The Abdomen Flashcards
Boundaries of the abdomen
The region lying between the thorax above and the pelvic cavity below.
The anterior abdominal wall is bounded by the 7-12th costal cartilages and the xiphoid process of the sternum superiorly, and the inguinal ligaments and pelvic bones inferiorly.
The abdominal cavity is separated from the thoracic cavity by the diaphragm.
Abdominal regions
Right hypochondrium – Epigastrium – Left hypochondrium
Right lumbar – Umbilical – Left lumbar
Right inguinal – Suprapubic – Left inguinal
Physiology of swallowing
The swallowing process is controlled by the medulla initially and by an autonomous peristaltic reflex coordinated by the enteric nervous system in the mid- and distal-oesophagus.
This complex process can be divided into 3 phases: oral phase, oro-pharyngeal phase, and oesophageal phase.
Physiology of swallowing: oral phase
Food enters the oral cavity.
Mastication and bolus formation.
Physiology of swallowing: oro-pharyngeal phase
Tongue elevates and propels the bolus to the pharynx.
The soft palate elevates to seal the nasopharynx.
The larynx and hyoid bone move anteriorly and cranially.
Epiglottis moves posteriorly and caudally to close the respiratory tract.
Respiration pauses.
Pharynx shortens.
Physiology of swallowing: oesophageal phase
Upper oesophageal sphincter relaxes. Bolus passes into the oesophagus. Oesophagus contracts sequentially (peristalsis). Lower oesophageal sphincter relaxes. Bolus enters the stomach.
Abdominal history: dysphagia overview
This is difficulty swallowing, the principal symptom of oesophageal disease. Level of obstruction Onset Time course Solids/liquids Associated symptoms
Abdominal history: dysphagia, level of obstruction
Where does the patient feel the obstruction?
Patients can often point to a level on the chest although the sensation usually correlates poorly with the actual level of obstruction.
Abdominal history: dysphagia, onset
How quickly did the symptoms emerge?
Obstruction caused by cancer may progress rapidly over a few months.
Benign peptic stricture may give very long history of GORD with slowly progressive dysphagia.
Abdominal history: dysphagia, time course
Is the symptom intermittent or constant?
Present for only the first few swallows: lower oesophageal ring, spasm?
Progressive: cancer, stricture, achalasia.
Abdominal history: dysphagia, solids/liquids
Solids, liquids, or both affected?
Both solids and liquids being affected equally suggests a motor cause (achalasia, spasm).
Solids affected more than liquids suggests some physical obstruction is more likely (e.g. cancer).
Abdominal history: dysphagia, associated symptoms
Heartburn (leads to oesophageal strictures)
Weight loss
Wasting
Fatigue (perhaps suggestive of cancer)
Coughing and choking suggest pharyngeal dysphagia due to motor dysfunction, e.g. motor neuron disease causing bulbar or pseudobulbar palsy.
Types of dysphagia
Oropharyngeal
Oesophageal
What is oropharyngeal dysphagia?
‘High’ dysphagia.
Patients have difficulty initiating a swallow and often feel as though the cervical/neck area is the level of apparent obstruction.
Symptoms relate to both the dysphagia itself and likely underlying causes: difficulty initiating swallow, nasal regurgitation, coughing, nasal speech, diminished cough reflex, choking, dysarthria and diplopia, halitosis.
What is oesophageal dysphagia?
‘Low’ dysphagia.
Patients find the site of apparent obstruction difficult to localise and may often point to their neck when the obstruction is actually within the distal oesophagus (e.g. in achalasia).
Causes of oropharyngeal dysphagia
Mechanical and obstructive: infections (e.g. retropharyngeal abscess), enlarged thyroid, lymphadenopathy, Zenker’s diverticulum, reduced muscle compliance (e.g. myositis, fibrosis), malignancy, large cervical osteophytosis.
Neuromuscular: stroke, Parkinson’s disease, bulbar palsy, motor neuron disease, multiple sclerosis, myasthenia graves, muscular dystrophy.
