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  1. 1. PAIN As A Symptom Of Urologic Diseases, Causes And Workup DR AHMED REHMAN FCPS (uro) Assistant Professor of Urology
  2. 2. Learning objectives <ul><li>To be able to enumerate causes of pain in different quadrants of abdomen, especially flanks and hypogastrium. </li></ul><ul><li>To be able take elaborate history and conduct relevant clinical examination </li></ul><ul><li>To be able to make a diagnosis based on history and examination. </li></ul><ul><li>To be able to suggest and interpret relevant investigations. </li></ul>
  3. 3. Causes of urologic pain in general <ul><li>Urinary tract obstruction </li></ul><ul><ul><li>distention of relatively unyielding capsule </li></ul></ul><ul><ul><li>Peristalsis </li></ul></ul><ul><ul><li>Muscle spasm </li></ul></ul><ul><li>Inflammation & abscess </li></ul><ul><ul><li>Edema / Distention of relatively unyielding capsule </li></ul></ul><ul><ul><li>Mucosal inflammation - discomfort </li></ul></ul><ul><li>Retention of urine </li></ul><ul><li>Trauma, local irritation </li></ul><ul><li>Tumors </li></ul><ul><ul><li>Obstruction </li></ul></ul><ul><ul><li>Nerve involvement in advance stages </li></ul></ul><ul><li>Ischemia </li></ul>
  4. 4. CAUSES Of LOIN PAIN <ul><li>Skin / subcutaneous tissues ---- Herpes Zoster </li></ul><ul><li>Muscles spasm, myalgias, psoss abscess </li></ul><ul><li>Bones – spine caries, psuedo renal (Radicular- T 10-12 ) pain, slip disc, </li></ul><ul><li>rib cage fracture </li></ul><ul><li>Lungs basal Puemonia, plurecy, effusion </li></ul><ul><li>Liver hepatitis, abscess, congestive hepatomegaly </li></ul><ul><li>Inferior wall MI </li></ul><ul><li>GB causes cholecystitis, cholelitheasis, advance Ca </li></ul><ul><li>GI causes Appendicitis, typhlitis, bowl obsruction, constipation, APD </li></ul><ul><li>Splenomegaly </li></ul><ul><li>Sub-ferenic abscess, </li></ul><ul><li>Pancreatitis </li></ul><ul><li>Renal / peri-renal causes </li></ul><ul><li>Adrenals diseass </li></ul><ul><li>Ureteric causes </li></ul><ul><li>Testicular pain, </li></ul><ul><li>Varicocele </li></ul><ul><li>Adrenal causes </li></ul><ul><li>Vascular causes - aortic aneursym, thrombosis, </li></ul><ul><li>Hernial obstruction </li></ul><ul><li>Gynaecologic causes Salpingitis, ectopic pregnency, Ovarion cyst / tortion, PID </li></ul><ul><li>Malingering </li></ul>
  5. 5. Renal causes of loin pain <ul><li>Stone – caliceal, pelvic, PUJ, ureteric, stag horn, (irritation, inflamation, obstruction) </li></ul><ul><li>Hydrnephrosis due to any cause -Congenital PUJ obstruction, ureteric obstruction </li></ul><ul><li>Papilary necrosis </li></ul><ul><li>Arterrial / venous thrombosis / emboli </li></ul><ul><li>Advance malignancy –obstruction, infiltration, clot colic </li></ul><ul><li>Abscesses – renal, peri- & para-renal </li></ul><ul><li>Cysts – distention, obstruction, bleeding in cyst </li></ul><ul><li>pyelonephritis, acute, chronic, tuberculus </li></ul><ul><li>Glomerulonephritises & intersticial nephritises </li></ul>
  6. 6. Painless diseases of kidney <ul><li>Tumors </li></ul><ul><li>Staghorn calculi </li></ul><ul><li>TB </li></ul><ul><li>Ch pylonephritis </li></ul><ul><li>p32smith </li></ul>
  7. 7. Renal Pain <ul><li>Constant, deep seated, dull, sickening ache </li></ul><ul><li>Costovertebral angle  upper abdomen hypochondrium , umbilicus, testes </li></ul><ul><li>Inflammatory – steady, obstructive – colicky </li></ul><ul><li>GI symptoms ( shared supply – celiac ganglion, contiguous viscera) </li></ul><ul><li>Radicular pain similar distribution but not colicky, and associated with position & movements </li></ul><ul><li>Pain of intraperitoneal origin is seldom colicky, radiates to shoulder and patients lies motionless and is tender in contrast to renal ain who moves and roll around, holding the flank to get relief. </li></ul><ul><li>There are sites of maximum tenderness like epigastrium in perf DU & panceatitis. (radiate to back also) </li></ul><ul><li>Only sudden ureteric obstruction causes pain, chronic does not. </li></ul>
  8. 8. ureteric Colic <ul><li>Ureteric colic is a excruciating sharp pain in background of continuous discomfort. Radiates around flank towards inguinal ligament . Roles around /tosses </li></ul><ul><li>Radiation of upper ureteric pain testes </li></ul><ul><li>Mid right ureter RIF mecberny’s, appendicitis sacrotum, labium magus </li></ul><ul><li>left LIF diverticulitis </li></ul><ul><li>lower ureter irritative LUTS, urethral , penile pain </li></ul>
