URINARY SX
(Linda Costarella)
A. pain
1. nerve supply
a. kidneys
-ANS from vagus and T6 - L3 afferents
b. ureters
-lower part: S2-S4, upper: T11-L2
c. bladder
-S2-4; autonomics from sacral plexus
2. renal pain
-visceral pain, coliky, dull, can referred to other areas; usually felt in back or flanks ; costovertebral
tenderness when positive it hurts a lot
3. ureter pain
-radiate thigh, lower abdomen, testes, labia
-excruicating pain with stones; often misdx as peritonitis; there may be nausea and vomitting
-chronic: vague, irritate sthe diaphagm so pain radiates to the shoulder
4. bladder pain
-lower abdomen; suprapubically; dull to borderline sharp pain
B. color of urine
1.normal
- straw color
2. red
- beets, red cabbage(may be a sign of hypochloridia)
- breakdown of hemoglobulin or myoglobulin
3. dark yellow-brown-jaundice
4. chartreuse yellow-bright yellow (neon): riboflavin (B2)
5. very yellow-increase amount of urobilogen
6. brown/smokey-nephritis possible
7. black-rare
-blackwater fever
- if urine is left to stand around too long it can turn black
-melanuria: melanin in the urine
-alkaptonuria
8. green-pseudomonas in the lower urinary tract
9. cloudy-with UTI, bacteria, mucous, WBC
C. Hematuria
-can be a problem in any part of the urinary tract; non-specific
1. gross blood(macroscopic)-lower urinary tract
2. amber or brown-hemolyzed already so from the upper urinary tract.
3. casts with RBCs
-fragment of tissue from the kidney; signifies upper urinary tract ; glomerulonephritis ??
4. miscroscopic hematuria causes
-blood cannot be seen; occur from fevers, dehydration, vigorous exercise; hemolysis occuring
5. systemic causes of hematuria
-sickle cell anemia; hemophilia; anticoagulation therapy (heparin)
6. non-renal causes of hematuria
-prostitis, urethritis; acute cystitis; neoplasms; calculi; malformation of the vasculature; extraurinary
(endometriosis or cancer of the endometrium)
7. renal parenchymal causes of hematuria
-systemic lupus; Good Pasteur's; tumors of the kidney; leukemia; infections such as pyelonephritis
8. trauma
-to the kidney and bladder
9. idiopathic
-unknown
10. associated sx of hematuria
-associated with dysuria & suprapubic pain-> cystitis(bladder)
-colicky pain in ureter and kidneys ->nephrolithiasis
-renal infarction, ureteritis, drugs, echymoses, lymphadenopathy and splenomegaly->hemolytic anemia
-history of anticolagulent therapy
-blood clotting disorder (eg. hemolytic anemias)
-prostitis: tender, boggy , hypertrophy of prostate
-costovertebral tenderness angle and fever->pyelonephritis or other kidney inflammation
D. Dysuria, frequency, urgency, hesitancy
1. Dysuria
a. definition
- painful or difficult urination; associated with frequency, urgency, and hesitancy (one or all)
-lower urinary tract
-pain before void-> bladder irriation
-pain when starts:->bladder outlet irritation
b. causes
1)bladder tumor- mostly male; late symptom is dysuria throughout voiding; associated frequency,
urgency, nocturia, hematuria, flank pain possible
2)chemical irritants-bath salts or feminine deodorants; pain at end of voiding; may have
frequency & urgency
3)cystitis-dysuria throughout voiding; often assoc. with frequency, nocturia, and hematuria
A)bacterial
-urinary urgency; low back pain; suprapubic tenderness; low grade fever; tired
B) chronic interstitial
- frequency; sometimes urgency; decrease volume voided
-constant irritation of bladder
-cultures may show nothing repeatly (periodically assoc. with endometriosis)
-may want to consider possibility of abuse in women; as well as, anatomical and/or
physiological abnormalities
4) diverticulosis- older; SAD diet; may cause dysuria throughout voiding
5) prostatitis
-dysuria common throughout voiding
- usually diminished urinary stream
-frequency, urgency, possibly hematuria
-chronic: may also have back pain
6)pyelonephritis
-most common in females
-dysuria throughout voiding, costovertebral angle tenderness, fever, chills, flank pain, nocturia,
hematuria, urgency, frequency, sometimes even nausea and vomitting
7) Reiter's syndrome
-mostly males, dysuria after sexual contact (1-2 weeks)