Other: poor dentition, oral ulcers, xerostomia.
Causes of oesophageal dysphagia
Mucosal disease: peptic stricture, oesophageal rings and webs (e.g. Plummer-Vinson syndrome), oesophageal tumours, chemical injury, radiation injury, infectious oesophagitis, eosinophilic oesphagitis.
Mediastinal disease: tumours, infection (e.g. TB, histoplasmosis), cardiovascular (e.g. vascular compression).
Smooth muscle/ innervation disease: achalasia (e.g. idiopathic, Chagas disease), scleroderma, post-surgical (e.g. post-fundoplication, antireflux devices, gastric banding).
Abdominal history: odynophagia
This is pain on swallowing and usually reflects a severe inflammatory process involving the oesophageal mucosa or, rarely, the oesophageal musculature.
The character may range from a dull retrosternal ache to a sharp, stabbing pain with radiation through to the back.
Severity can be such that patients feel unable to swallow their own saliva.
Abdominal history: odynophagia, causes
Chemical irritation: acid, alkali
Drug-induced oesophagitis: antibiotics e.g. doxycycline, potassium chloride, quinidine, iron sulphate, zidovudine, NSAIDs.
Radiation oesophagitis.
Infectious oesophagitis.
Healthy patients: Candida albicans, herpes simplex.
Immunocompromised patients: fungal (Candida, histoplasmosis), viral (herpes simplex, cytomegalovirus, HIV, EBV), Mycobacteria (tuberculosis, avium-complex), protozoan (Cryptosporidium, Pneumocystis jiroveci), idiopathic ulceration.
Severe ulcerative oesophagitis secondary to GORD.
Oesophageal carcinoma.
Abdominal history: globus sensation
This is the sensation of a ‘lump’ or tightness in the throat and is usually not related to swallowing.
Patients may describe this as a ‘tightness’, ‘choking’, or ‘strangling feeling’ as if something is caught in the throat.
Present between meals.
Swallowing solids or large liquid boluses may give temporary relief.
Exacerbated by emotional stress.
Dysphagia and odynophagia are not present.
Abdominal history: globus sensation, causes
The cause of globus sensation is often unclear and may be a combination of physiological and psychological factors.
Anxiety, panic disorder, depression, and somatisation are often present.
Physiological tests of oesophageal motility are often normal.
A combination of biological factors, hypochondriacal traits, and learned fear following an episode of choking can increase the symptom.
Abdominal history: heartburn and reflux
GORD.
Caused by the regurgitation of stomach contents into the oesophagus due to an incompetent anti-reflux mechanism at the gastro-oesophageal junction.
Site: mid-line, retrosternal.
Radiation: to the throat and occasionally the infra-scapular regions.
Nature: ‘burning’.
Aggravating factors: worse after meals and when performing postures which raise the intra-abdominal pressure (bending, stooping, lying supine); pregnancy.
Associated symptoms: acid or bitter taste (acid regurgitation), sudden filling of the mouth with saliva (waterbrash).
Acid reflux may be worsened by certain foods (alcohol, caffeine, chocolate, fatty meals) and some drugs (calcium channel blockers, anticholinergics) which act to reduce the GOJ sphincter pressure.
Hiatus hernia is another important cause of reflux symptoms.
Abdominal history: heartburn, causes
Decreased lower oesophageal sphincter pressure: foods (fats, sugars, chocolate, onions, coffee, alcohol); cigarette smoking; medication (calcium channel blockers, nitrates, diazepam, theophylline, progesterone, anticholinergics).
Direct mucosal irritation: foods (citrus fruits, tomato-based foods, spicy foods, coffee); medication (aspirin, NSAIDs, tetracycline, quinidine, potassium chloride, iron).
Increased intra-abdominal pressure: bending over, lifting, straining at stool, exercise.
Other: lying supine, lying on the right, red wine, high emotion.
