Signs & Symptoms of Urological Diseases (lecture notes)

Mr. Lau Ban Eng

Adjunct Associate Professor of Surgery
Consultant Urologist, Loh Guan Lye Specialists Centre
Urology

A surgical specialty devoted to the study and

treatment of diseases and disorders of the male
genitourinary and female urinary tracts
Urology

Abt 15% of patients initially presenting to a physician

will have a urologic complaint or abnormality

Wide overlap with other specialities

Nephrology, neurology, O&G, cardiology etc

Urologic Manifestations of Disease

UT

Direct
Signs & symptoms directly related to the male GUT or female

e.g. haematuria, scrotal swelling

Referred to or from other organ system

to other areas within the GUT or to contiguous organ systems

Ureteric stone causing testicular pain, nausea & vomiting

associated with renal colic, other GIT symptoms
Manifest in different organ systems

Bone pain, pathological fracture, lower limb paralysis fr bone

metastases secondary to prostate cancer
Primary disease in other organ systems result in secondary
urologic signs & symptoms

Polyuria fr. DM, lower lobe pneumonia as loin pain

Systemic
Fever , weight loss, malaise

Asymptomatic

Symptoms arising fromUrinary Tract

Systemic
Fever
General malaise
Weight loss
Nausea vomiting
Edema
Specific
Pain
Alterations in micturation
Changes in the gross appearance of Urine
Abnormal appearance and/or function of male external
genitalia

Pain from GUT

Renal pain
Ureteric (ureteral) pain
Bladder pain
Prostate pain
Penile pain
Scrotal pain

Renal Colic

Kidney & its capsule: sensory nerve T10 to L1

Due to
Capsular distension or peritoneal irritation
Distension of the renal collecting system

Dull, aching to very severe pain over the renal angle

May radiate towards umbilicus or lower abdomen

Type of sensation experienced

Determined by the primary disease process within the
kidney
depends on the degree and rapidity of capsular and/or
collecting system distension

Ureteric Colic

Due to sudden obstruction and distension, caused by renal

pelvic and ureteric muscle spasm, and renal capsular distension

Upper ureter
same innervation as the kidney
Upper ureteric pain similar distribution as renal pain

Lower Ureter
Sensory fibers to the cord through ganglia subserving major
pelvic organ
Lower ureteric pain felt in suprapubic area, bladder, penis or
urethra

Loin pain renal /ureteric causes

Inflammatory
Pyelonephritis
Fever, chills
Dysuria, haematuria
Papillary Necrosis
DM, sickle cell disease, analgesic abuse
Perirenal abscess
Obstructive
Stones
Ureteric stricture
Previous surgery, radiation
Compression of ureters
Colonic mass, pelvic mass, retroperitoneal fibrosis
Neoplastic
Renal cell carcinoma
Traumatic
Congenital
PUJ Obstruction

Questions to ask

Pain
Onset of pain
Sudden suggest obstruction - stones
Severity of pain
Dull or sharp
Constant or intermittent
Aggravating / relieving factors
Breathing, posture, activities
Similar prior episodes
Possible stone recurrence
Associated symptoms
Fever, chills, dysuria
Inflammatory / infective in origin
Weight loss
Malignancy, chronic infection
Haematuria
Malignancy, stones, infection
Medical history
DM, Stone, radiation therapy, trauma, drug abuse, TB.
Surgical History
FH
Malignancy, stones
Smoking
RCC, TCC

Loin pain other causes

Posterior of kidneys

spines, muscles
Kidneys / ureters
Anterior of kidneys
Right Side
Gallbladder
Duodenum
Pancreas
Ascending colon, appendix
Left side
Spleen
Aorta
Superior
Basal pneumonia
Factitious/drug seeking
Pain

Bladder
Sharp or dull in suprapubic area
Due to retention, overdistension or inflammation
Severe pain or discomfort if acute distention
Painless in chronic distention
Inflammation - sharp, burning pain, often referred to tip
of penile urethra in male and entire urethra in female

Pain

Prostate Pain
Dull ache in lower abdomen, rectum, perineum or
anterior thigh
Associated with micturation symptoms

Pain

Penile/ Urethral pain

Generally directly related to a site of inflammation

Pain over tip of penis

Exacerbated by micturation
Scrotal Pain
Arises from disorders of testis and epididymis
May be referred pain from lower ureter
May refer to groin or lower abdomen
Acute pain
Trauma, torsion, acute inflammation
Dragging sensation, dull ache
Hydroceles, varicoceles or tumours
Mass in the loin / Upper quadrant

Renal
Hydronephrosis
Polycystic kidney
Renal tumour
Perinephric abscess
Non-Renal

