WEEK 17: Urological system - History
Upper GU tract=kidneys, renal pelvis and ureter
Lower GU tract=bladder, urethra, prostate, genetalia
Functions: kidney(Ca2+; BP, EPO, H2O balance); bladder(storage+excrete urine); prostate+seminal vesicles(semen);
urethra(urine+ejaculate conduit)
PC: Pain (voiding, loin, abdominal); Lethargy/malaise; Increased micturition; Incontinence; Oedema; SOB; Temp/rigor;
Hyper/hypotension; Discharge(urethra); Proteinuria/haematuria/pyuria; Abnormal blood results (U & E’s); Anorexia
/dimished appetite
Condition
Pain
Lower
urinary tract
symptoms
Symptoms
Pain due to acute inflammation of the bladder or urethra is called dysuria
SOCRATES
Pain may arise from:
1. The kidney (loin pain)
Renal angle (between the 12th rib and the spine) or loin pain is due to stretching of the renal
capsule or renal pelvis. Causes=infection(constant loin pain, with systemic upset, fever, rigors
and pain on voiding suggests infection of the upper urinary tract and kidney (acute
pyelonephritis); inflammation(chronic dull, aching loin discomfort may occur with chronic renal
infection and scarring from vesico-ureteric reflux, adult polycystic kidney disease (APKD) or
chronic urinary tract obstruction) or mechanical obstruction(chronic obstruction may be painfree. Dull, non-localized pain occurs in renal stone disease and some forms of glomerulonephritis,
e.g. IgA nephropathy, and can mimic musculoskeletal conditions).
2. The ureter (ureteric colic) (loin to groin pain)
Caused by acute obstruction with distension of the renal pelvis and ureter by a stone, blood clot
or, rarely, a necrotic renal papilla. The pain is of sudden onset, severe and sustained(colicky), and
may radiate to the iliac fossa, the groin and the genitalia, especially the testis. The patient is
restless and nauseated, and often vomits. Once the obstructing pathology reaches the bladder,
symptoms may resolve.
3. The bladder (suprapubic, constant pain or pain on passing urine - voiding)
Voiding pain (dysuria) is pain during or immediately after passing urine, often described as a
'burning' sensation felt at the urethral meatus or suprapubically and associated with a desire to
pass urine more often (frequency). Boxer short distribution of pain. The most common cause is
infection and/or inflammation of the bladder (cystitis).
4. Prostate
Prostatitis and urethritis produce similar symptoms. Prostatitis causes perineal/rectal pain. Pain
localized to the penis indicates local pathology, such as stricture, stone or, rarely, tumour. Causes
retention of urine.
5. Penile/erectile deformity/testicular
Testicular and epididymal pain may be felt primarily in the groin and lower abdomen. Distinguish
tenderness and swelling of the testis from a strangulated hernia or acute epididymo-orchitis; in
pubertal boys and young men consider torsion of the testis, which is an emergency.
1. Storage symptoms/irritative (females usually eg cystitis) Symptoms are ‘FUN’
 Frequency is increased micturition with no increase in the total urine output
 Urgency is a sudden strong need to pass urine and may cause incontinence if there is no
opportunity to urinate. Urgency is due either to overactivity in the detrusor muscle or abnormal
stretch receptor activity from the bladder
 Nocturia means being wakened at night to void.
Storage symptoms are usually associated with bladder, prostate or urethral problems, e.g. lower
urinary tract infection, tumour, urinary stones or urinary tract obstruction, or are a consequence of
neurological disease
2. Voiding/obstructive phase symptoms (males usually)
 Hesitancy is difficulty or delay in initiating urine flow. In men over 40 this is commonly due to
bladder outlet obstruction by prostatic enlargement. In women these symptoms suggest urethral
obstruction due to stenosis or genital prolapse. Pt normally has slow or intermittent flow, strains
abdominals to increase abdo pressure, has terminal dribbling and may even double void due to
incomplete emptying(try once, then go back five mins later)
3. After micturition (effects of 1 and 2 combined = detrussor problem)
 Dribbling and incomplete emptying are caused by obstruction but, with associated storage
symptoms, indicate abnormalities of detrusor function.
