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Diseases » Kidney stones » Diagnosis
 

Diagnosis of Kidney stones

Diagnostic Test list for Kidney stones:

The list of medical tests mentioned in various sources as used in the diagnosis of Kidney stones includes:

Kidney stones Diagnosis: Book Excerpts

Tests and diagnosis discussion for Kidney stones:

Kidney Stones in Adults: NIDDK (Excerpt)

Sometimes "silent" stones--those that do not cause symptoms--are found on x-rays taken during a general health exam. These stones would likely pass unnoticed.

More often, kidney stones are found on an x-ray or sonogram taken on someone who complains of blood in the urine or sudden pain. These diagnostic images give the doctor valuable information about the stone's size and location. Blood and urine tests help detect any abnormal substance that might promote stone formation.

The doctor may decide to scan the urinary system using a special x-ray test called an IVP (intravenous pyelogram). The results of all these tests help determine the proper treatment. (Source: excerpt from Kidney Stones in Adults: NIDDK)

What Are Kidney Stones: NIDDK (Excerpt)

The best way for your doctor to find out what kind of stone you have is to test the stone itself. If you know that you are passing a stone, try to catch it in a strainer.

Your doctor may ask for a urine sample or take blood to find out what is causing your stones. You may need to collect your urine for a 24-hour period. These tests will help your doctor find ways for you to avoid stones in the future. (Source: excerpt from What Are Kidney Stones: NIDDK)

Kidney Stones: NWHIC (Excerpt)

The urologist will order laboratory tests, including urine and blood tests. He or she will also ask about the patient's medical history, occupation and dietary habits. If a stone has been removed, or if the patient has passed a stone and saved it, the lab can analyze the stone to determine its composition. (Source: excerpt from Kidney Stones: NWHIC)

Diagnosis of Kidney stones: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Kidney stones:

Diagnostic Tests for Kidney stones: Online Medical Books

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


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

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

DIAGNOSTIC WORKUP

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

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

  1. Is there abdominal pain? The presence of abdominal pain with hematuria should first suggest renal calculus, but other causes, such as renal embolism, renal contusion, or laceration, must be considered.
  2. Is there dysuria or frequency of micturition associated with the hematuria? The presence of dysuria and frequency with the hematuria should suggest a bladder stone, prostatic disease, or a UTI.
  3. Is there fever? The presence of fever with the hematuria would suggest pyelonephritis.
  4. Is there a flank mass? The presence of bilateral flank masses with hematuria should suggest polycystic kidneys and hydronephrosis, whereas a unilateral flank mass would suggest a hypernephroma or unilateral hydronephrosis. A solitary cyst or renal vein thrombosis may also present with a flank mass and hematuria.
  5. Is there hypertension? The presence of hypertension with the hematuria suggests glomerulonephritis, polycystic kidneys, and collagen diseases.
  6. Are there other systemic signs and symptoms? If there are other systemic signs and symptoms, one should be looking for collagen disease, coagulation disorders, leukemia, and sickle cell anemia. When there is no hypertension or other signs and symptoms of systemic diseases, one should be looking for a benign or malignant tumor of the bladder, tuberculosis, or parasitic infection.

DIAGNOSTIC WORKUP

The workup begins with a urinalysis and microscopic examination of the urinary sediment. The physician can easily do this in his office. If there is proteinuria, granular cast, and red cell cast, glomerulonephritis or collagen disease should be suspected. A culture and sensitivity and colony count should be done if a UTI is suspected. A three-glass test may be done. If there is blood in the initial specimen, the cause is most likely in the urethra or male genitalia. If it is in the final specimen, the cause is most likely a bladder lesion. Phase-contrast microscopy may also be helpful in identifying hematuria from a glomerular lesion. If this is negative, an anaerobic culture should be done also and then an AFB smear and culture and guinea pig inoculation to rule out tuberculosis. An intravenous pyelogram will also usually have to be done. A CBC, sedimentation rate, chemistry panel, coagulation profile, and ANA test will help rule out blood dyscrasias, collagen diseases, and other systemic diseases. Ultrasonography may help diagnose a renal cyst.

If the above are not revealing, referral to a urologist is indicated. He will probably do a cystoscopy and retrograde pyelography. He may also want to order a CT scan of the abdomen and pelvis and a renal biopsy. Renal angiography and aortography may be necessary to evaluate renovascular hypertension and renal embolism.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

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

    • Workup and Diagnosis

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

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

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

    • Transient hematuria
      –Urinary tract infection/pyelonephritis
      –Nephrolithiasis (kidney or bladder stones)
      –Exercise
      –Trauma, instrumentation, catheterization, or foreign bodies
      –Endometriosis
      –Transient unexplained
      –Henoch-Schönlein purpura/HUS
      –Coagulopathy and excess anticoagulation
      –Prostatitis, epididymitis
  • Persistent hematuria
    –Sickle cell anemia
    –Cancer (prostate, bladder, kidney)
    –Benign prostatic hypertrophy
    –Polycystic kidney disease
    –Intrinsic glomerular disease
  • Other causes of red or brown urine (pseudohematuria)
    –Beeturia (14% population are susceptible after eating beets): Due to excretion of betalaine, a reddish pigment
    –Myoglobinuria: Rapidly filtered and excreted; source is usually due to rhabdomyolysis; look for increased elevation of plasma CPK levels
    –Hemoglobinuria: Occurs when the filtered load of unbound dimer exceeds resorptive capacity of the proximal tubules, generally at serum levels >100–150 mg/dL
  • Urethral carbuncle
  • Urethritis (e.g., Chlamydia)
  • Porphyria
  • Phenazopyridine (bladder analgesic): Produces an orange color in urine
  • Postinfectious glomerulonephropathy
  • Hereditary (Alport's syndrome)
  • IgA nephropathy (Berger's disease): Often see gross hematuria without positive family history of disease
  • Loin pain hematuria syndrome
  • Thin basement membrane disease (benign familial hematuria): Usually see microscopic hematuria; gross hematuria or renal failure is rare
  • Hypercalciuria or hyperuricuria
  • Arteriovenous malformation
  • Fistula
  • Others include food dyes, phenolphthalein, rifampin, and porphyrins
  • Excessive anticoagulation
  • Trauma

