Diagnostic Tests for Acute urinary conditions
Acute urinary conditions Tests: Book Excerpts
Home Diagnostic Testing
These home medical tests may be relevant to Acute urinary conditions:
- Bladder & Urinary Health: Home Testing:
- Prostate Health: Home Testing:
- Kidney Health: Home Testing:
Acute urinary conditions Diagnosis: Book Excerpts
Diagnostic Tests for Acute urinary conditions: Online Medical Books
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for more information about the diagnostic tests for Acute urinary conditions.
DYSURIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
GLYCOSURIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
NOCTURIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
POLYURIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
PROTEINURIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
PYURIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
ANURIA OR OLIGURIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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
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.
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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.
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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.
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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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
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
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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
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:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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.
Testing
The history and physical examination usually suggests which tests are most appropriate. A urinalysis is the most common study performed. It is important also to gather samples for gonorrhea, chlamydia, and HSV, using wet preparations and potassium hydroxide testing when appropriate. Rapid tests on urine samples for the detection of bacteria and leukocytes can be done while patients wait. Direct microscopic examination of the urine can isolate bacteria and leukocytes. Rapid dipstick biochemical tests can isolate leukoesterase and nitrate, which are consistent with leukocytes and urea-fixing bacteria. Urine cultures require overnight to 48 hours of incubation to detect specific bacterial pathogens. Pyuria (defined as white blood cell count >10/mm3 of urine) is seen in more than 95% of patients with acute UTI but is uncommon in the absence of infection. Pyuria without bacteriuria suggests a chlamydia infection. Urine dipstick testing is generally less sensitive for pyuria than microscopic examination, but it is more convenient (5).
Diagnostic assessment
Given the many causes of dysuria, an accurate diagnosis can be difficult without a thorough approach to each patient. Because most causes have other associated symptoms and findings, a diagnosis can usually be made with a carefully taken history, a focused physical examination, and appropriate laboratory tests. Separating an uncomplicated UTI or STD from the more serious pyelonephritis and other possible diagnoses is the challenge in these patients.
References
1. Carlson KJ, Mulley AG. Management of acute dysuria. Ann Intern Med 1985;102:
244–249.
2. Johnson JR, Stamm WE. Diagnosis and treatment of acute urinary tract infections. Infect Dis Clin North Am 1987;4(1):773–791.
3. Ainsworth JG, Weaver T, Murphy S, Renton A. General practitioners’ immediate management of men presenting with urethral symptoms. Genitourin Med 1996;72(6):427–430.
4. Roberts RO, Lieber MM, Rhodes R, Girman CJ, Bostwick DG, Jacobsen SJ. Prevalence of a physician-assigned diagnosis of prostatitis: the Olmsted County Study of Urinary Symptoms and Health Status Among Men. Urology 1998;51(4):578–584.
5. Kurowiski K. The woman with dysuria. Am Fam Physician 1998;57(9):2155–2164, 2169–2170.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Nocturia:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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.
Testing
A routine urinalysis by dipstick testing will identify infection and some types of renal disease. A low specific gravity can indicate increased fluid intake or renal disease with the inability to concentrate urine. Microscopic evaluation and urine culture can be helpful in selected cases. Serum blood urea nitrogen and creatinine can be elevated in renal disease. Urine electrolytes can help to diagnose diabetes insipidus. Measurement of postvoid residual urine will evaluate for urinary retention. A voiding diary with measurement of urine volume can be helpful. If the nighttime voided urine volume is high, the cause is excessive urine production. If the volume is less than bladder capacity (highest daytime voided volume), the nocturia is caused by a sleep-related problem or lower urinary tract pathology. Cystoscopy, renal ultrasound, intravenous pyelogram, and urodynamic studies are not usually needed in the evaluation of nocturia.
