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Diagnosis of Acute urinary conditions

Acute urinary conditions Diagnosis: Book Excerpts

Diagnostic Tests for Acute urinary conditions: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Acute urinary conditions.


DYSURIA: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is there fever? A significant fever would suggest either pyelonephritis, particularly in females, or acute prostatitis in males.
  2. Is the urine grossly bloody or are there a significant number of red cells on microscopic examination? Grossly bloody urine in a young female should suggest acute cystitis, particularly if she has just returned from a honeymoon. In older patients it may indicate bladder carcinoma, but generally these patients have blood in their urine before they develop dysuria. Really significant blood in the urine may also indicate schistosomiasis or tuberculous cystitis. Dysuria and hematuria can occur in renal or vesicular calculi as well.
  3. Is there a urethral or vaginal discharge? If either of these signs is present, one must consider that the patient may have gonorrhea until proven otherwise. Repeated negative smears and cultures for gonococcus should suggest that the patient may have female urethral syndrome or nonspecific urethritis due to chlamydia.
  4. Are there systemic symptoms? If there are systemic symptoms, one must consider the possibility of Reiter's syndrome or collagen disease. One should not forget that systemic symptoms of arthritis and rash may also be present in gonorrhea.
  5. Is the pain very severe? Severe pain, particularly a need to stay close to the restroom so one can empty one's bladder, may indicate tabes dorsalis, although this condition is rarely seen today.

DIAGNOSTIC WORKUP

Obviously, a urinalysis and Gram stain of the unspun urine should be done in all cases. If this is positive, treatment can be initiated. Urine cultures are only necessary for resistant or repeated episodes. I also recommend a urethral smear and a vaginal smear and culture if sufficient material can be obtained. This may mean massaging the prostate for an adequate specimen. Even four white cells per high-powered field on a urethral smear probably indicates urethritis. Cultures for both gonorrhea and chlamydia should be done. In persistent cases of dysuria, an intravenous pyelogram and a cystoscopy must be done. A urologist needs to be consulted before ordering these tests. Blood cultures should be done in cases of acute pyelonephritis. Cultures for anaerobic bacilli and tuberculosis may be necessary in persistent pyuria. It should go without saying that a rectal and vaginal examination should be done in all cases. However, this is frequently neglected.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

ENURESIS: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is the bed-wetting frequent or only occasional? Frequent bed-wetting should signify pathology in the urogenital tract or endocrine system. If the bed-wetting is infrequent, one should consider epilepsy.
  2. Are there abnormalities found on the urogenital examination? There are many causes of enuresis that can be found on a simple examination, such as phimosis, balanitis, meatal stricture, vulvitis, or intestinal worms.
  3. Are there abnormalities on the urinalysis? Urinalysis alone is usually not adequate, and a urine culture should be done to rule out cystitis and pyelonephritis. The simple examination of the urine sediment for bacteria is also helpful. Sugar in the urine may indicate diabetes mellitus, but it may also indicate Fanconi's syndrome.
  4. Is there polyuria? Polyuria might indicate diabetes insipidus, diabetes mellitus, hyperthyroidism, and hypoparathyroidism.
  5. Are there abnormalities on the neurologic examination? Here one would be looking for cerebral palsy and congenital anomalies of the spinal cord.

Finally, if the neurologic examination, urogenital examination, and urinalysis are normal, perhaps the patient has a simple neurosis or situational maladjustment.

DIAGNOSTIC WORKUP

Patients who are suspected of having a urologic condition as the cause of their enuresis should have a urinalysis, intravenous pyelogram, and voiding cystogram with a urine culture and colony count. Referral to a urologist for cystometric testing may be required. If there is polyuria, a glucose tolerance test, a thyroid profile, and tests for calcium phosphorus, alkaline phosphatase, and parathyroid hormone level should be done. If epilepsy is suspected, an EEG should be ordered. If the neurologic examination is abnormal, referral to a neurologic specialist would be in order. If all the studies and examinations are within normal limits, a referral to a psychiatrist or psychologist may be in order. However, the child may have simple enuresis, in which case all that is required is to reassure the parents that the child will grow out of it by puberty.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

GLYCOSURIA: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Was the test used specific for glucose? Glucose oxidase tests (Clinistix, etc.) are specific for glucose, whereas other tests (Benedict's, etc.) are not. Thus, the latter will give false positives for lactose, fructose, galactose, and salicylates.
  2. What is the blood sugar? If the blood sugar is elevated or a glucose tolerance test is positive, one should suspect diabetes mellitus. If these tests are normal, one should suspect renal glycosuria, pregnancy, or renal tubular acidosis.

DIAGNOSTIC WORKUP

The investigation of glycosuria should include a glucose tolerance test, chemistry panel, and electrolyte panel. If there are clinical features of an endocrine disorder, the various tests for these disorders should be ordered.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

NOCTURIA: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is there daytime frequency of urination also? If there is daytime frequency, the differential diagnosis of polyuria should be considered.
  2. Is there associated pain or difficulty voiding? These findings would suggest cystitis, prostatitis, and urethritis.
  3. Is there dyspnea, orthopnea, or peripheral edema? These findings would suggest congestive heart failure. If there is no dyspnea or edema, one should consider chronic nephritis.

DIAGNOSTIC WORKUP

Routine laboratory tests should include a CBC, sedimentation rate, urinalysis, chemistry panel, and urine culture and sensitivity. A quantitative 24-hr urine volume should be determined. If this is above normal, the differential diagnosis of polyuria should be considered and additional workup can be found on page 372 .

Catheterization for residual urine will help determine if there is bladder neck obstruction. If congestive heart failure is suspected, a chest x-ray, EKG, and venous pressure and circulation time should be done. For further evaluation, a nephrologist or urologist may be consulted.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

POLYURIA: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is it transient? Migraine, asthma, and drugs such as diuretics may produce transient polyuria.
  2. Is it massive? Massive polyuria is usually due to pituitary or nephrogenic diabetes insipidus and psychogenic polydipsia. It may also be due to diabetes mellitus.
  3. Is there polyphagia and polydipsia? The presence of polyphagia and polydipsia suggests the possibility of diabetes mellitus and hyperthyroidism.
  4. Is the polyuria mild? The presence of a mild polyuria suggests chronic nephritis, renal tubular acidosis, hyperparathyroidism, Fanconi's syndrome, and mild diabetes mellitus.
  5. Is there glycosuria? The presence of glycosuria suggests diabetes mellitus, hyperthyroidism, and Fanconi's syndrome.

DIAGNOSTIC WORKUP

Routine tests include a CBC, sedimentation rate, urinalysis, urine culture and colony count, chemistry panel, thyroid panel, and x-rays of the skull and long bones. The 24-hr intake and output should be measured. A serum and urine osmolality will be helpful, as would a spot urine sodium.

If pituitary diabetes insipidus is suspected, a CT scan of the brain and tests for pituitary hormones should be done. The intake and output before and after Pitressin® may be measured.

If renal disease is suspected, the urinary sediment should be examined microscopically and renal biopsy may be necessary. An endocrinologist and nephrologist should be consulted before undertaking expensive diagnostic tests.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PROTEINURIA: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Are there significant numbers of white blood cells (WBCs) in the urine? This would suggest a UTI. If there are white cell casts or clumps, the infection may be a pyelonephritis. A urine culture and colony count should be ordered. Sterile urine with persistent proteinuria and pyuria may be seen in toxic nephritis.
  2. Are there increased RBCs in the urine? This would suggest glomerulonephritis, collagen disease, polycystic kidney, tuberculosis, renal calculus, trauma, or neoplasm. The presence of red cell casts would make glomerulonephritis or collagen disease more likely.
  3. Is glucose present in the urine? This would point to diabetic nephritis or nephrosis.
  4. If none of the above associated findings are present, one should look for hypertension, toxemia of pregnancy, fever, cardiac disease, poisoning, orthostatic proteinuria, multiple myeloma, or amyloidosis.

DIAGNOSTIC WORKUP

When faced with a report of protein in the urine, the first thing to do is look at the urine under the microscope. If there are significant numbers of bacteria and WBCs, one has only to order a urine culture and colony count and begin therapy. Recurrent UTIs warrant an IVP and a referral to a urologist, especially in males. If no infection is found, a more thorough workup is warranted, including CBC, chemistry panel, serum protein electrophoresis, ANA, sedimentation rate, urine for Bence-Jones protein, Addis count, ASO titer, IVP, and CT scan of the abdomen. A urologist may need to be consulted for cystoscopy and retrograde pyelography. A nephrologist may need to be consulted for renal biopsy and further evaluation.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PYURIA: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Are there significant RBCs in the urine? If so, one should consider glomerulonephritis, collagen disease, tuberculosis, neoplasm, trauma, renal calculus, and polycystic kidney disease. If not, the most likely etiology is a UTI.
  2. Are there WBC casts in the urine? This would make pyelonephritis or interstitial nephritis more likely.
  3. Are there RBC casts in the urine? This would help differentiate glomerulonephritis and collagen diseases from the other conditions associated with hematuria.

DIAGNOSTIC WORKUP

First, look at the urinary sediment under a microscope. Further workup should include a urine culture and colony count, AFB smear and culture, CBC, sedimentation rate, ANA test, chemistry panel, serum protein electrophoresis, IVP, and a urology consultation. A urologist may do cystoscopy and retrograde pyelography. He may order a CT scan of the abdomen to rule out renal carcinomas and other kidney disease. A nephrologist may need to be consulted in difficult cases. A urologist should be consulted in all cases of recurrent or persistent pyuria.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

ANURIA OR OLIGURIA: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Has the patient been on any drugs? Sulfonamides are notorious for causing renal failure, but one must also consider amphotericin B, gold compounds that might be administered in arthritis, and lead and other drugs or heavy metals.
  2. What is the blood pressure? If there is hypertension and anuria, one should consider acute or chronic glomerulonephritis, polycystic kidneys, and acute tubular necrosis. If there is a low blood pressure, one should consider prerenal causes of anuria such as dehydration, blood loss, the acute abdomen, and other causes of shock.
  3. Is there cardiomegaly or chest pain? If there is an enlarged heart, one should consider congestive heart failure. If there is chest pain, one should consider myocardial infarction or pulmonary infarction. If there is chest or abdominal pain with hypertension, then one should consider dissecting aneurysm.
  4. Is there enlargement of the kidneys? Enlargement of both kidneys should suggest bilateral hydronephrosis or polycystic kidneys. Unilateral enlargement of the kidneys is not usually associated with anuria.
  5. Is there bladder enlargement? Enlarged bladder would make one think of bladder neck obstructions due to prostatic hypertrophy or carcinoma or a urethral stricture. Occasionally, what is thought to be an enlarged bladder is actually a pelvic mass that is obstructing the ureter.
  6. Is there hematuria? Hematuria would suggest glomerulonephritis, acute tubular necrosis, intravascular hemolysis, and nephrolithiasis.
  7. What has been the patient's recent intake of fluid? Dehydration is a frequent cause of oliguria and anuria.

DIAGNOSTIC WORKUP

The first thing to determine is whether the patient really has anuria or oliguria. A Foley catheter should be passed and attached to drainage to determine the urine output. If there is obstructive uropathy due to bladder neck obstruction, obviously this will determine the diagnosis, as there will be a large volume of urine and it should be taken off gradually. Then studies of obstructive uropathy can be done, including cystoscopy and retrograde pyelography. If the obstructive uropathy is due to obstruction of the ureter, renal ultrasonography can be reliable in detecting the dilated calyces or dilated ureter.

If the patient presents with anuria and hypotension, the most important thing is to reestablish the blood pressure. If the anuria does not cease at this point, high-dose furosemide or a mannitol infusion can be started. Meanwhile, a CBC, chemistry panel, urinalysis, spot urine sodium, serum protein electrophoresis, an ANA assay, an EKG, and chest x-ray should be done. A flat plate of the abdomen should give an idea of the kidney size. The clinician should examine the urinary sediment himself, and this will identify cases of acute glomerulonephritis, lupus erythematosus, and acute tubular necrosis with considerable accuracy. The blood urea nitrogen (BUN) and creatinine ratio are helpful in distinguishing pre-renal from renal azotemia.

If intravascular hemolysis is suspected, serum haptoglobins and serum hemoglobin should be done. Eosinophilia of the blood or urine will be found in drug-induced nephritis. Renal angiography and aortography should be done in cases of suspected dissecting aneurysm or bilateral renal artery stenosis. Abdominal ultrasound will also be helpful in diagnosing polycystic kidneys and pelvic masses that may be obstructing the ureter. A CT scan may be necessary as well.

In difficult cases, a renal biopsy may be necessary to diagnose the various collagen diseases and the various forms of glomerulonephritis. Referral to a nephrologist would be best at this point.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Dysuria: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Lower urinary tract etiologies (male)
    –Infectious cystitis: E. coli (#1 cause), Staphylococcus saprophyticus, Proteus, Klebsiella, Enterococcus
    –Acute prostatitis
    –Benign prostatic hypertrophy
    –Epididymitis/urethritis: Chlamydia, gonorrhea, E. coli, staphylococcus aureus
    –External infections (e.g., herpes)
    –Allergic reaction to contraceptives, soaps, lotions
    –Malignancy (urethral or bladder cancer)
    –Urethral strictures
  • Lower urinary tract etiologies (female)
    –Infectious cystitis: E. coli (#1 cause), Staphylococcus saprophyticus, Proteus, Klebsiella, Enterococcus
    –Acute urethritis: Chlamydia, gonorrhea
    –Vaginitis: Candida, herpes
    –Atrophic vaginitis
    –Allergic reaction to contraceptives, soaps, lotions
    –Malignancy: Urethral cancer, bladder cancer
    –Urethral strictures
    –Vaginitis (Trichomonas, bacterial vaginosis)
    • Upper urinary tract etiologies
      –Pyelonephritis: Fever, chills, nausea, vomiting, and CVA tenderness
      –Urolithiasis: Acute onset of dysuria with associated flank pain, with or without hematuria
  • Reiter's syndrome
    –Genital ulcers, conjunctivitis, and arthritis
  • Noninfectious cystitis (e.g., drugs, radiation, granulomatous, allergic)
  • Behçet syndrome
    –Oral and genital ulcers, arthritis, and uveitis
  • Trauma
  • Rectal fissure
  • Psychogenic (e.g., conversion disorder)

