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.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Neurogenic bladder:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
The patient’s history may include a condition or disorder that can cause neurogenic bladder, incontinence, and disruptions of micturition patterns. Voiding cystourethrography evaluates bladder neck function, vesicoureteral reflux, and continence.
Urodynamic studies help evaluate how urine is stored in the bladder, how well the bladder empties, and the rate of movement of urine out of the bladder during voiding. These studies consist of four components:
❑ Urine flow study (uroflow) shows diminished or impaired urine flow.
❑ Cystometry evaluates bladder nerve supply, detrusor muscle tone, and intravesical pressures during bladder filling and contraction.
❑ Urethral pressure profile determines urethral function with respect to the length of the urethra and the outlet pressure resistance.
❑ Sphincter electromyelography correlates the neuromuscular function of the external sphincter with bladder muscle function during bladder filling and contraction. This evaluates how well the bladder and urinary sphincter muscles work together.
❑ Retrograde urethrography reveals the presence of strictures and diverticula. This test may not be performed on a routine basis.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
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.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urethral discharge:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient when he first noticed the discharge, and have him describe its color, consistency, and quantity. Does he experience pain or burning on urination? Does he have difficulty initiating a urine stream? Does he experience urinary frequency? Ask the patient about other associated signs and symptoms, such as fever, chills, and perineal fullness. Explore his history for prostate problems, sexually transmitted disease, or urinary tract infection. Ask the patient if he has had recent sexual contacts or a new sexual partner.
Inspect the patient’s urethral meatus for inflammation and swelling. Using proper technique, obtain a culture specimen. (See Collecting a urethral discharge specimen, page 778.) Then obtain a urine specimen for urinalysis, culture and, possibly,, a three-glass urine test. (See How to perform the three-glass urine test.) Palpation of the male patient’s prostate gland may be necessary.
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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
Urethral Discharge:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A detailed medical history is essential for the evaluation of UD. The essential symptoms addressed at the time of interview are (a) dysuria, (b) urethral discharge, (c) itching at the urethra, (d) hematuria, (e) rectal symptoms, (f) contact with infectious agents, and (g) sexual history. The characteristics of UD are noted in relation to color, quantity, odor, consistency, frequency, and relationship to urination. Profuse, yellowish UD occurring 3 to 7 days after sexual exposure is characteristic of GC. GC infection is more common in men than in women. In 1997, 324,901 cases of gonorrhea were reported to the Centers for Disease Control, with a case rate of 122/100,000 (1). Clear to white, scanty, or mucopurulent UD (23% to 55%) that develops gradually at least a week after exposure, with waxing and waning in intensity, suggests chlamydial infection. This is the most common sexually transmitted disease (STD) in the United States, with 3 million new cases occurring annually (2). As many as 85% of women with chlamydial infections and 40% of infected men are asymptomatic (3). Sexual history should include sexual behaviors, condom usage, number of sexual partners, recent sexual contacts, and the orifices used for sexual contacts. Consistent usage of condoms prevents sexually transmitted urethritis. Oral sex increases UD from oral flora infections.
Physical examination
A. Focused physical examination (PE) should include vital signs, and urologic and rectal examination. In men, this should include examination of the penis, perimeatal region (for evidence of erythema), urethral meatus, scrotum, testicles, epididymis, prostate, and perianal and inguinal region. Stains present on the patient’s underwear may indicate the characteristics of the discharge, which is particularly useful in a patient who has urinated shortly before examination. Recent micturition can eliminate much inflammatory discharge. Sometimes it is necessary to examine the patient in the morning before voiding to enhance the diagnosis. Perform a complete gynecologic and urologic examination in women.
B. Abdomen. Completely examine the abdomen to rule out intraabdominal pathology, including masses and inflammation, obstruction, or distention of organs.
C. Additional physical examination should include the skin and other systems, as needed. If a patient is suspected of gonococcal infection, it may be essential to check the patient’s joints, skin, throat, eye and other organs.
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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.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
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
Bladder cancer:
Diagnosis
(Handbook of Diseases)
Only cystoscopy and a biopsy can confirm bladder cancer. Cystoscopy should be performed when hematuria first appears. When it’s performed under anesthesia, a bimanual examination is usually done to determine if the bladder is fixed to the pelvic wall. A thorough history and physical examination may help determine whether the tumor has invaded the prostate or the lymph nodes.
The following tests can provide essential information about the tumor:
❑ Urinalysis can detect blood in the urine and malignant cytology.
