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SYMPTOMS IN UROLOGY. Classification. A- Upper urinary tract symptoms. B- Lower urinary tract Symptoms. C- General symptoms. A- UPPER URINARY TRACT SYMPTOMS. 1- Renal pain. 2- Renal swelling. 3- Abnormal urine colour . 4- Urinary fistula. 5- Abnormal urine volume. RENAL PAIN.
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Classification A- Upper urinary tract symptoms. B- Lower urinary tract Symptoms. C- General symptoms.
A- UPPER URINARY TRACT SYMPTOMS 1- Renal pain. 2- Renal swelling. 3- Abnormal urine colour. 4- Urinary fistula. 5- Abnormal urine volume.
RENAL PAIN It is felt in the loin. Types • Dull aching: • Heaviness, continuous, chronic, tolerable and seldom affected by movement. • Caused by distention of the renal capsule, pelvicalyceal system, dragging on the renal pedicle or infiltration of an adjacent organ. • It must be differentiated from 1- Flank pain 2- Radiculitis 3- Irritable colon
B) Renal colic: • Sever Intermittent, spasmodic, intolerable pain, sudden onset, sudden offset, short duration. • The patient is often rest1ess and uncomfortable. • It usually radiates along the course of genitofemoral nerve (L1) • It is usually associated with other urologic complaints. • It is usually associated with GIT symptoms due to • Shared innervations. • Near by structure • Peritoneal irritation
It is caused by: • Migrating stone. • Migrating blood clot. • Ureteral stricture. • Crystaluria. • Pathogenesis: • Acute pelvicalyceal or ureteral obstruction. • Increased peristalsis and spasm of the muscles. • sequent sudden distension of the renal capsule. • Hyper peristalsis aims at pushing down the obstructing element.
Differential diagnosis 1.Biliary colic. 2. Acute appendicitis. 3. Colonic colic. 4. Basal pleurisy and pneumonia. 5. Herpes zoster.
(C) Throbbing pain: • It means pus in a cavity under tension • It may be caused by: 1. Renal abscess. 2. Perinephric abscess. • It is usually associated with symptoms of toxemia.
Renal Swelling • Painless or painful swelling in the upper quadrant of the Abdomen that may extend downward and medially. • Causes of renal swelling: (Loin pain and other urinary symptoms) • Hydronephrosis • Renal tumors • Polycystic kidney disease • Simple cystic renal disease. • Differential diagnosis A. Hepatic swelling: (Right hypochondrial pain and upper GIT symptoms). B. Colonic swelling: (Left or right hypochondrial pain and lower GIT symptoms). C. Gall bladder swelling: (Localized right hypochondrial pain Associated with biliary dyspepsia). D. Retro peritoneum swelling: (Vague diffuse abdominal pain + nonspecific GIT symptoms).
Abnormal urine color • It will be discussed later on.
Upper urinary fistula • It is a tract connecting two opened cavities (urinary tract to colon) or an opened cavity to the skin (urinary tract to the skin). • The patient complains of flank opening discharging fluid of uriniferousodour.
Etiology of flank fistula A.Spontaneous: • Calculus pyonephrosis, • Ruptured hydronephrosis • Osteomyelitis • TB B.Traumatic: C. Post-operative: • General cause • Distal obstruction • infection D. Post-nephrectomy : 1. Refluxing ureter. 2. Missed renal tissue. 3. TB pyonephrosis. 4. Renal bed infection. 5. Missed horseshoe kidney.
Abnormal urine volume • Normal urine volume: (500 cc to 1500 cc/24 hs). • Abnormal urine volume: • Anuria: It means no urine output for 12 hours or passage of less than 50 cc of urine per 24 hs. • Pri-renal causes (shock ,dehydration). • renal (acute renal failure). • post renal causes (bilateral ureteral obstruction).
B. Oliguria: It means decreased urine volume to less than 500 cc/24 hs. that may be secondary to acute renal failure. C. Polyuria: It means increased urine volume. • Phsiologic; (increased fluid intake, cold weather, diuretics). • pathologic; (DM,DI, early stages in chronic renal failure, polyuric stage of acute renal failure).
B. LOWER URINARY TRACT SYMPTOMS 1- PAIN 2- IRRITATIVE SYMPTOMS 3- OBSTRUCTIVE SYMPTOMS 4- INCONTINENCE 5- ABNORMAL URINE COLOUR 6- SWELLING 7- URINARY FISTULA
1- Pain 1. Suprapubic pain 1. Bladder 2. Colon 3. Uterus Cystitis syndrome: • increased urinary frequency • Painful micturition • change in the colour of urine.