4. Urinary incontinence: points to cover in the history
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Age at onset and frequency of wetting
Ever dry at night? Occurrence during sleep (enuresis)
Number of pads used. Are they damp, wet or soaked?
Any other urinary symptoms
Provocative factors, e.g. coughing, sneezing, exercising (suggest stress-induced incontinence)
Past medical, obstetric and surgical histories
Impact on daily living
 Causes of urinary incontinence: Degenerative brain diseases and stroke; Spinal cord damage;
Neurological diseases, e.g. multiple sclerosis; Pelvic floor weakness following childbirth; Bladder
outlet obstruction; Urinary tract infection; pelvic surgery or radiotherapy;
 Stress – physical activity, coughing, sneezing – increased abdo pressure+effects on bladder
 Urge – bladder spasms = UTI/hyperactive detrussor muscle
 Mixed
 Overflow – dry during day but wet at night
Functional assessment methods of lower urinary tract function
Frequency/volume chart
 Use to monitor micturition patterns, including nocturia, and fluid intake
 The patient collects his/her urine, measures each void, and charts it against time over 3-5 days
Urine flow rate
 The patient voids into a special receptacle that measures the rate of urine passage
 A low flow does not differentiate between poor detrusor contractility and bladder outlet obstruction
– determine using invasive tests and filling studies
Urodynamic tests
 Invasive tests, necessitating insertion of bladder and rectal catheters to measure total bladder
pressure and abdominal pressure and to allow bladder filling
 Filling studies determine detrusor activity and compliance
o Low detrusor pressures with low urine flow suggest detrusor function problems
o High detrusor pressures with a low flow suggest bladder outlet obstruction
Sexual dysfunction
Erectile dysfunction = inability to obtain/maintain erection for satisfactory intercourse(diabetes)
Premature ejaculation = avg time is 3 mins!; may have performance anxiety
Haematuria
CYSTITIS
Dysuria associated urinary frequency, urgency of micturition with occasional 'urge incontinence';
haematuria; these are typical symptoms of lower urinary tract infection
1.
How much/what does it look like: clots/debris/mucus?
Microscopic (detected on urinalysis) is a common feature of renal or urinary tract disease, especially
if associated with proteinuria, hypertension, raised serum creatinine or reduced estimated glomerular
filtration rate (eGFR). It may be a solitary and benign finding if these are all normal.
Small quantities of blood give the urine a 'smoky appearance’
Macroscopic/frank (visible to the naked eye).
Larger quantities make the urine brown or red
2. When:
 start of stream = urethral problem
 entire stream = bladder/UT disease
 end of stream = prostate problem
Haematuria = malignancy until proven otherwise
3. Ass symptoms: pain, fever, trauma, exercise.
Distinguish haematuria from contamination of the urine during menstruation. Confirm haematuria by
urinalysis and urine microscope.
Painless – serious!
 Glomerulonephritis
 Tumours of the kidney(renal carcinoma), ureter, bladder or prostate
 Renal Tuberculosis
 Schistosomiasis(haematobium)
 Hypertensive nephrosclerosis
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Interstitial nephritis (unless very acute/severe)
Acute tubular necrosis
Renal ischaemia (renovascular disease)
Distance running or other severe exercise
Coagulation disorders, anticoagulant therapy
Painful
 Urinary tract infection: severe cystitis ; urethritis;
 Renal stones with obstruction; ureteric stone colic
 Loin pain-haematuria syndrome
May be either
 Urinary tract infection
 Reflux nephropathy and renal scarring
 Adult polycystic kidney disease
 Renal stones without obstruction
Pneumaturia ‘fizzy/bubbles’
Passing gas bubbles in the urine is rare. It may be associated with faecuria, in which faeces are
voided. It suggests a fistula between the bladder and the colon, from a diverticular abscess, cancer or
Crohn's disease.