  9. 9. History Taking <ul><li>Pain </li></ul><ul><ul><li>Duration, onset, site, severity, character, continuous / episodic, aggravating- relieving factors, radiation / referral & shift of pain, association with meals, movements, posture, trauma, drugs and other symptoms like </li></ul></ul><ul><ul><ul><li>Heamaturiaa, fever, LUTS, wt loss, retention, anuria, GI symptoms, swelling & edema, </li></ul></ul></ul><ul><li>Systemic diseases </li></ul><ul><li>History should lead to making mind that What is cause / origin of pain </li></ul>
  10. 10. Clinical Examination <ul><li>No significant sign </li></ul><ul><li>Distress and agony of severe pain </li></ul><ul><li>Tachycardia, Fever, hypo- hypertension </li></ul><ul><li>Sweating </li></ul><ul><li>Herpetic vesicals </li></ul><ul><li>Tenderness, abdominal, bones, muscular, epigastric, Some tenderness and rigidity over costo-vertebral angle or some part of course of ureter </li></ul><ul><li>Palpable kidney, masses </li></ul><ul><li>Peritonitis </li></ul><ul><li>Hernnias, varicocele </li></ul>
  11. 11. Causes of ureteric colic / Obstruction <ul><li>Ureteric Obstruction – complete / partial </li></ul><ul><ul><li>Extramural </li></ul></ul><ul><ul><ul><li>Tumors of cervix, ovary, uterous, vagina, urinary bladder, prostate, rectum, colon, caecum & lymphomas </li></ul></ul></ul><ul><ul><ul><li>Idiopathic retroperitoneal fibrosis </li></ul></ul></ul><ul><ul><ul><li>Retrocaval ureter </li></ul></ul></ul><ul><ul><ul><li>Pararenal cysts </li></ul></ul></ul><ul><ul><ul><li>Aberent vessels </li></ul></ul></ul><ul><ul><li>Intraluminal </li></ul></ul><ul><ul><ul><li>Calculus, sloughed papilla, clot, ureteric malignancy </li></ul></ul></ul><ul><ul><li>Intramural </li></ul></ul><ul><ul><ul><li>Congenital PUJ obstruction or stenosis </li></ul></ul></ul><ul><ul><ul><li>Ureterocele and congenital small ureteric orifice </li></ul></ul></ul><ul><ul><ul><li>Strictures ( stone, repair, tuberculosis, schistosomiasis) </li></ul></ul></ul><ul><ul><ul><li>Ureteric / vecsical malignanncy </li></ul></ul></ul><ul><ul><ul><li>Kenks & adhesions ( sec to VUR) </li></ul></ul></ul>
  12. 12. Causes of hypogastric pain <ul><li>Vesical </li></ul><ul><ul><li>Stone </li></ul></ul><ul><ul><li>Cystitis </li></ul></ul><ul><ul><ul><li>Nonspecific </li></ul></ul></ul><ul><ul><ul><li>Tuberculus, schistosomal, intersticial </li></ul></ul></ul><ul><ul><li>CIS, advance malignancy </li></ul></ul><ul><ul><li>Acute urinary retention </li></ul></ul><ul><li>Pelvic and gynecological causes </li></ul><ul><li>Lower ureteric causes </li></ul><ul><li>Urethral causes – stone, inflammation, </li></ul><ul><li>Prostatic causes – abscess, prostatitis, advance tumor </li></ul><ul><li>Hernial obstruction, prolapse </li></ul><ul><li>Ostiitis pubis </li></ul><ul><li>Anorectal and colonic pathologies </li></ul>
  13. 13. Vesical pain <ul><li>Inflammatory: severe either when bladder fills up or when evacuates ( lator called STRANGURY= urge to void, inability to pass except few drops of blood stained urine = distal ureteric , vesical stone irritation of trigone </li></ul><ul><li>Obstruction. Chronic retention is painless </li></ul><ul><li>Constant hypogastric pain not associated with urinary symptoms is seldom vesical </li></ul><ul><li>Referred to tip of penis </li></ul>
  14. 14. Penile Pain <ul><li>Flaccid penis </li></ul><ul><ul><li>Bladder urethral inflammation stone </li></ul></ul><ul><ul><li>Paraphemosis </li></ul></ul><ul><li>Errect penis </li></ul><ul><ul><li>priapism </li></ul></ul><ul><ul><li>Peyronies disease </li></ul></ul>
  15. 16. Investigations <ul><li>Urine RE n CS </li></ul><ul><ul><li>Stone rbc, us associated infection </li></ul></ul><ul><li>RFTs </li></ul><ul><li>USG – hydro ureteronephrosis / stone, mass, cysts </li></ul><ul><li>X-ray KUB </li></ul><ul><li>IVU </li></ul><ul><ul><li>Stone mass cysts obstruction anomalies </li></ul></ul><ul><ul><li>If not visualized = delayed films </li></ul></ul><ul><li>Spiral CT </li></ul><ul><li>cystoscoy </li></ul><ul><li>Retrograde urography </li></ul><ul><ul><ul><li>Obstruction, CRF, contrast sensitivity, </li></ul></ul></ul>
  16. 17. X ray KUB <ul><li>T12 – lower border of pubic symphesis, supie plain x ray </li></ul><ul><li>Preparation – purgation, no break fast, can take liquids </li></ul><ul><li>ROS, </li></ul><ul><li> negative – small stone, obscured by gases, bones </li></ul><ul><li>DD of different ROS </li></ul><ul><ul><li>Hypochondrium – renal, ureteric, gall stones, lymph nodes, ROS in GIT, radio opaque tablets </li></ul></ul><ul><ul><li>Pelvis – ureteric, vesical calculi, phleboliths, phecoliths, lymph nodes, calcificationns in tumor or inflammatory masses </li></ul></ul>