2-Perineal pain • caused by painful pathology in the prostate. 3- Testicular Pain a- acute testicular pain b- chronic testicular pain c- Scrotal skin d- Referred pain
2- Irritative voiding symptoms A) Increased urinary frequency • Decreased intervals between voids with small amount of urine at each voiding. • Caused by 1- Increased urine output (Polyuria): A- Physiological: • increased water intake. • cold weather. • Duretics. B- Pathological: • Diabetes mellitus. • Diabetes insipidus. • Early symptom in chronic renal failure.
2- decreased bladder capacity A- Anatomical • Intramural: • giant stones. • malignant mass. • high residual urine. • Mural: (contracted bladder) • Extramural: (compression) B- Functional • Spastic Neurogenic bladder. • OAB. Types of increaed frequency: A-Diurnal: (stone bladder) B-Nocturnal: (BPH) C-Constant: (cancer bladder)
B) Urinary urgency: • Painless sudden intense desire to micturate with voluntary control of urine (strong contraction of the sphincter mechanism) . • Caused by uninhibited Detrusor activity due to. 1. infravesical obstruction . 2. Cystitis. 3. Neurogenic bladder 4. Idiopathic
C) Precipitancy: • Painless sudden strong desire to micturate with involuntary loss of few drops of urine (weak contraction of the sphincter mechanism). D) Urge incontinence: • Painless sudden strong desire to micturate with involuntary loss of whole urine (complete detrusor failure with no contraction of the sphincter mechanism).
3- Obstructive voiding symptoms 1-straining with micturition 2-stream changes (weak ,narrow stream) • Normal stream (single, continuous, forceful, 0.5 cm in caliber, for a distance about 0.5-1 meter in front of male patient in standing position with non-supported non-erected penis). 3- Hesitancy: • Difficulty to start micturation due to contracted external sphincter. 4-interrupted stream: • Difficulty to maintain micturation with interruption of the urinary stream due to bladder exhaustion. 5-Terminal dribbling: • Difficulty to terminate micturation due to defective bladder neck closure.
6- Urinary retention: • Inability to empty a full bladder. Types: A) Acute urinary retention: • inability to pass even a single drop of urine per urethra despite of full bladder and severe desire Etiology: A. Infant and children: • PUV. • meatalstenosis. • impacted stone. • phimosis. • paraphimosis. B. Adults: • stone post urethra. • acute prostatitis. • prostatic abscess. • uretheral trauma. • Urethritis. • reflex due to painful operations. C. Elderly: • BPH. • stone post urethra. • clot retention
(B) Chronic urinary retention: • Painless gradual progressive accumulation of residual urine, due to log standing lower urinary tract obstruction, reaching then exceeding the anatomical capacity of the urinary bladder. • The patient complains of frequency, nocturnal enuresis ,diurnal and nocturnal enuresis and lastly overflow incontinence. • non-tender doughy suprapubic mass reaching up to the umbilicus. (C) Acute on top of chronic urinary retention: Causes of obstructive voiding symptoms: 1- BPH 2- BNO 3- Prostate cancer 3- URETHERAL STRICTURE 4- NEUROGENIC BLADDER
4 -Urinary Incontinence • Involuntary loss of urine per urethra. Types 1- True incontinence: a) Urge incontinence (bladder cause). b) Stress incontinence (Sphincteric cause). • Involuntary loss of urine on stress conditions due to weakening of urethral sphincter. c) Mixed type urinary in continence. 2-False incontinence: • Involuntary constant loss of urine, with a full palpable bladder due to chronic retention. 3- Extra-urethral causes of urine loss: (1) Uro-vaginal fistula. (2) Ureteralectopia.
5 - Suprapubic Urinary Fistulas • Suprapubic opening discharging fluid of uriniferousodour. Post-operative fistula: (Most common) • Distal obstruction. • Stricture ureter • BNO. • stricture urethra. • missed stone. • Infection. • Neurogenic bladder. • Undiagnosed cancer bladder. • Missed FB.
6- Suprapubic swelling Differential diagnosis 1- Bladder: • Retention of urine • Huge bladder mass 2- Sigmoid colon: • Cancer colon • Distended colon 3- Uterus: • Pregnancy. • fibroid 4- Ovary: • Cyst. • Tumor. 5- Retroperitoneal tissue: • Sarcoma
Perineal swelling Differential diagnosis • Urethra: • trauma and extravasation • Bilharzial perineal mass. • Anal canal: • perianal abcess • Skin and subcutaneous tissues: • lipoma
7- Abnormal Urine Colour • Normal fresh urine (clear, amber yellow, acidic, with uriniferousodour). 1- Red discoloration of urine: • Hematuria: • Presence of blood in urine. • It may be the first sign of serious disease in urinary tract. • It may be gross or microscopic hematuria,
Etiology: 1-SYSTEMIC CAUSES • anticoagulant intake. • sickle cell disease. • coagulopathy. 2- LOCAL CAUSES A-Glomerular: glomerulonephritis • Usually occur in children • Dysmorphic RBCS • RBCS casts • Significant proteinuria ( > 150 mg per 24 hours) B- Urologic: • Congenital: polycystic kidney disease • Traumatic causes: Renal, ureteral, and bladder injury • urinary tract stones and urine crystals • Neoplastic: Renal tumors, and urothelial carcinoma • BPH
B-Myoglobinuria: • due to significant muscle trauma. • C-Hemoglobinuria: • following hemolysis. • D-Bilirubinuria: • In cases of jaundice (dark orange urine). • E-Pigmentation: • Natural food pigments (berries). • F-Drugs: • Phenolphthalein in laxatives. • Phenothiazine. • Rifampicin, • Macrodantin. • Nitrofurantion. • mitronidazole.
