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  1. 1. Urinary Symptoms Dr. Atef Galal
  2. 2. U r in a r y im p o r t a n t s y m p t o m sU p p e r u r in a r y t r a c t L o w e r u r in a r y t r a c t G e n e ra l s y m p to m s s y m p to m s s y m p to m s P a in O b s t r u c t iv e In c o n t in e n c e Ir r ia t it iv e C h a n g e in u r in e Fever H e m a t u r ia C o lo u r U r e m ia S w e llin g T u r b id it y M a jo r o r g a n f a ilu r e S tr e a m D ru g p a in fre q u e n c y u rg e n c y S .O .I.E m p t y in g
  3. 3. PainPain is usually associated with eitherurinary tract obstruction orinflammation.• Edema and distention of the capsule surrounding the organ. Thus, pyelonephritis, prostatitis, and epididymitis are typically quite painful.
  4. 4. PainTumors in the GU tract usually do notcause pain unless they produceobstruction or extend beyond theprimary organ to involve adjacentnerves.Pain associated with GU malignancies isusually a late manifestation and a sign ofadvanced disease.
  5. 5. PainPain of renal origin is usually located inthe ipsilateral costovertebral angle justlateral to the sacrospinalis muscle andbeneath the 12th rib.The pain may radiate across the flankanteriorly toward the upper abdomenand umbilicus and may be referred tothe testis or labium.
  6. 6. PainPain of renal origin may be associatedwith gastrointestinal symptomsbecause of:• Reflex stimulation of the celiac ganglion• Proximity of adjacent organs (liver, pancreas, duodenum, gallbladder, and colon).
  7. 7. PainRenal pain may be confused with pain ofintraperitoneal origin:• Perforated duodenal ulcer or pancreatitis may radiate into the back, but the site of greatest pain and tenderness is in the epigastrium.• Intraperitoneal origin pain radiates into the shoulder.• Patients with intraperitoneal pathology prefer to lie motionless to minimize pain.
  8. 8. PainRenal pain may be confused withradicular pain (resulting from irritationof the costal nerves,T10–T12)• It has a similar distribution (from the costovertebral angle across the flank toward the umbilicus.• Is not colicky.• Intensity may be altered by changing position.
  9. 9. PainUreteral pain is usually acute andsecondary to obstruction.It results from acute distention of theureter and by hyperperistalsis and spasmof the smooth muscle of the ureterUsually produced by a stone or bloodclot.
  10. 10. Pain Site of ureteral obstruction can bedetermined by location of referred pain
  11. 11. PainMidureteral obstruction:• Referred McBurneys point simulating appendicitis on rt. side• On the left side is referred over the left lower quadrant and resembles diverticulitis.• Also, may be referred to the scrotum in the male or the labium in the female.
  12. 12. PainLower ureteral obstruction:• Produces symptoms of vesical irritability, (frequency, urgency, and suprapubic discomfort)• May radiate along the urethra in men to the tip of the penis.
  13. 13. PainVesical Pain :• Produced either by overdistention or inflammation.• Inflammatory conditions of the bladder usually produce intermittent suprapubic discomfort.• It is severe when the bladder is full and relieved by voiding.• Strangury: sharp, stabbing suprapubic pain at the end of micturition.
  14. 14. PainDysuria:• Is painful urination that is usually caused by inflammation.• This pain is usually not felt over the bladder but is commonly referred to the urethral meatus.• Pain occurring at the start of urination may indicate urethral pathology, whereas pain occurring at the end of micturition (strangury) is usually of bladder origin.
  15. 15. PainProstatic Pain:• It is usually secondary to inflammation with edema and distention of the capsule.• It is poorly localized.• Patient may complain of lower abdominal, inguinal, perineal, lumbosacral, or rectal pain.• It is frequently associated with irritative urinary symptoms.
  16. 16. PainPenile Pain:• Pain in the flaccid penis is usually secondary to inflammation in the bladder or urethra and is experienced maximally at the meatus.• Pain in the erect penis is usually due to Peyronies disease or priapism.
  17. 17. PainScrotal Pain:• Scrotal pain may be primary or referred.• Primary pain arises from within the scrotum and is usually secondary to acute epididymitis or torsion of testis or testicular appendices.• Edema and pain associated with acute epididymitis and torsion, it is difficult to distinguish these two conditions.