Gynae
Chronic
renal failure
= CKD
HPC
PAIN
Urine
Proteinuria
Proteinuria is usually asymptomatic and detected by simple urinalysis; it usually indicates kidney
disease. Proteinuria up to 2g/24hrs is non-specific. Values greater than this indicate a glomerular
abnormality, most commonly glomerulonephritis or diabetic nephropathy. Radioimmunoassay
techniques can detect albumin excretion rates as low as 30 mg/day(early diabetic nephropathy).
Proteinuria may occur in normal patients with febrile illness. Proteinuria <1 g/l which disappears when
lying supine (orthostatic proteinuria) is occasionally found in healthy young subjects in whom protein
is not detected in the first urine passed after sleeping recumbent overnight, but is present during the
day.
Severe proteinuria may produce frothy urine. If it lowers the plasma albumin concentration enough to
reduce the plasma oncotic pressure, the patient develops generalized oedema: the nephrotic
syndrome. Causes: Renal disease(Glomerulonephritis; Diabetes mellitus; Amyloidosis; Systemic
lupus erythematosus; Drugs, e.g. gold, penicillamine; Malignancy, e.g. myeloma; Infection); nonrenal disease(Fever; Severe exertion; Severe hypertension; Burns; Heart failure; Orthostatic
proteinuria); Causes of transient proteinuria(Cold exposure; Vigorous exercise; Febrile illness;
Orthostatic proteinuria; Abdominal surgery; Congestive heart failure)
Menstrual discharge, contraception, pregnancy, births (#+mode of delivery)-esp for incontinent
women, previous surgery/radiotherapy(inc risk of PID), smoking(inc risk of bladder cancer),
occupation(rubber, dye, chemicals at hairdressers), inherited renal disease(polycystic kidney disease,
renal stones)
Oliguria, nocturia, polyuria, anorexia/poor appetite, insomnia/sleep disturbance, metallic taste,
vomiting, fatigue, hiccups, SOB, pruritus, bruising, oedema, sallow complexion, uraemic fetor, growth
retardation in children, restless legs particularly at night, muscle twitching due to hypocalcaemia and,
in advanced renal failure, vomiting, diarrhoea, confusion and altered consciousness.
Rationale
SOCRATES
Frequency of micturition must be distinguished from POLYURIA. Causes: Chronic renal failure;
Hyperglycaemia as in DM; Diabetes insipidus; Compulsive water drinking; Excessive caffeine ingestion
Oligouria: a reduction in urinary output is characteristic of acute renal failure.
Anuria: complete cessation of micturition usually suggests obstruction of both kidneys or the bladder
outflow
Volume, frequency, odour
Appearance Due to hydration status, medications, bilirubin levels, foods
Orange-brown
 Conjugated bilirubin
 Rhubarb, senna
 Concentrated normal urine, e.g. very low fluid intake
Red-brown
 Blood, myoglobin(rhabdomyolysis), free haemoglobin(haemolysis), porphyrins
 Beetroot(beeturia), blackberries
 Drugs: rifampicin, metronidazole, warfarin
Brown-black
 Conjugated bilirubin
 Drugs: L-dopa
 Homogentisic acid (in alkaptonuria or ochronosis)
Blue-green
 Drugs/dyes, e.g. propofol, fluorescein
Yellow and stingy
 Asparagus
Past Medical History
Any similar problems in the past?
Recurrent UTIs as a child / adult?
Strepto. throat infection/ tonsillitis?
Vascular disease?
Systemic illness? (SLE, RA, cancer)
Prolonged labour/ Caesarian section
Pelvic inflammatory disease (PID)
JADE
TAB
MARCH
Thyroid
Rationale
Renal calculi(stones); onset & duration
Recurrent infections (particularly urinary - associated with renal scarring
URTIs associated with glomerulonephritis and/or vasculitis)
Vascular disease at other sites (which makes renovascular disease more
likely); anaemia
Sexual history (as necessary), menarche, menstruation
Diabetes mellitus (associated with diabetic nephropathy and renovascular
disease)
Hypertension(may cause/result from renal disease)
Drug History
ALLERGIES (response)
Nephrotoxic drugs (anti-hypertensives/
antibiotics include(affect renal function):
 Aminogycosides(amphotericin,
lithium, tacrolimus)
 Cyclosporins
 NSAIDs(paracetamol overdose)
 Frusemide
 Ace inhibitors
 Penicillamine
 Gold
Accumulate in renal failure
Rationale
Iodine
Current medication N.B. certain medication/food can affect the colour of
urine e.g. rifamipicin, beetroot.
