Hydronephrosis and Ureteral Obstruction in Crohn’s Disease

doi:10.4236/oju.2013.35041

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Open Journal of Urology, 2013, 3, 219-221

http://dx.doi.org/10.4236/oju.2013.35041 Published Online September 2013 (http://www.scirp.org/journal/oju)

Hydronephrosis and Ureteral Obstruction in Crohn’s

Disease*

Robert Jansen, Stanley Zaslau#

Division of Urology, West Virginia University, Morgantown, USA

Email: #[email protected]

Received August 2, 2013; revised September 1, 2013; accepted September 8, 2013

License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Hydronephrosis and ureteral obstruction are rare sequelae of Crohn’s disease. Chronic obstruction can ultimately lead to

dysfunction of the affected kidney, and atypical presenting symptoms create pitfalls in diagnosis. Few reviews in the

literature focus on this process and are limited to isolated case reports and case reviews. We performed a PubMed

search using such terms as “Hydronephrosis” AND “Crohn’s disease” AND/OR “ureteral obstruction”. References

from selected papers were reviewed for relevance and used for information-gathering as well. Ureteral obstruction most

commonly occurs on the right side, due to ileal involvement. Clinical diagnosis is difficult, as symptoms are no tably no t

genitourinary in origin; rather they are more musculoskeletal in nature. Treatment centers on disease control and tem-

porary drainage of the affected kidney. Though rare, hydronephrosis and ureteral obstruction may develop as a result of

inflammatory bowel disease. Due to atyp ical presenting symptoms, a high clinical susp icion is needed to affirm the di-

agnosis and ensure proper treatment.

Keywords: Hydronephrosis; Ureteral Obstruction; Crohn’s Disease

1. Background/Etiology

First described by Hyams et al. in 1943, ureteral obstruc-

tion is a rare but clinically si gn ificant sequella o f Cro hn ’s

disease [1]. As the pathophysiology of Crohn’s disease

involves inflammation, fistulas, local abscess formation,

and fibrosis, obstructive hydronephrosis can occur if any

of these processes involve areas of the bowel adjacent to

the ureters. Hydronephrosis occurs most commonly on

the right side via involvement of the terminal ileum; as

other areas of the bowel may be affected including the

sigmoid colon, in rare cases obstruction may be seen on

the left side. Obstruction usually occurs at the level of the

linea terminalis. The incidence of ureteral obstruction is

difficult to ascertain, as much of the literature focuses on

isolated case reports and case reviews; the reported inci-

dence is 0.3% - 25% [2-5]. At presentation, patients are

usually in the 3rd decade of life [6-8] and though Ben-

Ami and Block report 5.6 years and 3.9 years respec-

tively with Crohn’s disease prior to diagnosis, others

have reported patients presenting as long as 22.6 years

after initial Crohn’s diagnosis [3,6-8].

2. Pathophysiology

Ureteric compression occurs due to development of a

phlegmon with subsequent inflammation and retroperi-

toneal fibrosis. Presence of abscess or fistula in the ante-

rior retroperitoneal compartment has been implicated in

ureteral obstruction and at times, a dense cicatrix encas-

ing the ureter may arise at well [8,9]. Obstruction is usu-

ally noted at the level of the linea terminalis or SI joint

[2,6,7,10-12]. Most commonly, hydronephrosis will oc-

cur on the right side due to enteritis of th e terminal ileum

and the location of the right ureter posterior to th e termi-

nal ileum. Left-sided hydronephrosis occurs with sig-

moid colon o r je jun al involv ement and as such, the ureter

may be obstructed more proximally with jejunal disease.

One case report describes left ureteral obstruction arising

due to a right lower quadrant mass; the mass was associ-

ated with a fistulous tract extending through the root of

the mesentery to the left retroperitoneal sp ace [13].

3. Diagnosis

Surprisingly, urinary symptoms are quite rare in cases of

Crohn’s-related ureteral obstruction. Present reported

on l y 1 of 10 patients experiencing irritative void i n g s y mp-

toms, while other authors report a complete absence of

*No conflicts of interest or financial disclosures to report.

#Corresponding author.

R. JANSEN, S. ZASLAU

220

urinary complaints in their respective series [8.13 ]. Com-

mon physical findings reported by many include flank

pain, hip pain, or anterior thigh pain resulting in diffi-

culty walking [7-8,12-13]. Abdominal, vaginal, or rectal

examination may reveal the presence of a mass in the

right or left lower abdo minal quadrants [8].

Computed tomography allows for full visualization of

any conglomerate mass in relationship to the level of ure-

teral obstruction, though bowel wall thickening and in-

flammation may be the only signs of direct involvement.

Intravenous pyelography will show hydronephrosis with

tapering of the affected ureter, usually at the level of the

pelvic brim. Medial deviation of the ureter is sometimes

seen as well [13].

One would suspect that ureteral involvement with

Crohn’s disease would lead to urinary tract infections;

however this is certainly not commonplace. In a series of

27 patients by Block et al., only 15 had grossly abnormal

urinary sediment on routine examination; 12 patients had

normal urinalyses and 21 patients had sterile urine cul-

tures [8]. Should a urinary tract infection arise, E. coli is

the most common pathogen, with Pseudomonas aerugi-

nosa, Streptococcus faecalis, Aerobacter aerogenes, En-

terococci, and Klebsiella implicated as well [8].