  18. 18. Pain• Chronic scrotal pain is usually related to noninflammatory conditions; hydrocele, varicocele.• It is generally characterized as a dull, heavy sensation that does not radiate.• Pain arising in the kidneys or retroperitoneum may be referred to the testicles.• Dull pain associated with an inguinal hernia may be referred to the scrotum.• It may also result from inflammation of the
  19. 19. Hematuria2-Hematuria:• Is the presence of blood in urine;• >3 red blood cells per (HPF) is significant.Hematuria of any degree shouldnever be ignoredHematuria in adults, should beregarded as a symptom ofmalignancy until proved
  20. 20. HematuriaIn evaluating hematuria,several questions shouldalways be asked:• Is the hematuria gross or microscopic?• At what time during urination does the hematuria occur?• Is the hematuria associated with
  21. 21. HematuriaTiming of Hematuria:• Initial hematuria: arises from the urethra.• Total hematuria: from the bladder or upper urinary tracts.• Terminal hematuria: is usually secondary to inflammation in the area of the bladder neck or prostatic urethra.
  22. 22. HematuriaAssociation with Pain:• If it is associated with inflammation or obstruction it will be painfull• Or from upper urinary tract with obstruction of ureters with clots or calculus.
  23. 23. HematuriaPresence of Clots:• The presence of clots usually indicates a more significant degree of hematuria, and, accordingly, the probability of identifying significant urologic pathology increases.
  24. 24. HematuriaShape of Clots:• (wormlike) clots, particularly if associated with flank pain, identifies the hematuria as coming from the upper urinary tract.
  25. 25. Irritative Symptoms:Frequency: • The normal adult voids five or six times per day, with a volume of approximately 300 mL with each void. • Urinary frequency is due either to increased urinary output (polyuria) or to decreased bladder capacity.
  26. 26. Irritative Symptoms:Frequency:• Polyuria should be evaluated for diabetes mellitus, diabetes insipidus, or excessive fluid ingestion.• Causes of decreased bladder capacity include: increased sensitivity and decreased compliance; pressure from extrinsic sources; or anxiety
  27. 27. Irritative Symptoms:Nocturia: is nocturnal frequency.• Normally, adults arise no more than once at night to void.• Nocturia may be secondary to increased urine output or decreased bladder capacity.• Nocturia without frequency may occur in the patient with congestive heart failure, in the geriatric patient.
  28. 28. Irritative Symptoms:Frequency:• Frequency during the day without nocturia is usually of psychogenic origin and related to anxiety.
  29. 29. Obstructive Symptoms1-Decreased force of urination• Is usually secondary to bladder outlet obstruction• Most patients are unaware of a change in the force and caliber of their urinary stream.• These changes usually occur gradually and go generally unrecognized by most patients.
  30. 30. Obstructive Symptoms2-Difficulty:• Urinary hesitancy : • Refers to a delay in the start of micturition.• Intermittency: • Refers to involuntary start-stopping of the urinary stream.• Postvoid dribbling: • Refers to the terminal release of drops of urine at the end of micturition. • This is secondary to a small amount of residual urine in either the bulbar or the prostatic urethra.
  31. 31. Obstructive Symptoms3-Straining:• Refers to the use of abdominal musculature to urinate.• Normally, it is unnecessary for a man to perform a Valsalva maneuver except at the end of urination.• Increased straining during micturition is a symptom of bladder outlet obstruction.
  32. 32. Obstructive or irritative SymptomsIt is important for the urologist to distinguish irritative fromobstructive lower urinary tract symptoms.This most frequently occurs in evaluating men with BPH.Although BPH is primarily obstructive, it produces changes inbladder compliance that result in increased irritative symptoms.In fact, men with BPH more commonly present with irritativethan obstructive symptoms, and the most common presentingsymptom is nocturia.The urologist must be careful not to attribute irritative symptomsto BPH unless there is documented evidence of obstruction.In general, lower urinary tract symptoms are nonspecific and mayoccur secondary to a wide variety of neurologic conditions as wellas to prostatic enlargement (Lepor and Machi, 1993).
  33. 33. Symptom scoreSince its introduction in 1992, theAmerican Urological Association (AUA)symptom index has been widely used (Barry et al, 1992).The original AUA symptom score is basedon the answers to seven questionsconcerning frequency, nocturia, weakurinary stream, hesitancy, intermittency,incomplete bladder emptying, andurgency.