    • Workup and Diagnosis

    • History and physical examination
    • Male genital exam with gonorrhea/chlamydia test, culture, Gram stain
      –Tender, boggy, swollen prostate suggests prostatitis (avoid prostatic massage, because of risk of bacteremia)
      –Tender epididymitis and testicles suggest infection
      –Generally enlarged prostate associated with nocturia and increasing frequency suggests BPH
    • Female genital exam with KOH prep, wet mount, Gram stain, and DNA tests/culture as indicated
      –Thin, papery vaginal tissue suggests atrophic vaginitis
      –Candida discharge is thick, cheesy, and white; pruritic
      –Chlamydia discharge is scant, watery and gradual onset
      –Gonorrhea discharge is profuse, yellow-green with abrupt onset, intracellular gram-negative diplococci
      –Bacterial vaginosis discharge is pruritic, with clue cells on wet mount and a fishy odor with KOH (whiff test)
      –Trichomonas discharge is frothy, grey-green, with pruritis and mobile organisms on wet mount
      • Urinalysis should be done in all patients
        –Hematuria suggests urolithiasis, pyelonephritis, or cystitis; painless hematuria suggests bladder cancer
        –Positive nitrites, leukocyte esterase, or WBCs with suprapubic tenderness suggests uncomplicated cystitis
      • Urine culture is indicated if positive urinalysis and in pregnant women, diabetic or immunocompromised patients, or males with urethral discharge

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Polyuria: Differential Diagnosis
    (In a Page: Signs and Symptoms)

    • Diuretic use
    • Primary polydipsia
      –Usually in middle-aged, anxious women
      –Psychiatric illnesses due to increased water intake (e.g. psychogenic polydipsia)
      –May be due to hypothalamic lesions in the thirst centers (e.g., sarcoidosis)
    • Chronic lithium use
      –20% of patients develop polydipsia
    • Central diabetes insipidus
      –Due to decreased output of antidiuretic hormone
      –May be idiopathic, familial, autoimmune, or due to head trauma, infiltrative diseases (e.g., sarcoidosis, granulomas, Langerhans cell histiocytosis), pituitary tumors (intrasellar, suprasellar), or ischemic or hypoxic encephalopathy
    • Nephrogenic diabetes insipidus
      –Due to decreased response of the kidneys to antidiuretic hormone
      –May be idiopathic, familial, or due to drugs (e.g., colchicine, fluoride, phenothiazine), chronic renal disease, hypercalcemia, hypokalemia, sickle cell disease
    • Uncontrolled diabetes mellitus
      –Patients have polydipsia and subsequent polyuria secondary to high sugar levels

    Workup and Diagnosis

    • Complete history and physical exam with corroboration from caretakers and family if available
    • Initial laboratory studies include serum and urine fasting glucose, creatinine, electrolytes, osmolality, and serum BUN
    • Water deprivation test
      –Give no fluids for 12–18 hours and measure body weight, plasma and urine osmolarity, blood pressure, and urine specific gravity every 2 hours
      –Stop test if severe dehydration or drop in BP occurs (indicates diabetes insipidus likely)
      –A normal response is a drop in urine output to 0.5 mL/min, and urine osmolarity >plasma osmolarity
      –Maintenance of dilute urine with specific gravity <1.005 indicates diabetes insipidus (central or nephrogenic)
      –Continue test until plateau phase (hourly increase UOP <30 mOsm/kg for 3 consecutive hours)
      –Then give 5 mg ADH SQ and measure urine osmolarity 1 hour later
    • Measure ADH and osmolarity levels during water test
      –Nephrogenic diabetes insipidus: Normal or slightly increased ADH; urine osmolality increases <50% after ADH given
      –Complete central diabetes insipidus: Decreased levels of ADH; urine osmolarity >plasma osmolarity
      –Primary polydipsia: Serum and urine osmolarity are decreased before the test and increase during the water deprivation test
    >>>

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Urinary Stream (Decreased): Differential Diagnosis
    (In a Page: Signs and Symptoms)

    • Benign prostatic hyperplasia

    • –Most common cause of decreased urinary stream in men >40
  • Urethral stricture
    –May be congenital or acquired
    • Chronic urethritis
      –May be secondary to stricture or chronic infection
  • Prostate cancer
    –More frequent in men >40
    • Neuropathic bladder
      –Spinal cord trauma
      –Herniated disc
      –Multiple sclerosis
      –Spina bifida
      –CVA
      –Parkinson's disease
      –Nerve injury secondary to pelvic surgery
    • (e.g., prostatectomy)
    • Bladder neck contracture
      –May be congenital or acquired (e.g., post-prostatectomy)
  • Urethral or bladder foreign body
  • Bladder stones
  • Bladder neck cancer
  • Urethral cancer
  • Urethral polyp
  • Posterior urethral valves
    –Frequently presents with recurrent UTIs

    • Workup and Diagnosis

    • History and physical examination, including abdomen, back, genitalia (palpate penis for areas of tenderness or induration), digital rectal examination, neurologic exam
      –Note previous urinary tract instrumentation and STDs
      –Exploration of urethra with catheter to check for obstruction and postvoid residual (normal <100 mL)
  • Initial labs include urinalysis (pyuria indicates secondary infection), urine culture and sensitivity, CBC (may reveal leukocytosis in infection, anemia in chronic disease), BUN/creatinine (elevated in acute renal failure, such as obstruction), and electrolytes
  • Consider PSA, which is elevated in prostate cancer and prostatitis; may be mildly elevated in BPH
  • Consider urine cytology and alkaline phosphatase (elevated in metastatic prostate cancer)
  • Uroflowmetry: Calculate urine flow rate during timed void (normal 20–25 mL/second; <10 indicates obstruction)
  • Consider renal ultrasound to rule out hydronephrosis and stones
  • Consider abdominal/pelvic CT scan to detect stones and workup cancer
  • Consider cystoscopy (to rule out cancer and anatomic problems), retrograde urethrography (to assess for strictures), voiding cystourethrogram (pressure/volume curves), transrectal ultrasound with needle biopsy (prostate CA), and/or intravenous pyelogram (stones and anatomic abnormalities)

    • >>

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Dysuria: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    • Urinary tract infection (UTI)
      –Common cause of dysuria in children
      –Common pathogens: bacteria including E. coli (85%), Klebsiella pneumoniae, Proteus vulgaris, Pseudomonas aeruginosa and other gram negatives
    • Sexually transmitted disease (STD)
      –Gonorrhea, Chlamydia, Trichomonas
      –Very common in sexually active patients
      –More common in girls
      • Bacterial vaginosis
        –Gardnerella or Mobiluncus spp, may be sexually or nonsexually transmitted
    • Candidal vaginitis
      –Common after antibiotic treatment
    • Local urethral irritation
      –Pinworms
      –Irritative dermatitis (e.g., bubble bath)
      –Diarrhea
    • Hemorrhagic cystitis
      –Typically viral in origin
      –Sudden in onset
    • Macroscopic blood in the urine from any cause, causing urethral irritation
    • Periurethral herpes simplex
    • Periurethral varicella
    • Hypercalciuria
      –Dysuria and urinary frequency
    • Kidney stone (within the urethra)
    • Renal tuberculosis (rare)
      –Typically asymptomatic
      –Sterile pyuria
    • Prostatitis (uncommon)
      –Can affect adolescent boys
      –Gonorrhea is the most common cause
    • Trauma to the perineum
      –Sexual abuse
      –Masturbation
    • Meatal ulceration
      –In boys, may occur from contact with diapers
    • Pelvic abscess, including appendicitis
    • Drugs
      –Amitriptyline hydrochloride (antidepressant)
    • Reiter disease
      –Uncommon in children
      –Triad of arthritis, urethritis, and conjunctivitis

    Workup and Diagnosis

    • History
      –UTI, STD, sexual activity, recent antibiotic exposure
      –Instrumentation/irritation (urinary catheters, bubble baths, creams, masturbation)
      –Fever, abdominal pain, flank pain, vaginal discharge
      –Enuresis (especially new-onset), macroscopic hematuria, frequency, urgency
      –Family history of kidney stones (increased likelihood of hypercalciuria)
      • Physical exam
        –Fever, CVA tenderness
        –Exam of the urethra/periurethral area for irritation
        –Pelvic exam (if done) for cervical motion tenderness, cervicitis, or vaginal discharge
      • Labs
        –Urinalysis, urine culture
        –STD screening if sexually active
        –Urine spot calcium and creatinine if evidence of microscopic hematuria
    • Additional studies based on clinical situation
      –Pelvic ultrasound if PID suspected
      –Renal ultrasound/voiding cystourethrogram if history of previous UTI (in girls <7 and boys of any age), or if macroscopic hematuria is present
      –High-resolution CT without contrast (kidney stones)
      –24-hour urine calcium (hypercalciuria, kidney stones)
    >

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Enuresis: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    • Urinary tract infection (UTI)
      –Most common cause of new onset, secondary enuresis
      –Common pathogens: E. coli (85%), Klebsiella pneumoniae, Proteus vulgaris, Pseudomonas aeruginosa, and other gram-negatives
      • Primary nocturnal enuresis
        –Normal in children up to 8 years
        –Often there is a strong family history
        –Affected family members may not achieve night-time continence until adolescence
      • Dysfunctional voiding
        –Unstable (uninhibited) bladder of childhood
        –Infrequent voiding
        –Neurogenic bladder
      • Psychosocial stress
      • Chronic constipation
        –Often associated with encopresis
      • Chronic kidney disease
      • Nephrogenic diabetes insipidus (DI)
      • Central DI
      • Diabetes mellitus (DM)
      • Ectopic ureter
      • Posterior urethral valves
      • Urethral stricture
      • Developmental delay
      • Neurologic disease
        –Tethered cord
        –Spina bifida
        –Spinal tumors
        –Spinal dysraphism
      • Sexual abuse
      • Prostatic tumor or abscess
      • Hydrocolpos or hematocolpos
      • Osteomyelitis of vertebral body with compression of the spinal cord
      • Spinal epidural abscess
      • Obstructive sleep apnea
      • Giggle micturition

    Workup and Diagnosis

      • History
        –Primary vs secondary; daytime vs night-time
        –Previous urinary tract infection or renal disease
        –Poor growth, recurrent dehydration
        –“Curtsying” or urinary withholding/delay maneuvers
        –Stooling frequency
        –Psychosocial stressors, social withdrawal, poor performance in school (depression or sexual abuse)
        –Developmental delay
    • Family history: Primary nocturnal enuresis, polyuria; early infant death (suggests nephrogenic DI)
      • Symptoms
        –Fever, flank pain (UTI), dysuria, urgency, frequency (cystitis or dysfunctional voiding)
        –Fatigue and polyuria (renal disease)
        –Headache or vision changes (intracranial process)
      • Physical exam
        –Affect, developmental assessment, growth parameters (height/weight), blood pressure
        –Pallor (e.g., due to anemia of renal failure)
        –Neuro: Reflexes, anal wink, sensation, strength
        –Spinal exam (hair tufts, clefts suggest spina bifida)
        –GU exam
    • Labs: Urinalysis, urine culture, chemistry panel
    • Additional evaluation based on the clinical situation
      –Spinal MRI for sacral dimple or hair cleft
      –Ultrasound/VCUG for UTI or other kidney /bladder disease

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Proteinuria: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

      • Transient proteinuria
        –With fever, dehydration, exercise, seizures, cold exposure, or stress
        –Rarely >2+ on dipstick
        –Usually remits within 1–2 weeks
    • Orthostatic (postural) proteinuria
      –Occurs mostly in adolescence
      –First morning U/A is negative for protein
    • Primary glomerular disease
      –MCNS: Most common cause of nephrotic syndrome (NS) in younger children, usually presents in ages 2–6, more common in boys; etiology possibly immune-mediated, typically responds to corticosteroids
      –Mesangial proliferative GN: Intermediate lesion between MCNS and FSGS
      –FSGS: Progressive disease of glomerular scarring, more common in blacks and adolescents, presents as NS or asymptomatic proteinuria, frequently resistant to corticosteroid therapy
      –Membranous nephropathy
      –Any primary GN (e.g., APSGN) can present with hematuria and proteinuria
    • Systemic lupus erythematosus nephritis
    • Henoch-Schönlein purpura (HSP)
    • Wegener granulomatosis
      • Tubulointerstitial disease: Proteinuria is less than with primary glomerular diseases
        –Reflux nephropathy
        –Renal dysplasia
        –Interstitial nephritis (especially NSAIDs)
        –Polycystic kidney disease
      • Infectious disease
        –Bacterial (e.g., poststrep, shunt nephritis, leprosy, syphilis, infective endocarditis)
        –Viral (e.g., HBV, CMV, EBV, VZV, HIV)
        –Protozoal (e.g., malaria, toxoplasmosis)
        –Parasitic (e.g., schistosomiasis, filariasis)
    • Neoplasm (e.g., lymphoma, leukemia, Wilms tumor, pheochromocytoma)
    • Alport syndrome
    • Fabry disease
    • Nail-patella syndrome
    • Medications (e.g. gold, mercurials)
    • Constrictive pericarditis

    Workup and Diagnosis

    • History
      –Renal disease
      –Recurrent UTIs
      –HIV infection
      –Edema (periorbital or extremity)
      –Fatigue
      –Weight loss or gain
      –Pallor (seen with anemia of chronic disease)
      –Gross hematuria
      –“Foamy” urine
    • Physical exam
      –Blood pressure, growth parameters
      –Edema (periorbital or extremity), ascites
      –Rashes or joint abnormalities
    • Labs
      –Serum chemistries including albumin and triglycerides
      –U/A, 24-hour urine collection for protein
      –C3, C4
      • If asymptomatic proteinuria, obtain “first morning” void, preferably prior to ambulation, to rule out orthostatic proteinuria before performing extensive lab workup
        –If U/A is negative for protein, additional diagnostic testing is not necessary
    • Additional tests as indicated by the history
      –ANCA, ANA, HIV
    • Renal ultrasound

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Pyuria: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    • Urinary tract infection
    • Asymptomatic bacteriuria
      –Relatively common in school-age girls
      –Urine cultures are repeatedly positive
      –Patients remain asymptomatic
      • Sexually transmitted disease (STD)
        –Gonorrhea, Chlamydia, Trichomonas
        –Bacterial vaginitis (can be nonsexually transmitted)
    • Other causes of vaginal discharge/perineal irritation (e.g., candidal vaginitis)
      • Acute interstitial nephritis
        –“Allergic” tubulointerstitial process
        –Occurs 7–14 days after exposure to inciting agent (e.g., antibiotics or NSAIDs)
        –May have polyuria, fever, and rash, and elevated serum creatinine of unclear etiology
        –Urinalysis is otherwise unremarkable
    • Inherited cystic diseases
      –PKD: Occurs in both autosomal dominant and autosomal recessive forms
      –Juvenile nephronophthisis: Rare cause of inherited chronic tubulointerstitial nephritis, steady progression to kidney failure in the first two decades of life, autosomal recessive inheritance
      • Appendicitis
        –May present with symptoms suggestive of acute pyelonephritis (fever, flank or abdominal pain)
        –Urine culture is negative
        –Symptoms are progressive
      • Renal tuberculosis
        –Routine urine culture negative
      • Gastroenteritis (typically viral)
      • Lupus nephritis
      • Alport syndrome
      • Nail-patella syndrome
      • Urethritis
      • Kawasaki disease
        –Most common vasculitis of childhood
        –Characterized by high fever, irritability, mucous membrane changes, edema of the hands and feet, lymphadenopathy
        –Coronary vasculitis and aneurysms may result
        –Treated with aspirin and IVIG