4. Treatment

A primary goal in the treatment of Crohn’s-related ure-

teral obstruction is drainage of the affected kidney to

prevent the deterioration of renal function. The table be-

low demonstrates available minimally invasive treatment

options for ureteral obstruction related to Crohn’s Dis-

ease. The indwelling ureteral stent can be placed cysto-

scopically to allow for the maintenance of ureteral pa-

tency and drainage of the kidney. While traditional stents

require changes every 3 - 4 months, long-term stents can

also be considered. Typical stents placed for patients

with Crohn’s disease are 6 French in diameter. However,

in our experience, placement of more flexible 4.7 French

stents may be associated with reduced flank and pelvic

pain. For patients who do not tolerate ureteral stents due

to pain or there is significant ureteral stricture that pro-

hibits stent placement, percutaneous nephrostomy tube

drainage may be considered. Drainage via an 8 French to

12 French nephrostomy tube provides excellent renal

drainage. Typically placed by interventional radiology

and changed every 3 to 4 month s, this drainage modality

is associated with less pelvic pain. However, patients

sometimes find the percutaneous flank drainage bags to

be cumbersome. Some situation s mitigate placement of a

percutaneous nephrostomy tube with a universal stent of

the ureter. This form of renal drainage allows both renal

drainage and the maintenance of ureteral patency. Used

rarely in our practice, these stents can be considered for

patients with hydronephrosis and significant intraperito-

neal inflammation that is causing retroperitoneal com-

pression with subsequent inflammation.

Table 1: Minimally invasive treatment options for ure-

teral obstruction:

 Indwelling ureteral stent

 Percutaneous nephrostomy

 Percutaneous nephrostomy with universal stent of the

ureter

Along with renal drainage, mild cases of Crohn’s dis-

ease with subsequent obstruction have successfully been

treated medically, while more moderate to severe cases

will require surgical intervention. “Pulse therapy” with

corticosteroids, in conjunction with mesalamine and re-

nal drainage, proved successful in 4 patients on whom

Ben-Ami et al. reported in two different studies [3,14].

Angelberger et al. reported success with one patient in

his series who had a milder form of Crohn’s disease than

the others in his cohort [6]. While there is a paucity of

data on the newer immunostimulatory and immunomo-

dulatory agen ts used for the management of Crohn’s d is-

ease with ureteral obstruction, we postulate that similar

improvements in the degree of hydronephrosis and renal

obstruction will be observed. We postulate that the im-

provements in obstruction may be quicker with the in-

travenous forms of the newer immunostimulatory and

immunomodulatory agents.

A surgical approach involves resection or bypass of

the affected bowel with or without ureterolysis. Bowel

resection with primary reanastamosis is commonly per-

formed and the preferred method of treatment, however

in severe cases in which it is deemed too difficult to ex-

tricate the bowel without injuring the ureter, temporary

bypass may be performed with later resection of the af-

fected segment [6-9]. Ureterolysis can be reserved for the

presence of a dense cicatrix encasing the ureter, however

success rates vary and the ultimate need for ureterolysis

is debatable [8,15]. Ureterolysis as a sole modality for

the treatment of ureteral obstruction is unlikely to be suc-

cessful when performed as a monotherapy. It will most

likely be successful when combined with primary medi-

cal therapy for Crohn’s disease or if medical disease re-

mission can be induced prior to ureterolysis. Good me-

thods to follow the relative presence of inflammatory

disease include immune markers such as C-reactive pro-

tein and the erythrocyte sedimentation rate. Ureterolysis

or any other surgical intervention is likely to be most

Table 1. Minimally invasive treatment options for ureteral

obstruction.

Indwelling ureteral stent

Percutaneous nephrostomy

Percutaneous nephrostomy with universal stent of the ureter

R. JANSEN, S. ZASLAU

221

successful when inflammatory markers are at their lowest

levels and preferably in the normal range.

Following bowel resection, decompression of the ure-

ter may be seen via intravenous pyelogr aphy as early as 7

or 8 days postoperatively [7,8]. Success rates approach

100% [3,8], though occasionally prolonged dilation of

the ureter and kidney occurs [7].

5. Conclusion

While hydronephrosis and ureteral obstruction are rare

sequelae of Crohn’s disease, chronic obstruction can ul-

timately lead to dysfunction of the affected kidney, and

atypical presenting symptoms create pitfalls in diagnosis.

Consideration of these problems by the treating medical

team as well as early identificati on of obstructi on may pre-

serve renal function. Minimally invasive treatments of

ureteral obstruction include uret eral stents while more sig-

nificant cases of obstruction may require ureterolysis. The

best treatment modalities for ureteral obstruction will in-

volve m axim i zati on of m edi cal t hera py fo r t he u nde rly ing

bowel disease and selection of the appropriate urinary

drainage method for obstruction that will cause the patient

the least amount of morbidity.

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