  34. 34. Symptom scoreThe total symptom score rangesfrom 0 to 35 with scores of 0 to 7, 8to 19, and 20 to 35 indicating mild,moderate, and severe lower urinarytract symptoms, respectively.
  35. 35. Incontinence Urinary incontinence is the involuntary loss of urine. A careful history of the incontinent patient will often determine the etiology. It can be subdivided into four categories:
  36. 36. 1-ContinuousIncontinenceInvoluntary loss of urine at all times and in allpositions.Commonly due to complete damage to thesphincter or a urinary tract fistula thatbypasses the urethral sphincter, vesicovaginaland ureterovaginal fistulaEctopic ureter that enters either the urethra orthe female genital tract may cause urinaryincontinence.It may be misdiagnosed for many years as achronic vaginal discharge.Ectopic ureters never produce urinaryincontinence in males, because they alwaysenter the bladder neck or prostatic urethraproximal to the external urethral sphincter.
  37. 37. 2-Stress Incontinence Refers to the sudden leakage of urine with coughing, sneezing, exercise, or other activities that increase intra-abdominal pressure. Intra-abdominal pressure rises transiently above urethral resistance, resulting in a sudden, urine leakage. It is most commonly seen in women It is also observed in men following prostatic surgery.
  38. 38. 3-Urgency incontinence Is the precipitous loss of urine preceded by a strong urge to void. This is commonly observed in patients with cystitis, neurogenic bladder, and advanced bladder outlet obstruction with secondary loss of bladder compliance. It is important to distinguish urgency incontinence from stress incontinence.
  39. 39. 4-Overflow urinary incontinence (paradoxical incontinence), is secondary to advanced urinary retention and high residual urine. the bladder is chronically distended and never empties completely. Urine may dribble out in small amounts as the bladder overflows. This is particularly likely to occur at night when the patient is less likely to inhibit urinary leakage. It is usually develop over a considerable length of time, and patients may be totally unaware of incomplete bladder emptying.
  40. 40. Enuresis Refers to urinary incontinence that occurs during sleep. It occurs normally in children up to 3 years of age but persists in about 15% of children at age 5 and about 1% of children at age 15 (Forsythe and Redmond, 1974). All children over age 6 years with enuresis should undergo a urologic evaluation, although the vast majority
  41. 41. ImpotenceImpotence refers specifically to theinability to achieve and maintain anerection sufficient for intercourse. Acareful history will oftendetermine whether the problem isprimarily psychogenic or organic.Impotence
  42. 42. Impotence In men with psychogenic impotence,the condition frequently develops ratherquickly secondary to a precipitatingevent such as marital stress or changeor loss of a sexual partner. In men withorganic impotence, the condition usuallydevelops more insidiously andfrequently can be linked to advancingage or other underlying risk factors.
  43. 43. ImpotenceIn evaluating men with impotence, it isimportant to determine whether theproblem exists in all situations. Manymen who report impotence may not beable to have intercourse with onepartner but will with another. Similarly, itis important to determine whether menare able to achieve normal erectionswith alternative forms of sexualstimulation (e.g., masturbation, eroticvideos).
  44. 44. ImpotenceFinally, the patient should be askedwhether he ever notes nocturnal orearly morning erections. In general,patients who are able to achieveadequate erections in somesituations but not others haveprimarily psychogenic rather thanorganic impotence.
  45. 45. Failure of EjaculateAnejaculation may result fromseveral causes: (1) androgendeficiency, (2) sympatheticdenervation, (3) pharmacologicagents, and (4) bladder neck andprostatic surgery. Androgendeficiency results in decreasedsecretions from the prostate andseminal vesicles
  46. 46. Failure of Ejaculatecausing a reduction or loss of seminalvolume. Sympathectomy or extensiveretroperitoneal surgery, most notablyretroperitoneal lymphadenectomy fortesticular cancer, may interfere withautonomic innervation of the prostate andseminal vesicles, resulting in absence ofsmooth muscle contraction and absence ofseminal emission at time of orgasm.Pharmacologic agents, particularly α-adrenergic antagonists, may interfere withbladder neck closure
  47. 47. Failure of Ejaculateat time of orgasm and result inretrograde ejaculation. Similarly,previous bladder neck or prostaticurethral surgery, most commonlytransurethral resection of the prostate,may interfere with bladder neck closure,resulting in retrograde ejaculation.Finally, retrograde ejaculation maydevelop spontaneously in diabetic men.