    Workup and Diagnosis

      • History
        –Previous UTI or positive urine culture
        –Unprotected sexual activity, previous STD
        –Recent antibiotic or other medication exposure
        –Poor growth (seen in chronic kidney disease)
        –Dysuria, urgency, frequency, fever, flank pain
        –Polyuria, polydipsia
        –Abdominal pain (particularly right lower quadrant)
        –Family history of polycystic kidney disease or other inherited kidney disease
    • Physical exam
      –Temperature, BP, height, and weight
      –Rashes
      –Pelvic exam (if patient sexually active)
      –Exam of the external genitalia
      –Abdominal masses
      –Costovertebral angle tenderness
    • Labs
    • Urinalysis (including microscopy), urine culture
      –STD screen if sexually active: GC culture, Chlamydia DNA probe or ligase chain test, wet prep for Trichomonas
      –Chemistry panel to screen for renal disease
      • Additional studies depend on the clinical situation
        –Abdominal CT scan or ultrasound for appendicitis
        –Renal ultrasound if inherited cystic diseases are suspected

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    DYSURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis includes a urinalysis, urine cultures, smear and culture of any discharge, an intravenous pyelogram, voiding cystogram and cystoscopy, and cystometric examination. In females with “negative” cultures, Chlamydia urethritis must be considered and treated. In males with negative cultures, prostatic examination, massage, and evaluation of discharge are done.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    GLYCOSURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The investigation of glycosuria should include a glucose tolerance test, chemistry panel, and electrolyte panel. A clinical history of polyuria, polyphagia, weakness, and weight loss will be helpful. If there are clinical features of one of the endocrine diseases listed above, various tests for these disorders and an endocrinology consult should be ordered.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    INCONTINENCE, URINARY: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    First, exclude stress incontinence with a pad test. Perineal pads are weighed before and after walking and stress for 30 minutes. An increase in weight identifies urine loss. Catheterization and examination, smear, and culture of the urine are essential at the outset. Cystoscopy and cystometric studies are often needed. Surgical repair of a cystocele or a parasympathomimetic drug in cases of a flaccid neurogenic bladder and propantheline bromide (ProBanthine), a parasympatholytic drug, for spastic neurogenic bladders may be all that is necessary. A neurologist and urologist often need to cooperate in the diagnosis and treatment of these unfortunate individuals.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    NOCTURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The workup of nocturia is essentially the same as the workup of polyuria and urinary frequency (see page 429). Obviously, the search for obstruction and infection are most important. A venous pressure and circulation time and pulmonary function studies to rule out congestive heart failure should be done if the urinary tract is clean.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    POLYURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The diagnosis of polyuria depends largely on the association of other symptoms. Polyuria, polyphagia, and polydipsia suggest diabetes mellitus and hyperthyroidism. Polyuria with only polydipsia suggests psychogenic or idiopathic diabetes insipidus; the Hickey–Hare test will differentiate the two. Polyuria with polydipsia and weakness but with no significant weight loss suggests hypercalcemia and possible hyperparathyroidism. Chronic nephritis will be diagnosed by examination of the urine sediment and a specific gravity that remains at 1.010. Nephrogenic diabetes insipidus can be differentiated from neurogenic diabetes insipidus by the inability of the kidney to respond to a pitressin injection.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    PROTEINURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The first step is to determine whether the proteinuria is caused by infection. A urinalysis for WBCs and examination of a fresh drop of unspun urine under the microscope for the bacteria are the fastest ways of determining this. The urine can also be cultured. Next, determine if there are red cells in the urine. This would indicate a more serious cause for the proteinuria such as collagen disease, stone, glomerulonephritis, or neoplasm and prompts the need for an IVP, cystoscopy, and urology consult.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    PYURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    How does one track down the cause of pyuria? First, it must be determined that the cloudy urine is really pyuria. Amorphous phosphates and other inert material will disappear on treating the urine with dilute acetic acid. Then, just as for other nonbloody discharges, one must do a smear and culture for the offending organism; an examination of the urine, especially the unspun specimen, is axiomatic. If one finds clumps of leukocytes, renal gitter cells, or WBC casts, the infection almost certainly comes from the kidney. Motile bacteria in an unspun specimen examined under high-power microscopy and a colony count of over 100,000 ÷mL signify infection. A three-glass test may be helpful in localizing the site of origin of the pyuria. Anaerobic cultures and cultures for Chlamydia may be needed. Look for eosinophils on a Wright stain of the urine if toxic nephritis is suspected.

    Vaginal examination and culture may disclose a source for the infection. In the male, one episode of pyuria should be sufficient indication for an IVP; a female should have one after her second episode, especially if no cause can be found on physical examination. Cystoscopy and a voiding cystogram are often indicated at this time.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    ANURIA AND OLIGURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The clinical picture will be helpful in determining the cause of anuria. In cases of prerenal azotemia, there will be decreased skin turgor and orthostatic hypotension if the cause is volume depletion. If the cause is CHF, there will be jugular vein distention, hepatomegaly, and pedal edema. Patients with postrenal azotemia may have an enlarged prostate, a distended bladder, and other signs of obstructive uropathy. Patients with renal azotemia may have bilateral flank masses (polycystic kidney), hypertension, peripheral emboli (embolic glomerulonephritis), or a rash (collagen disease, interstitial nephritis).

    The initial workup includes a CBC; urinalysis; urine culture and sensitivity; personal examination of the urine for casts, and so forth; chemistry panel; spot urine sodium; serum and urine osmolality; flat plate of the abdomen for kidney size; chest x-ray; and ECG. The bladder is catheterized for residual urine and if this is significant, postrenal azotemia is likely and a urologist is consulted. He will most likely do a cystoscopy and retrograde pyelography once the patient’s condition is stabilized. Ultrasonography can be used to determine if there is significant residual urine also.

    The laboratory studies will determine whether there is prerenal or renal azotemia. If the sodium concentration in the spot urine is less than 10 meq/L, prerenal azotemia is likely. Also, in prerenal Azotemia, the BUN: creatinine ratio is 20:1 or greater and the urine osmolality is 450 mOsm per kilogram of water or greater. The urine sediment will show granular and red cell casts in most cases of renal azotemia, and the BUN:creatinine ratio will be 10:1 or less.

    Further workup will depend on what the presumptive diagnosis is. If volume depletion is the cause, intravenous saline and plasma volume expanders are given while carefully monitoring the urine output. If this is ineffective, furosemide and a mannitol drip can be utilized to reestablish urine output. If these measures are ineffective, the patient obviously has a renal cause for his/her anuria and a urologist should be consulted.

    Renal causes can be differentiated by further workup. If intravascular hemolysis is suspected, serum haptoglobins should be ordered. If dissecting aneurysm or bilateral renal artery stenosis is suspected, aortography and angiography would be done. If polycystic kidney disease is suspected, ultrasonography or CT scan of the abdomen may be done. Eosinophilia of the blood or urine will be found in drug-induced nephritis. If a collagen disease is suspected, one should order an ANA, double-stranded DNA (dsDNA) antibody titer or lupus erythematosus (LE) cell prep. A renal biopsy may also be necessary in these disorders and many others.

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    Source: Differential Diagnosis in Primary Care, 2007

    ENURESIS (BEDWETTING): Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    From the above discussion it should be obvious that simple bedwetting prior to age 6 may not require a workup at all. After that age a careful examination of the urine, including smear and culture for bacteria, should be done. An intravenous pyelogram and voiding cystogram are usually necessary. If these suggest a congenital lesion or are negative, cystoscopy may need to be done. An x-ray film for spina bifida and a sleep EEG are probably worthwhile if urologic investigation is negative.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Anuria: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Take the patient’s vital signs and obtain a complete history. First, ask about changes in his voiding pattern. Determine the amount of fluid he normally ingests each day, the amount of fluid he ingested in the last 24 to 48 hours, and the time and amount of his last urination. Review his medical history, noting especially previous kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about drug use and about abdominal, renal, or urinary tract surgery.

    Inspect and palpate the abdomen for asymmetry, distention, or bulging. Inspect the flank area for edema or erythema, and percuss and palpate the bladder. Palpate the kidneys anteriorly and posteriorly, and percuss them at the costovertebral angle. Auscultate over the renal arteries, listening for bruits.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Bladder distention: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    If distention isn't severe, begin by reviewing the patient's voiding patterns. Find out the time and amount of the patient's last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva's or Credé's maneuver to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.

    Explore the patient's history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Note his drug history, including his use of over-the-counter drugs.

    Take the patient's vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can't be palpated through the abdominal wall.) Inspect the urethral meatus, and measure its diameter. Describe the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Enuresis: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    When taking a history, include the parents as well as the child. First, determine the number of nights each week or month that the child wets the bed. Is there a family history of enuresis? Ask about the child's daily fluid intake. Does he drink much after supper? What are his typical sleep and voiding patterns? Find out if the child has ever had control of his bladder. If so, try to pinpoint what may have precipitated enuresis, such as an organic disorder or psychological stress. Does the bed-wetting occur at home and away from home? Ask the parents how they've tried to manage the problem, and have them describe the child's toilet training. Observe the child's and parents' attitudes toward bed-wetting. Finally, ask the child if it hurts when he urinates.

    Next, perform a physical examination to detect signs of neurologic or urinary tract disorders. Observe the child's gait to check for motor dysfunction, and test sensory function in the legs. Inspect the urethral meatus for erythema, and obtain a urine specimen. A rectal examination to evaluate sphincter control may be required.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Nocturia: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Begin by exploring the history of the patient’s nocturia. When did it begin? How often does it occur? Can the patient identify a specific pattern? Precipitating factors? Also, note the volume of urine voided. Ask the patient about changes in the color, odor, or consistency of his urine. Has the patient changed his usual pattern or volume of fluid intake? Next, explore associated symptoms. Ask about pain or burning on urination, difficulty initiating a urine stream, costovertebral angle (CVA) tenderness, and flank, upper abdominal, or suprapubic pain.

    Determine if the patient or his family has a history of renal or urinary tract disorders or endocrine and metabolic diseases, particularly diabetes. Is the patient taking a drug that increases urine output, such as a diuretic, a cardiac glycoside, or an antihypertensive?

    Focus your physical examination on palpating and percussing the kidneys, CVA, and bladder. Carefully inspect the urinary meatus. Inspect a urine specimen for color, odor, and the presence of sediment.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Oliguria: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Begin by asking the patient about his usual daily voiding pattern, including frequency and amount. When did he first notice changes in this pattern and in the color, odor, or consistency of his urine? Ask about pain or burning on urination. Has the patient had a fever? Note his normal daily fluid intake. Has he recently been drinking more or less than usual? Has his intake of caffeine or alcohol changed drastically? Has he had recent episodes of diarrhea or vomiting that might cause fluid loss? Next, explore associated complaints, especially fatigue, loss of appetite, thirst, dyspnea, chest pain, or recent weight gain or loss (in dehydration).

    Check for a history of renal, urinary tract, or cardiovascular disorders. Note recent traumatic injury or surgery associated with significant blood loss as well as recent blood transfusions. Was the patient exposed to nephrotoxic agents, such as heavy metals, organic solvents, anesthetics, or radiographic contrast media? Next, obtain a drug history.

    Begin the physical examination by taking the patient’s vital signs and weighing him. Assess his overall appearance for edema. Palpate both kidneys for tenderness and enlargement, and percuss for costovertebral angle (CVA) tenderness. Also, inspect the flank area for edema or erythema. Auscultate the heart and lungs for abnormal sounds and the flank area for renal artery bruits. Assess the patient for edema or signs of dehydration such as dry mucous membranes.

    Obtain a urine sample and inspect it for abnormal color, odor, or sediment. Use reagent strips to test for glucose, protein, and blood. Also, use a urinometer to measure specific gravity.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Polyuria: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Because the patient with polyuria is at risk for developing hypovolemia, evaluate his fluid status first. Take his vital signs, noting an increased body temperature, tachycardia, and orthostatic hypotension (a ≥10 mm Hg decrease in systolic blood pressure upon standing and a ≥10 beats/minute increase in heart rate upon standing). Inspect for dry skin and mucous membranes, decreased skin turgor and elasticity, and reduced perspiration. Is the patient unusually tired or thirsty? Has he recently lost more than 5% of his body weight? If you detect these effects of hypovolemia, you’ll need to infuse replacement fluids.

    If the patient doesn’t display signs of hypovolemia, explore the frequency and pattern of the polyuria. When did it begin? How long has it lasted? Was it precipitated by a certain event? Ask the patient to describe the pattern and amount of his daily fluid intake. Check for a history of visual deficits, headaches, or head trauma, which may precede diabetes insipidus. Also check for a history of urinary tract obstruction, diabetes mellitus, renal disorders, chronic hypokalemia or hypercalcemia, or psychiatric disorders (past and present). Find out the schedule and dosage of any drugs the patient is taking.

    Perform a neurologic examination, noting especially any change in the patient’s level of consciousness. Then palpate the bladder and inspect the urethral meatus. Obtain a urine specimen and check its specific gravity.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Urinary frequency: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask the patient how many times a day he voids. How does this compare to his previous pattern of voiding? Ask about the onset and duration of the abnormal frequency and about any associated urinary signs or symptoms, such as dysuria, urgency, incontinence, hematuria, discharge, or lower abdominal pain with urination.

    Ask also about neurologic symptoms, such as muscle weakness, numbness, or tingling. Explore his medical history for urinary tract infection, other urologic problems or recent urologic procedures, and neurologic disorders. With a male patient, ask about a history of prostatic enlargement. If the patient is a female of childbearing age, ask whether she is or could be pregnant.

    Obtain a clean-catch midstream sample for urinalysis and culture and sensitivity tests. Then palpate the patient’s suprapubic area, abdomen, and flanks, noting any tenderness. Examine his urethral meatus for redness, discharge, or swelling. In a male patient, the physician may palpate the prostate gland.

    If the patient’s medical history reveals symptoms or a history of neurologic disorders, perform a neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Urinary hesitancy: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask the patient when he first noticed hesitancy and if he’s ever had the problem before. Ask about other urinary problems, especially reduced force or interruption of the urine stream. Ask if he’s ever been treated for a prostate problem or urinary tract infection or obstruction. Obtain a drug history.