-may have hematuria, uveitis, conjunctivitis, arthritic symptoms
8) urethritis
-mostly males, dysuria throughout voiding; urethral meatus may be reddened,
-may have copious yellow purulent discharge if gonococcus vs. NGU(non-gonococcal urethritis,
mucus discharge)
9) urinary obstruction
-urethral strictures form past STD's or calculi
-dysuria throughout voiding, discontinuous stream, frequency, urgency
10) vaginitis
-dysuria throughout voiding due to perineal pain from the vaginal discharge & irritation of labia
11) other
-MAI inhibitors may cause dysuria
2. urinary frequency
a. definition
- increased incidence of the urge to void
-usually the bladder cannot hold as much
-important sign for UTI
-other causes : pressure (tumor), MS, pregnancy
b. causes
1)anxiety
2)benign prostatic hypertrophy(BPH)
-frequency, nocturia, possibly hematuria and incontinance
-usually force of stream is less, hesitancy and tenesmus (inability to begin bowel movement)
3) bladder calculus
-irritation of bladder, frequency and urgency, bladder spasm causing suprapubic pain, possibly
incontinence
4) bladder cancer
-frequency, dribbly, nocturia,
-often the first sign is hematuria without pain
-there may be suprapubic pain with bladder spasm if invasive
5) diabetes insipidus
-lack of ADH, huge amount of fairly clear urine; polydipsia is constant
6) diabetes mellitus
-polydypsia, polyuria, polyphagia
7) multiple sclerosis
-frequency, urgency, incontinence is an early sign
8) prostatic cancer
- in the advanced stages there is dribbling and urgency
9) prostatitis-see 8)
10) Urethral stricture
-something is restricting outflow
-frequency, nocturia, reduced force and caliber
-may have incontinence
11) urinary tract infection
-can affect any part
-urgency, hematuria, cloudy urine, possible urethral discharge
12) other
-diuretics including caffeine, radiation therapy
3. urinary urgency
a. definition
- sudden compelling urge to urinate
-accompanied by bladder pain, frequent voiding to try and eliminate discomfort of bladder irritation
-only a few mls. come out at a time
b. causes
1)bladder caluculus
2)multiple sclerosis
3) Reiter's syndrome
-uveitis, urethritis, arthritis
4)urethral stricture
5) urinary tract infection
-no chills, fever, flank pain, casts , costovertebral angle tenderness while an upper UTI will
probably have these symptoms
-important to ddx upper and lower UTI; upper requires more aggressive treatment.
4. urinary hesitancy
a. definition
- difficulty to start urinary stream
b. causes
1)BPH-older men, early finding
2) prostatic cancer
-advanced; also frequency and dribbling, nocturia, dysuria
-Prostate: hard texture, altered shape
-decreased force and caliber or urinary stream
3) urethral stricture
-urinary hesitancy and decreased force and caliber
4) urinary tract infection
5)gravid uterus
6) ovarian carcinomas
7) uterine fibroids
E.Pyruria
1. definition-pus in urine
2. general
-generally leukocytes are present; bacteria may be present; may occur with fever; may persist after
infection
-may not be a clean catch; confounding bacteria
3. bacteria causing pyuria
-gram negative bacilli, E. coli mostly; occassionally gram positive cocci ie. staph
-catheterization may cause bacterial infection
4. most common causes of pyuria
a. acute pyelonephritis
-frequency, chills, nausea, vomit, 10 5 bacteria in urine (100,000) plus other general UTI sx
b. chronic pyelonephritis
-fatigue, normochromic anemia
c. cystitis
-frequency, urgency, often burning, suprapubic tenderness, usually no fever
d. prostatitis
-similar signs and symptoms to cystitis; tenderness in lower abdomen, possibly radiates to groin;
prostate boddy and tender
F. Oliguria and anuria
-oliguria: very low urine output
-anuria: virtually no urine output
G. conditions predisposing to UTIs
-infants up to two years old; females >males; ease of contamination
-women: short urethra
-older males: prostatic hypertrophy, infection
-tumors, stones can cause stasis
-MS; spinal cord injuries; other neurogenic etiologies
-diabetes mellitus; decreased tissue resistance; decreased circulation; decreased immune response