Abdominal history: nausea
A feeling of sickness- the inclination to vomit.
Usually occurs in waves.
May be associated with retching or heaving.
Can last from seconds to days depending on the cause.
Abdominal history: vomiting (emesis)
The forceful expulsion of the gastric contents by reflex contractions of the thoracic and abdominal muscles.
Usually follows nausea and autonomic symptoms such as salivation.
Abdominal history: nausea and vomiting, onset
Over what time period have the symptoms developed?
Acute: cholecystitis, gastroenteritis, recreational drug use, pancreatitis.
Chronic: metabolic disorders, gastroparesis, GORD, pregnancy, medications.
Abdominal history: nausea and vomiting, timing
Be clear on exactly when vomiting tends to occur, particularly its relation to meals.
Before breakfast: alcohol, raised intracranial pressure, pregnancy, uraemia.
During or immediately after eating: psychiatric causes (also peptic ulcer disease, pyloric stenosis).
1-4 hours after a meal: gastric outlet obstruction, gastroparesis.
Continuous: conversion disorder, depression.
Irregular: major depression.
Abdominal history: nausea and vomiting, nature of the vomitus
Undigested food: achalasia, oesophageal disorders (e.g. diverticulum, strictures).
Partially digested food: gastric outlet obstruction, gastroparesis.
Bile: proximal small bowel obstruction.
Faeculent/ malodorous: fistula, obstruction.
Large volume: >1.5L in 24hrs, more likely physical than psychiatric.
Abdominal history: nausea and vomiting, associated symptoms and their causes
Malignancy: weight loss.
Viral: diarrhoea, myalgia, malaise, headache.
Central neurologic: headache, neck stiffness, vertigo, focal neurological signs/symptoms.
Gastroparesis: early satiety, post-prandial bloating, abdominal discomfort.
Cyclical vomiting syndrome: repetitive migraine headaches, symptoms of IBS.
Abdominal history: nausea and vomiting, haematemesis
Presence of blood indicates bleeding in the upper GI tract (oesophagus, stomach, duodenum, above the ligament of Treitz).
The amount of blood and the exact nature of it:
- Large volume of fresh, red blood suggests active bleeding (coincident liver disease and/or heavy alcohol intake may suggest bleeding oesophageal varies, abdominal pain and heartburn may suggest a gastric or oesophageal source such as PUD or GORD).
- Small streaks at the end of prolonged retching may indicate minor oesophageal trauma at the GOJ (Mallory-Weiss tear).
- Coffee-grounds: looking like small brown granules, this blood has been ‘altered’ by exposure to stomach acid, implying that the bleeding has ceased or is relatively modest.
Previous bleeding episodes, treatment, and outcome (e.g. previous surgery).
Cigarette smoking.
Use of drugs such as aspirin, clopidogrel, NSAIDS, and warfarin.
Ask about weight loss, dysphagia, abdominal pain, and melaena.
Abdominal history: causes of upper GI bleeding
Peptic ulceration Oesophagitis Gastritis/erosions Erosive duodenitis Varices Portal hypertensive gastropathy Malignancy Mallory-Weiss tear Vascular anomalies (e.g. angiodysplasia, AV malformation) Connective tissue disorders (e.g. Ehlers-Danlos syndrome) Vasculitis Bleeding diathesis
Abdominal history: nausea and vomiting, vomiting bile
Assess the presence or absence of bile.
Bile comes largely in 2 colours- the green pigment (biliverdin) often seen to colour the vomitus in the absence of undigested food; the yellow pigment (bilirubin) appears as orange, often occurring in small lumps.
Undigested food without bile suggests a lack of connection between the stomach and the small intestine (e.g. pyloric obstruction).
Abdominal history: abdominal pain, site
Pain from most abdominal organs cannot be felt directly- the sensation is referred to areas of the abdominal wall according to the organ’s embryological origin.
Ask the patient to point to the area affected.
Patients often find this challenging and may indicate a wide area.