    Inspect the patient’s urethral meatus for inflammation, discharge, and other abnormalities. Examine the anal sphincter and test sensation in the perineum. Obtain a clean-catch sample for urinalysis and culture. In a male patient, the prostate gland requires palpation. A female patient requires a gynecologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Urinary incontinence: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If he is occasionally able to control urination, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he’s ever sought treatment for incontinence or found a way to deal with it himself.

    Obtain a medical history, especially noting urinary tract infection, prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies she has had and how many childbirths.

    After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious inflammation or anatomic defect. Have female patients bear down; note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.

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    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Urinary urgency: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask the patient about the onset of urinary urgency and whether he’s ever experienced it before. Ask about other urologic symptoms, such as dysuria and cloudy urine. Also ask about neurologic symptoms, such as paresthesia. Examine his medical history for recurrent or chronic UTIs or for surgery or procedures involving the urinary tract.

    Obtain a clean-catch sample for urinalysis and culture. Note urine character, color, and odor, and use a reagent strip to test for pH, glucose, and blood. Then palpate the suprapubic area and both flanks for distention and tenderness. If the patient’s history or symptoms suggest neurologic dysfunction, perform a neurologic examination.

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    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Urine cloudiness: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask about symptoms of UTI, such as dysuria; urinary urgency or frequency; or pain in the flank, lower back, or suprapubic area. Also ask about recurrent urinary tract infections or recent surgery or treatment involving the urinary tract.

    Obtain a urine sample to check for pus or mucus. (See Peforming the three-glass urine test, page 608.) Using a reagent strip, test for blood, glucose, and pH. Palpate the suprapubic area and flanks for tenderness.

    If you note cloudy urine in a patient with an indwelling urinary catheter, especially with concurrent fever, remove the catheter immediately (or change it if the patient must have one in place).

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Lower urinary tract infection: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Characteristic clinical features and a microscopic urinalysis showing red blood cells and white blood cells greater than 10/high-power field suggest lower UTI.

    CONFIRMING DIAGNOSIS A clean-catch midstream urine specimen revealing a bacterial count above 100,000/µl confirms the diagnosis.

    Lower counts don’t necessarily rule out infection, especially if the patient is voiding frequently because bacteria require 30 to 45 minutes to reproduce in urine. Careful midstream, clean-catch collection is preferred to catheterization, which can reinfect the bladder with urethral bacteria.

    Sensitivity testing determines the appropriate therapeutic antimicrobial agent. If patient history and physical examination warrant, a blood test or a stained smear of the discharge rules out venereal disease. Voiding cystoureterography or excretory urography may detect congenital anomalies that predispose the patient to recurrent UTIs.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Anuria: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Take the patient’s vital signs and obtain a complete history. First ask about any changes in his voiding pattern. Determine the amount of fluid he normally ingests each day, the amount of fluid he ingested in the last 24 to 48 hours, and the time and amount of his last urination. Review his medical history, noting especially previous kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about drug use and about any abdominal, renal, or urinary tract surgery.

    Inspect and palpate the abdomen for asymmetry, distention, or bulging. Inspect the flank area for edema or erythema, and percuss and palpate the bladder. Palpate the kidneys both anteriorly and posteriorly, and percuss them at the costovertebral angle. Auscultate over the renal arteries, listening for bruits.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Bladder distention: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If distention isn’t severe, begin by reviewing the patient’s voiding patterns. Find out the time and amount of the patient’s last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva’s or Credé’s maneuver to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.

    Explore the patient’s history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Ask about his drug history, including his use of over-the-counter drugs.

    Take the patient’s vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can’t be palpated through the abdominal wall.) Inspect the urethral meatus, and measure its diameter. Describe the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Dysuria: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If the patient complains of dysuria, have him describe its severity and location. When did he first notice it? Did anything precipitate it? Does anything aggravate or alleviate it?

    Next, ask about previous urinary or genital tract infections. Has the patient recently undergone an invasive procedure, such as cystoscopy or urethral dilatation, or had a urinary catheter inserted? Also, ask if he has a history of intestinal disease. Ask the female patient about menstrual disorders and use of products that irritate the urinary tract, such as bubble bath salts, feminine deodorants, contraceptive gels, or perineal lotions. Also ask her about vaginal discharge or pruritus.

    During the physical examination, inspect the urethral meatus for discharge, irritation, or other abnormalities. A pelvic or rectal examination may be necessary.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Enuresis: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    When taking a history, include the parents as well as the child. First, determine the number of nights each week or month that the child wets the bed. Is there a family history of enuresis? Ask about the child’s daily fluid intake. Does he drink much after supper? What are his typical sleep and voiding patterns? Find out if the child has ever had control of his bladder. If so, try to pinpoint what may have precipitated enuresis, such as an organic disorder or psychological stress. Does the bed-wetting occur both at home and away from home? Ask the parents how they have tried to manage the problem, and have them describe the child’s toilet training. Observe the child’s and parents’ attitudes toward bed-wetting. Finally, ask the child if it hurts when he urinates.

    Next, perform a physical examination to detect signs of neurologic or urinary tract disorders. Observe the child’s gait to check for motor dysfunction, and test sensory function in the legs. Inspect the urethral meatus for erythema, and obtain a urine specimen. A rectal examination to evaluate sphincter control may be required.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Nocturia: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Begin by exploring the history of the patient’s nocturia. When did it begin? How often does it occur? Can the patient identify a specific pattern? Precipitating factors? Also, note the volume of urine voided. Ask the patient about any change in the color, odor, or consistency of his urine. Has the patient changed his usual pattern or volume of fluid intake? Next, explore associated symptoms. Ask about pain or burning on urination, difficulty initiating a urine stream, costovertebral angle tenderness, and flank, upper abdominal, or suprapubic pain.

    Determine if the patient or his family has a history of renal or urinary tract disorders or endocrine and metabolic diseases, particularly diabetes. Is the patient taking a drug that increases urine output, such as a diuretic, a cardiac glycoside, or an antihypertensive?

    Focus your physical examination on palpating and percussing the kidneys, the costovertebral angle, and the bladder. Carefully inspect the urinary meatus. Inspect a urine specimen for color, odor, and the presence of sediment.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Oliguria: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Begin by asking the patient about his usual daily voiding pattern, including frequency and amount. When did he first notice changes in this pattern and in the color, odor, or consistency of his urine? Ask about pain or burning on urination. Has the patient had a fever? Note his normal daily fluid intake. Has he recently been drinking more or less than usual? Has his intake of caffeine or alcohol changed drastically? Has he had recent episodes of diarrhea or vomiting that might cause fluid loss? Next, explore associated complaints, especially fatigue, loss of appetite, thirst, dyspnea, chest pain, or recent weight gain or loss (in dehydration).

    Check for a history of renal, urinary tract, or cardiovascular disorders. Note recent traumatic injury or surgery associated with significant blood loss, as well as recent blood transfusions. Was the patient exposed to nephrotoxic agents, such as heavy metals, organic solvents, anesthetics, or radiographic contrast media? Next, obtain a drug history.

    Begin the physical examination by taking the patient’s vital signs and weighing him. Assess his overall appearance for edema. Palpate both kidneys for tenderness and enlargement, and percuss for costovertebral angle (CVA) tenderness. Also, inspect the flank area for edema or erythema. Auscultate the heart and lungs for abnormal sounds, and the flank area for renal artery bruits. Assess the patient for edema or signs of dehydration such as dry mucous membranes.

    Obtain a urine sample and inspect it for abnormal color, odor, or sediment. Use reagent strips to test for glucose, protein, and blood. Also, use a urinometer to measure specific gravity.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Polyuria: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Because the patient with polyuria is at risk for developing hypovolemia, evaluate fluid status first. Take vital signs, noting increased body temperature, tachycardia, and orthostatic hypotension (a 10-mm Hg decrease in systolic blood pressure upon standing and a 10-beats per minute increase in heart rate upon standing). Inspect for dry skin and mucous membranes, decreased skin turgor and elasticity, and reduced perspiration. Is the patient unusually tired or thirsty? Has he recently lost more than 5% of his body weight? If you detect these effects of hypovolemia, you’ll need to infuse replacement fluids.

    If the patient doesn’t display signs of hypovolemia, explore the frequency and pattern of the polyuria. When did it begin? How long has it lasted? Was it precipitated by a certain event? Ask the patient to describe the pattern and amount of his daily fluid intake. Check for a history of visual deficits, headaches, or head trauma, which may precede diabetes insipidus. Also check for a history of urinary tract obstruction, diabetes mellitus, renal disorder, chronic hypokalemia or hypercalcemia, or psychiatric disorder (both past and present). Find out the schedule and dosage of any drugs the patient is taking.

    Perform a neurologic examination, noting especially any change in the patient’s level of consciousness. Then palpate the bladder and inspect the urethral meatus. Obtain a urine specimen and check its specific gravity.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Urinary frequency: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask the patient how many times a day he voids and how this compares to his previous pattern of voiding. Also ask about the onset and duration of the increased frequency and about any associated urinary signs or symptoms, such as dysuria, urgency, incontinence, hematuria, discharge, or lower abdominal pain during urination.

    Also ask about neurologic symptoms, such as muscle weakness, numbness, and tingling. Explore the patient’s medical history for UTIs or other urologic problems, recent urologic procedures, and neurologic disorders. Ask a male patient about a history of prostatic enlargement. Ask a female patient of childbearing age whether she is or could be pregnant.

    Obtain a clean-catch midstream urine specimen for urinalysis and culture and sensitivity tests. Then palpate the patient’s suprapubic area, abdomen, and flanks, noting any tenderness. Examine the urethral meatus for redness, discharge, or swelling. The physician may palpate the prostate gland of a male patient.

    If the patient’s history or symptoms suggest a neurologic disorder, perform a neurologic examination.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Urinary hesitancy: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask the patient when he first noticed hesitancy and if he has ever had the problem before. Ask about other urinary problems, especially reduced force or interruption of the urine stream. Ask if he has ever been treated for a prostate problem, a UTI, or a urinary tract obstruction. Obtain a drug history.

    Inspect the patient’s urethral meatus for inflammation, discharge, and other abnormalities. Examine the anal sphincter and test sensation in the perineum. Obtain a clean-catch urine specimen for urinalysis and culture and sensitivity tests. A male patient requires prostate gland palpation. A female patient requires a gynecologic examination.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Urinary incontinence: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If can control urination occasionally, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he’s ever sought treatment for incontinence or found a way to deal with it himself.

    Obtain a medical history, especially noting urinary tract infection (UTI), prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies and childbirths she has had.

    After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious signs of inflammation or an anatomic defect. Have female patients bear down, and note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Urinary urgency: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask the patient about the onset of urinary urgency and whether he’s ever experienced it before. Ask about other urologic symptoms, such as dysuria and cloudy urine. Also ask about neurologic symptoms such as paresthesia. Explore his medical history for recurrent or chronic UTIs and for surgery or procedures involving the urinary tract.

    Obtain a clean-catch urine specimen for urinalysis and culture and sensitivity tests. Note urine character, color, and odor, and use a reagent strip to test for pH, glucose, and blood. Then palpate the suprapubic area and both flanks for distention and tenderness. If the patient’s history or symptoms suggest neurologic dysfunction, perform a neurologic examination.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Urine cloudiness: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask about symptoms of UTI, such as dysuria; urinary urgency or frequency; and pain in the flank, lower back, or suprapubic area. Also ask the patient if he has had recurrent UTIs or recent surgery or treatment involving the urinary tract.

    Obtain a urine specimen to check for pus or mucus. (See How to perform the three-glass urine test, page 777.) Using a reagent strip, test for blood, glucose, and pH. Palpate the suprapubic area and flanks for tenderness.

    If you note cloudy urine in a patient with an indwelling urinary catheter, especially if he also has a fever, remove the catheter immediately (or change it if the patient must have one in place).

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Dysuria: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A good general history is critical and can help direct further questions.

     A. Distinguishing between symptoms of “internal” dysuria and “external” dysuria is often helpful. Internal dysuria is where the discomfort seems to be centered inside the body and begins before or with the initiation of voiding. External dysuria is when the discomfort appears after voiding has initiated. Symptoms of internal dysuria suggest inflammation of the bladder or urethra, whereas those of external dysuria suggest vaginitis, vulvar inflammation, or external penile lesions.

     B. Careful questioning about other associated symptoms and risk factors is the key to sorting out the diagnosis. The history of a new sex partner may support an STD cause. Diaphragm usage may support a bladder infection as well as associated symptoms of frequency, urgency, voiding small volumes, hematuria, and abrupt onset. Gradual onset is more suggestive of urethritis and external causes. Other symptoms of suprapubic pain, costovertebral angle tenderness, fever, flank pain, and so on should be asked about and can direct the diagnostic workup.

    Physical examination

     The physical examination is essential in narrowing the diagnosis. It helps to rule out pyelonephritis and other systemic infections in patients with dysuria, allowing the physician to search for the less severe causes. Fever, flank tenderness, and suprapubic tenderness are useful findings. A careful genital examination (speculum in women, foreskin retraction and prostate examination in uncircumcised men) can point to specific localized causes. The genital examination also allows collection of samples for testing. Attention to localized lesions (e.g., HSV lesions), discharge (yeast, bacterial vaginosis, gonorrhea, and trichomoniasis) and trauma also help make the diagnosis.

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    Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

    Nocturia: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    Possible causes of nocturia include:

    A. Increased urine output. The history should include questions concerning the following causes of increased urine output:

    1. Excess intake of fluids

    2. Drugs (i.e., caffeine, alcohol, diuretics, nonsteroidal antiinflammatory drugs, calcium channel blockers, lithium)

    3. Diabetes mellitus (Chapter 14.1)

    4. Diabetes insipidus (central or nephrogenic)

    5. Hypercalcemia (Chapter 17.4)

    6. Peripheral edema (from any cause) (Chapter 2.3)

    7. Congestive heart failure (Chapter 7.5)

    8. Renal disease

    9. Aging (1)

    B. Sleep-related nocturia. Disrupted sleep will cause a patient to arise and empty a partially filled bladder. Causes of disrupted sleep include:

    1. Use of a short-acting sedative hypnotic

    2. Pain (acute or chronic)

    3. Dyspnea (from pulmonary or cardiac disease) (Chapter 8.7)

    4. Anxiety or depression

    5. Drugs that interfere with the sleep cycle (2)

    6. Parkinson’s disease

    C. Dementia

    D. Sleep apnea (3)

    E. Urinary tract dysfunction. Causes of lower urinary dysfunction include:

    1. Lower urinary tract infection

    2. Small bladder capacity

    3. Detrusor hyperactivity

    4. Prostatic hypertrophy

    5. Urinary retention for any reason

     6. Decreased bladder compliance (interstitial cystitis, radiation, tuberculosis) (2)

     7. Sensory stimulation in a paraplegic

    8. Neurogenic bladder (spastic or atonic) from multiple sclerosis, cerebrovascular accidents, herniated disks, or spinal cord injury

    9. Obstetric, gynecologic, or urologic disease or injury

    10. Chronic obstructive pulmonary disease (COPD) (4)

    11. Fecal impaction

    Physical examination

    The extent of the physical examination will be guided by the history. Essential for all patients is a genitourinary examination to identify lower urinary tract abnormalities such as bladder distention, cystocele, or rectocele. Examination of the heart, lungs, and extremities will identify pulmonary, cardiac disease, and peripheral edema. A rectal examination (with sphincter contraction during the examination) will identify sphincter laxity, fecal impaction, tumors, and prostate abnormalities. Absence of the anal wink (S4-5) or bulbocavernosus reflex (S2-3) can indicate spinal cord pathology. (In older patients, the absence of these reflexes is not always pathologic.) An expanded neurologic examination will be necessary in patients with other neurologic symptoms.

