Urinothorax | |
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Right sided pleural effusion caused by urinothorax | |
Specialty | Pulmonology |
Symptoms | Similar to pleural effusion |
Usual onset | Hours after triggering condition onset |
Causes | Obstructive uropathy, trauma |
Treatment | Treating the underlying condition |
Prognosis | Good |
Frequency | Extremely rare |
Urinothorax (pl. urinothoraces) is defined as urine in the fluid-filled cavity that surrounds the lungs. [1] It is usually caused by obstructive uropathy. It is mainly diagnosed by analyzing the pleural fluid. Treatment involves treating the underlying condition, which typically results in resolution of the urinothorax. It is an extremely rare cause of pleural effusion. [2]
The characteristics of people affected by urinothorax are poorly defined. Urological symptoms tend to occur, while the respiratory symptoms are typically nonexistent or mild. [3] Difficulty breathing, occurring in moderate to large pleural effusions, is the most common respiratory symptom. [4] Other symptoms include fever, abdominal pain, chest pain, and reduced urination. [3] It typically occurs within hours of the causative condition. [5]
Urinothorax is usually caused by obstructive uropathy. The obstructive uropathy may be at the urinary bladder or urethral level. [6] Obstructive causes have been caused by prostate disease, kidney cyst, retroperitoneal fibrosis, and supernumerary kidney. [3] Traumatic cases tend to occur on one side, while obstructive cases tend to be bilateral. [2] In cases caused by urinoma, the urinothorax is usually on the same side of it. Rarely, it can be on both sides or on the opposite side of the urinoma. [7] It can also be caused by renal biopsy, kidney transplantation, lithotripsy, failed tube nephrostomy, or cancer of the urinary tract. [6]
Injury to the urinary tract can result in collections of fluid known as a urinoma. [4] It has the smell of normal urine. [5] The urine arrives in the pleural space either retroperitoneally (under the peritoneum), or via the retroperitoneal lymphatics. [8] Urine can reach the pleural space either directly or indirectly. It can reach directly, by going through pores in the thoracic diaphragm due to a pressure gradient, or by a rupture of a urinoma releasing the contents into the pleural space. [4] It can also reach indirectly, when a urinoma drains into the pleural space via linkage between the lymphatics of the retroperitoneal and pleural regions. [4]
Due to the main symptoms typically being urological rather than respiratory, the condition requires exclusion of other conditions and the identification of specific symptoms before diagnosis. [7] Pleural fluid analysis is one way to diagnose the condition. The pleural fluid is most often straw-colored, and it has a distinct smell like ammonia. The fluid usually has a nucleated cell count between 50 and 1500 per cm3. [4] The pH of the fluid is usually between 5 and 7. [9] Primary factors for diagnosing urinothorax by pleural fluid include low protein and high lactate dehydrogenase content. [10] Low glucose levels and acidity are also described, but are not reliable ways to diagnose or rule out urinothorax. [2] The most important chemical diagnostic factor of the fluid is that the ratio of creatinine to serum is more than 1 and usually more than 10. [10]
Abdominal ultrasonography and CT scan can help diagnose the underlying condition of the genitourinary tract. If other methods prove inconclusive, an accurate diagnosis can be made by a technetium-99m kidney scan, which shows albumin labeled with 99Tc that translocates into the pleural space from the genitourinary tract. [4]
Treatment mainly consists of treating the underlying disorder of the genitourinary tract. [2] It requires a multidisciplinary team that includes a pulmonologist and urologist. A nephrostomy tube or Foley catheter can be used to relieve any underlying obstruction. Any injuries are repaired. [11] When the underlying disorder is addressed, the urinothorax rapidly resolves. Thoracic surgery is usually not needed, [4] especially if respiratory symptoms are minimal or nonexistent. [2] Pleurodesis is also ineffective. [11] A chest tube can be used to drain urine from the pleural cavity. [12]
Urinothoraces typically resolve spontaneously without recurring after the underlying urinary tract disorder is treated. [11]
Urinothorax remains a rare, possibly under-diagnosed, differential in the case of transudative pleural effusion. There were only 58 reported cases up until January 2006. In the literature, there are under 100 reported cases. [8]
The pleural cavity, pleural space, or interpleural space is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enable lubrication between the membranes, and also to create a pressure gradient.