A very localised pain may originate from the parietal peritoneum, e.g. appendicitis: may begin as umbilical pain then move to the right iliac fossa as the inflammation spreads to the peritoneum overlying the appendix.
Epigastric pain: foregut (stomach, duodenum, liver, pancreas, gallbladder).
Periumbilical pain: midgut (small and large intestines including appendix).
Suprapubic pain: hindgut (rectum and urogenital organs).
Abdominal history: abdominal pain, radiation
Ask the patient if the pain is felt elsewhere or if they have any other pains.
Right scapula: gallbladder.
Shoulder-tip: diaphragmatic irritation
Mid-back: pancreas
Abdominal history: abdominal pain, character
Ask the patient what sort of pain it is.
Give some examples if they have trouble but be careful not to lead the patient.
Colicky: pain that comes and goes in waves, indicates obstruction of a hollow, muscular-walled organ (intestine, gallbladder, bile duct, ureter).
Burning: may indicate an acid cause, related to the stomach, duodenum, or lower end of the oesophagus.
Abdominal history: abdominal pain, exacerbating/relieving factors
Ask the patient what appears to make the pain better or worse, or what they do to get rid of the pain if they suffer from it often.
Character of pain: renal colic
Colicky pain at the renal angles and loins, which are tender to touch, radiating to the groins/testicles/labia.
Typically, the patient writhes, unable to find a position that relieves the pain.
Character of pain: bladder pain
A diffuse, severe pain in the suprapubic region.
Character of pain: prostatic pain
A dull ache which may be felt in the lower abdomen, rectum, perineum, or anterior thighs.
Character of pain: urethral pain
Variable in presentation ranging from a ‘tickling’ discomfort to a severe sharp pain felt at the end of the urethra (tip of the penis in males) and exacerbated by micturition.
Can be so severe that patients attempt to ‘hold on’ to urine.
Character of pain: small bowel obstruction
Colicky central pain associated with vomiting, abdominal distension, and/or constipation.
Character of pain: colonic pain
Colicky central pain associated with vomiting, abdominal distension, and/or constipation.
Sometimes relieved by defaecation or passing flatus.
Character of pain: biliary pain
Severe, constant, right upper quadrant/epigastric pain that can last hours and is often worse after eating fatty foods.
Character of pain: bowel ischaemia
Dull, severe, constant, right upper quadrant/central abdominal pain exacerbated by eating.
Character of pain: pancreatic pain
Epigastric, radiating to the back and partly relieved by sitting up and leaning forwards.
Character of pain: peptic ulcer pain
Dull, burning pain in the epigastrium.
Typically episodic at night, waking the patient from sleep.
Exacerbated by eating and sometimes relieved by consuming milk or antacids.
Abdominal history: bowel habit
How often do you open your bowels?
Has this changed recently?
Blood?
Abdominal history: bowel habit, constipation
A disorder that can mean different things to different people.
Normal bowel habit ranges from 3 times a day to once every 3 days.
Constipation is the passage of stool <3 times/week, or stole that area hard or difficult to pass.
Duration of constipation?
Frequency of bowel action?
Stool size and consistency?
Straining, particularly at the end of evacuation?
Associated symptoms (nausea, vomiting, weight loss)?
Pain on defaecation?
Rectal bleeding?
Intercurrent diarrhoea?
Fluid and fibre intake?
Depression, lack of exercise?
DHx (prescription and over the counter)?- codeine, antidepressants, aluminium, and calcium antacids.
Metabolic or endocrine diseases?- thyroid disorders, hypercalcaemia, diabetes, phaeochromocytoma.
Neurological problems?- autonomic neuropathy, spinal cord injury, multiple sclerosis, Hirschprung’s disease.
Abdominal history: bowel habit, diarrhoea
Defined as an increase in stool volume (>200mL daily) and frequency (3/day).
Also a change in consistency to semi-formed or liquid stool.
Establish the time course since acute diarrhoea is suggestive of infection.