  48. 48. Failure of EjaculatePatients who complain of absence ofejaculation should be questionedregarding loss of libido or othersymptoms of androgen deficiency,present medications, diabetes, andprevious surgery. A careful history willusually determine the cause of thisproblem.
  49. 49. Absence of OrgasmAnorgasmia is usuallypsychogenic or caused by certainmedications used to treatpsychiatric diseases. Sometimes,however, anorgasmia may be due todecreased penile sensation owing toimpaired pudendal nerve function.
  50. 50. Absence of OrgasmMost commonly, this occurs in diabeticswith peripheral neuropathy. Men whoexperience anorgasmia in associationwith decreased penile sensation shouldundergo vibratory testing of the penisand further neurologic evaluation asindicated.
  51. 51. Premature EjaculationMen who complain of premature ejaculationshould be questioned carefully because this isobviously a very subjective symptom. It iscommon for men to ejaculate within 2 minutesafter initiation of intercourse, and many menwho complain of premature ejaculation inactuality have normal sexual function withabnormal sexual expectations.
  52. 52. Premature EjaculationHowever, there are men with true prematureejaculation who reach orgasm within less than1 minute after initiation of intercourse. Thisproblem is almost always psychogenicand best treated by a clinical psychologist orpsychiatrist who specializes in treatment ofthis problem and other psychological aspectsof male sexual dysfunction. With counselingand appropriate modifications in sexualtechnique, this problem can usually beovercome.
  53. 53. Premature EjaculationAlternatively, treatment with serotoninre-uptake inhibitors, such as sertralineand fluoxetine, have beendemonstrated to be helpful in men withpremature ejaculation (Murat Basar etal, 1999).
  54. 54. HematospermiaHematospermia refers to the presenceof blood in the seminal fluid. It almostalways results from nonspecificinflammation of the prostateand/or seminal vesicles andresolves spontaneously, usuallywithin several weeks. It frequentlyoccurs after a prolonged period ofsexual abstinence,
  55. 55. Hematospermiaand we have observed it several timesin men whose wives are in the finalweeks of pregnancy. Patients withhematospermia that persists beyondseveral weeks should undergo furtherurologic evaluation, because, rarely, anunderlying etiology will be identified. Agenital and rectal examination shouldbe done to exclude the presence oftuberculosis,
  56. 56. Hematospermiaa prostate-specific antigen (PSA) and arectal examination done to excludeprostatic carcinoma, and a urinarycytology done to exclude the possibilityof transitional cell carcinoma of theprostate. It should be emphasized,however, that hematospermiaalmost always resolvesspontaneously and rarely isassociated with any significanturologic pathology.
  57. 57. PneumaturiaPneumaturia is the passage of gas inthe urine. In patients who have notrecently had urinary tractinstrumentation or a urethral catheterplaced, this is almost always due to afistula between the intestine andthe bladder. Common causesinclude diverticulitis,
  58. 58. Pneumaturiacarcinoma of the sigmoid colon,and regional enteritis (Crohnsdisease). In rare instances, patientswith diabetes mellitus may have gas-forming infections, with carbon dioxideformation from the fermentation of highconcentrations of sugar in the urine.
  59. 59. Urethral DischargeUrethral discharge is the most commonsymptom of venereal infection. Apurulent discharge that is thick, profuse, andyellow to gray is typical of gonococcalurethritis; the discharge in patients withnonspecific urethritis is usually scant andwatery. A bloody discharge is suggestive ofcarcinoma of the urethra.
  60. 60. Fever and ChillsFever and chills may occur withinfection anywhere in the GU tract butare most commonly observed inpatients with pyelonephritis, prostatitis,or epididymitis. When associatedwith urinary obstruction, feverand chills may portend septicemiaand necessitate emergencytreatment to relieve obstruction
  61. 61. Past Medical HistoryThe past medical history is extremelyimportant because it frequently providesclues to the patients current diagnosis.The past medical history should beobtained in an orderly and sequentialmanner.Previous Medical Illnesses withUrologic Sequelae
  62. 62. Past Medical HistoryThere are obviously many diseases that mayaffect the GU system, and it is important tolisten and record the patients previousmedical illnesses. Patients with diabetesmellitus frequently develop autonomicdysfunction that may result in impairedurinary and sexual function. A previoushistory of tuberculosis may be important in apatient presenting with impaired renalfunction, ureteral obstruction, or chronic,unexplained UTIs.
