Approach to - If a unilateral hydronephrosis is detected, USG should be repeated after 3-7 days when dilatation becomes more evident.
- If ureter is dilated - MCU should be done to detect VUR.
- If ureter is not seen- Tc99DTPA renal scan with diuretic renography should be done to detect PUJ obstruction and its severity so that surgery is planned.
Approach to Bilateral mild to moderate Same as above + S.creatine/BUN to diagnose renal insufficiency
Aims of systematic evaluation of hydronephrosis is to detect obstructive lesions which may require surgery in asymptomatic stage to prevent progressive renal damage for e.g.
- Recurrent UTI leading to reflux nephropathy and CRF;
- Obstructive nephropathy leading to CRF / ESRD, hypertension, growth failure, anemia and urolithiasis.
Indications of PUJ obstruction
surgery in HDN
At initial diagnosis:
* Symptomatic HDN (UTI, renal mass, growth failure),
* Solitary kidney with impaired function,
* Bilateral severe HDN
* Relative renal function of obstructive kidney <30%.
On follow up:
* 10% decline in relative renal function on DTPA renal scan when repeated after 6-12 weeks
* Increasing HDN
* Post urethral valves, ureteroceles
* VUR Grade IV-V persisting beyond infancy
* New renal scars or recurrent UTI despite antibiotic prophylaxis
In asymptomatic HDN or HDN which is mild to moderate and stable after USG within 3-7 days, with no obstruction (Hydronephrosis due to ?VUR)
Management of Hydronephrosis
- Antibiotic prophylaxis (amoxycillin /cephalexin for 3 months and then oral cotrimoxazole / nitrofurantoin single night dose for 6 months - 2 years to prevent UTI.
- Urine cultures may be necessary if fever occurs.
- Diuretic renography, MCU are recommended at 1-2 months after antibiotics
- USG after a year.
If VUR is detected,
- DMSA renal scan to detect renal scars
- Surgery may needed if scars are present or there is presence of Grade IV-V VUR.
- Repeat MCU/diuretic venography at 2 years to decide about resolution of VUR.
- DMSA renal scan should be done every 2-3 yearly if scars are persistent or to detect presence of new scars.
- BP; growth monitoring; S. Creatine / BUN, USG should be done yearly till 15-20 years.