Colour, consistency, offensive smell, ease of flushing?
Duration?
Does the diarrhoea disturb the patient’s sleep?
Is there any blood, mucus, or pus?
Associated pain or colic?
Is there urgency?
Nausea, vomiting, weight loss?
Any difference if the patient fasts?- no change in ‘secretory’ diarrhoea, e.g. E. coli, S. aureus; disappears on fasting = ‘osmotic’ diarrhoea.
Foreign travel?
Recent antibiotics?
Abdominal history: bowel habit, causes of constipation
Low fibre diet.
Physical immobility (e.g. stroke, Parkinson’s disease).
Functional bowel disease (constipation-predominant IBS).
Drugs (e.g. opiates, iron, antidepressants, aluminium, antacids).
Metabolic and endocrine diseases (e.g. hypothyroidism, hypercalcaemia, hypokalaemia, diabetes mellitus, porphyria, phaeochromocytoma).
Neurological disorders (e.g. autonomic neuropathy, spinal cord injury, multiple sclerosis).
Colonic stricture.
Anorectal disease (e.g. anal fissure- causes pain to the extent that the patient may avoid defaecating altogether).
Habitual neglect.
Depression.
Dementia.
Abdominal history: bowel habit, causes of diarrhoea
Malabsorption: may cause steatorrhoea, a fatty, pale stool which is extremely odorous and difficult to flush.
Increased intestinal motility: hyperthyroidism, IBS.
Exudative: inflammation of the bowel causes small volume, frequent stools, often with blood or mucus (e.g. colonic carcinoma, Crohn’s disease, ulcerative colitis).
Osmotic: large volume of stool which disappears with fasting; causes include lactose intolerance, gastric surgery.
Secretory: high volume of stool which persists with fasting; no pus, blood, or excessive fat; causes include GI infections, carcinoid syndrome, villous adenoma of the colon, Zollinger-Ellison syndrome, VIP (vasoactive intestinal polypeptide)-secreting tumour.
Other: drugs (especially antibiotics), laxative abuse, constipation and faecal impaction (overflow), small bowel or right colonic resection.
Abdominal history: bowel habit, fat malabsorption (steatorrhoea)
A common feature of pancreatic insufficiency.
Also caused by coeliac disease, IBD, blind bowel loops, and short bowel syndrome.
Pale stool.
Offensive smell.
Poorly formed.
Difficult to flush (floats).
Abdominal history: bowel habit, rectal bleeding
Amount?- small amounts can appear dramatic, colouring the toilet water red.
Nature of the blood?- red, brown, black.
Is it mixed with the stool or in the stool?
Is it spattered over the pain, with the stool, or only seen on the paper?
Any associated features?- mucus may indicate IBD or colonic cancer.
Abdominal history: bowel habit, melaena
This is jet-black, tar-like and pungent-smelling stool representing blood from the upper GI tract (or right side of the large bowel) that has been ‘altered’ by passage through the gut.
Ask about iron supplementation or bismuth-containing compounds- cause blackened stools but without the melaena smell or consistency.
Abdominal history: bowel habit, causes of lower GI bleeding
Haemorrhoids. Anal fissure. Diverticular disease. Colorectal carcinoma. Colorectal polyp. Angiodysplasia. IBD. Ischaemic colitis. Meckel's diverticulum. Small bowel disease (e.g. tumour, diverticula, intussusception, Crohn's). Solitary rectal ulcer. Haemobilia (bleeding into the biliary tree).
Abdominal history: bowel habit, mucus
Clear, discoid secretion of the mucous membranes.
Mucus contains epithelial cells, leukocytes, and various salts suspended in water.
Presence of mucus in or on stool may indicate: IBD, solitary rectal ulcer, small or large bowel fistula, colonic villous adenoma, IBS.
Abdominal history: bowel habit, flatus
Small amounts of gas frequently escape from the bowel via the mouth (eructation) and anus and the notable excessiveness of this is a common feature of both functional and organic disorders of the GI tract.