  63. 63. Past Medical HistoryPatients with hypertension have an increasedrisk of sexual dysfunction because they aremore likely to have peripheral vasculardisease and because many of themedications that are used to treathypertension frequently cause impotence.Patients with neurologic diseases such asmultiple sclerosis are also more likely todevelop urinary and sexual dysfunction. Infact, 5% of patients with previouslyundiagnosed multiple sclerosis presentwith urinary symptoms as the first
  64. 64. Past Medical HistoryAs mentioned earlier, in men with bladderoutlet obstruction, it is important to be awareof preexisting neurologic conditions. Surgicaltreatment of bladder outlet obstructionin the presence of detrusorhyperreflexia may result in increasedurinary incontinence postoperatively.Finally, patients with sickle cell anemia areprone to a number of urologic conditionsincluding papillary necrosis
  65. 65. Past Medical Historyand erectile dysfunction secondary torecurrent priapism. There are obviouslymany other diseases with urologicsequelae, and it is important for theurologist to take a careful history in thisregard.
  66. 66. Family HistoryIt is similarly important to obtain a detailedfamily history because many diseases aregenetic and/or familial in etiology. Examplesof genetic diseases include adult polycystickidney disease, tuberous sclerosis, vonHippel–Lindau disease, renal tubular acidosis,and cystinuria; these are but a few commonand well-recognized examples.
  67. 67. Family HistoryIn addition to these diseases of knowngenetic predisposition, there are otherconditions in which the precise pattern ofinheritance has not been elucidated, butwhich clearly have a familial tendency. It iswell known that individuals with a familyhistory of urolithiasis are at increased risk forstone formation. More recently, it has beenrecognized that about 8% to 10% of menwith
  68. 68. Family Historyprostate cancer have a familial form ofthe disease that tends to developabout a decade earlier than the morecommon type of prostate cancer (Bratt,2000). There are other familial conditions thatare mentioned elsewhere in the text, butsuffice it to state again that obtaining a carefulhistory of previous illnesses and a familyhistory of urologic disease can be extremelyvaluable in establishing the correct diagnosis.
  69. 69. MedicationsIt is similarly important to obtain anaccurate and complete list of presentmedications because many drugsinterfere with urinary and sexualfunction. For example, most of theantihypertensive medicationsinterfere with erectile function,and
  70. 70. Medicationschanging antihypertensive medicationscan sometimes improve sexualfunction. Similarly, many of thepsychotropic agents interfere withemission and orgasm. In our own recentexperience, we cared for a man whopresented with anorgasmia. He had been toseveral physicians without improvement inthis problem. When we obtained his pastmedical history, he mentioned that he hadbeen taking
  71. 71. Medications a psychotropic agent for transient depressionfor several years, and his anorgasmiaresolved when this no longer neededmedication was discontinued. The list ofmedications affecting urinary and sexualfunction is exhaustive, but, once again, eachmedication should be recorded and its sideeffects investigated to be sure that thepatients problem is not drug related. A listingof common medications that may causeurologic side effects is presented in
  72. 72. Cigarette smoking and consumption ofalcohol are clearly linked to a number ofurologic conditions. Cigarettesmoking is associated with anincreased risk of urothelialcarcinoma, most notably bladdercancer, and it is also associatedwith increased peripheralvascular disease and erectiledysfunction.
  73. 73. Chronic alcoholism may result inautonomic and peripheral neuropathywith resultant impaired urinary andsexual function. Chronic alcoholismmay also impair hepatic metabolism ofestrogens, resulting in decreasedserum testosterone, testicular atrophy,and decreased libido.In addition to the direct urologic effects ofcigarette smoking and alcohol consumption,patients who are actively smoking or
  74. 74. drinking at the time of surgery are atincreased risk for perioperative complications.Smokers are at increased risk for bothpulmonary and cardiac complications. Ifpossible, they should discontinue smokingat least 8 weeks before surgery tooptimize their pulmonary function (Warner et al, 1989). If they are unable to dothis, they should at least quit smoking for 48hours before surgery, because this will resultin a significant improvement in cardiovascularfunction. Similarly,
  75. 75. chronic alcoholics are at increased risk forhepatic toxicity and subsequent coagulationproblems postoperatively. Furthermore,alcoholics who continue drinking up to thetime of surgery may experience acutealcohol withdrawal during thepostoperative period that can be life-threatening. Prophylacticadministration of lorazepam (Ativan)greatly reduces the potential risk ofthis significant complication.