Nephrotic syndrome is a collection of symptoms due to kidney damage. This includes protein in the urine, low blood albumin levels, high blood lipids, and significant swelling. Other symptoms may include weight gain, feeling tired, and foamy urine. Complications may include blood clots, infections, and high blood pressure.
Pleurisy, also known as pleuritis, is inflammation of the membranes that surround the lungs and line the chest cavity (pleurae). This can result in a sharp chest pain while breathing. Occasionally the pain may be a constant dull ache. Other symptoms may include shortness of breath, cough, fever, or weight loss, depending on the underlying cause. Pleurisy can be caused by a variety of conditions, including viral or bacterial infections, autoimmune disorders, and pulmonary embolism.
A pleural effusion is accumulation of excessive fluid in the pleural space, the potential space that surrounds each lung. Under normal conditions, pleural fluid is secreted by the parietal pleural capillaries at a rate of 0.6 millilitre per kilogram weight per hour, and is cleared by lymphatic absorption leaving behind only 5–15 millilitres of fluid, which helps to maintain a functional vacuum between the parietal and visceral pleurae. Excess fluid within the pleural space can impair inspiration by upsetting the functional vacuum and hydrostatically increasing the resistance against lung expansion, resulting in a fully or partially collapsed lung.
Acute kidney injury (AKI), previously called acute renal failure (ARF), is a sudden decrease in kidney function that develops within 7 days, as shown by an increase in serum creatinine or a decrease in urine output, or both.
Atelectasis is the partial collapse or closure of a lung resulting in reduced or absent gas exchange. It is usually unilateral, affecting part or all of one lung. It is a condition where the alveoli are deflated down to little or no volume, as distinct from pulmonary consolidation, in which they are filled with liquid. It is often referred to informally as a collapsed lung, although more accurately it usually involves only a partial collapse, and that ambiguous term is also informally used for a fully collapsed lung caused by a pneumothorax.
Hydronephrosis describes hydrostatic dilation of the renal pelvis and calyces as a result of obstruction to urine flow downstream. Alternatively, hydroureter describes the dilation of the ureter, and hydronephroureter describes the dilation of the entire upper urinary tract.
A hemothorax is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may include reduced breath sounds on the affected side and a rapid heart rate. Hemothoraces are usually caused by an injury, but they may occur spontaneously due to cancer invading the pleural cavity, as a result of a blood clotting disorder, as an unusual manifestation of endometriosis, in response to Pneumothorax, or rarely in association with other conditions.
A chylothorax is an abnormal accumulation of chyle, a type of lipid-rich lymph, in the space surrounding the lung. The lymphatics of the digestive system normally returns lipids absorbed from the small bowel via the thoracic duct, which ascends behind the esophagus to drain into the left brachiocephalic vein. If normal thoracic duct drainage is disrupted, either due to obstruction or rupture, chyle can leak and accumulate within the negative-pressured pleural space. In people on a normal diet, this fluid collection can sometimes be identified by its turbid, milky white appearance, since chyle contains emulsified triglycerides.
Respiratory diseases, or lung diseases, are pathological conditions affecting the organs and tissues that make gas exchange difficult in air-breathing animals. They include conditions of the respiratory tract including the trachea, bronchi, bronchioles, alveoli, pleurae, pleural cavity, the nerves and muscles of respiration. Respiratory diseases range from mild and self-limiting, such as the common cold, influenza, and pharyngitis to life-threatening diseases such as bacterial pneumonia, pulmonary embolism, tuberculosis, acute asthma, lung cancer, and severe acute respiratory syndromes, such as COVID-19. Respiratory diseases can be classified in many different ways, including by the organ or tissue involved, by the type and pattern of associated signs and symptoms, or by the cause of the disease.