Often associated with abdominal bloating and caused by the colonic bacterial fermentation of poorly absorbed carbohydrates.
Excessive flatus is a particular feature of: hiatus hernia, peptic ulceration, chronic gallbladder disease, air-swallowing (aerophagy), high-fibre diet, lactase deficiency and intestinal malabsorption.
Abdominal history: bowel habit, tenesmus
This is the feeling of the need to ope the bowels with little or no stool actually passed.
The sensation may be constant or intermittent and is usually accompanied by pain, cramping, and involuntary straining.
Causes include: IBD, anorectal abscess, infective colitis, colorectal tumours/polyps, radiation proctitis, IBS, and thrombosed haemorrhoids.
Abdominal history: generalised abdominal swelling, causes
Fat Fluid Flatus Faeces Foetus Functional F'ing big tumour Fibroids
Abdominal history: ascites in decompensated liver disease
In decompensated cirrhosis, a combination of portal (sinusoidal) hypertension and Na and H2O retention favours the transudation of fluid into the peritoneal cavity (ascites).
The resultant swelling may be unsightly- it can also cause shortness of breath by putting pressure on the diaphragm from below, particularly when supine and may be associated with pleural effusions.
Abdominal history: jaundice
Jaundice (‘icterus’) is a yellow pigmentation of skin, sclera, and mucosae caused by excess bilirubin in the tissue.
Jaundice results from interference in the normal metabolism of bilirubin (including uptake, transport, conjugation, and excretion).
Colour of the urine?- dark in cholestatic jaundice due to renal excretion of conjugated bilirubin.
Colour and consistency of stools?- pale in cholestatic jaundice.
Abdominal pain? e.g. caused by gallstones.
Previous blood transfusions?
Past history of jaundice, hepatitis, pancreatitis, or biliary surgery.
Drugs? e.g. antibiotics, NSAIDs, oral contraceptives, phenothiazines, herbal remedies, anabolic steroids.
IVDU?
Tattoos and body piercing?
Foreign travel and immunisations?
Sexual history?
FHx of liver disease?
Alcohol consumption?
Personal contacts who also have jaundice?
Occupational exposure to hepatotoxins?
Abdominal history: jaundice, pre-hepatic causes (unconjugated hyperbilirubinaemia)
Overproduction: haemolysis; ineffective erythropoiesis.
Impaired hepatic uptake: drugs (contrast agents, rifampicin), congestive cardiac failure.
Impaired conjugation: Gilbert’s syndrome, Crigler-Najjar syndrome.
Abdominal history: jaundice, hepatic causes (conjugated hyperbilirubinaemia)
Infection: viral hepatitis, CMV, liver abscess, septicaemia.
Alcohol and toxins: carbon tetrachloride, fungi (Amanita phalloides).
Drug-induced hepatitis: paracetamol, anti-tuberculosis drugs (isoniazid, rifampicin, pyrazinamide), statins, sodium valproate, halothane.
Metabolic: haemochromatosis, alpha-1-antitrypsin deficiency, Wilson’s disease, Rotor syndrome.
Vascular: Budd-Chiari, right-sided heart failure.
Abdominal history: jaundice, post-hepatic causes (conjugated hyperbilirubinaemia)
Luminal: gallstones.
Mural: cholangiocarcinoma, sclerosing cholangitis, primary biliary cirrhosis, choledochal cyst.
Extra-mural: pancreatic cancer, lymph nodes at porta hepatis.
Drugs: antibiotics (flucloxacillin, fusidic acid, coamoxiclav, nitrofurantoin), steroids, sulphonylureas, chlorpromazine, prochlorperazine.
Abdominal history: pruritus
This is itching of the skin and may be either localised or generalised.
The mechanism is not fully understood but is likely due to increased bile acid levels secondary to cholestasis.
It has many causes, but is particularly associated with choletatic liver disease (e.g. primary biliary cirrhosis, sclerosing cholangitis).
