Symptoms, signs and investigation of urinary tract disorders

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34

Symptoms, signs and investigation of urinary tract disorders

Introduction

Urinary tract disorders are common and comprise a significant part of the workload of GPs, general physicians, paediatricians and surgeons. Many general surgeons deal with urological problems, which make up about 25% of their workload. Prostate disorders account for at least half of the work in urological surgery. The main conditions are benign prostatic hyperplasia, affecting about 10% of ageing males in Western countries, and prostatic carcinoma, now the second most common cancer in men worldwide and the commonest cancer diagnosed in men in developed countries. The remaining surgical disorders of kidney and urinary tract can be divided into five broad groups: tumours, stone disease (urolithiasis), infections, congenital abnormalities and finally, local and systemic disorders secondarily involving the urinary tract.

This chapter deals with the symptoms, signs, approach to investigation and diagnosis of urinary tract disease. The various disease entities are then discussed in the following five chapters.

Symptoms of urinary tract disease

Urinary symptoms may be caused by intrinsic disease of the urinary tract or by disease of other structures.

Symptoms caused by intrinsic disease of the urinary tract

Outflow of urine from the kidney may become impeded by urinary tract obstruction, which may secondarily interfere with renal function. Chronic obstruction to bladder outflow or bilateral upper tract obstruction may lead to renal failure, often without any localising symptoms.

Benign prostatic hyperplasia is the most common prostatic disorder, and usually presents with symptoms of bladder outflow obstruction (i.e. micturition disorders or urinary retention or both) and sometimes with haematuria. Prostatic obstruction predisposes to bladder infections or stones and the patient may present with the consequent symptoms.

Prostate cancer may present with bladder outflow obstruction similar to benign hyperplasia or it may be discovered at an asymptomatic stage at a medical check-up, by digital rectal examination (DRE) or by a blood test (prostate specific antigen, PSA). Some cases are first diagnosed because of symptoms of metastases, such as bone pain.

Chronic prostatitis may be bacterial or abacterial and usually presents with a chronic perineal ache. In the acute form, bacterial prostatitis can present as a systemic illness (or even Gram-negative sepsis) with urinary symptoms and an exquisitely tender prostate. Occasionally, a prostatic abscess develops.

The important urinary tract tumours, stone diseases and infections are outlined in Table 34.1. Any of these may present with haematuria. Disorders which cause urinary stasis also predispose to urinary tract infection.

Congenital abnormalities may involve the kidneys, ureters, bladder, urethra and genitalia, either alone or in combination. Most of the serious abnormalities are recognised antenatally by ultrasound, at birth or in early childhood. The exceptions are polycystic disease and medullary sponge kidney, which usually present in adulthood. Less serious congenital abnormalities such as duplex systems may predispose to urinary tract infections because of abnormal flow dynamics. These abnormalities may be discovered at any age during investigation of recurrent urinary infections. Congenital disorders which present mainly in adulthood are discussed in Chapter 39 and those presenting mainly in childhood in Chapter 51.

Abdominal pain

Urinary tract disorders may cause abdominal pain with or without urinary symptoms.

Pain arising from the kidneys and upper tract: Both renal inflammation and stretching of the renal capsule cause pain in the renal angle, the posterior gap between the lowest rib and iliac crest. This area may also become tender to palpation or percussion. Renal stones, tumours or polycystic disease may cause dull and persistent loin pain even without obstruction.

In acute infections such as pyelonephritis (affecting renal pelvis and kidney) or bladder infection, the pain is severe and is usually associated with systemic features and urinary tract symptoms.

Acute upper ureteric obstruction and distension of the pelvicalyceal system produce excruciating loin pain. The pain is colicky (resulting from powerful ureteric peristalsis) and often radiates to the hypochondrium (right or left upper quadrant of the abdomen) or groin (see Fig. 34.1). This pain is known as renal or ureteric colic. When obstruction is low in the ureter, the pain may radiate to the genitalia.

Pain simulating urinary tract disease: Pain from other abdominal pathology may sometimes mimic pain arising from the urinary tract. Acute appendicitis may present with suprapubic pain, and biliary tract pain may be referred to the right thoracolumbar region, while posterior duodenal ulcers and pancreatic disease may cause pain in the central lumbar region. An expanding or leaking abdominal aortic aneurysm may sometimes mimic urinary tract disease, particularly if a ureter is compressed. Diseases of the thoracolumbar spine, such as metastatic cancer, tuberculosis, spondylosis and disc lesions, may also simulate upper urinary tract disorders. Suspected renal colic with a local rash is usually due to shingles (herpes zoster); the rash may not appear for several days after the onset of pain; perineal zoster may cause retention of urine. In women, pain arising from the ovaries or genital tract (e.g. pelvic inflammatory disease) may be confused with bladder pain.

Haematuria

Patients may notice blood or even clots in the urine (frank haematuria) and this needs to be distinguished from urethral bleeding. More often, blood is discovered on ‘dipstick’ testing or microscopy of a midstream urine specimen (microscopic haematuria). Haematuria is often episodic rather than persistent, whatever the cause. ‘Dipstick’ testing for haematuria is extremely sensitive and yields many false positive results.

Causes of haematuria (see Fig. 34.2 for renal causes)

Tumours are a common cause of frank or microscopic haematuria and must be suspected even if another possible cause is found. Haematuria from tumours is typically painless. However, carcinoma-in-situ of the bladder, a dysplastic condition with a high probability of progression to invasive carcinoma, usually presents with irritative voiding, dysuria and haematuria. Irritation from infection or stones may also cause bleeding, but is usually accompanied by pain or dysuria. If the urethra is obstructed by prostatic enlargement, straining at micturition may cause bleeding from dilated veins at the bladder neck.

Trauma to a normal kidney may cause frank haematuria if substantial force has been applied, but microscopic haematuria is common after minor trauma in contact sports and rarely indicates significant injury. Enlarged kidneys are more susceptible to trauma, whatever the primary pathology. In hydronephrosis or polycystic kidneys, minor blunt trauma may cause gross haematuria.

Sometimes urine becomes red with haemoglobin rather than blood. In young people this may be induced by vigorous exercise such as jogging (exercise haemoglobinuria and haematuria). These patients are believed to have defective red cell membranes which makes them more vulnerable to trauma. Exercise haemoglobinuria is self-limiting and requires no treatment.

Haematuria also occurs in renal parenchymal inflammation such as glomerulonephritis or arteritis. Haematuria may also be caused by microemboli impacting in the kidneys, as in atrial fibrillation or infective endocarditis. Any urinary tract disorder with a potential for haematuria is more likely to be revealed when a patient is on anticoagulant therapy or develops a bleeding diathesis.

Diagnostic features of haematuria

The stage of micturition at which blood appears is sometimes diagnostically useful. Blood from the kidneys, ureters or bladder wall will completely mix with the urine, and be present throughout the urinary stream. Urethral bleeding may leak out independently of micturition, or be seen only at the beginning or end of the urinary stream. Blood arising from the bladder neck or posterior urethra may sometimes present as terminal haematuria. Gross bleeding may result in the passage of clots.

Haematuria on dipstick testing should be confirmed by urine microscopy for red blood cells, and checked for infection by culture and sensitivity. Microscopic haematuria may represent a noteworthy lesion anywhere in the urinary tract and must be taken seriously; however, a significant cause is found in only 5–25% of patients.

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