❑ Excretory urography can identify a large, early-stage tumor or an infiltrating tumor, delineate functional problems in the upper urinary tract, assess hydronephrosis, and detect rigid deformity of the bladder wall.
❑ Retrograde cystography evaluates bladder structure and integrity. Test results help to confirm the diagnosis.
❑ Pelvic arteriography can reveal tumor invasion into the bladder wall.
❑ Computed tomography scan reveals the thickness of the involved bladder wall and detects enlarged retroperitoneal lymph nodes.
❑ Ultrasonography can detect metastasis beyond the bladder and can distinguish a bladder cyst from a tumor.
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Source: Handbook of Diseases, 2003
Neurogenic bladder:
Diagnosis
(Handbook of Diseases)
The patient’s history may include a condition or disorder that can cause neurogenic bladder, incontinence, and disruptions of micturition patterns. The following tests will help evaluate the patient’s bladder function:
❑ Voiding cystourethrography evaluates bladder neck function, vesicoureteral reflux, and continence.
❑ Urodynamic studies help evaluate how urine is stored in the bladder, how well the bladder empties, and the rate of movement of urine out of the bladder during voiding. These studies consist of four components:
– Urine flow study (uroflow) shows diminished or impaired urine flow.
– Cystometry evaluates bladder nerve supply, detrusor muscle tone, and intravesical pressures during bladder filling and contraction.
– Urethral pressure profile determines urethral function with respect to the length of the urethra and the outlet pressure resistance.
– Sphincter electromyelography correlates the neuromuscular function of the external sphincter with bladder muscle function during bladder filling and contraction. This evaluates how well the bladder and urinary sphincter muscles work together.
❑ Retrograde urethrography reveals the presence of strictures and diverticula. This test may not be performed on a routine basis.
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Source: Handbook of Diseases, 2003
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.
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Source: Handbook of Diseases, 2003
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
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
Urethral discharge:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient when he first noticed the discharge, and have him describe its color, consistency, and quantity. Does he experience pain or burning on urination? Does he have difficulty initiating a urine stream? Does he experience urinary frequency? Ask the patient about other associated signs and symptoms, such as fever, chills, and perineal fullness. Explore his history for prostate problems, sexually transmitted disease, or urinary tract infection. Ask the patient if he has had recent sexual contacts or a new sexual partner.
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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 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
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
Urethral discharge:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when he first noticed the discharge, and have him describe its color, consistency, and quantity. Does he experience pain or burning on urination? Does he have difficulty initiating a urine stream? Does he experience urinary frequency? Ask the patient about other associated signs and symptoms, such as fever, chills, and perineal fullness. Explore his history for prostate problems, sexually transmitted disease, or urinary tract infection. Ask the patient if he has had recent sexual contacts or a new sexual partner. Obtain a complete drug history.
Inspect the patient's urethral meatus for inflammation and swelling. Using proper technique, obtain a culture specimen. (See Collecting a urethral discharge specimen.) Then obtain a urine specimen for urinalysis, culture, and possibly a three-glass urine specimen. (See Performing the three-glass urine test, page 613.) In the male patient, the prostate gland may have to be palpated.
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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
URETHRAL DISCHARGE:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The association of other symptoms and signs is helpful in narrowing the
list of possibilities. The discharge of acute urethritis is usually
associated with severe pain on micturation, whereas the discharge of prostatitis is often not. The discharge of
chronic prostatitis is usually painless and occurs most frequently on
arising. Urethral caruncles, papillomas, and carcinomas frequently have a
bloody discharge, at least intermittently. On examination, the physician can
detect induration of a urethral chancre, and the erythema of a balanitis is
obvious when the prepuce is retracted. The presence of arthritis or
conjunctivitis makes Reiter syndrome a distinct possibility, although
gonorrhea may do the same. The boggy prostate of prostatitis and the
increase of the discharge on massage will assist greatly in this diagnosis.
In the laboratory, a smear and culture are axiomatic in diagnosis, and one
must massage the prostate and milk the urethra if little discharge is found
on simple inspection. After massaging the prostate, the first portion of a
voided specimen should be examined, smeared, and cultured if no discharge is
apparent. Culture for Chlamydia if routine cultures are negative. Cystoscopy and
cystograms may be necessary, but the indications for these will be at the
discretion of the urologist, who should be consulted if routine treatment is
ineffective.
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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.
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Source: Differential Diagnosis in Primary Care, 2007
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