Urinary Presentation Flashcards
Pain at beginning of mixturating is more common in
Urethritis
Pain at end of mixturation is more common in
Cystitis
Purapubic pain is more commonly associated with
Cystitis (bladder infection)
3 most important (and common) causes of dysuria in women?
- Acute cystitis (~40%)
- Vaginitis (esp amongst adolescents) ~15%
- Post-menopausal ostrogen deficiency (5-10%) –> lower bladder and urethra are ostrogen-dependent
Dysuria described more as ‘burning on the outside’, with pain either at beginning or end of mixturation is associated with
Vaginitis
Key questions to ask patients presenting with urinary discomfort
Could you describe the discomfort? Colour of urine? Odour to urine? Discharge? Could it be sexually acquired? Is intercourse painful / uncomfortable (women)? Have you any fever, sweats or chills?
Initial investigations for urinary complaints
Urine dipstick (RBCs, WBCs, proteins, nitrates)
Midstream microscopy/culture (for UTI)
First pass urine for STIs
Specific investigation for macroscopic hematuria
Intravenous Urogram (radiology)
UNLESS iodine allergy, severe asthma, or other contraindications
US is next choice
What might macroscopic hematuria suggest?
Always abnormal, except in menstruating women
Radiation Cystitis (massive hematuria)
Serious Pathologies:
Bladder cancer, kidney cancer, renal pelvis cancer, ureter cancer, prostate cancer
Trauma
*Pseudohematuria - e.g. from beetroot consumption
Bleeding disorders / Anticoagulants
What might microscopic hematuria suggest?
Most common:
Infection: cystitis (women), urethritis, prostatitis
Renal Calculi
More serious: CV: Kidney infarction of other damage Malignancy Severe infections Nephropathy - IgA
Often missed: Vigorous exercise Menstrual contamination Trauma Bleeding disorders/anticoagulants
Hematuria occurring in the first part of the stream suggests
Urethral or prostatic involvement
Hematuria occuring at the end of the stream suggests
Bladder involvement
Drugs that can cause hematuria?
Cytotoxics
Anticoagulants
How can benign prostatic enlargement cause hematuria?
Large prostatic veins can rupture as man strains to urinate
Key questions for hematuria
Any injuries of blows to the loin / pelvis / genital area?
Is the redness at the start or towards the end of your stream?
Have you noticed any other bleeding elsewhere, such as bruising or nosebleeds?
Any pain in loin or abdomen?
Burning or frequency with urine?
Problems with flow of urine?
Eating large amounts of beetroot, red lollies, berries?
Could the problem be sexually acquired?
Been overseas recently?
What is general health like?
Aware of any other symptoms?
Do you engage in strenuous sports? Jogging?
Any kidney problems in the past?
Key points for examination with hematuria
Signs of bleeding tendency and anemia
CV:
Assess heart to exclude atrial fibrillation or infective endocarditis with emboli t the kidney
Examine chest for possible pleural effusions associated with perinephric or kidney infections
ABDO:
Palpably enlarged kidneys - kidney tumour, hydronephrosis, polycystic disease
Or spleen - possible bleeding disorder
SUPRAPUBIC:
Palpate for bladder tenderness or enlargement
Men: Prostate exam for enlargement, or tenderness of prostatitis
Women: Vaginal exam for possible pelvic masses
Investigations in Hematuria
Urine dipstick urinalysis
Urine Microscopy - RBCs in true hematuria, deformed RBCs or RBC casts in glomerular bleeding
Urine culture - for infective organism. If suspect TB, 3 early morning urine cultures to be taken looking for tubercle bacilli
Urine cytology - may detect bladder malignancies (not do good for kidney malignancies)
FBC: ESR, kidney function (U&C)
Radiology: Intravenous pyelogram / urography (IVP/IVU) (best)
Also US, CT, kidney angiography
Cytoscopy: Advisable in all pts regardless of IVU
Kidney Biopsy: If glomerular disease suspected - esp if presence of dysmorphic RBCs detected on microscopy