Alternations of Micturation
Changes in urine volume
Irritative (filling) symptoms
Obstructive (voiding) symptoms
Incontinence
Enuresis

Changes in Urine Volume

Anuria & oliguria

UO< 0.5mls/kg/hr
Prerenal, renal and post renal
Shock hypovolaemia, sepsis

Renal failure
Ureteric obstruction
Polyuria
Increase in UO (> 2.5l per day)
Increase fluid intake, diuretics, DM
Dysuria
Strangury
Frequency
Nocturia
Urgency

Irritative Symptoms

Irritative Symptoms

Dysuria

Painful micturation

Associated with inflammation of bladder, urethra or prostate

Felt in entire urethra in females and distal urethra in males

Strangury

Repeated desire to pass urine

Likely due to infection, stone in urethra

Increased frequency

Day time frequency

Urological causes

UTI, incomplete bladder emptying, detrusor instability, small

bladder volume, bladder cancer

Non-Urological causes

Excess fluid intake, psychological, or failure of kidneys to

concentrate urine: diabetes insipitus, hypercalcaemia, DM

Irritative Symptoms

Nocturia
> 2 times per night
vs nocturnal diuresis
Mobilisation of dependent fluids
Loss of diurnal secretion of ADH
Decrease in real or effective bladder capacity

Associate with increase in day time requency

Can be due to insomnia

Urgency
Sudden, severe urge to void that may or may not be
controllable (urge incontinence)
Due to inflammation, bladder stone, BPH, idiopathic,
neurogenic or neoplastic causes

Obstructive Symptoms
(Voiding Symptoms)

Hesitancy

Straining

Poor stream

Intermittency

Terminal dribbling

Sensation of incomplete emptying

Urinary retention

Bifurcation

Voiding symptoms a better term

Can be due to bladder outlet obstruction or poor

detrusor problem

Hesitancy
Need to wait before urine stream begins
Causes :

Psychological

Bladder outlet obstruction: tumour, stone, prostatic

enlargement

Urethral obstruction: stricture, stone

Straining
Obstruction or poor detrusor function

Intermittency
Urinary stream is interrupted during micturatuion
Bladder/urethral stone, benign prostatic hyperplasia

Poor stream

Bladder outlet obstruction or poor contrctility of

bladder

Incomplete emptying
Feeling that the bladder is not emptied at the end of
micturation
Prostatic enlargement, detrusor dysfunction

Terminal dribbling
Progressive reduction in rate of urine flow at the end of
urine stream
Associated with prostatic obstruction

Obstructive Symptoms

Urinary Retention
Acute

associated with severe suprapubic discomfort

Chronic

chronic, gradual due to progressive obstruction and

bladder decompensation

Usually asymptomatic

Associate with overflow incontinence

Palpable bladder

Bifurcation (split stream)

Occur intermittently without obvious pathology
Bladder outlet obstruction

LUTs
Lower Urinary Tract Symptoms
Irritative + obstructive symtoms
Due to Storage (bladder) or outlet problems
Incontinence

Incontinence
True or total constant dribbling of urine fr bladder

Fistula bt urinary tract and exterior

Injury to sphincter trauma, childbirth

Stress

Leakage during transient increase in abdominal

pressure e.g. coughing or laughing
Urge

A strong desire to pass urine of such severity that the

patient is unable to reach the toilet

Severe inflammation, overactive or neuropathic

bladder
Overflow or false

due to chronic retention of urine

Enuresis

Bed wetting at night

Changes in the appearance of urine

Cloudy urine
Pneumaturia
Red coloured urine
Macroscopic haematuria
Discoloration (pseudo-haematuria)

Cloudy Urine

Phosphaturia
Commonest cause of cloudy urine
Due to precipitation of phosphates in an alkaline urine
Intermittent, noted after meals or consumption of large
quantities of milk

Pyuria
Pus cells in urine
Infection, malignancy
Chyluria
Presence of lymph fluids & triglycerides in the urine
Noted after fatty food
Parasitic filariasis, TB, retroperitoneal tumours, trauma

Questions to ask
Intermittent or continous?

Occur after fatty meals or drinking of milk?

Fever/night sweats?

Hx of TB? Hx of trauma?

Loss of weight, appetite?

Travelling to filariasis countries?

Haematuria?