Diagnostic assessment
Patients with excessive fluid intake or use of alcohol or caffeine near bedtime or patients on medications (e.g., diuretics, theophylline, or calcium channel blockers) may complain of nocturia. Aging is associated with a loss of the nocturnal increase in vasopressin and increased nocturnal urine production (2). Nocturia, frequency, urgency, and dysuria coupled with a positive urinalysis indicate a urinary tract infection. Findings of rales on lung examination, an S3 gallop, and lower extremity edema suggests congestive heart failure. COPD can cause respiratory acidosis and increased excretion of hydrogen ion with the production of an acid urine and bladder irritation (4). In a male patient, a diminished urinary stream and an enlarged prostate suggest prostatic hypertrophy and obstructive uropathy. Patients with insomnia from any number of causes (depression, pain, dyspnea, and so on) may experience nocturia. Be alert for the patient with nocturia secondary to neurologic conditions, which can cause inadequate secretion of vasopressin (diabetes insipidus).
References
1. Resnick NM. Urinary incontinence. In: Cassel CK, Cohen HJ, Larson EB, et al., eds. Geriatric medicine, 3rd ed. New York: Springer-Verlag, 1997:562–566.
2. Donahue JL, Lowenthal DT. Nocturnal polyuria in the elderly person. Am J Med Sci 1977;314(4):232–237.
3. Pressman MR, Figueroa WG, Kendrick-Mohamed J, Greenspon LW, Peterson DD. Nocturia. A rarely recognized symptom of sleep apnea and other occult sleep disorders. Arch Intern Med 1996;156(5):545–550.
4. McAninch JW. Symptoms of disorders of the genitourinary tract. In: Tanagho EA, McAninch JW, eds. Smith’s general urology, 14th ed. Norwalk, CT: Appleton & Lange, 1995:36–38.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Urinary Incontinence:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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.
Testing
A. Voiding journal. A voiding journal is a good way to get additional information about the patient’s problem. Have the patient record the time and approximate amount of each voiding, and whether they were wet or dry.
B. Urinalysis. Be cautious when interpreting the urine analysis: in the absence of other symptoms, bacteriuria is seldom the primary cause of UI. Treat cystitis or urethritis when the rest of the clinical picture confirms them. Unexplained, persistent microhematuria requires investigation (Chapter 10.2).
C. Postvoiding urine volume. The patient should be catheterized immediately after voiding. In general, the postvoid urine volume should be less than 50 ml. Volumes in the range of 100 to 200 ml may suggest impaired bladder contractility or obstruction. Volumes greater than 200 ml strongly suggest obstruction.
D. Blood urea nitrogen, creatinine, and glucose are simple blood tests that help rule out underlying renal disease and diabetes.
E. Special tests are available via urologic consultation to further delineate the cause of UI. These include cystoscopy, cystometry, and other voiding studies. Up to two-thirds of patients can be successfully treated without urologic referral.
Diagnostic assessment
The clinical history is the most important factor leading to the correct diagnosis and successful treatment of urinary incontinence. However, it is an imperfect tool at best. In one review, clinical history had a sensitivity and specificity for stress incontinence of 0.90 and 0.50, respectively. For detrusor instability, the figures were 0.74 and 0.55 (2).
The task becomes even more problematic when considering the reluctance of patients to talk about their symptoms and the tendency for UI to be of a mixed type. Response to therapy (or lack thereof) often drives the practical management of this condition. Lack of response to multiple trials of therapy is a good indication for consulting a urologist. Remember, that your initial assessment will often be incorrect, so keep an open mind and consider all possible diagnoses. Finally, recall that UI frequently involves more than one causal factor. For example, many elderly people have a functional component (can’t get to the toilet quickly) in addition to one of the other types.
References
1. Urinary incontinence in adults: acute and chronic management. AHCPR Clinical Practice Guideline, No. 2 (1996 Update) Accessed August 1999; http://text.nlm.nih.gov/
ftrs/gateway/
2. Jensen JK, Nielsen FR, Ostergard DR. The role of patient history in the diagnosis of urinary incontinence. Obstet Gynecol 1994;83(5):904–910.
3. Finding out about incontinence. AAFP Patient Information Handout (1998) Accessed August 1999; http://www.aafp.org/patientinfo/incont.html
4. Goode PS, Burgio KL. Pharmacologic treatment of lower urinary tract dysfunction in geriatric patients. Am J Med Sci 1997;314(4):262–267.
5. Weiss BD. Diagnostic evaluation of urinary incontinence in geriatric patients. Am Fam Physician 1998;57(11):2665–2687. Accessed August 1999; http://www.aafp.org/afp/
980600ap/weiss.html
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Oliguria and Anuria:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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.