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    Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

    Urinary Incontinence: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A. Voiding history. It is important to fully characterize the patient’s problem by taking a detailed history, including the duration of the symptoms, timing of voluntary or involuntary voiding, amounts voided involuntarily, and the relationship to voluntary voiding. Focus on the following areas:

    1. Need for pads or diapers (measure of severity)

    2. Loss of urine with coughing or laughing (suggests stress type)

     3. Inability to hold urine after having the urge to urinate (suggests urge type)

     4. Pain or discomfort (suggests infection or inflammation) (Chapter 10.1)

    5. Inability to fully empty bladder (suggests obstruction)

    6. Decreased urinary stream (suggests obstruction)

    7. What impact does UI have on the patient’s life?

    8. What does the patient think is going on?

    B. Major medical problems. Does the patient have any known condition that is associated with UI? These include diabetes, heart failure, menopause, and neurologic problems. Does the patient have other genitourinary symptoms? In female patients, be sure to take a detailed obstetric history.

     C. Medication history. Since medications are a major cause of incontinence, a thorough medication history is essential. Offending agents include diuretics, older antidepressants, antihypertensives, narcotics, and alcohol.

     D. Special concern. Central and nephrogenic diabetes insipidus can present with UI because of increased urine output (many liters per day). These patients frequently have a concomitant polydypsia that closely matches their water loss (Chapter 14.5). Consider this diagnosis when the patient gives a history of voiding large volumes of urine.

    Physical examination

     The physical examination is often normal in cases of UI. Focus efforts in an attempt to uncover the underlying cause(s):

    A. General. Is the patient physically capable of getting to the toilet?

    B. Mental status. Can the patient understand and act on the urge to void?

     C. Neurologic, including the anal reflex; focal signs suggest a neurologic cause.

     D. Abdominal examination. Is the bladder distended?

    E. Rectal or prostate. Does the patient have a fecal impaction or an enlarged prostate?

     F. Pelvic examination. Look for atrophic vaginitis, uterine prolapse, or a pelvic mass.

    » READ BOOK EXCERPT ONLINE »

    Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

    Oliguria and Anuria: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A. Pertinent present history. A patient may complain of decreased urine output in some clinical situations. More often, however, the clinical situation and pertinent history should lead to an evaluation of the presence of oliguria or anuria.

    1. Are there symptoms of illness or trauma leading to hypotension?

    a. Hypovolemia (e.g., hemorrhage, diuretic overuse, gastrointestinal fluid loss, skin fluid loss owing to burns or heat exposure, third spacing, secondary to burns, peritonitis, pancreatitis, or trauma)?

    b. Decreased cardiac output (e.g., congestive heart failure, myocardial infarction, pericardial tamponade, or acute pulmonary embolus)?

    c. Peripheral vasodilatation (e.g., septic shock, anaphylactic shock)?

     2. Are there symptoms of vascular disease? Consider bilateral renal vascular obstruction due to severe renal artery stenosis, thrombosis, or embolism.

     3. Is there any history consistent with renal parenchymal injury [e.g., recent radiocontrast agent, nephrotoxin exposure such as ethylene glycol, nonsteroidal antiinflammatory drug overdose, acute nephritis, acute vasculitis, pyelonephritis (in the elderly), papillary necrosis (in diabetic patients), or prolonged hypotension with hypoperfusion of the kidney]?

     4. Is there any history consistent with urinary tract obstruction?

     a. Bladder neck obstruction (e.g., benign prostatic hypertrophy, prostate cancer, bladder cancer, or functional obstruction due to drug side effects)?

     b. Obstruction of the urethra or bilateral ureters—internally (2° blood clots, stones, sulfonamide or uric acid crystals, pyogenic debris, necrotizing papillitis or edema), or externally (2° tumor, periureteral fibrosis, accidental ureteral ligation during pelvic surgery, ascites, pregnancy, pelvic abscess, or hematoma).

     5. Medication use must be considered—diuretics, antihypertensives, anticholinergics, aminogycosides, amphotericin B, or chemotherapeutic drugs.

     B. Other pertinent past history. Is there a history of cancer, recent surgery, kidney stones, neurologic disorder, vascular disease, chronic liver disease (hepatorenal syndrome), or kidney transplant?

    Physical examination

    A. Focused physical examination (PE). This should include vital signs (notably blood pressure, pulse, and temperature). Orthostatic blood pressure and pulse may be necessary. Signs of hypovolemia, hypotension, and dehydration should be noted—skin turgor and color, mucous membranes, capillary refill, warmth of extremities.

     B. Additional PE. Depending on the history (e.g., skin rash, cardiac examination, bruits over kidneys) palpate for a distended bladder; if a cancer or outlet obstruction is suspected, perform a rectal or pelvic examination.

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    Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

    Dysuria: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Lower urinary tract infection

    ❑ Acute pyelonephritis

    ❑ Urethritis

    ❑ Vaginitis

    ❑ Acute prostatitis

    ❑ Urethral calculus

    ❑ Reiter syndrome

    Diagnostic Approach

    In women, ask whether burning is internal (urinary tract infection) or external (vaginitis). Women who have had a prior urinary tract infection are more than 90% accurate in identifying recurrences.

    The urine dipstick is a useful diagnostic adjunct for determining the presence of pyuria. Leukocyte esterase and nitrate tests are complementary, increasing the overall sensitivity.

    Always consider a sexually transmitted infection, especially with minimal pyuria and/or a new sexual partner.

    The combination of symptoms of dysuria and frequency without vaginal discharge or irritation has an overall likelihood ratio of 24.6 in predicting acute urinary tract infection.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Polyuria: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Urinary tract infection

    ❑ Diabetes mellitus

    ❑ Diuretic therapy

    ❑ Bladder outlet obstruction

    ❑ Nephrogenic diabetes insipidus

    ❑ Central diabetes insipidus

    ❑ Primary polydipsia

    Diagnostic Approach

    Polyuria is output of 3 L or more daily, and should be differentiated from urinary frequency and nocturia. Nocturia is most commonly due to drinking fluids before sleep, but is also associated with congestive heart failure, cirrhosis, nephrotic syndrome, chronic renal failure and diuretics. Mechanisms of polyuria include: loss of renal concentrating ability (parenchymal disease); decreased bladder capacity; solute diuresis of glucose (diabetes), urea (hypercatabolic states), mannitol, or radiocontrast; postobstructive and post-ATN nephropathy; and decreased responsiveness of the tubule to aldosterone with sodium diuresis (cystic renal disease, Bartter syndrome, or resolving ATN).

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Proteinuria: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Diabetes

    ❑ Drugs/toxins

    ❑ Acute tubular necrosis

    ❑ Glomerulonephritis

    ❑ Orthostatic

    ❑ Systemic lupus erythematosus

    ❑ Toxemia

    ❑ Polycystic kidneys

    ❑ Interstitial nephritis

    ❑ Renal vein thrombosis

    ❑ Multiple myeloma

    ❑ Amyloidosis

    Diagnostic Approach

    Proteinuria may present on urinalysis or as edema caused by reduced oncotic pressure from serum albumin loss. The dipstick detects albumin in concentrations of 30 mg/dL (Sensitivity 70%, Specificity 92%, Likelihood ratio 8.8), or 300 to 500 mg of proteinuria per day. False positives may be seen with dehydration and hematuria, both of which can be detected with the dipstick (specific gravity and hemoglobin). False negatives can occur when the protein is a low molecular weight tubular protein (not albumin), e.g., immunoglobulin light chains in myeloma or beta-2 microglobulin. In nephrotic syndrome more than 3.5 grams per day of proteinuria occurs.

    Systemic disease should be suspected in the presence of fever, rash, or arthritis.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Urinary Incontinence: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Cystitis

    ❑ Benign prostatic hypertrophy

    ❑ Pelvic floor relaxation

    ❑ Drugs

    ❑ Prostatitis

    ❑ Diabetes

    ❑ Cough

    ❑ Multiple sclerosis

    ❑ Spinal cord compression

    ❑ Decreased cortical inhibition

    ❑ Vesicovaginal fistula

    Diagnostic Approach

    On examination, test for stress-induced leakage with a full bladder, palpate for bladder distension after voiding, and check for post-void residual. Do a pelvic examination looking for pelvic floor laxity, atrophic vaginitis, urethritis, or pelvic mass, and a rectal examination for tone, fecal impaction, and prostate nodule. Check perineal sensation and neurosacral reflexes including volitional anal contraction, anal wink (anal contraction in response to a light scratch of the perineal skin), and bulbocavernosus reflex (anal contraction in response to a light squeeze of the penis or clitoris). An intact reflex arc but absent perineal sensation suggests a cord lesion or multiple sclerosis.

    Urge incontinence: Due to detrusor overactivity. Urine loss is accompanied by a strong desire to void. Incontinence is preceded by a warning of seconds to minutes. Leakage is periodic but frequent, and nocturnal incontinence is common. Voluntary control of the anal sphincter is intact, and sacral sensation and reflexes are preserved. The post-void residual is low. It is usually a result of detrusor instability caused by stroke, Alzheimer dementia, brain tumor, Parkinson disease, bladder outlet obstruction, spinal cord lesion, or interstitial cystitis.

    Reflex incontinence: Due to an excessive pressure response to bladder filling. Voiding occurs without stress or warning. Sacral reflexes are preserved, but voluntary sphincter control and perineal sensation are impaired. Post-void residual is increased. Usually caused by a spinal cord lesion, incontinence may be mimicked by cortical damage with decreased awareness of signals to void.

    Stress incontinence: Due to failure of the sphincter to remain closed during bladder filling. Incontinence of small amounts of urine occurs with increased abdominal pressure (e.g., coughing, laughing, sneezing). Stress-induced detrusor instability is suggested by a 5 to 15 second delay between stress and leakage, and by nocturnal leakage.

    Overflow incontinence: Due to impaired detrusor contractility and/or bladder outlet obstruction. There is frequent leakage of small amounts of urine, hesitancy, decreased flow, and incomplete emptying. The post-void residual is increased, and the bladder is palpable. Common mechanisms include bladder outlet obstruction caused by benign prostatic hypertrophy or urethral stricture; decreased detrusor tone due to a herniated disc; or peripheral neuropathy caused by diabetes, pernicious anemia, tabes, or cauda equina.

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    Source: Field Guide to Bedside Diagnosis, 2007

    Anuria/Oliguria: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Acute tubular necrosis

    ❑ Prerenal azotemia

    ❑ Tubular toxins

    ❑ Bladder outlet obstruction

    ❑ Bilateral renal artery occlusion

    ❑ Nephrosclerosis

    ❑ Acute glomerulonephritis

    ❑ Interstitial nephritis

    ❑ Renal artery thrombosis

    ❑ Renal vein thrombosis

    ❑ Ureteral calculus with a solitary kidney

    ❑ Pelvic tumor

    ❑ Retroperitoneal fibrosis

    ❑ Infiltrative renal disease

    ❑ Vasculitis

    ❑ Rhabdomyolysis

    Diagnostic Approach

    Distinguish anuria from urinary retention. Nonobstructive anuria is accompanied by symptoms of uremia with vomiting, drowsiness, muscle twitch, headache, and asterixis. Urinary retention causes suprapubic pain, constant urgency, and a palpable bladder with dullness to percussion in the suprapubic region.

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    Source: Field Guide to Bedside Diagnosis, 2007

    Urinary tract infection, lower: Diagnosis
    (Handbook of Diseases)

    Characteristic clinical features and a microscopic urinalysis showing red blood cells and white blood cells greater than 10/high-power field suggest lower UTI.

    ❑ A clean-catch, midstream urine specimen revealing a bacterial count of more than 100,000/ml confirms the diagnosis. Lower counts do not necessarily rule out infection, especially if the patient is voiding frequently, because bacteria require 30 to 45 minutes to reproduce in urine.

    Careful midstream, clean-catch collection is preferred to catheterization, which can reinfect the bladder with urethral bacteria.

    ❑ Sensitivity testing determines the appropriate therapeutic antimicrobial agent.

    ❑ Voiding cystoureterography or excretory urography may detect congenital anomalies that predispose the patient to recurrent UTIs.

    ❑  If patient history and physical examination warrant, a blood test or a stained smear of the discharge rules out a sexually transmitted disease.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Anuria: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Obtain a complete history, including changes in voiding pattern or urine characteristics. Ask the patient how much fluid he normally ingests each day, how much he ingested in the past 24 to 48 hours, and the time and amount of his last urination. Note a history of kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about abdominal, renal, or urinary tract surgery and about drug use.

    Physical examination

    Inspect and palpate the abdomen for asymmetry, distention, or bulging. Inspect the flank area for edema or erythema, and percuss and palpate the bladder. Palpate the kidneys anteriorly and posteriorly, and percuss them at the costovertebral angle. Auscultate over the renal arteries, listening for bruits.

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    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Bladder distention: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Ask the patient about voiding patterns, the time and amount of the last voiding, and the amount of fluid he consumed since the last voiding. Does he have a history of difficulty when urinating? Ask whether Valsalva’s maneuver or Credé’s maneuver is required to initiate urination. Does he experience an urgent need to urinate? Does the urge to urinate arise without warning? Is urination painful or irritating? Ask about the force and continuity of the urine stream and whether the bladder is empty after voiding.

    Assess the patient’s history for the presence of a urinary tract obstruction or infections, venereal disease, lower abdominal or urinary tract trauma, systemic or neurologic disorders, and neurologic, intestinal, or pelvic surgery. Note medication history, including the use of over-the-counter or recreational drugs.

    Physical examination

    Take the patient’s vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can’t be palpated through the abdominal wall.) Inspect the urethral meatus. Document the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.

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    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Anuria: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Begin by obtaining a complete history. First ask about any changes in the patient’s voiding pattern. Determine the amount of fluid he normally ingests each day, the amount of fluid he ingested in the last 24 to 48 hours, and the time and amount of his last urination. Review his medical history, noting especially previous kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about drug use and about any abdominal, renal, or urinary tract surgery.

