were no obstetric complications. Two patients had a urinary tract infection and one complained of stent-induced bladder irritation.

CONCLUSIONS

Rigid ureteroscopy is a safe and reliable method in the diagnosis and treatment of ureteric calculi during pregnancy. The procedure can be performed with ultrasonographic monitoring and without using fluoroscopy.

Detection, significance, and therapy of bacteriuria in pregnancy. Update in the managed health care era

Profound physiologic and anatomic changes of the urinary tract during pregnancy contribute to the increased risk for symptomatic urinary tract infection in women with bacteriuria. Asymptomatic bacteriuria is the major risk factor for developing symptomatic UTIs during pregnancy and may be associated with adverse effects on maternal and fetal health. Because most symptomatic UTIs develop in women with bacteriuria earlier in pregnancy, treatment of bacteriuria is undertaken to prevent symptomatic infections. All pregnant women should be screened at the first antenatal visit, which is reliably and inexpensively done with a dipstick culture. Short-course therapy should be given to women with bacteriuria and clearance of bacteriuria should be documented after therapy is complete. Failure to eliminate bacteriuria with repeated therapy or recurrence with the same organism is indicative of renal parenchymal infection or a structural abnormality. All women with persistent bacteriuria or recurrent infection should have follow-up cultures and a urologic evaluation after delivery.

Epidemiology, natural history, and management of urinary tract infections in pregnancy

The urinary tract undergoes profound physiologic and anatomic changes during pregnancy that facilitate the development of symptomatic UTIs in women with bacteriuria. Although the adverse effects of asymptomatic bacteriuria on maternal and fetal health continue to be debated, it is clear that asymptomatic bacteriuria is the major risk factor for developing symptomatic UTI and that symptomatic infections are associated with significant maternal and fetal risks. Because the majority of symptomatic UTIs develop in women with bacteriuria earlier in pregnancy, treatment of bacteriuria is undertaken to prevent symptomatic infections. All women should be screened at the first antenatal visit, which is reliably and inexpensively done with a dipstick culture. Short-course therapy is as effective as prolonged therapy and should be followed with a repeat culture to document clearing of the bacteriuria. Failure to eliminate bacteriuria with repeated therapy or recurrence with the same organism is indicative of renal parenchymal infection or a structural abnormality. All women with persistent bacteriuria or recurrent infection should have follow-up cultures and a complete urologic evaluation after delivery.

Sex hormones and the female urinary tract

Symptomatic clinical changes and urodynamic changes are apparent in the female urinary tract system during pregnancy, the menstrual cycle and following the menopause. The sex hormones exert physiological effects on the female urinary tract, from the ureters to the urethra, with oestrogens having an additional influence on the structures of the pelvic floor. High affinity oestrogen receptors have been identified in bladder, trigone, urethra and pubococcygeus muscle of women. Oestrogen pretreatment enhances the contractile response of animal detrusor muscle to alpha-adrenoceptor agonists, cholinomimetics and prostaglandins, as well as enhancing the contractile response to alpha-agonists in ureter and urethra. Progesterone on the other hand decreases tone in the ureter, bladder and urethra by enhancing beta-adrenergic responses. The dependence on oestrogens of the tissues of the lower urinary tract contributes to increased urinary problems in postmenopausal women. Urinary symptoms due to atrophic mucosal changes respond well to oestrogen replacement therapy. However, because they recur when treatment is stopped, continuous therapy with low dose natural oestrogens is recommended. Oestrogens may be of benefit in postmenopausal women with stress incontinence, but the doses necessary for clinical effect are higher than for the treatment of atrophic urethritis. The practice of adding a progestagen to long term oestrogen therapy to reduce the risk of endometrial carcinoma may, however, exacerbate stress incontinence by decreasing urethral pressure. Cyclical therapy with oestrogens may therefore be more appropriate particularly in women who are not suitable for surgery or have a mild degree of stress incontinence, along with other conservative measures such as pelvic floor exercises and alpha-adrenoceptor agonists. The place of oestrogen therapy in motor urge incontinence has not been determined. The risk of developing endometrial carcinoma as a result of long term high dose oestrogen replacement therapy must be borne in mind but remains to be clarified. However, oestriol has less of a uterotrophic effect compared to other oestrogens in standard therapeutic doses and is to be preferred. Side effects are usually dose related and tend not to be a problem with low dose therapy.

