Urologic symptoms

DR Tarek Ahmed Siefin

Lecturer of urology, Sohag University
 Agenda

Upper urinary tract symptoms

Lower urinary tract symptoms (LUTS)

Urine changes

Male genital symptoms

Uremic manifestations
 Upper
urinary
tract
symptoms
  It results from obstruction of urine flow with
distension of the capsule or the collecting
system.
 Pain due to inflammation is dull aching.
 It is felt in the posterior renal (costo-
Renal pain vertebral) angle, below the last rib and
lateral to the sacrospinalis.
 Pain radiates from the loin to the groin and
ipsilateral testis or labium.
 It is associated with gastrointestinal
symptoms: nausea, vomiting and distension.
  A stone is the most common cause leading to
hyperperistalsis.
 The most severe pain a human-kind can experience.
 Intermittent, occurring in waves.
Renal or  The site of maximum intensity varies with the site of
Ureteric obstruction.

Colic  Ureteric colic is usually accompanied by renal pain

due to distension of the pelvis.
 Upper ureter is innervated similar to kidney so pain
radiates to testis.
 Pain in mid-ureter simulates appendicitis or
diverticulitis.
  The lower ureter shares a common sensory
nerves with pelvic organs.
 Pain is felt as suprapubic discomfort with
vesical irritability (urgency, frequency) and
radiates along urethra to tip of penis.
Renal or  Often associated with nausea, vomiting,
Ureteric sweating and collapse.
Colic  Patients with ureteric colic are usually
moving around (restless) in agony and
holding the flank (the rolling sign) while
patients with intra-peritoneal pathology
prefer to lie motionless.
  Myo-skeletal causes e.g.:
 Muscle spasm, sprain or inflammation, rib fracture
and herniated intervertebral disc. Pain is provoked
by certain body positions, trunk movements,
coughing, sneezing and respiration.

Differential diagnosis  It may radiate to the lower limbs.

of renal pain (Non-  Gastro-intestinal causes e.g.:
urologic causes of
flank pain):  Irritable bowel syndrome (abdominal distension and
change in bowel habits), cholecystitis (fatty
dyspepsia and jaundice) and appendicitis (rebound
tenderness at the right iliac fossa and psoas
spasm).
  Gynecological causes e.g.:
 Torsion of an ovarian cyst and ectopic pregnancy
(in females especially in the child bearing period
and associated with menstrual changes).

Differential diagnosis  Herpes zoster:

of renal pain (Non-  Pain is severe and revealed by appearance of
urologic causes of specific eruption along the course of the intercostal
flank pain):
nerves.
 Basal pleurisy and pneumonia:
 (Related to respiration, associated with pulmonary
symptoms as dyspnea and cough).
  Renal swelling:
 When there is huge enlargement of the
kidney/s e.g. Hydronephrosis, polycystic
Swelling kidney disease and Wilms' tumor.
and Fistula
 Renal Fistula:
 Postoperative, calcular pyonephrosis.
 Lower
Urinary
Tract
Symptoms
(LUTS)
  Micturition is urine disposal from the bladder to outside through
the urethra. The process is voluntary in adults and depends
upon learned behavior, while in infants it is an involuntary
reflex. Micturition occurs as coordination between the vesico-
urethral unit and the nervous system and consists of two
phases:
 A) Filling or storage:
 During bladder filling the sympathetic tone predominates (T10
Normal to L2 through the hypogastric nerve). Alpha-receptors increase
the muscle tone in the bladder outlet, while beta- receptors in
voiding the bladder body relax the detrusor. Pudendal nerve (somatic
S2-4) causes contraction of the striated external urethral
sphincter.
 B) Voiding or emptying:
 - When the bladder is full stretch receptors are activated and
signals are transmitted to the sacral cord. The pelvic nerve
(parasympathetic, S2-4) endings release acetylcholine and the
detrusor contracts.
 - Inhibitory impulses from the CNS to the sympathetic and
pudendal nerves relax the bladder outlet.
  The process of normal micturition is defined as follows:
 A. Initiation:
 A human can start the act of micturition even when the
bladder is not full. Animals void only when the bladder is
full. A human can postpone voiding of a full bladder until
he can find a socially suitable place, go to it, adopt it and

Normal then start to pass urine.