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    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Bladder distention: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    If distention isn’t severe, begin by reviewing the patient’s voiding patterns. Find out the time and amount of the patient’s last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva’s or Credé’s maneuver to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.

    Explore the patient’s history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Note his drug history, including his use of over-the-counter drugs.

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    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Dysuria: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    If the patient complains of dysuria, have him describe its severity and location. When did he first notice it? Did anything precipitate it? Does anything aggravate or alleviate it?

    Next, ask about previous urinary or genital tract infections. Has the patient recently undergone an invasive procedure, such as cystoscopy or urethral dilatation, or had a urinary catheter placed? Also, ask if he has a history of intestinal disease. Ask the female patient about menstrual disorders and use of products that irritate the urinary tract, such as bubble bath salts, feminine deodorants, contraceptive gels, and perineal lotions. Also ask her about vaginal discharge and pruritus.

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    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Nocturia: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Explore the history of the patient’s nocturia. When did it begin? How often does it occur? Can the patient identify a specific pattern or precipitating factors? Also, note the volume of urine voided. Ask the patient about any change in the color, odor, or consistency of his urine. Has the patient changed his usual pattern or volume of fluid intake? Next, explore associated symptoms. Ask about pain or burning on urination, difficulty initiating a urine stream, costovertebral angle (CVA) tenderness, and flank, upper abdominal, or suprapubic pain.

    Determine if the patient or his family has a history of renal or urinary tract disorders or endocrine and metabolic diseases, particularly diabetes. Is the patient taking a drug that increases urine output, such as a diuretic, a cardiac glycoside, or an antihypertensive?

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    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Oliguria: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Begin by asking the patient about his usual daily voiding pattern, including frequency and amount. When did he first notice changes in this pattern and in the color, odor, or consistency of his urine? Ask about pain or burning on urination. Has the patient had a fever? Note his normal daily fluid intake. Has he recently been drinking more or less than usual? Has his intake of caffeine or alcohol changed drastically? Has he had recent episodes of diarrhea or vomiting that might cause fluid loss? Next, explore associated complaints, especially fatigue, loss of appetite, thirst, dyspnea, chest pain, or recent weight gain or loss (in dehydration).

    Check for a history of renal, urinary tract, or cardiovascular disorders. Note recent traumatic injury or surgery associated with significant blood loss, as well as recent blood transfusions. Was the patient exposed to nephrotoxic agents, such as heavy metals, organic solvents, anesthetics, or radiographic contrast media? Next, obtain a drug history.

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    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Polyuria: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Explore the frequency and pattern of the polyuria. When did it begin? How long has it lasted? Was it precipitated by a certain event? Ask the patient to describe the pattern and amount of his daily fluid intake. Is the patient unusually tired or thirsty? Has he recently lost more than 5% of his body weight? Check for a history of visual deficits, headaches, or head trauma, which may precede diabetes insipidus. Also check for a history of urinary tract obstruction, diabetes mellitus, renal disorder, chronic hypokalemia or hypercalcemia, or psychiatric disorder (both past and present). Find out the schedule and dosage of any drugs the patient is taking.

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    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Urinary frequency: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask the patient how many times per day he voids. How does this compare to his previous pattern of voiding? Ask about the onset and duration of the abnormal frequency and about any associated urinary signs or symptoms, such as dysuria, urgency, incontinence, hematuria, discharge, or lower abdominal pain with urination.

    Ask also about neurologic symptoms, such as muscle weakness, numbness, or tingling. Explore his medical history for UTI, other urologic problems or recent urologic procedures, and neurologic disorders. With a male patient, ask about a history of prostatic enlargement. If the patient is a female of childbearing age, ask whether she is or could be pregnant.

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    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Urinary hesitancy: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask the patient when he first noticed hesitancy and if he has ever had the problem before. Ask about other urinary problems, especially reduced force or interruption of the urine stream. Ask if he has ever been treated for a prostate problem or UTI or obstruction. Obtain a drug history.

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    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Urinary incontinence: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If he is occasionally able to control urination, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he has ever sought treatment for incontinence or found a way to deal with it himself.

    Obtain a medical history, especially noting urinary tract infection (UTI), prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies she has had and how many childbirths.

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    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Urinary urgency: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask the patient about the onset of urinary urgency and whether he has ever experienced it before. Ask about other urologic symptoms, such as dysuria and cloudy urine. Also ask about neurologic symptoms such as paresthesia. Examine his medical history for recurrent or chronic UTIs or for surgery or procedures involving the urinary tract.

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    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Dysuria: Clinical Features and Diagnosis
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Urinary Tract Infection (UTI)

  • UTI existswhen a significant number of bacteria are present in urine or whenthe urinary tract is infected with a virus. Infection can involveurethra, bladder, or renal parenchyma.
  • E. coli is most common pathogen inall age groups. Other pathogens include gram-negative enteric bacteria(Klebsiella, Proteus, Pseudomonas, and Enterobacter species) andgram-positive bacteria (Enterococcus species, coagulase-negativeStaphylococcus, group B Streptococcus, S. aureus).
  • Only virus likely to be encounteredas urinary tract pathogen is adenovirus, which causes acute hemorrhagiccystitis.
  • Manifestations vary with age. In neonatesclinical features include fever or temperature instability, poorfeeding, decreased activity, and vomiting. Fever, vomiting, anddecreased weight gain may occur in infants. In children and adolescents,common findings include fever, dysuria, frequency, urgency, vomiting,abdominal pain, and flank pain. In all age groups urine may be cloudyand foul smelling.
  • Pyuria and microscopic or gross hematuriamay be found. Positive urine culture is diagnostic.

    • Urethritis

  • In girlsvulvovaginitis is a common cause of urethritis. See Chap. 71, Vaginal Discharge.
  • Occasionally, dysuria occurs with labialadhesions, which are readily seen on physical exam. Proposed mechanismis pooling of urine behind adhesion and inadequate cleansing ofurethra.
  • In boys urethritis occurs most commonlyin adolescents. N. gonorrhoeae and C. trachomatis are the most commonpathogens in this age group.
  • Gonorrhea usually presents with creamyurethral discharge and dysuria 2–7 days after sexual contact.Gram-stained smear of discharge that shows gram-negative intracellulardiplococci is diagnostic, whereas positive culture of urethral dischargeis confirmatory.
  • Infection with C. trachomatis may ormay not produce mild mucoid discharge, and dysuria is usually mild.Positive urine culture is diagnostic.
  • When herpes simplex virus causes urethritis,vesicles are usually seen on genital exam.

    • Cystitis

  • Infectionof bladder with bacteria is common in girls but infrequent in boys.Long male urethra and bactericidal prostatic secretions may be responsiblefor lower incidence in boys.
  • Children with cystitis may have dysuria,urinary frequency, urgency, suprapubic tenderness, and occasionallyfever.
  • If dysuria persists in sexually activeindividuals and urine bacterial culture is negative, urine shouldbe cultured for C. trachomatis.
  • Adenovirus infection of bladder cancause severe dysuria and bloody urine (hemorrhagic cystitis). Usualurine culture for bacteria is sterile.

    • Pyelonephritis

  • Childrenwith acute pyelonephritis do not have dysuria unless cystitis isalso present. They are usually more ill and have higher fever thanthose with urethritis or cystitis.
  • Parenchymal infection should be suspectedin febrile child with flank pain and tenderness who may or may notbe toxic.
  • Renal scintigraphy using technetium99m–dimercaptosuccinic acid can show renal cortical involvementin most cases.

    • Chemical Irritation

  • Chemicalirritants, which include detergents, fabric softeners, perfumedsoaps, and bubble baths, are common causes of transient urethritis.
  • History and physical exam are diagnostic.

    • Diaper Dermatitis

  • Diaper dermatitiswith or without Candida infection can cause meatal inflammation withulcer formation in boys and urethral inflammation in girls.
  • History and physical exam are diagnostic.

    • Trauma

  • Any injuryto urethra (e.g., minor trauma, foreign body placed in urethra,or child abuse) can produce dysuria. Hematuria with or without bacteriuriaalso may occur.
  • History and physical exam are oftendiagnostic.
  • Urethrogram or cystogram may be necessaryif there is history of trauma and persistent hematuria. Pelvic radiographymay reveal radiopaque foreign body.

    • Psychogenic

    Dysuria may occur for psychologic reasonswithout any pathologic process involving genitourinary tract.

    Diagnostic Approach

    History and physical exam are usually diagnosticof trauma, vulvovaginitis, labial adhesions, chemical irritation,and diaper dermatitis. Otherwise, suspect UTI and perform UA andurine culture.

    Urinalysis

  • Presenceof WBCs (>10/high-power field) in sediment ofcentrifuged specimen of urine suggests but is not diagnostic ofUTI. Neither is positive leukocyte esterase test (urine dipstick), whichindicates presence of WBCs in urine.
  • Positive nitrite test using nitritestrip (Griess test) on urine dipstick is highly sensitive and specificfor detection of gram-negative bacteria (e.g., E. coli, Klebsiella,and Proteus species). Positive reaction usually indicates 105 CFUs/mL.False-positive reactions are uncommon if urine is fresh; however,if urine is not examined immediately, test result may be positivebecause of bacteria growing at room temperature. False-negativereactions may occur when there has been inadequate time for bacterialproliferation (random collection rather than first morning specimen)or when infection is due to Enterococcal species and some Staphylococcaland Pseudomonas species that do not convert nitrate to nitrite.
  • Presence of ≥1 bacteria/oilimmersion field of unspun urine (unstained or Gram stain) from clean-catchmidstream specimen correlates with urine colony count of >105 CFUs/mL80–95% of the time.

    • Urine Culture

    Quantitative culture of properly collectedurine specimen establishes diagnosis of UTI, and susceptibilitytesting can be performed. Table15.1, based on data from many studies, is useful guidefor diagnosis of UTI.

    Table 15.1. Criteria for Diagnosis of Urinary Tract Infections

    Method of CollectionColony Counta (Pure Culture)Probability of Infection (%)
    Suprapubic aspirationGram-negative bacilli: any number>99
    Gram-positive cocci: > a few thousand
    Catheterization>10595
    104–105Infection likely
    103–104Suspicious; repeat
    <103Infection unlikely
    Clean-voided (male)>104Infection likely
    Clean-voided (female)3 specimens: >10595
    2 specimens: >10590
    1 specimen: >10580
    5 × 104–105Suspicious; repeat
    104 to 5 × 104Symptomatic; suspicious; repeat
    104 to 5 ×104Asymptomatic; infection unlikely
    <104Infection unlikely
    aCFUs/mL of single isolate.From Hellerstein S. Recurrent urinary tract infections inchildren. Pediatr Infect Dis 1982;1:275, with permission.

    Radiologic Imaging

  • Differencesof opinion exist concerning usefulness of radiologic studies inevaluation of children with UTI. Studies are performed to searchfor anatomic abnormalities that may predispose to infection andalso to identify presence of vesicoureteral reflux.
  • In our hospital when infant or childhas first UTI, initial studies include renal U/S in both girlsand boys followed by a radionuclide voiding cystourethrogram ingirls and contrast voiding cystourethrogram in boys.
  • Use of renal cortical scintigraphyis controversial, but it can help diagnose acute pyelonephritisand identify renal scarring.
    • >>

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    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Proteinuria: Clinical Features and Diagnosis
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Functional/Transient Proteinuria

    Fever, exercise, extreme cold, cardiac failure,seizures, and emotional stress can cause transient proteinuria.Diagnosis is usually made by history, physical exam, and clinicalcourse. Proteinuria measured on dipstick is usually <2+.

    Postural Proteinuria (Orthostatic)

    Occurs when patient is in upright position,not recumbent. Can be transient or persistent and is unusual before7 yrs of age. Long-term prognosis is benign.

    Nephrotic Syndrome

  • Characterizedby proteinuria, hypoproteinemia, edema, and hyperlipidemia.
  • Congenital (Finnish type) form, whichis autosomal recessive, presents during first 3 mos of life. Mostcommon cause in children is minimal change disease, which most commonlyoccurs at 2–6 yrs of age. Other causes include focal glomerulosclerosis,mesangial proliferative glomerulonephritis, lupus nephritis, anddrug exposure (captopril, lithium, penicillamine, procainamide,NSAIDs).
  • Initial episode of nephrotic syndromeas well as relapses often follow viral URIs. First sign of generalizededema may be ankle or eyelid edema, and pleural effusions and ascitesalso may occur. UA usually reveals +3 or +4 proteinuria.Although microscopic hematuria can occur, gross hematuria is unusual.Serum albumin is usually <2 g/dL, whereas serumcholesterol and triglycerides are increased. Renal function maybe normal or impaired.
  • In children <6 yrs of age,in whom minimal change disease is most likely, corticosteroids canbe given as diagnostic and therapeutic trial. Lack of therapeuticresponse with persistence of proteinuria for >4–6wks is indication for renal biopsy.

    • Tubulointerstitial Disease

    Reflux Nephropathy

  • Occurs asconsequence of vesicoureteral reflux, which is abnormal retrogradeflow of urine from bladder into upper urinary tract.
  • Proteinuria, hypertension, and chronicrenal insufficiency may occur. History of recurrent urinary tractinfection is frequent.
  • Combination of renal U/S,voiding cystourethrography, and renal scintigraphy is commonly usedto evaluate reflux and its effects. Reflux may be graded from Ito V, with V being most severe.
  • Diagnosis is usually clinical and radiologic.

    • Tubulointerstitial Nephritis

  • Syndromewith inflammation and damage of tubular and interstitial structuresand relative sparing of glomerular and vascular structures.
  • Common causes include infection (mostcommonly pyelonephritis and streptococcal infections), drugs (penicillins,sulfonamides, cephalosporins, phenytoin, thiazides, furosemide,allopurinol, amphotericin B, NSAIDs), and idiopathic.
  • Clinical manifestations vary from mildazotemia to oliguric renal failure. Proteinuria may occur aloneor with hematuria (usually microscopic).
  • Renal biopsy is necessary for definitivediagnosis, unless serum creatinine begins to decrease followingwithholding of suspected offending agents.

    • Fanconi Syndrome

  • This autosomal-dominantdisorder whose gene locus has been mapped to chromosome 15q15.3is characterized by

  • Generalized dysfunction of proximal tubuletransport causing excessive urinary excretion of amino acids, glucose,phosphate, bicarbonate, and other solutes
  • Vitamin D–resistant metabolicbone disease (rickets in children)
  • Clinical features include aminoaciduria,proteinuria, glycosuria, hypokalemia, hypophosphatemia, metabolicacidosis, rickets, and impaired growth.
  • This syndrome also may be associatedwith cystinosis (most common), galactosemia, hereditary fructoseintolerance, tyrosinemia, Wilson disease, Lowe syndrome, lead poisoning,and drugs (aminoglycosides, cisplatin, valproic acid).

