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SYMPTOMS IN UROLOGY

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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SYMPTOMS IN UROLOGY

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  1. SYMPTOMS IN UROLOGY

  2. Classification A- Upper urinary tract symptoms. B- Lower urinary tract Symptoms. C- General symptoms.

  3. A- UPPER URINARY TRACT SYMPTOMS 1- Renal pain. 2- Renal swelling. 3- Abnormal urine colour. 4- Urinary fistula. 5- Abnormal urine volume.

  4. 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

  5. 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

  6. 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.

  7. Differential diagnosis 1.Biliary colic. 2. Acute appendicitis. 3. Colonic colic. 4. Basal pleurisy and pneumonia. 5. Herpes zoster.

  8. (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.

  9. 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).

  10. Abnormal urine color • It will be discussed later on.

  11. 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.

  12. 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.

  13. 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).

  14. 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).

  15. B. LOWER URINARY TRACT SYMPTOMS 1- PAIN 2- IRRITATIVE SYMPTOMS 3- OBSTRUCTIVE SYMPTOMS 4- INCONTINENCE 5- ABNORMAL URINE COLOUR 6- SWELLING 7- URINARY FISTULA

  16. 1- Pain 1. Suprapubic pain 1. Bladder 2. Colon 3. Uterus Cystitis syndrome: • increased urinary frequency • Painful micturition • change in the colour of urine.

  17. 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

  18. 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.

  19. 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)

  20. 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

  21. 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).

  22. 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.

  23. 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

  24. (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

  25. 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.

  26. 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.

  27. 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

  28. Perineal swelling Differential diagnosis • Urethra: • trauma and extravasation • Bilharzial perineal mass. • Anal canal: • perianal abcess • Skin and subcutaneous tissues: • lipoma

  29. 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,

  30. 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

  31. 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.

  32. 2- Cloudy Urine: (Turbid urine) Etiology: • Pyuria. • Phosphaturia. • Chyluria.

  33. 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).

  34. 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.

  35. 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

  36. C. General symptoms 1- Symptoms suggestive of uremia. 2- Symptoms suggestive of toxemia. 3- Symptoms suggestive of distant metastasis.

  37. 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.

  38. 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.

  39. 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

  40. 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

  41. 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 .

  42. 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.

  43. THANK YOU Thank you for your attention

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