 B. Maintenance:
voiding  The normal urinary stream is continuous and free of pain,
with adequate force, form and caliber
 C. Termination:
 A human can void all urine with no post-voiding residual.
 The normal adult bladder can hold up to 500 ml of urine.
We become aware of the need to void at 150 ml. At 400
ml we are seeking an appropriate toilet.
  Frequency:
 - Normal adult voids 5-6 times per day and arises no more than twice
at night, with a volume of about 300 ml each.
 - Frequency refers to increased number of times one feels the need
to urinate.
 - It is caused by functional or organic decrease in bladder capacity:
 Inflammation: Edema and impaired elasticity.

Irritative  Obstruction: Residual urine decreases the effective capacity.

symptoms  Stones.
 Foreign body.
 Tumors.
 Neuropathic bladders.
 Contracted bladder: bilharziasis, T.B., radiation, interstitial cystitis.
 Anxiety.
 Pharmacological agents.
 Psychogenic frequency: No nocturia.
  Urgency:

 Pericipitancy:
Irritative
symptoms  Urge –incontinence:

 Nocturia:
  (A) Difficulty in relation to voiding:
 1- Difficulty to start:
 Hesitancy: The need to wait before urine stream is
voluntarily initiated.
 2- Difficulty to maintain:
 Intermittency: Involuntary stop and start of urine stream.
 Weak stream: Decreased force and caliber of stream.
Obstructive  Straining is the use of abdominal muscles to increase
symptoms intra-abdominal pressure to urinate.
 3- Difficulty to terminate:
 - Sense of Incomplete emptying: A feeling that the
bladder is not completely emptied at the end of urination.
 - Strangury: Incomplete emptying with sharp stabbing
suprapubic pain.
 - Post void dribbling
  Suprapubic pain:
 Due to different bladder pathologies e.g. acute
bacterial cystitis and anterior bladder wall malignancy.
 Urethral pain:
 Usually is expressed as burning micturition (dysuria).
It is due to inflammation (urethritis & cystitis), stones
Pain (urethral, bladder & intramural) and bladder ulcer or
cancer.
 Low back, perineal or peri-anal pain:
 May be caused by different diseases including
prostatic and urethral pathologies e.g. stones,
inflammations (urethritis, prostatitis & prostatic
abscess)
  It is due to acute inflammation.
 Localized in the perineum and referred to
Prostate lower back and rectum.
pain  Acute prostatitis is associated with fever,
frequency, dysuria or acute retention and
tenesmus.
  Referred or secondary to cystitis or a
stone.
 Pain in the flaccid penis is usually due to
bladder or urethral inflammation.
Penile pain  Paraphimosis: the uncircumcised foreskin
is trapped behind the glans penis.
 Priapism: painful, persistent, purposeless
penile erection.
  Primary pain is due to acute epididymo-
orchitis, torsion of the testis or trauma.
 In patients with testicular discomfort and a
normal scrotal examination, renal or
Testicular retroperitoneal disease should be
pain considered.
 Referred in renal or ureteric colic.
 Hydrocele, varicocele and testicular tumor
may be associated with scrotal discomfort.
  It is detected in the clothes and not
related to the act of micturition.

Urethral  Its amount, color and associated

discharge symptoms should be assessed.
 It may be; Mucous, muco-purulent
and purulent discharge.
  Suprapubic swelling: mostly due to chronic
urine retention.

Swelling  Perineal or penile swelling: due to urine

and/or blood extravasation after urethral
trauma or
 Penile fracture.
  The cause can be congenital,
inflammatory, post- traumatic (accidental or
surgical) or neoplastic
 e.g. Vesico-cutaneous (suprapubic),
Lower
vesicovaginal, vesicorectal or
urinary tract ureterovaginal.
fistulae and
sinuses  Urachal: congenital umbilical vesico-
cutaneous urinary fistula.
 Urethro-cutaneous (perineal or penile),
urethrovaginal or urethrorectal.
  It is the inability to pass urine in spite of severe painful
desire to void with full urinary bladder.
 Etiology:
 Stone impacted in the urethra or bladder neck.
 Urethral trauma with complete rupture
 Prostatic diseases as benign prostatic hyperplasia (BPH)

Acute
and prostatic abscess.
 Neuropathic bladder e.g. after spinal cord injuries
Urinary  Occasional causes e.g.: Reflex urinary retention due to

Retention severe painful perineal and anal conditions e.g. after anal
surgeries.
 Obstructed Foley catheter.
 Acute urethritis and impermeable urethral stricture.
 Bladder neck or prostatic cancer.
 Phimosis.
 Hysterical retention.
  Definitions
 Urinary incontinence (UI): the complaint of any
involuntary leakage of urine.