    • Ischemic Tubular Injury

  • Acute tubularnecrosis usually occurs as result of prerenal failure or after severehypoxic insult.
  • UA may be unremarkable or show low-gradeproteinuria and granular casts. There is inability to conserve sodiumand water.
  • Renal U/S shows normal-sizedkidneys with loss of corticomedullary differentiation, and renalscintigraphy demonstrates decreased renal function.

    • Benign Persistent Proteinuria

  • Persistentproteinuria without evidence for postural proteinuria or renal disease.
  • Renal biopsy is normal or shows minimalnonspecific changes.
  • This is a diagnosis of exclusion.
  • Even though this is a benign disorder,follow-up is important because focal glomerulosclerosis may presentsimilarly.

    • Diagnostic Approach

  • First stepin evaluation of a child with proteinuria is to determine if thereare any predisposing factors for transient or functional proteinuria(e.g., fever or strenuous exercise).
  • If history is negative for these factorsand dipstick protein is persistently ≥1+, next step isto do complete UA and determine protein:creatinine ratio in a firstmorning spot urine specimen.
  • If results of UA are normal and protein:creatinineratio is in normal range, diagnosis is postural proteinuria andno further studies are necessary.
  • If results of UA are otherwise abnormalor first morning protein:creatinine ratio is above normal, furtherstudies are necessary. Serum electrolytes, creatinine, albumin,and cholesterol as well as blood urea nitrogen should be measured,and renal U/S should be performed. C3 and antinuclear antibody shouldbe considered.
  • If diagnosis remains uncertain andno chemical or radiographic evidence of renal disease exists, renalbiopsy may be performed or child may tentatively be considered tohave benign persistent proteinuria. If renal biopsy is not performedor is normal, child should be monitored at 6-mo intervals for urinaryand chemical changes indicative of renal disease.
    • >>>

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    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Urinary Incontinence: Clinical Features and Diagnosis
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Maturational Delay

  • Most commoncause of primary urinary incontinence is lag in maturation of normal inhibitingmechanism of urine control. There is often family history of incontinence.
  • Many children may achieve daytime controlbut still experience incontinence during sleep.
  • This is a diagnosis of exclusion inan otherwise normal child who has no evidence of organic disease,no history of stress-related or psychologic disturbance, and normalUA and urine culture.
  • At 5–10 yrs of age, spontaneouscure rate of nocturnal enuresis is about 15%/yr.

    • Stress-Related Causes

    Stress is frequent cause of secondary incontinence.Examples of stress-related factors are illness, separation, birthof sibling, attending new school, death of family member, divorcein family, and other personal and family problems. Once problemis recognized, proper support and counseling usually help with itsresolution.

    Urinary Tract Disorders

    Urinary Tract Infection

  • May causenighttime and daytime incontinence.
  • Other common findings include fever,dysuria, urinary frequency, abdominal or flank pain, and vomiting.
  • Positive urine culture confirms diagnosis(see Chap. 15, Dysuria).

    • Dysfunctional Voiding Disorders

  • Voidingdysfunction occurs in many children who do not have known organiccause (e.g., neurologic disorder, injury, or malformation).
  • Although some children have small-capacitybladder and experience urgency and often incontinence, others havehyperreflexic bladder with uninhibited detrusor contractions duringfilling. Still others have large hypotonic bladder that does notempty completely with voiding.
  • Failure to empty bladder results inchronically distended bladder that is prone to urinary tract infectionand overflow incontinence.
  • Urinary urodynamic testing is helpfulin determining abnormality in each case.

    • Lower Urinary Tract Obstruction

  • Can producebladder distension and overflow incontinence. Poor urinary streamwith dribbling and excessive straining with urination are prominentfeatures.
  • Specific causes include posterior urethralvalves, urethral duplication, or urethral cyst.
  • Combination of tests including renalU/S, intravenous urography, and voiding cystourethrographyusually can confirm diagnosis. Retrograde urethrography is generallyrequired for adequate evaluation of urethral duplication.

    • Ectopic Ureter in Girls

  • Ectopicureter may empty into bladder neck, urethra, vagina, or, rarely,uterus with continuous leakage of small amount of urine. Child hasnormal voiding habits but is frequently wet.
  • Because of frequent occurrence of completeureteral duplication and associated renal parenchymal dysplasiain segment drained by ectopic ureter, renal U/S, intravenousurography, and voiding cystourethrography are useful in evaluation.
  • If diagnosis remains uncertain afterthese studies, but ectopic ureter is still suspected, magnetic resonanceurography may be diagnostic. Cystoscopy can help identify ureteralorifice if it is in urethra, whereas vaginoscopy may be needed ifureter empties into vagina.

    • Neurologic Disorders

    Mental Retardation

    Although children with mild mental retardationmay have voluntary control of urination, they may have incontinencefor behavioral reasons, while those with severe retardation usuallylack voluntary control of urination.

    Neurogenic Bladder

  • Lower extremityweakness, gait disturbance, fecal incontinence, decreased or absent perianalsensation, and lack of normal anal sphincter tone are common findingsin children with neurogenic bladder.
  • Bladder size can be small, normal,or large, but usually it is small with thick wall.
  • Evaluation of urinary tract may includerenal U/S, voiding cystourethrography, and urodynamic testing.
  • Spinal dysraphism, a common cause ofneurogenic bladder in children, includes myelomeningocele, congenitaldermal sinus, diastematomyelia, and tethered cord syndrome.

  • Myelomeningoceleand dermal sinus tract are visible on physical exam.
  • Diastematomyelia is the splitting ofspinal cord at 1 or more vertebral levels, usually by bony or fibrousspur in spinal canal. The bone spicule may be detectable on spineradiography, but MRI is definitive imaging procedure.
  • Tethering of spinal cord maintainsabnormally low position of cord and prevents its normal ascent.Lipoma, dermoid cyst, or dermal sinus tract are associated lesions,and MRI is diagnostic.
  • Other causes of neurogenic bladderare sacral agenesis, spinal cord injury, and spinal cord tumors.
  • Failure to palpate sacrum and coccyxsuggest sacral agenesis. Radiography of lumbosacral spine showsabsence of sacral segments.
  • History of trauma exists with spinalcord injury.
  • Tumors affecting spinal cord are discussedin Chap. 5, Back Pain.

    • Abdominal or Pelvic Mass

    Abdominal or pelvic mass (fecal impaction,mesenteric cyst, presacral teratoma) that impinges on bladder cancause urinary incontinence during running, laughing, coughing, orlifting. Abdominal or pelvic U/S is most useful screeningtest.

    Polyuria

  • Childrenwith diabetes mellitus may have incontinence, especially at night,if they have persistent hyperglycemia that is difficult to control.Other causes of polyuria are diabetes insipidus and psychogenicpolydipsia.
  • Diabetes insipidus is associated withdefect in urine-concentrating ability. Random sample of urine withspecific gravity of >1.028 rules out concentration defect.Even specific gravity of >1.020 on random or early-morningurine sample is evidence of good concentrating ability and againstconcentrating defect.
  • Children with persistent polyuria mayhave structural and functional changes in bladder, which contributeto voiding dysfunction.
  • See Chap.47, Polyuria and Polydipsia.

    • Primary Psychologic Disturbance

    Urine incontinence occurs in some childrenwith primary psychologic problems (e.g., depression, a severe personalityor behavioral disorder, or psychosis). History, physical exam, clinicalobservation, and psychologic testing are diagnostic.

    Diagnostic Approach

  • Thoughtfullistening to parents and child usually reveals maturational, stress-related, orother psychologic factors that contribute to urinary incontinence.
  • History, physical exam, UA (includingmeasurement of specific gravity), and urine culture screen for organicdisorders and are helpful in pinpointing the cause of urinary incontinence.Physical exam should include observation of any gait disturbance,exam of sacrum, and testing of perianal sensation, anal sphinctertone, and lower extremity strength, sensation, and reflexes.
  • Abdominal U/S is useful forsuspected lower urinary tract obstruction, ectopic ureter, and abdominalor pelvic mass. Urinary urodynamic testing helps distinguish varioustypes of dysfunctional voiding disorders. CT and MRI are usefulin diagnosis of lesions that cause neurogenic bladder.

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    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Polyuria and Polydipsia: Clinical Features and Diagnosis
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Diabetes Mellitus

  • By far,most common cause of polyuria and polydipsia in pediatric populationis diabetes mellitus.
  • Most common form is insulin-dependentdiabetes mellitus (type 1), in which autoimmune destruction of betacells of pancreas causes diminished insulin secretion and hyperglycemia.Subsequent glucosuria produces osmotic diuresis with polyuria, polydipsia,and polyphagia.
  • Second form is non–insulin-dependentdiabetes mellitus (type 2), which is characterized by insulin resistanceand usually relative insulin deficiency.
  • Criteria for diagnosis of diabetesmellitus have been established by American Diabetes Association(1999) and include symptoms of diabetes mellitus plus plasma glucoseconcentration ≥200 mg/dL at any time of day regardlessof time of last meal or fasting plasma glucose concentration ≥126 mg/dL(fasting is defined as no caloric intake for ≥8 hrs).

    • Diabetes Insipidus

  • 2 formsof diabetes insipidus are antidiuretic hormone (ADH) deficiencyand ADH resistance.
  • Primary clinical manifestations arepolyuria and polydipsia. Episodes of hypernatremic dehydration withhypotonic urine also may occur.

    • Antidiuretic Hormone Deficiency (Central Diabetes Insipidus)

  • Kidney isunable to conserve water with ADH deficiency because of absenceor lack of release of ADH (arginine vasopressin).
  • Genetic transmission of primary formis autosomal-dominant, and gene locus has been mapped to chromosome20p13.
  • Secondary form includes lesions thatdamage neurohypophyseal system: head trauma, infection (meningitis,encephalitis), tumors (most commonly craniopharyngioma), Langerhanscell histiocytosis, and metastatic neoplasia (leukemia).
  • Specific gravity of morning urine specimenshould be ≥1.018 in normal children without any overnight fluidintake. Presence of inappropriately dilute urine with hyperosmolarserum suggests ADH deficiency, and water deprivation test shouldbe performed under controlled supervised conditions.
  • Inability to concentrate urine by waterdeprivation and resolution with administration of exogenous argininevasopressin confirm diagnosis.

    • Antidiuretic Hormone Resistance (Nephrogenic Diabetes Insipidus)

  • The defectin this form of diabetes insipidus is inability of renal tubuleto respond to ADH.
  • Primary form is usually due to X-linkeddisorder with defect in vasopressin receptor; however, autosomal-dominantand -recessive forms also occur.
  • Secondary form is due to several disorders(renal dysplasia, medullary cystic disease, cystinosis, sickle celldisease, chronic renal failure, Fanconi syndrome, Bartter syndrome,hypercalcemia) and drugs (lithium, demeclocycline, methoxyflurane,amphotericin B, phenytoin) that produce renal concentrating defects.

    • Primary Polydipsia

  • Is the excessiveingestion of water, when it is not needed to maintain fluid balance.
  • Causes include compulsive water drinkingfor psychological reasons and frequent presentation of fluids toinfants. Another cause of primary polydipsia is hypothalamic damagethat affects thirst center but not ADH release.
  • When overnight fluids are withheld,concentrated urine can be produced in the morning. Serum vasopressinlevels are low but increase to normal with fluid deprivation.

    • Diagnostic Approach

  • Polyuriamust be distinguished from small volume urinary frequency, whichis common in pediatric practice. Children with polyuria often havenocturia and are unable to sleep through the night without wakingup to urinate. Most children with urinary frequency do not havepolyuria or a defect in urinary concentrating ability. Common causesof isolated urinary frequency are habit, attention-seeking behavior,and urinary tract infection.
  • Random sample of urine with specificgravity of >1.028 and absence of polyuria rules out a concentrationdefect. Even urinary specific gravity of >1.020 on randomor early morning sample indicates sufficient urinary concentrationsuch that symptomatic diabetes insipidus is unlikely. Children whohave urine with a somewhat lower than normal specific gravity butwho can sleep through the night without passing urine do not needfurther evaluation.
  • Presence of polyuria, dehydration,and high urinary specific gravity is evidence for osmotic diuresis,which is most commonly caused by diabetes mellitus. Dilute urineassociated with polyuria suggests diabetes insipidus or psychogenicpolydipsia. If blood glucose and urea nitrogen are normal, high serumosmolality with hyposmolar urine suggests ADH deficiency or resistance.Low serum osmolality with hyposmolar urine suggests primary polydipsia.
  • With either ADH deficiency or resistance,urine specific gravity rarely exceeds 1.005 and urinary osmolalityrarely exceeds 200 mOsm/kg. Water deprivation test thatdemonstrates inability to concentrate urine indicates diabetes insipidusand distinguishes it from primary polydipsia. If urine remains hypotonicwith dehydration, next step is to determine response to exogenousvasopressin, which distinguishes ADH deficiency from resistance.With ADH deficiency, administration of vasopressin causes diminishingof symptoms and increase in urine specific gravity, whereas no responseoccurs with ADH resistance.
  • With suspected renal disease, certaintests should be performed: CBC and differential; UA; urine culture;serum electrolytes, calcium, phosphorus, and creatinine; blood ureanitrogen; hemoglobin electrophoresis; and renal U/S. Othertests (e.g., determination of serum and urinary amino acids, voiding cystourethrography,and renal biopsy) may be necessary to define specific renal abnormality.
  • Psychosocial history of emotional disturbance,including episodes of compulsive water drinking and formation ofconcentrated urine with fluid deprivation, are evidence for psychogenicpolydipsia. This disorder may sometimes be difficult to distinguishfrom hypothalamic thirst defect, and consultation with a pediatricendocrinologist is recommended.

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    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Anuria: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Take the patient's vital signs and obtain a complete history. First, ask about changes in his voiding pattern. Determine the amount of fluid he normally ingests each day, the amount of fluid he ingested in the last 24 to 48 hours, and the time and amount of his last urination. Review his medical history, noting previous kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about drug use and about abdominal, renal, or urinary tract surgery.

    Inspect and palpate the abdomen for asymmetry, distention, or bulging. Inspect the flank area for edema or erythema, and percuss and palpate the bladder. Palpate the kidneys anteriorly and posteriorly, and percuss them at the costovertebral angle. Auscultate over the renal arteries, listening for bruits.

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    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Bladder distention: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If distention isn't severe, begin by reviewing the patient's voiding patterns. Find out the time and amount of the patient's last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva's maneuver or Credé's method to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.

    Explore the patient's history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Note his drug history, including his use of over-the-counter drugs and herbal medicines.