Testing
A. An indwelling urinary catheter serves as a diagnostic tool (if obstruction has occurred at the bladder neck or urethra) and for accurate urine volume measurement. Urine output and blood pressure monitoring can often lead to expedient correction of prerenal causes, thus avoiding further complications.
B. Urinalysis is often normal in prerenal causes of oliguria or anuria, except being highly concentrated with possible qualitative proteinuria because of the high concentration. Microscopic analysis is usually unremarkable (or reveals few hyaline or granular casts) in prerenal causes; whereas proteinuria, casts, and hematuria can point to renal causes.
C. Urine osmolality is typically high in prerenal causes (>500 mOsm/kg H2O) versus impaired in renal causes (<350 mOsm/kg H2Ο) (2).
D. Urine sodium is typically less than 20 mEq/L in prerenal causes (unless diuretics have been used) versus more than 40 mEq/L in renal causes (2).
E. Blood urea nitrogen and creatinine levels are elevated. The ratio must be interpreted considering the entire clinical situation. Urine:plasma creatinine ratio (U:P Cr) is calculated to help differentiate between prerenal (U:P Cr >40) and renal (U:P Cr <20) causes (2).
F. Diagnostic imaging, which may be necessary in some cases, is guided by the history and PE findings [e.g., ultrasound (US), computed tomography (CT), retrograde pyelogram, renal biopsy].
Diagnostic assessment
The key to a diagnosis of oliguria or anuria is to actively anticipate when it is likely to manifest and accurately measure using an indwelling catheter. Once recognized and a cause is suggested, (a) prerenal causes can be assessed further by measuring hemodynamic status and administering fluids; (b) renal causes can be assessed further with urinalysis (qualitative and quantitative), renal US, or renal biopsy; and (c) postrenal causes can be assessed further using US, CT, or retrograde pyelography.
References
1. Eliahou HE. Oliguria and anuria. In: Massry SG, Glassock RJ, eds. Massry and Glassock’s textbook of nephrology, 3rd ed. Baltimore: Williams & Wilkins, 1995:543–546.
2. Lake EW, Humes HD. Acute renal failure including cortical necrosis. In: Massry SG, Glassock RJ, eds. Massry and Glassock’s textbook of nephrology, 3rd ed. Baltimore: Williams & Wilkins, 1995:984–987.>>>>
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Dysuria:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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.
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Source: Field Guide to Bedside Diagnosis, 2007
Polyuria:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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).
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Source: Field Guide to Bedside Diagnosis, 2007
Proteinuria:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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.
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Source: Field Guide to Bedside Diagnosis, 2007
Urinary Incontinence:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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
Anuria:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Take the patient’s vital signs. 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.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Bladder distention:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Dysuria:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient to void before beginning your examination. Inspect the urethral meatus for discharge, irritation, and other abnormalities. Then percuss over the kidneys. Costovertebral angle tenderness indicates kidney inflammation. Percuss the bladder. Start at the symphysis pubis and percuss upward. You should hear tympany; a dull sound signals retained urine. Then palpate the kidneys. Normally, they aren’t palpable unless they’re enlarged. If the kidneys feel enlarged, the patient may have hydronephrosis, cysts, or tumors. You won’t be able to palpate the bladder unless it’s distended. (See Palpating the kidneys.) A pelvic or rectal examination may be necessary.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Nocturia:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Focus your physical assessment on palpating and percussing the kidneys, the CVA, and the bladder. Carefully inspect the urinary meatus. Inspect a urine specimen for color, odor, and the presence of sediment.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Oliguria:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the physical assessment 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.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Polyuria:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Take vital signs, noting increased body temperature, tachycardia, and orthostatic hypotension (a 10 mm Hg or greater decrease in systolic blood pressure upon standing and a 10 beats per minute or greater increase in heart rate upon standing). Inspect for dry skin and mucous membranes, decreased skin turgor and elasticity, and reduced perspiration.
Perform a neurologic assessment, 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.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary frequency:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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 assessment.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary hesitancy:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary incontinence:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary urgency:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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 assessment.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Dysuria:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Proteinuria:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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).
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Source: Nursing: Interpreting Signs and Symptoms, 2007
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