 True incontinence:
Urinary  It is defined as continuous involuntary loss of urine
Incontinenc at all times and in all positions.

e  Vesico-vaginal fistula: the most common cause.

 Exstrophy-epispadias.
 Neuropathic bladder.
 Sphincter injury by prostatectomy.
 Ectopic ureter that enters the female genital tract.
  Stress urinary incontinence (SUI): the complaint of
involuntary leakage of urine on effort or exertion or
sneezing or coughing. SUI can also be a sign— the
observation of involuntary leakage of urine from the
urethra that occurs synchronously with exertion,
coughing, etc.
 Urge urinary incontinence (UUI): the complaint of any
involuntary leakage of urine accompanied by, or
immediately preceded by, urgency.
Other types  Mixed urinary incontinence (MUI): a combination of SUI
of and UUI.

incontinence  False (Overflow or paradoxical)Incontinence:

 Loss of urine due to chronic retention as in cases of
enlarged prostate, stricture urethra or secondary to a
flaccid bladder.
 The bladder is decompansated and acts as a fixed
reservoir. When the intravesical pressure equals the
urethral resistance, constant dribbling of urine occurs
(mechanical overflow).
  1- Color:
 A. Red urine
 B. Milky urine:
Changes in the
gross  The passage of lymphatic fluid (Chyle) is
appearance of noted by the patient as milky white urine.
urine  Chyluria is caused by filariasis, trauma, T.B.
and retroperitoneal tumors leading to
lymphatic-urinary fistula.
 2- Turbidity: Cloudy urine
 a) Phosphaturia: The most common cause of cloudy
urine.
 Phosphate crystals precipitate in alkaline urine causing
turbidity. It clears if acetic acid is added.
 b) Uricosuria:
 Uric acid crystals are dissolved in urine at body
temperature. Uric acid precipitates if urine is left to cool
down at room temperature causing turbidity. Urine
becomes clear if heated.
 c) Pyuria :
 Bacterial
 Abacterial or sterile pyuria (stones, obstruction, tumors,
T.B.).
 Turbidity which neither disappears by acidification nor by
heating is caused by pus.
 3- Pneumaturia
 The passage of gas bubbles in urine can be caused by:
 a- Fistula between bowel and bladder secondary to
diverticulitis, regional ileitis, trauma and colon cancer.
 b- UTI by sugar-fermenting organisms in poorly controlled
diabetic patients.
 c- Iatrogenic: recent urinary tract instrumentation.
 d- Congenital: Urethro-rectal fistula.
 4- Necroturia
 The passage of pieces of tumor tissue in cases of
carcinoma of the bilharzial bladder and described by the
patient as "pieces of fat".

 5- Passage of stones.
  The presence of blood in the urine.
 Visible haematuria (Vh), previously referred to as
‘frank’ or ‘gross’ haematuria is when the patient or
doctor has seen blood in the urine or describes
the urine as red or pink (or ‘cola’-coloured-
occasionally seen in acute glomerulonephritis).

Haematuria  Microscopic or dipstick haematuria is ‘non- visible’

haematuria (nVh).
 Non- visible haematuria is categorized as
symptomatic [s- nVh, i.e. lower urinary tract
symptoms (LUtS) such as frequency, urgency,
urethral pain on voiding, suprapubic pain] or
asymptomatic (a- nVh).
  Any single episode of Vh.
 Any single episode of s- nVh [in the absence of
urinary tract infection (Uti) or other transient
causes].