Pneumaturia

Passage of gas along with urine while voiding

Fistula bt GI and GUT

Colonic diverticular disease, malignancy, post
radiation, inflammatory bowel disease

Gas forming organisms (rare)

Red-coloured Urine
Pseudo-haematuria

Drugs (pyridium, rifanpicin)

Vegetables (beetroots)
Dyes
Vaginal bleeding (menstrual bleeding)
Medical diseases (obstructive jaundice, prophyria)

Haematuria

Haematuria - causes

Kidneys
Ureters
Bladder
Distal to bladder
Prostate (in male)
Urethra
Outside kidneys

Haematuria
Urologic causes

Kidney
Congenital
polycystic kidney
Trauma
Stone
Neoplastic
RCC, TCC renal pelvis
Inflammatory
TB, pyelonephritis
Infarction
SBE, arterial embolism
Ureter
Stone

Neoplasm
Bladder
Trauma
Stone
Neoplasm
Inflammatory
Cystitis, TB, bilharzia
Prostate
Neoplasm
BPH, CaP
Urethra
Trauma
Stone
Inflammatory
Neoplasm
TCC

Gross haematuria

Painless or painful?
Painless
Renal / ureteric tumour
Painful
Acute pyelonephritis, renal/ureteric calculus
Whole, initial or terminal stream
Initial: urethra
Whole stream: bladder or above
Terminal: trigone, prostate
Associated fever
Abnormal Appearance and/or Function of the Male Genitalia
Sexual dysfunction

Infertility
Penile Problems
Scrotal problems

Erectile dysfunction

Unable to achieve an erection or erection cannot last

long enough to achieve a satisfactory sexual intercourse
Penile problems

Cutaneous lesions
Infective (STD) vs non infective
Benign vs malignant

Penile curvature
Peyronies disease

Urethral discharge
Infection (STD)
Sexual partners

Haemospermia
Benign congestion, inflammation/infection of prostate,
seminal vesicles,
Need to exclude prostate cancer in elderly
Scrotal Problems

Scrotal swelling and masses

Age, onset, pain
Physical examination is important
Torsion, epididymo-orchitis, testicular cancer,
hydrocele, varicocele, inguinal hernia, undescended testis

History Taking
General points
Other clinical complaints which may be urological
Backpain from metastatic CaP
PUO from renal carcinoma
Fever

UTI esp. acute pyelonephritis

Chronic pyelonephritis is not associated with fever
Renal carcinoma
General Malaise and Weight Loss

Cancer
Chronic infection: TB
Chronic renal failure
Chronic renal failure
Renal tumours
Chronic infection
Blood loss
Severe haematuria

Anaemia

Previous and Family history

Previous history:
Occupation: hot climax
Dietary intake e.g. excess milk intake
Fluids intake (frequency-volume chart)
Previous operation
Family history of stone, renal tumour
Occupational history:

Important in Ca bladder

Naphthylamines and benzinine in chemical and dye

industry

Clinical Examination Urinary Tract

Inspection
Pallor, Fever, Blood pressure
Tongue
Dehydration from water and electrolyte disturbances
Fishy smell of uraemia
Abdomen and loin

Most reliable method of identifying a renal mass in

children
Scar from previous operation
Mass from renal tumour, renal abscess

Groin mass
Transplanted kidney

Palpation
Examination of the kidney
Lie supine on a firm surface
Bimanual palpation
Kidney move downwards on deep inspiration
Size, shape and consistency
Right side
lower than left
Possible to feel lower pole in thin patients
Left side
Not felt unless enlarged or displaced
Enlargement
Polycystic kidney, renal cyst, tumour, hydronephrosis,
pyonephrosis
Palpation

Renal colic:
Tenderness over renal angle, iliac fossa.
No rebound or guarding
Percussion

Renal mass
More easily outlined by percussion

Renal punch
Gentle percussion with the heel of the hand in the
angle bt lumbar vertebrae and 12th rib to elicit underlying
tenderness in kidney due to obstruction or inflammation

Auscultation
Bruit over the upper abdomen
Renal artery stenosis or aneurysm
AV fistula
Physical examination

Bladder
Supine position
Distended bladder might be visible and palpable,
cannot get below it!
Dullness on percussion

External genitalia
Foreskin, glan penis, urethral meatus
Hypospadias, phimosis, penile tumour, warts,
hydrocele, testicular cancer, varicocele

Clinical Examination of scrotal swelling

Can I get above the swelling?

Can I identify the testis and epididymis?

If yes: what is the relationship of the mass to the testis
and epididymis?

Is the swelling transilluminated?

Is the swelling tender?

Retractile
Can be coaxed into the scrotal sac

Ectopic
Outside the external ring but not along the course of
descent
Suprapubic, infrapubic, superficial pouch bt external
oblique fascia & Scarpas fascia, femoral, perineal &
prepenile

Undescended
Palpable
at the external ring
neck of scrotum
sometimes along the inguinal canal
Non-palpable
Inguinal canal
Intra-abdomen
?? Truly absent
Physical examination
Digital rectal examination
To identify abnormality within anal canal and rectum
To determine size, contour and consistency of prostate
PV examination in female
Urethral prolapse, urethral tumour