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**Patients with urological problems may

complain of many symptoms

**You should identify each symptom and make

analysis to have an idea about the cause of these
symptoms

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 Pain
1- renal pain:
dull pain in the loin area
less dramatic in onset than uretric colic
not radiating to the external genetalia
mainly caused by stones
(infection ,inflammation ,obstruction )

2- uretric colic
intermittent , dramatic onset, no relieving position
so severe: not relieved until the patient takes
narcotic

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 Associated with nausea, vomiting and
sweating
Caused by stones:

if in upper ureter radiates to groin

if in lower ureter radiates to scrotum and
external meatus and (to labia in females)

if stone is close to VUJ the patient will have

irritation, frequency, and urgency
3- bladder pain: supra-pubic pain
4- prostatic pain: in the perineum/and or rectal
pain

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 4- acute scrotum:
sudden onset of scrotal pain is testicular torsion until
proven otherwise

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 Testicular Epididymo-
Torsion orchitis
Onset Sudden Gradual
Common age Around 15 yrs Elderly
Urine analysis -ve +ve
Associated Sx Vomiting Fever
Change in pain Releived No change
with elevation
Cremastic Abscent Preserved
reflex

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Dysuria
(burning sensation) during micturition
Mainly due to irritation of the urethra or urinary bladder

Causes :
MC is infection or inflammation of the bladder
Also could be psychogenic or due to reduced UB
compliance

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 Hematuria:
May be microscopic (e.g. .renal or urinary tract disease) or
macroscopic (e.g. hemorrhagic cystitis/bladder CA)
May be painful (e.g. calculi) or painless (e.g. malignancy).

Relationship between hematuria and voiding:

- early hematuria: urethral
- mid stream hematuria (total): urinary bladder and above
- terminal hematuria: prostate or bladder neck

color: bright red (recent) or dark (old)

causes of hematuria:
infectious (UTI), stones, tumors (painless hematuria), renal diseases
(e.g. burgers glomerulonephritis),
bleeding disorders, vasculitis

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 Types of incontinence:
1- urge incontinence: results due to
involuntary rise in intravesical pressure
secondary to bladder contraction that
overcomes outlet resistance

causes:
1) loss of cortical inhibition( elderly,
parkinsons, MS)
2) local cause of detrusor instability/overactivity
(UTI, stones, tumors, foreign bodies)

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 2-Stress incontinence
Leak of urine due to increase in intra-abdominal pressure
at risk: elderly female, multiple pregnancies (weak pelvic floor), male post
TURP

3- overflow incontinence
leak of urine after prolonged obstruction and failure of the bladder to empty
MC associated with BPH and detrusor hypo-tonicity secondary to autonomic
neuropathy (DM)

4- total (true/continual) incontinence

no control over the act of voiding
e.g. -injury to the external sphincter
-ectopic ureter opening distal to external sphincter
-congenital (e.g patent urachus, epispadius, ectopia vesicae)

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Enuresis
Involuntary wetting in children (especially nocturnal
bed-wetting)
Good cortical control of urination (inhibition) is achieved
at 2.5 years
2 types of enuresis
-primary: child was never able to attain control
-secondary: child experienced control, then lost
(6 mon at least)

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 Polyurea
Normal urine output= 1.8 L/day
Polyurea is defined as an increase in total
volume of urine >3 L/day
Caused by: DM(hyperglycemia), diabetes
insipidus, chronic renal failure,
hypocalcaemia, drugs (diuretics), psychogenic
polydipsia

Frequency
Normally people void at rate of 4-8 times per day
Frequency is defined as an incresed rate of
micturition without an increase in the total volume
of urine voided
Caused by: infections, metabolic disease,
psychogenic (anxiety)

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Urgency

the feeling of a sudden and immediate desire to void due

to irritation of the urinary bladder or the urethra;
neurogenic bladder, pelvic organ prolapse
(overactive detrusor or abn. Stretch receptors in
bladder)

Nocturea
Defined as an increased number of micturition at
night (being awaked at night to void)
Caused by: -same causes as polyurea
-edematous state
-irritation : by infection, inflammation, or tumors

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Oligurea
Defined by reuction in urine output to < 400
ml/day
Extreme oligurea= Anurea= urine output <50
ml/day
Causes : obstruction, arterial or venous
occlusion, acute renal failure

Pneumaturea
defined as passage of air bubbles with urine
Caused by internal fistula (e.g. vesico-colic fistula from
chrons or diverticular disease)

Cloudy urine
Caused by: infection (pyurea) and protienurea(frothy )

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 Urine retention:
Acute: usually painful without renal impairment ..
Chronic: usually painless with renal impairment

Causes:
mechanical: BPH, prostate CA, prostitis
neurological
psychogenic

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 Poor urinary stream
Tested by uro-flowmeter in (ml/sec) normally >= 15 ml/sec
The patient must have voided at least 200 ml during test

Hesitancy:
Difficulty to initiate urination
(usu due to BOO e.g BPH)