ACE-I, angiotensin receptor antagonists and NSAIDS do not affect
normal kidneys, but reduce glomerular filtration when the kidneys are
underperfused.
Digoxin, lithium, aminoglycosides, opioids and water-soluble β-blockers,
e.g. atenolol.
Insulin
Ensure compliance if diabetic? Hyperglycaemia ass with CKD
OTC medications
OTC NSAIDs can dramatically reduce renal function in systemic
infection or hypovolaemia.
Homeopathic remedies
Indirectly cause renal failure: eg rhabdomyolysis and myoglobinuria
cause acute renal failure in intravenous drug users.
Renal failure affects drug metabolism and pharmacokinetics, and drugs may affect renal function or
damage the kidneys.
‘SADOO’
Social History
Rationale
Occupation (exposure Living and working in hot conditions with more concentrated urine may increase renal
toxins, lead,
stones. Exposure to organic solvents may cause glomerulonephritis. Aniline dye and rubber
hydrocarbons)
workers have an increased incidence of urothelial cancer. Long-term exposure to lead and
cadmium may cause chronic renal damage.
Alcohol (units)
Excess alcohol consumption is associated with hypertensive renal damage and increased
incidence of IgA nephropathy.
Smoker (pack years)
Atheromatous renal vascular disease; nephropathy in diabetic patients; urothelial cancers.
Recreational drugs
Diet & exercise
Take a dietary history in patients with renal stones: intake of water, calcium, e.g. milk and
dairy products, and oxalate(plant based food), e.g. chocolate(cocoa), rhubarb, spinach and
soya. Assess dietary protein intake in patients with chronic renal failure. Ask about sodium
intake in patients with hypertension and renal disease.
Sexual practices, overseas travel, housing, spouse/dependents
Kidney stones: predisposing factors
Environmental and dietary
 Low urine volumes: high ambient temperature, low fluid intake
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Diet: high protein intake, high sodium, low calcium
High sodium excretion
High oxalate excretion; metal ions (Ca2+) bind and form stones
High urate excretion
Low citrate excretion
Other medical conditions
 Hypercalcaemia of any cause
 Ileal disease or resection (leads to increased oxalate absorption and urinary excretion)
 Renal tubular acidosis type I (distal), e.g. in Sjögren's syndrome
Congenital and inherited conditions
 Familial hypercalciuria
 Medullary sponge kidney
 Cystinuria
 Renal tubular acidosis type I (distal)
 Primary hyperoxaluria
Family History
Autosomal dominant Polycystic Kidney
Disease (APKD)
Alport’s syndrome (x-linked)
Renal Disease
Hypertension
Diabetes
Parents/siblings alive & well?
Rationale
Associated with subarachnoid haemorrhage from intracranial berry
aneurysms
Associated with high-tone sensineural deafness
Familial predisposing factors e.g. hypertension, polycystic kidney
disease.
Some pts with T1DM have inc risk to diabetic nephropathy
Example case
History & Examination of a patient with Urological Disease
Case
Presenting
complaint
Students:
PAINFUL HAEMATURIA (right ureteric calculus)
Paul Hamilton, a 37-year-old man, presents as an emergency to the A&E dept at SJUH with a
history of right-sided abdominal pain and the passage of bloodstained urine.
How do you approach this?
You should concentrate on the history of the presenting complaint: nature of pain, haematuria.