Abdominal history: appetite and weight loss, triggers for concern
Poor intake for longer than 1-2 weeks.
Weight loss of >10%.
Abdominal history: appetite and weight loss
Ask the patient about their eating habit and average daily diet.
When was the symptom first noticed?
Quantify the problem- how much weight lost, over what time period?
Cause of the anorexia?- does eating make the patient feel sick?
Does eating cause pain? e.g. gastric ulcer, mesenteric angina, pancreatitis.
Any accompanying symptoms?- abdominal pain, nausea, vomiting, fever, menstrual irregularities, low mood.
Colour and consistency of stools? e.g. steatorrhoea.
Urinary symptoms?
Recent change in temperature tolerance?
Abdominal history: lower urinary tract symptoms
Urinary frequency Urgency Nocturia Urinary incontinence Terminal dribbling Hesitancy Dysuria Haematuria Incomplete emptying Intermittency Oliguria Anuria Polyuria
Abdominal history: lower urinary tract symptoms, urinary frequency
This is the passing of urine more often than is normal for the patient.
How many times in a day?
How much urine is passed each time?
Are they producing more urine than normal or simply feeling the urge to urinate more than normal?
Abdominal history: lower urinary tract symptoms, urgency
This is the sudden need to urinate, a feeling that the patient may not be able to make it to the toilet in time.
Ask about the volume expelled.
Abdominal history: lower urinary tract symptoms, nocturia
Urination during the night.
Does the patient wake from sleep to urinate?
How many times a night?
How much urine is expelled each time?
Abdominal history: lower urinary tract symptoms, urinary incontinence
The loss of voluntary control of bladder emptying.
Patients may be hesitant to talk about this.
“Have you ever not made it in time?”
True: total lack of control of urinary excretion, suggestive of a fistula between the urinary tract and the exterior, or a neurological condition.
Giggle: incontinence during bouts of laughter, common in young girls.
Stress: leakage associated with a sudden increase in intra-abdominal pressure of any cause, e.g. coughing, laughing, sneezing.
Urge: intense urge to urinate such that the patient is unable to get to the toilet in time; causes include overactivity of the detrusor muscle, urinary infection, bladder stones, and bladder cancer.
Dribbling or overflow: continual loss of urine from a chronically distended bladder, typically in elderly males with prostate disease.
Abdominal history: lower urinary tract symptoms, terminal dribbling
A male complaint usually indicative of prostate disease.
This is a dripping of urine from the urethra at the end of micturition, requiring an abnormally protracted shake of the penis, and may cause embarrassing staining of clothing.
Abdominal history: lower urinary tract symptoms, hesitancy
Difficulty in starting to micturate.
The patient describes standing and waiting for the urine to start flowing.
Usually due to bladder outflow obstruction caused by prostatic disease or strictures.
Abdominal history: lower urinary tract symptoms, haematuria
The passage of blood in urine.
Always an abnormal finding.
‘Microscopic haematuria’ will be undetectable to the patient, only showing on dip-testing.
Abdominal history: lower urinary tract symptoms, incomplete emptying
This is the sensation that there is more urine left to expel at the end of micturition.
Suggests detrusor dysfunction or prostatic disease.
Abdominal history: lower urinary tract symptoms, dysuria
‘Pain on micturition’ usually described by the patient as ‘burning’ or ‘stinging’ and felt at the urethral meatus.
Ask whether it is throughout or only at the end (terminal dysuria).
Abdominal history: lower urinary tract symptoms, intermittency
The disruption of urine flow in a stop-start manner.
Causes include prostatic hypertrophy, bladder stones, and ureterocoeles.
Abdominal history: lower urinary tract symptoms, oliguria
Oliguria is a scanty or low-volume urination and is defined as the excretion of <400mL urine in 24 hours.
Causes can be physiological (dehydration) or pathological (intrinsic renal disease, shock, or obstruction).