2- Cloudy Urine: (Turbid urine) Etiology: • Pyuria. • Phosphaturia. • Chyluria.
1-Pyuria: • Presence of pus cells (> 5 /HPF) in urine. • It my be microscopic(< 100 / HPF ) or gross (>100 / HPF ). • Microscopic examination confirms the diagnosis. Etiology of gross pyuria: • Bilateral chronic pyelonephritic kidneys • open pyonephrosis. • open TB (caseous material). • Big retentive vesicaldiverticulum . • Stag horn stones. Etiology of sterile pyuria: • Stones • Early malignancy. • TB • Irradiation • Fungal infection • Drugs (steroid, aspirin).
2-Phosphaturia • Precipitation of phosphate crystals in alkaline urine. • Turbidity disappears on addition of acetic acid. Causes • alkaline urine. • Hyperparathyroidism. 3-Chyluria: • presence of lymph fluid mixed with the urine due to communication between the lymphatic system and urinary tract. • Turbidity disappears on addition of ether. Heavy proteinuria: Clear urine that turns white on heating >>>>Denaturation>>>> Induced turbidity.
3- Abnormal Urine Contents: A- Pneumaturia: • Passage of air bubbles in the urine. Etiology: • Post-endoscopic treatment. • Infection • Vesico-enteric fistula: • Uretrosigmoidostomy. B-Necroturia: • Passage of pieces of necrotic tissue in urine. • It is a sign of bad prognosis • Ischemic necrosis of the tumor surface>>>> Separation into the bladder >>>> Urine . C- Fecaluria: • Presence of feaces in urine in cases of uro-enteric fistulae. D.D: • Pyuria = whitish inspissated pus that breaks in between fingers as it is digested protein • Necrotic tissue consists of dead tissues (undigested proteins)>>>> does not dissolve in between fingers
C. General symptoms 1- Symptoms suggestive of uremia. 2- Symptoms suggestive of toxemia. 3- Symptoms suggestive of distant metastasis.
1- Symptoms suggestive of uremia. 1- GIT : • Anorexia. • Nausea and vomiting • Glossitis and stomatitis. • Hematemesis and melena. • Diarrhea or constipation. 2- Cardiovascular : • Renal hypertension. • Arrhythmias. • Pericardial pain. 3- Respiratory: • Uremic smell. • Rapid deep breathe. • Pulmonary oedema and dyspnea. • Hiccough.
4- Musculoskeletal: • Easy fatigability. • Abdominal distension. • Bone pain. 5- Hemopoeitic system: 1. Pallor. 2. Bleeding tendency. 3. Bone marrow depression. 6- Genito-urinary system: • Recurrent Urinary tract infections. • Polyuria. 7- CNS: • Lack of concentration • Confusion ~ stupor ~ semi coma and finally coma. • Inverted sleep rhythm: • Lack of interest in life.
8- Skin and its appendages: • loss of skin luster • Pale. • Yellowish. • Subcutaneous hemorrhages • Pruritis and scratch marks. • Earliest manifestation of uremia: • Easy fatigability • Anorexia • nocturnal polyuria. • Inattention
2.Symptoms suggestive of toxemia: Etiology and Symptoms: 1. High grade fever with chills: • Kidney ( high grade fever with chills and loin pain). • prostate (high grade fever with chills and perineal pain and voiding symptoms).. • Testis (high grade fever with chills and testicular pain). 2. Low-grade fever with weight loss: chronic urinary tract infection as in pyonephrosis 3. General weakness and wt loss: • advanced malignancy. • renal insufficiency. • chronic toxemia as pyonephrosis. 4.General weakness and malaise. 5. Intense sweating 6. Prostration
3. Symptoms suggestive of distant metastasis: • Metastasis leads to: • Pain of recent onset. • Impaired function of metastasized organ • Mass development. Liver: • Right hypochondrial pain, • jaundice, ascitis. • liver enlargement or masses Lungs: • Chest pain. • Hemoptysis. • dry Irritative cough. • dyspnea .
Brian: • Headache, • Blurring of vision. • projectile vomiting. • neurological manifestations. Bone: • Severe boring pain, constant persistent, progressive, localized to the same area, not responding to ordinary analgesics. • Pathologic fractures and bone mass may occur.
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