Associated features. The characteristics are:
- the pain is colicky, starting in the right renal angle and radiating round into the groin
- it is severe, and the patient finds it impossible to find a comfortable position
- it comes in waves and is associated with nausea
- the urine is tinged pink in colour
- there is no pain on passing urine itself
- the patient has no history of previous urinary tract symptoms and has been fit and well in the past
PMH
-
nil of note
family history
-
nil of note
drug history
-
nil of note
allergies
-
?penicillin rash in the past
review of
systems
-
CVS: no specific features
RS: no specific features
GIT: no specific features
GU: no specific features
CNS: no specific features
Locomotor: no specific features
social history
- foundry worker
- alcohol: 20-30 units per week
- smoking: none
Comment:
This is a fairly classic history of right-sided renal colic. You should appreciate the type of
pain seen with renal colic, and the fact that as the kidneys are paired organs the colic is felt
not in the mid line as with intestinal colic but on either the right or left side of the abdomen.
Features on examination
- the patient would be in pain and obviously distressed
- the abdomen would be tense but there would be no other specific signs.
Specific examination features for students to practise:
general abdominal examination
palpation of kidneys
palpation of bladder
urinalysis
inspection of urological X-rays (KUB, IVU)
MSU results
Below is a list of the common symptoms of urological disorders. Tick when you are confident you can
recognise a pt’s description of them. In addition, give one example of a condition which may present with
this symptom.
Incontinence
Urinary frequency
Polyuria
Haematuria
Dysuria
Acute retention
Loin pain
Testicular pain/swelling
Give 3 examples of drugs used in treatment of the following:
glomerulonephritis
urinary incontinence
List 4 risk factors for urological disorders (if necessary indicating for which condition risk applies):
1
2
3
4
WEEK 17: Urological system - Examination
Physical examination may be normal even with significant kidney disease.
Macleod’s describes CV exam, RS+CNS exam
45° with a pillow
CKD=drowsy, oedematous, fistula(dialysis), anaemia, bruising/scratches, Terry’s nails(brown)
General Inspection
Examine
Is the patient in any discomfort/pain?
Colour: unhealthy pale/yellow
Bruising/scatchmarks/pigmentation?
Pallor/SOB
Level of consciousness/drowsy
Bedside clues(a-v fistula for dialysis,
sputum pot, IVI)
General drug effects
Performed/Identified
Sallow appearance/uraemic complexion in CKD
CKD
CKD
Arteriovenous(a-v) fistula at wrist or elbow for vascular access for
haemodialysis
Cushingoid appearance(steroids); hirtuism(cyclosporin); warts and skin
cancer(immunosupression in pts with renal transplant)
Hands
Check for:
Terry’s nails(brown nail pigmentation; leukonychia;
Muehrcke’s nails(band-like pale discolourations);
Beau’s line(transverse grooves on nail plate)
Capillary refill time
Cyanosis
Palmar creases
Hydration – skin turgor
Splinter haemorrhages
Temperature
Pitting oedema
Asterixis(hand flap)
Performed/Identified
Chronic hypoalbuinaemia
Good circulation – anaemic/hypotensive?
Anaemia
Rule out liver problem if pt sallow appearance(yellowish)
Arms & Neck
Examine
Performed/Identified
Pulse rate, rhythm and volume
Blood pressure and respiratory rate
Inc RR(+deep sighing ‘Kussmaul respiration’) in metabolic acidosis
Palpate lymph nodes
JVP
Don’t measure pulse/BP on arm with av fistula
Face & Eyes
Examine
Colour: Jaundice
Conjuncitva
Corneal Arcus, Xanthelasma
Central cyanosis
Hydration – eyeball tone
Pitting oedema
Halitosis
Mouth ulcers
Fungal infections
Chest
Examine
Palpate apex beat; auscultate
midsystolic flow murmur, 3rd and
4th heart sounds, pericardial
friction rub/ basal lung crackles
Abdomen
Performed/Identified
Pallor indicates anaemia
Hypercholestraemia – RF for atherosclerosis
Uraemic fetor
Performed/Identified
In nephritic syndrome, oedema is present but normal JVP and heart sounds; raised
JVP and low BP in end-stage renal failure; apex beat is displaced in fluid overload
and heart failure; flow murmurs are common in pts with ‘renal’ anaemia; basal lung
crackles(fluid overload/nephrotic syndrome)
Inspection
Symmetry & Shape
Obvious lumps, swellings or distension
Surgical scars(loin scar on back/iliac
fossae; suprapubic/in skin fold: bladder)
Striae
Urostomy
Peritoneal Dialysis Catheter
Palpation
9 areas of abdomen
Kidneys
Performed/Identified
Enlarged kidneys of polycystic kidney disease; gross bladder distension
causes suprapubic swelling
Transplant surgery
Small scars present midline or in the hypochondrium
Performed/Identified
Distended bladder is a smooth firm mass arising from the pelvis; polycystic kidneys
have a nodular surface
Normal kidney palpable in thin individuals (the right kidney is usually easier to feel
than the left).
