Symptoms, signs and investigation of urinary tract disorders Flashcards
Symptoms of urinary tract disease
Symptoms caused by intrinsic disease of the urinary tract
- Urinary tract obstruction
- BPH
- Prostate cancer
- Chronic prostatitis
Symptoms of urinary tract disease
Symptoms caused by intrinsic disease of the urinary tract
Tumours
Renal Cell Carcinoma:
- Also known as renal adenocarcinoma: occurs in adults, derived from renal tubular cells
- Presents either incidentally (e.g. on CT scan) or with symptoms of haematuria, a mass or constitutional signs such as pyrexia or polycythaemia or is asymptomatic
Nephroblastoma (Wilms’):
- Developmental origin - usually diagnosed at age 5
- Presents as abnormal mass without pain or haematuria
- Presents as an abnormal mass with or without pain and haematuria
Urothelial carcinoma (transitional cell carcinoma or TCC)—common:
- May arise in transitional epithelium anywhere in urinary tract from pelvicalyceal system to urethra, but most common in bladder
- Usually presents with haematuria. Predisposes to urinary tract infections.
May cause ureteric obstruction
Squamous cell carcinoma—very rare:
- Arises in metaplastic squamous epithelium. Secondary to chronic stone or schistosomal irritation, especially in bladder.
- Also arises de novo in squamous epithelium of distal urethra
- As for transitional cell carcinoma
Adenocarcinoma of bladder—very rare:
- Arises from columnar epithelium of urachal remnant
- As for transitional cell carcinoma
Symptoms of urinary tract disease
Symptoms caused by intrinsic disease of the urinary tract
Stone disease
In general:
- Stones in situ may cause irritation of urinary tract epithelium
- Present as pain or haematuria or recurrent infection
Stones may develop in pelvicalyceal system or bladder. Pelvicalyceal stones can pass into the ureter—very common:
- Chronic—renal stones may cause chronic pelviureteric or ureteric obstruction either directly or by causing fibrotic strictures
- Acute—renal stones may cause ureteric obstruction as they pass down the tract
- Present with chronic pain (due to back pressure) or recurrent infection
- Present as acute colicky pain often with renal tenderness (renal or ureteric colic).
- Infection may supervene, destroying the kidney if untreated
Symptoms of urinary tract disease
Symptoms caused by intrinsic disease of the urinary tract
Infections
‘Common’ infections due to bowel organisms:
- Infection develops either via bloodstream (haematogenous) or lower urinary tract stasis predisposes to infection
- Typically present with dysuria and frequency with or without haematuria.
- Any urinary tract abnormality or stasis predisposes to infection
Ascending infection may cause pyelonephritis, i.e. infection of kidney and renal pelvis
Tuberculosis—uncommon:
- Kidney involvement via bloodstream from pulmonary or other primary disease. May spread via urine to ureters and bladder
- May present as haematuria, persistent sterile pyuria, or as an incidental finding in pulmonary tuberculosis
Urinary schistosomiasis (also known as bilharzia)—very common in some developing countries; probably the world’s most common cause of haematuria:
- Induces chronic inflammation and fibrosis in bladder wall leading to gross bladder distortion, stones and sometimes squamous cell carcinoma
- Presents with haematuria and various symptoms of infection and bladder fibrosis
Urethritis:
- Usually caused by sexually transmitted infections, e.g. gonococcus or Chlamydia
- Presents with urethral discharge and dysuria
Symptoms of urinary tract disease
Urinary symptoms caused by non-urinary disease
- Crohn’s disease or diverticular disease.
- Fistulae may form, resulting in passage of flatus and/or faeces in the urine (pneumaturia and faecuria).
- Retroperitoneal fibrosis, diverticulitis, tumours of the prostate, cervix or colon, and sometimes aortic or iliac aneurysms may secondarily involve the ureters and cause upper urinary tract obstruction
The common symptoms of urinary tract disease
- Abdominal pain
- Passage of blood in the urine (haematuria)
- Pain associated with micturition (dysuria)
- Disorders of micturition such as frequency or hesitancy
- Retention of urine (acute or chronic)
- Urinary incontinence
- Passage of bowel gas in the urine (pneumaturia)
- Passage of blood in the semen (haemospermia)
Causes of incontinence of urine
Loss of cortical control:
- Cortical disease
- Spinal cord disease, i.e. supra-sacral neurogenic bladder
Abnormalities of the sacral reflex mechanism:
- Sacral neurogenic bladder
- Overactive bladder
- Infection producing bladder hyperactivity
- Hypotonic bladder
Detrusor or sphincter abnormalities:
- Stress incontinence
- Post-prostatectomy
- Tumour invasion
- Urethral trauma
- Contracted bladder
- Rare congenital abnormalities
Pneumaturia
Passage of gas mixed with urine. Causes of vesicocolic fistula and pneumaturia:
- Diverticular disease and pericolic abscess bursting into bladder (most common cause)
- Carcinoma of bladder invading colon
- Colonic carcinoma invading bladder
- Crohn’s disease inflammation fistulating into bladder
Blood tests useful in diagnosing urinary tract disease
Full blood count:
- Hypochromic microcytic anaemia—chronic iron deficiency anaemia due to haematuria (rare)
- Normochromic normocytic anaemia—chronic renal failure (lack of erythropoietin), chronic inflammatory disorders, e.g. tuberculosis
- Polycythaemia—renal adenocarcinoma
- Leucocytosis—infection
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP):
- Raised in chronic and acute infections, renal adenocarcinoma and retroperitoneal fibrosis
Urea, electrolytes and creatinine:
- Impaired renal function in bilateral obstructive uropathy or chronic renal failure associated with hypertension, diabetes, etc
Prostate specific antigen:
- Raised in carcinoma of prostate. A normal level does not exclude prostatic carcinoma.
- Moderate elevations occur in benign disease, especially with acute retention of urine, urinary tract infection and following urethral instrumentation or prostatic biopsy
Alkaline phosphatase (bone isoenzyme):
- Raised in multiple bony metastases from any type of tumour
Calcium, phosphate, uric acid and parathyroid hormone levels:
- Useful investigations in stone disease
What urine tests are indicated?
Midstream urine (MSU):
- specimen for microscopy and bacteriology
- will show the presence or absence of significant numbers of red blood cells (microscopic haematuria),
- white cells (pyuria) and bacteria (bacteriuria).
Urine cytology
- screening test for urothelial tumours in people at high risk
- The test has a high positivity in carcinoma-in-situ and poorly differentiated tumours.
- Cytology needs to be performed on freshly voided urine