    Take the patient's vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can't be palpated through the abdominal wall.) Inspect the urethral meatus, and measure its diameter. Describe the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Dysuria: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient complains of dysuria, have him describe its severity and location. When did he first notice it? Did anything precipitate it? Does anything aggravate or alleviate it?

    Next, ask about previous urinary or genital tract infections. Has the patient recently undergone an invasive procedure, such as cystoscopy or urethral dilatation, or had a urinary catheter placed? Also ask if he has a history of intestinal disease. Ask the female patient about menstrual disorders and the use of products that irritate the urinary tract, such as bubble bath salts, feminine deodorants, contraceptive gels, or perineal lotions. Also ask her about vaginal discharge or pruritus.

    During the physical examination, inspect the urethral meatus for discharge, irritation, or other abnormalities. A pelvic or rectal examination may be necessary.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Enuresis: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    When taking a history, include the parents as well as the child. First, determine the number of nights each week or month that the child wets the bed. Is there a family history of enuresis? Ask about the child's daily fluid intake. Does he drink much after dinner? What are his typical sleep and voiding patterns? Find out if the child has ever had control of his bladder. If so, try to pinpoint what may have precipitated enuresis, such as an organic disorder or psychological stress. Does the bed-wetting occur at home and away from home? Ask the parents how they've tried to manage the problem, and have them describe the child's toilet training. Observe the child's and parents' attitudes toward bed-wetting. Finally, ask the child if it hurts when he urinates.

    Next, perform a physical examination to detect signs of neurologic or urinary tract disorders. Observe the child's gait to check for motor dysfunction, and test sensory function in the legs. Inspect the urethral meatus for erythema, and obtain a urine specimen. A rectal examination to evaluate sphincter control may be required.

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    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Nocturia: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Begin by exploring the history of the patient's nocturia. When did it begin? How often does it occur? Can the patient identify a specific pattern or precipitating factors? Also, note the volume of urine voided. Ask the patient about changes in the color, odor, or consistency of his urine. Has the patient changed his usual pattern or volume of fluid intake? Next, explore associated symptoms. Ask about pain or burning on urination, difficulty initiating a urine stream, costovertebral angle (CVA) tenderness, and flank, upper abdominal, or suprapubic pain.

    Determine if the patient or his family has a history of renal or urinary tract disorders or endocrine and metabolic diseases, particularly diabetes. is the patient taking a drug that increases urine output, such as a diuretic, a cardiac glycoside, or an antihypertensive?

    Focus your physical examination on palpating and percussing the kidneys, CVA, and bladder. Carefully inspect the urinary meatus. Inspect a urine specimen for color, odor, and the presence of sediment.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Oliguria: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Begin by asking the patient about his usual daily voiding pattern, including frequency and amount. When did he first notice changes in this pattern and in the color, odor, or consistency of his urine? Ask about pain or burning on urination. Has the patient had a fever? Note his normal daily fluid intake. Has he recently been drinking more or less than usual? Has his intake of caffeine or alcohol changed drastically? Has he had recent episodes of diarrhea or vomiting that might cause fluid loss? Next, explore associated complaints, especially fatigue, loss of appetite, thirst, dyspnea, chest pain, or recent weight gain or loss (in dehydration).

    Check for a history of renal, urinary tract, or cardiovascular disorders. Note recent traumatic injury or surgery associated with significant blood loss as well as recent blood transfusions. Was the patient exposed to nephrotoxic agents, such as heavy metals, organic solvents, anesthetics, or radiographic contrast media? Next, obtain a drug history.

    Begin the physical examination by taking the patient's vital signs and weighing him. Assess his overall appearance for edema. Palpate both kidneys for tenderness and enlargement, and percuss for costovertebral angle (CVA) tenderness. Also, inspect the flank area for edema or erythema. Auscultate the heart and lungs for abnormal sounds and the flank area for renal artery bruits. Assess the patient for edema or signs of dehydration such as dry mucous membranes.

    Obtain a urine specimen and inspect it for abnormal color, odor, or sediment. Use reagent strips to test for glucose, protein, and blood. Also, use a urinometer to measure specific gravity.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Polyuria: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Because the patient with polyuria is at risk for developing hypovolemia, evaluate his fluid status first. Take his vital signs, noting an increased body temperature, tachycardia, and orthostatic hypotension (a 10 mm Hg decrease in systolic blood pressure upon standing and a 10 beats/minute increase in heart rate upon standing). Inspect for dry skin and mucous membranes, decreased skin turgor and elasticity, and reduced perspiration. Is the patient unusually tired or thirsty? Has he recently lost more than 5% of his body weight? If you detect these effects of hypovolemia, you'll need to infuse replacement fluids.

    If the patient doesn't display signs of hypovolemia, explore the frequency and pattern of the polyuria. When did it begin? How long has it lasted? Was it precipitated by a certain event? Ask the patient to describe the pattern and amount of his daily fluid intake. Check for a history of visual deficits, headaches, or head trauma, which may precede diabetes insipidus. Also check for a history of urinary tract obstruction, diabetes mellitus, renal disorders, chronic hypokalemia or hypercalcemia, or psychiatric disorders (past and present). Find out the schedule and dosage of any drugs the patient is taking.

    Perform a neurologic examination, noting especially any change in the patient's level of consciousness. Then palpate the bladder and inspect the urethral meatus. Obtain a urine specimen and check its specific gravity.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Urinary frequency: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient how many times per day he voids. How does this compare with his previous pattern of voiding? Ask about the onset and duration of the abnormal frequency and about any associated urinary signs or symptoms, such as dysuria, urgency, incontinence, hematuria, discharge, or lower abdominal pain with urination.

    Ask also about neurologic symptoms, such as muscle weakness, numbness, or tingling. Explore his medical history for urinary tract infection, other urologic problems or recent urologic procedures, and neurologic disorders. With a male patient, ask about a history of prostatic enlargement. If the patient is a female of childbearing age, ask whether she is or could be pregnant. Obtain a complete drug history.

    Obtain a clean-catch midstream specimen for urinalysis and culture and sensitivity tests. Then palpate the patient's suprapubic area, abdomen, and flanks, noting any tenderness. Examine his urethral meatus for redness, discharge, or swelling. In a male patient, the physician may palpate the prostate gland.

    If the patient's medical history reveals symptoms or a history of neurologic disorders, perform a neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Urinary hesitancy: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient when he first noticed hesitancy and if he has ever had the problem before. Ask about other urinary problems, especially reduced force or interruption of the urine stream. Ask if he has ever been treated for a prostate problem or UTI or obstruction. Obtain a drug history.

    Inspect the patient's urethral meatus for inflammation, discharge, and other abnormalities. Examine the anal sphincter and test sensation in the perineum. Obtain a clean-catch specimen for urinalysis and culture. In a male patient, the prostate gland requires palpation. A female patient requires a gynecologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Urinary incontinence: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If he can occasionally control urination, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he has ever sought treatment for incontinence or found a way to deal with it himself.

    Obtain a medical history, especially noting urinary tract infection (UTI), prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies she has had and how many childbirths. A diary of voiding habits for a 24- to 48-hour period may provide useful information. Obtain a complete drug history.

    After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious inflammation or anatomic defect. Have female patients bear down; note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Urinary urgency: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient about the onset of urinary urgency and whether he has ever experienced it before. Ask about other urologic symptoms, such as dysuria and cloudy urine. Also ask about neurologic symptoms, such as paresthesia. Examine his medical history for recurrent or chronic UTIs or for surgery or procedures involving the urinary tract. Obtain a complete drug history.

    Obtain a clean-catch specimen for urinalysis and culture. Note urine character, color, and odor, and use a reagent strip to test for pH, glucose, and blood. Then palpate the suprapubic area and both flanks for distention and tenderness. If the patient's history or symptoms suggest neurologic dysfunction, perform a neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Urine cloudiness: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask about symptoms of UTI, such as dysuria; urinary urgency or frequency; or pain in the flank, lower back, or suprapubic area. Also ask about recurrent UTIs or recent surgery or treatment involving the urinary tract. Obtain a complete drug history.

    Obtain a urine specimen to check for pus or mucus. (See Performing the three-glass urine test, page 613.) Using a reagent strip, test for blood, glucose, and pH. Palpate the suprapubic area and flanks for tenderness.

    If you note cloudy urine in a patient with an indwelling urinary catheter, especially with concurrent fever, remove the catheter immediately (or change it if the patient must have one in place).

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    DYSURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis includes a urinalysis, urine cultures, smear and culture of any discharge, an IVP, voiding cystogram and cystoscopy, and cystometric examination. In women with “negative” cultures, Chlamydia urethritis must be considered and treated. In men with negative cultures, prostatic examination, massage, and evaluation of discharge are done. Massage of the prostate should be avoided in acute prostatitis.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    GLYCOSURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The investigation of glycosuria should include a glucose tolerance test, chemistry panel, and electrolyte panel. A clinical history of polyuria, polyphagia, weakness, and weight loss will be helpful. If there are clinical features of one of the endocrine diseases listed above, various tests for these disorders and an endocrinology consult should be ordered.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    INCONTINENCE, URINARY: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    First, exclude stress incontinence with a pad test. Perineal pads are weighed before and after walking and stress for 30 minutes. An increase in weight identifies urine loss. Catheterization and examination, smear, and culture of the urine are essential at the outset. Cystoscopy and cystometric studies are often needed. Surgical repair of a cystocele or a parasympathomimetic drug in cases of a flaccid neurogenic bladder and propantheline bromide (ProBanthine), a parasympatholytic drug, for spastic neurogenic bladders may be all that is necessary. A neurologist and urologist often need to cooperate in the diagnosis and treatment of these unfortunate individuals.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    NOCTURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The workup of nocturia is essentially the same as the workup of polyuria and urinary frequency . Obviously, the search for obstruction and infection are most important. Venous pressure, circulation time, and pulmonary function studies to rule out congestive heart failure should be done if the urinary tract is clean.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    POLYURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The diagnosis of polyuria depends largely on the association of other symptoms. Polyuria, polyphagia, and polydipsia suggest diabetes mellitus and hyperthyroidism. Polyuria with only polydipsia suggests psychogenic or idiopathic diabetes insipidus; the Hickey–Hare test will differentiate the two. Polyuria with polydipsia and weakness but with no significant weight loss suggests hypercalcemia and possible hyperparathyroidism. Chronic nephritis will be diagnosed by examination of the urine sediment and a specific gravity that remains at 1.010. Nephrogenic diabetes insipidus can be differentiated from neurogenic diabetes insipidus by the inability of the kidney to respond to a pitressin injection.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    PROTEINURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The first step is to determine whether the proteinuria is caused by infection. A urinalysis for WBCs and examination of a fresh drop of unspun urine under the microscope for the bacteria are the fastest ways of determining this. The urine can also be cultured. Next, determine if there are red cells in the urine. This would indicate a more serious cause for the proteinuria such as collagen disease, stone, glomerulonephritis, or neoplasm and prompts the need for an IVP, cystoscopy, and urology consult.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    PYURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    How does one track down the cause of pyuria? First, it must be determined that the cloudy urine is really pyuria. Amorphous phosphates and other inert material will disappear on treating the urine with dilute acetic acid. Then, just as for other nonbloody discharges, one must do a smear and culture for the offending organism; an examination of the urine, especially the unspun specimen, is axiomatic. If one finds clumps of leukocytes, renal gitter cells, or WBC casts, the infection almost certainly comes from the kidney. Motile bacteria in an unspun specimen examined under high-power microscopy and a colony count of over 100,000 per mL signify infection. A three-glass test may be helpful in localizing the site of origin of the pyuria. Anaerobic cultures and cultures for Chlamydia may be needed. Look for eosinophils on a Wright stain of the urine if toxic nephritis is suspected. Vaginal examination and culture may disclose a source for the infection. In the male, one episode of pyuria should be sufficient indication for an IVP; a female should have one after her second episode, especially if no cause can be found on physical examination. Cystoscopy and a voiding cystogram are often indicated at this time.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    ANURIA AND OLIGURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The clinical picture will be helpful in determining the cause of anuria. In cases of prerenal azotemia, there will be decreased skin turgor and orthostatic hypotension if the cause is volume depletion. If the cause is CHF, there will be jugular vein distention, hepatomegaly, and pedal edema. Patients with postrenal azotemia may have an enlarged prostate, a distended bladder, and other signs of obstructive uropathy. Patients with renal azotemia may have bilateral flank masses (polycystic kidney), hypertension, peripheral emboli (embolic glomerulonephritis), or a rash (collagen disease, interstitial nephritis). The initial workup includes a CBC; urinalysis; urine culture and sensitivity; personal examination of the urine for casts, and so forth; chemistry panel; spot urine sodium; serum and urine osmolality; flat plate of the abdomen for kidney size; chest x-ray; and ECG. The bladder is catheterized for residual urine; if this is significant, postrenal azotemia is likely and a urologist is consulted. He will most likely do a cystoscopy and retrograde pyelography after the patient’s condition is stabilized. Ultrasonography can be used to determine if there is significant residual urine also. The laboratory studies will determine whether there is prerenal or renal azotemia. If the sodium concentration in the spot urine is less than 10 meq/L, prerenal azotemia is likely. Also, in prerenal azotemia, the BUN/creatinine ratio is 20:1 or greater and the urine osmolality is 450 mOsm per kilogram of water or greater. The urine sediment will show granular and red cell casts in most cases of renal azotemia, and the BUN/creatinine ratio will be 10:1 or less. Further workup will depend on what the presumptive diagnosis is. If volume depletion is the cause, intravenous saline and plasma volume expanders are given while carefully monitoring the urine output. If this is ineffective, furosemide and a mannitol drip can be utilized to reestablish urine output. If these measures are ineffective, the patient obviously has a renal cause for his or her anuria, and a urologist should be consulted. Renal causes can be differentiated by further workup. If intravascular hemolysis is suspected, a serum haptoglobin test should be ordered. If dissecting aneurysm or bilateral renal artery stenosis is suspected, aortography and angiography would be done. If polycystic kidney disease is suspected, ultrasonography or CT scan of the abdomen may be done. Eosinophilia of the blood or urine will be found in drug-induced nephritis. If a collagen disease is suspected, one should order an ANA, double-stranded DNA (dsDNA) antibody titer, or lupus erythematosus cell prep. A renal biopsy may also be necessary in these and many other disorders.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    ENURESIS (BEDWETTING): Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    From the above discussion it should be obvious that simple bedwetting prior to age 6 may not require a workup at all. After that age a careful examination of the urine, including smear and culture for bacteria, should be done. An intravenous pyelogram and voiding cystogram are usually necessary. If these suggest a congenital lesion or are negative, cystoscopy may need to be done. An x-ray film for spina bifida and a sleep electroencephalogram (EEG) are probably worthwhile if urologic investigation is negative.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007


     » Next page: Signs of Acute urinary conditions

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