Dribbling:
usu due to obstruction

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 Blood
CBC, KFT,

Creatinine is better reflects kidney function than BUN

Urine routine and microscopy (R&M)

Routine: sugar protein, specific gravity, color, pH
Alkaline urine indicates either infections or drugs
Glucosurea occurs when serum glucose >180 mg/dl

Microscopy: WBC (NL < per 3 HPF)

RBC (NL <2 per HPF)
Epithelia cells, casts, bacteria

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 Urine culture and sensitivity (C&S)
-Culture: +ve if >100,000/ ml in a clean sample or one
bacterial cell on microscope.
-sensitivity of the organism to various drugs

Methods of sampling:
-suprapubic (any single growth is significant)
-midstream
Catheter sampling

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 Prostate specific antigen (PSA)
Causes of high PSA: infections, malignancy, BPH, trauma,
prostate manipulation(PR,folyes)
Causes of low PSA: prostatectomy, drugs (e.g. finasteride)

Normal values:
Age: 60-69 yrs: NL free <0.9
PSA <= 4.5 ng/ml
NL total < 4
Age: 50-59 yrs: Age: 40-49 yrs:
PSA <= 3.5 PSA <=2.5
ng/ml ng/ml

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 PSA velocity (i.e. rate of increase over time.. Must read at least 3 values in
order to calculate)
Normally< .75ng/ml/yr

PSA fraction (ratio of free-to-total serum PSA)

If ratio is < 0.18 probably prostate CA

PSA density (ratio of serum PSA to prostate volume)

If >=0.18 ng/ml/cm highly suggestive of malignancy

Note: normal PSA and normal biopsy do not rule out prostate CA

Half life:
Free: 2-3hrs
Total:60hrs

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 KUB film (kidney-ureter-bladder)
Look for abnormal areas (e.g. radio-opaque shadow, Psoas shadow, bony
metastasis

Intravenous urogram (IVU)/(IVP)

Show internal urinary tract as well as renal vasculature
Must ask about radio contrast allergy and do a baseline KFT in order to avoid
allergic reactions and death (occur 1 in 30,000 to 40,000)
Must ask about Hx of pregnancy
In case of anaphylactic rxn: ttt with adrenaline, antihistamine, and
hydrocortisone (all IV)

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 Procedure if IVU
Insert a large iv cannula
First minute: nephrogram (shows kidney vasculature) then take serial
nephrogram
Then take a full bladdr x-ray
Finally take a post-void x-ray

Signs of acute obstruction

Dense cortex on nephrogram
Hydronephrosis above the level of obstruction graded:
Minor : only dilation
Moderate: cupping of small calyces
Severe: loss of normal configuration

Filling defect DDX:

Tumor,radioleucent stone,thrombus

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 Micturition cysto-urethro-gram (MCUG)
Contrast is injected into the bladder using a catheter and the patient
is asked to void the contrast under fluroscopic vision
Used to diagnose vesico-ureteric reflux (VUR)

Ultrasound (US)
Used to distinguish between cystic and solid masses
For diagnosis of hydronephrosis
Used to see post-void urine volume as well as to see the
VUJ,prostate size
Stones only seen if >5 mm in size (esp renal stones)

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 CT scan +/_ contrast
Usually we do a CT without contrast (esp if contrast allergy) yet a contrast
study is mandatory if there is a mass
With CT: can see both radio-opaque and rario-lucent stones

MRI
Good to see soft tissue

Retrograde ureterography
Under cystoscopic guidance, locate the ureteral orifices and inject contrast
into them
Used to see dilated or obstructed ureters,strictures or injuries

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 Anterograde urethrography
Used to evaluate urologic strictures: size, length, and number of
strictures

Angiography
To evaluate renal masses
see a filling defects if the mass was cystic
see abnormal vessels if the mass was malignant
To evaluate renal artery stenosis
To evaluate vascular injuries to the kidney
Lymphangiography
Less popular.. Replaced by CT-scan

Scrotal U/S +/- doppler

Mandatory for scrotal pain and swelling to rule out torsion

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 Types of radio nuclear scans:
DMSA scan: Di-mercapto Succinic Acid
DTPA scan (before renal transplantation)
Hippuran scan: linked to iodine-131 hippuran
Perfusion Radio-isotope scan
Bone scan to evaluate for bony metastasis

In DMSA & DTPA scans a radio-active substance is given IV and

the cortex is assessed for cortical functioning (used to see if the
cortex is scarred secondary to VUR)

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 Hippuran scan is used to asses obstruction in the setting
of significant renal failure. Here a graph showing flow
and excretion phases is produced:
a-shows a normal vascular phase
b-shows normal drainage phase
c-shows slow flow: indicating renal artery stenosis
D-shows slow drainage: indicating PUJ obstrucion

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 Other diagnostic methods

-cystoscopy: diagnostic and therapeutic

-flowmetry: shows rate of flow of urine

(urodynamic study)

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THANK
YOU

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