Enlarges downwards (spleen enlarges to RIF)
Edge usually rounded ( not as sharp as liver or spleen ).
Moves late on inspiration.
Palpable bi – manually (the right hand is placed anteriorly in the lumbar region and
the left hand is placed posteriorly in the loin; palpate when pt is breathing in; easier
to feel the right kidney as it liees lower than the left).State size, surface, consistency
Bladder
Loin tenderness
MAY BE ABLE TO GET ABOVE IT
Resonant to percussion ( the ascending and descending colon is fixed and often it
is gas filled. It is anterior to the kidney and thus a renal mass may give a resonant
note on percussion because of this).
Both kidneys may be enlarged: Polycystic kidney disease(nodular and irregular);
amyloidosis; acute glomerulonephritis; tumour or infiltration(firm and irregular);
One kidney may be enlarged because of compensatory hypertrophy due to renal
agenesis, hypoplasia or atrophy, or surgical removal of the other kidney. It may also
be due to renal tumour or hydronephrosis.
Normal bladder is not palpable
A distended bladder as in urinary retention : a smooth, often tender swelling ( oval
shaped ) palpable suprapubically -> dome may reach the umbilicus
lateral and upper border -> easily defined
cannot get below it(can’t define lower border) -> ‘arises from the pelvis’
symmetrical and central
dull to percussion
swelling disappears on catheterisation
Causes of enlargment: pregnant uterus, fibroid uterus, ovarian cyst.
Ask pt to sit up; strike renal angle with ulnar aspect of fist to test for tenderness after
warning them. Most commonly due to acute pyelonephritis or acute urinary
obstruction
Lymph nodes
Percussion
Bladder
Loin percussion tenderness
Shifting dullness
Auscultation
Renal arteries
Performed/Identified
Percuss over a resonant area in upper abdomen in the midline and then down
towards the pubic symphysis. A change to a dull percussion indicates the upper
border of the bladder
Test for ascites(nephritic syndrome or pts with peritoneal dialysis)
Performed/Identified
Auscultate over posterior loins and in the epigastrum using the diaphragm of the
stethoscope for bruits (increases risk of co-existent atheromatous renal artery disease)
Genitailia
Inspection
Performed/Identified
Skin changes e.g. Redness, ulceration
Swelling, pitting oedema
Stress incontinence (cough)
In males – ask adults to retract their foreskin. Do so in children
Palpation
Performed/Identified
Penis
Scrotum
Testicles
In females if suspect malignant disease of pelvis, ureters or bladder
Palpation
Performed/Identified
Vaginal examination (VE)
Nervous system examination: test sensation and tendon reflexes(peripheral neuropathy occurs in chronic renal
failure) and optic fundi(retinal infarcts are seen in severe vasculitis or SLE; retinopathy in diabetes mellitus)
Completing The Examination
Examine
Rectal examination of prostate
Urinalysis
Performed/Identified
Specific examination features for you to practise:
general abdominal examination
palpation of kidneys
palpation of bladder
external genitalia
urinalysis
inspection of urological X-rays (KUB, IVU)
MSU results
I have seen and read about the following conditions and can identify the common symptoms and signs
seen
read about
give one common symptom and sign
prostatic hypertrophy
prostatic carcinoma
renal carcinoma
bladder tumour
urinary tract stones
acute renal failure
chronic renal failure
urinary incontinence
testicular torsion
testicular cancer
epididymo-orchitis
I have seen or heard described the following signs or symptoms and can distinguish the most common
causes
seen
read about
haematuria
Polyuria
acute urinary retention
loin pain
nocturia
give one common cause