What is  Persistent a- nVh— defined as two out of three

significant dipsticks positive for nVh (in the absence of Uti or
other transient causes).
haematuria  Transient (non- significant haematuria) is caused
? by:
 UTI:
 Exercise- induced haematuria or rarely
myoglobinuria.
 Menstruation.
  Cancer: bladder [transitional cell carcinoma (tCC),
squamous cell carcinoma (SCC)], kidney
(adenocarcinoma), renal pelvis and ureter (tCC),
prostate.
 Stones: kidney, ureteric, bladder.
 Infection: bacterial, mycobacterial [tuberculosis
(tB)], parasitic (schistosomiasis), infective urethritis.
Causes of  Inflammation: cyclophosphamide cystitis, interstitial
Haematuria cystitis.
 Trauma: kidney, bladder, urethra (e.g. traumatic
catheterization), pelvic fracture causing urethral
rupture.
 Renal cystic disease (e.g. medullary sponge
kidney).
 Other urological causes: benign prostatic
hyperplasia (BPh, the large, vascular prostate), loin
pain haematuria syndrome, vascular malformations.
 Nephrological causes of haematuria: tend
to occur in children or young adults and
include commonly immunoglobulin a (iga)
nephropathy and post- infectious
glomerulonephritis.
 Other ‘medical’ causes of haematuria:
include coagulation disorders— congenital
(e.g. haemophilia), anticoagulation therapy
(e.g. warfarin), sickle- cell trait or disease,
renal papillary necrosis, vascular disease
(e.g. emboli to the kidney cause infarction
and haematuria).
  Erectile dysfunction (ED).
 Ejaculatory disorders.
 An ejaculation:-Inability to ejaculate semen
as in spinal cord injuries, postoperative in
surgeries that damage pelvic nerves.

Male genital  Premature ejaculation: - when ejaculation

happen sooner than man or his partner
symptoms would like during sex.
 Delayed ejaculation: - man take an extended
period of sexual stimulation to release
semen.
 Subfertility. Sexually mature male unable to
impregnate a fertile woman
  Either:
 Pain: referred (from the upper urinary
tract) or due to local cause (as testicular
torsion, trauma, mumps or epididymitis)
 Swelling e.g. epididymo-orchitis,
Scrotal hydrocele, varicocele, spermatocele,
conditions hernia or testicular tumor.
 Empty scrotum e.g. testicular
maldescent
 Scrotal sinus e.g. posterior TB
epididymal sinus
  Position of the external urethral meatus at
an abnormal site e.g. hypospadias or
epispadias.

 Penile abnormalites e.g.

Penile  Penile curvature,
Conditions  Micropenis,
 Concealed penis,
 Priapiasm and
 Peyronie’s disease.
  Definition: the presence of blood in the semen
 Usually intermittent, benign, self- limiting, and no
cause identified.
 Causes
 • Age <40y: usually inflammatory (e.g. prostatitis,
epididymo- orchitis,urethritis); infective, including
sexually transmitted diseases (StDs) (e.g.
Haemospermia gonococcus), non- StD infection (e.g.
Enterococcus faecalis), or viral infection (e.g.
herpes simplex), urethral warts, or idiopathic .
 Rarely, testicular tumour; perineal or testicular
trauma.
 • Age >40y: as for men aged <40— the
commonest cause is now post-transrectal
ultrasound (trUS) biopsy of the prostate; prostate
cancer; bladder cancer; testicular cancer.
  Pathology within the scrotum (strangulated
inguinal hernia).
 Torsion of the testicles.
 Torsion of testicular appendages.
Acute  Epididymo- orchitis.
Scrotal pain  Testicular tumour.
 Infected Hydrocele, Hematocele.
 Referred pain (Ureteric colic).
  Testicular pain syndrome.
 Testicular tumour.
 Previous trauma or surgery, e.g. hernia
repair, hydrocele repair, epididymal cyst
removal, varicocele repair.
Chronic  Post- infection.
scrotal pain  Diabetic neuropathy.
 Post- vasectomy pain syndrome (1– 15%
of men post vasectomy; in some men,
caused by obstruction to the vas, sperm
granuloma, and chronic epididymitis).
 Epididymal pain syndrome.
  Mild cases are asymptomatic (discovered incidentally)
or show non-specific symptoms as headache, lack of
concentration, anorexia and easy fatigability.
 The symptoms of renal failure include:
 Lack of concentration (an early symptom).
 Headache and blurring of vision.
Uremic  Easy fatigability, tachypnea and palpitation (due to
Manifestations anemia, acidosis and hypertension)
 Gastrointestinal manifestations (Early: anorexia &
dyspepsia. Late: dry mouth, metallic taste, nausea,
vomiting, hiccup & abdominal distension)
 Bleeding tendency (late) e.g. epistaxis and
hematemesis.
 Itching (late).
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