A nephrostomy or percutaneous nephrostomy is an artificial opening created between the kidney and the skin which allows for the urinary diversion directly from the upper part of the urinary system. It is an interventional radiology/surgical procedure in which the renal pelvis is punctured whilst using imaging as guidance. Images are obtained once an antegrade pyelogram, with a fine needle, has been performed. A nephrostomy tube may then be placed to allow drainage.
Feline lower urinary tract disease (FLUTD) is a generic category term to describe any disorder affecting the bladder or urethra of cats.
Frequent urination, or urinary frequency, is the need to urinate more often than usual. Diuretics are medications that increase urinary frequency. Nocturia is the need of frequent urination at night. The most common cause of this condition for women and children is a urinary tract infection. The most common cause of urinary frequency in older men is an enlarged prostate.
Lymphangiomatosis is a condition where a lymphangioma is not present in a single localised mass, but in a widespread or multifocal manner. It is a rare type of tumor which results from an abnormal development of the lymphatic system.
Reflux nephropathy is kidney damage (nephropathy) due to urine flowing backward (reflux) from the bladder toward the kidneys; the latter is called vesicoureteral reflux (VUR). Longstanding VUR can result in small and scarred kidneys during the first five years of life in affected children. The end results of reflux nephropathy can include high blood pressure, excessive protein loss in the urine, and eventually kidney failure.
Malignant pleural effusion is a condition in which cancer causes an abnormal amount of fluid to collect between the thin layers of tissue (pleura) lining the outside of the lung and the wall of the chest cavity. Lung cancer and breast cancer account for about 50-65% of malignant pleural effusions. Other common causes include pleural mesothelioma and lymphoma.
Obstructive shock is one of the four types of shock, caused by a physical obstruction in the flow of blood. Obstruction can occur at the level of the great vessels or the heart itself. Causes include pulmonary embolism, cardiac tamponade, and tension pneumothorax. These are all life-threatening. Symptoms may include shortness of breath, weakness, or altered mental status. Low blood pressure and tachycardia are often seen in shock. Other symptoms depend on the underlying cause.
Fibrothorax is a medical condition characterised by severe scarring (fibrosis) and fusion of the layers of the pleural space surrounding the lungs resulting in decreased movement of the lung and ribcage. The main symptom of fibrothorax is shortness of breath. There also may be recurrent fluid collections surrounding the lungs. Fibrothorax may occur as a complication of many diseases, including infection of the pleural space known as an empyema or bleeding into the pleural space known as a haemothorax.
Bladder outlet obstruction occurs when urine is unable to flow from the kidneys through the ureters and out of the bladder through the urethra. Decreased flow of urine leads to swelling of the urinary tract, called hydronephrosis. This process of decreased flow of urine through the urinary tract can begin as early as during intrauterine life and it prevents normal development of fetal kidneys and fetal urine. Low levels of fetal urine leads to low amniotic fluid levels and incomplete lung maturation. Older children and adults can also experience bladder outlet obstruction; however, this process is usually reversible and isn't associated with as many poor outcomes as in infants with congenital bladder outlet obstruction.
Hepatic hydrothorax is a rare form of pleural effusion that occurs in people with liver cirrhosis. It is defined as an effusion of over 500 mL in people with liver cirrhosis that is not caused by heart, lung, or pleural disease. It is found in 5–10% of people with liver cirrhosis and 2–3% of people with pleural effusions. It is much more common on the right side, with 85% of cases occurring on the right, 13% on the left, and 2% on both. Although it is most common in people with severe ascites, it can also occur in people with mild or no ascites. Symptoms are not specific and mostly involve the respiratory system.