The effect of hydroxyprogesterone on ureteral stones

It has been suggested that dilatation of the ureter seen in pregnancy is caused by progesterone. Twenty-four patients with ureteral calculi, therefore, were given an intramuscular injection of 250 mg hydroxyprogesterone in order to facilitate the discharge of the stones. Irrespective of the duration of symptoms there was a potential effect of treatment in up to 66% of the patients. In patients with symptoms of less than three weeks duration the stones were discharged within three weeks after the first symptom in 75% of the cases, which is a much higher incidence rate than that stated in the literature for spontaneous stone discharge (18-30%). In patients with longstanding symptoms 50% of the stones had passed, as compared to 39% reported in the literature. Especially concrements with a diameter larger than 4 mm had a better discharge rate. As the treatment is simple, cheap and without side effects, it seems worthwhile trying it in order to avoid surgery.

Serial quantitative maternal nephrosonography in pregnancy

Real time ultrasound provides a quick, safe and convenient method of examining not only the appearance but also the dimensions of the kidneys and the upper renal tract in pregnant women. Using an on-screen measuring system, the length, width and thickness of the renal and pelvicalyceal outline of both left and right kidney were measured in a non-pregnant control group, and also at regular intervals throughout pregnancy and into the puerperium in a group of healthy primigravid patients. From the results the behaviour of the total renal pelvicalyceal and renal parenchymal volumes can be followed. Furthermore they clearly illustrate the separate and independent influences on the pregnant maternal upper renal tract of urinary stasis, increased renal blood flow, and possibly cellular hypertrophy.

The use of progesterone for ureteral stones: a preliminary report

Two ureteral stone patients were given injections of a progesterone derivative, resulting in prompt passage of the stones. The case reports are presented as well as a discussion of hydronephrosis of pregnancy and hormonal influences on the ureter.

Hydronephrosis of pregnancy

This review was done because most texts and some recent reviews do not recognize the obstructive cause. It is important only because of the high incidence of acute pyelonephritis during pregnancy. This is so common that it has been given a special name, "pyelitis of pregnancy". We have shown in the monkey that bacteria when introduced into the ureter under low pressure does not often cause pyelonephritis unless associated with ureteral obstruction. The presence of bacteria even with partial ureteral obstruction increases the chances of acute pyelonephritis. Care must thus be taken to eradicate bacteriuria during pregnancy to prevent acute pyelonephritis as has been shown by Kass, especially since vesicoureteral reflux occurs more frequently in the pregnant than nonpregnant primate. When we understand the obstructive cause of hydronephrosis of pregnancy and the effect of positional change, therapy will be more effective. The left lateral position then will not only relieve the pain of acute hydronephrosis of pregnancy but will also greatly assist in the therapy of acute pyelonephritis of pregnancy since it will relieve the associated ureteral obstruction.

Pyleonphritis as a side effect of hormonal contraception: an experimental research

In animal experiments it was proved that contraceptives may cause considerable renal changes. It is necessary to call gynecologists' attention to possible side effects; the contrapaceptives are contra-indicated in chronic pyelonephritis.

The findings reported in patients undergoing excretory urography for recurrent urinary tract infection

There was little difference between the proportion of lesions found by excretion urography in patients with recurrent urinary tract infections referred by general practitioners or hospital staff, or between Horton General Hospital which is a district general hospital, and the United Oxford Hospitals, which is a teaching group. Many patients with urinary tract infections may be saved an unnecessary visit to the hospital consultant if this is first investigated by the general practitioner.About one fifth of all patients had significant lesions shown by excretory urography which suggests that the investigation is worthwhile in patients with recurrent urinary tract infections.