    • Workup and Diagnosis

    • History and physical examination
    • Urinalysis in all patients (consider catheterization to distinguish vaginal bleeding from other sources)
      –Blood clots occur with extraglomerular sources
      –Glomerular source of bleeding results in RBC casts, large amounts of protein, dysmorphic RBCs
      –UTI results in pyuria, nitrates, leukocyte esterase
      • Initial labs include BUN/creatinine, electrolytes, calcium, uric acid, CBC, and PT/PTT
      • Centrifuge urine sample: Red sediment only suggests hematuria (RBCs in the urine); heme-negative red supernatant suggests hemoglobinuria; heme-positive clear supernatant suggests myoglobinuria
        • Three-tube test: #1, collect first few mL of urine; #2, midstream; #3, last few mL
          –Hematuria in #1 suggests urethral lesion; in #3, bladder trigone lesion; equally in all three, diffuse lesion
        • IVP (contraindicated in dye allergy), renal ultrasound, or spiral CT to evaluate for stones and renal masses
        • Urine cytology and cystoscopy for patients at risk for bladder cancer (e.g., smoking, cyclophosphamide)
        • Consider C3 level, ANA, ANCA, Anti-GBM, ASO, cryoglobulins, and hepatitis C antibodies
        • Renal biopsy if persistent hematuria with negative workup and evidence of progression (increasing proteinuria, creatinine, and blood pressure)

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

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

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

    Workup and Diagnosis

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

    » READ BOOK EXCERPT ONLINE »

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

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

    • Transient (fever, dehydration, exercise)
    • Urinary tract infection
      –Most common cause of gross hematuria
    • Hypercalciuria (common)
    • Primary glomerulonephritis (GN)
      –Acute poststreptococcal GN: Gross hematuria ±hypertension, oliguria; 5 days to several weeks after Group A strep pharyngitis or pyoderma; can also occur after other infections
      –IgA nephropathy (Berger disease): recurrent gross hematuria occurs at or near onset of a URI
      –Membranoproliferative GN
    • GN associated with systemic disease
      –HSP
      –SLE
      –Other vasculitis (rare) e.g.,Wegener
      • Other glomerular disease
        –Benign familial hematuria
        –Alport syndrome: Usually X linked, high- frequency deafness, progression to renal failure
        –Glomerular disease (e.g., FSGS) usually presents as nephrotic syndrome
      • Tubulointerstitial disease
        –Polycystic kidney disease, interstitial nephritis, papillary necrosis, ATN
    • Urinary pelvic junction obstruction
    • Urolithiasis/nephrolithiasis
      –Painless in up to 50% of children
      • Urethrorrhagia
        –Recurrent gross hematuria (spotting on the underwear)
        –Most common in peripubertal males
    • Malignancies (e.g., Wilms tumor)
    • Vascular (e.g., renal vein thrombosis)
    • Trauma
      • Non-urinary tract blood
        –Menses, perineal irritation, pinworms, masturbation, STDs, sexual abuse
    • Munchausen/Munchausen by proxy (rare)

    Workup and Diagnosis

      • History
        –Antecedent illness (including timing)
        –Prior episodes, medication/food exposure
        –Quality of gross hematuria (if present): Color, terminal vs present throughout stream, clots
        –Symptoms: Fever, flank pain, dysuria, rash, hemoptysis, breathing difficulty, joint complaints
        –Family history: Kidney stones, kidney disease, deafness (Alport)
    • Physical exam
      –Blood pressure, growth parameters, skin or pharyngeal lesions, cardiac gallop, rales, edema, CVAT, genitourinary exam (external)
      • Labs/studies
        –U/A (dipstick and microscopy), urine culture
        –Dipstick negative =foods, medications
        –Dipstick positive, no RBCs =myoglobin, hemoglobin
        –Dipstick positive, with RBCs =hematuria
        –Macroscopic or microscopic with symptoms (e.g., HTN): Serum chemistries, CBC, ASO, C3, ANA, sickle prep, spot urine calcium/creatinine, STD screen (if sexually active), renal/bladder ultrasound, consider noncontrast helical CT if kidney stones suspected
        –Microscopic hematuria, no symptoms: Repeat U/A two times, 1 week apart; if persists, check serum chemistries, urine culture, sickle prep, spot urine calcium/creatinine and U/As of parents/siblings

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

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

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

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

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

    The clinical picture will point to the diagnosis in many cases. If there is a history of abdominal trauma, a contusion or laceration of the kidney or bladder should be suspected. Massive trauma anywhere prompts a tentative diagnosis of crush syndrome. Purpura or bleeding from other sites suggests a coagulation disorder. Severe colicky pain in the abdomen suggests kidney stone. A long history of hypertension tension suggests polycystic kidneys, renal artery stenosis, or glomerulonephritis. A history of fever and rheumatic valvular disease suggests SBE with renal embolism. Painless hematuria in an otherwise healthy looking adult suggests neoplasm, whereas painful hematuria with frequency and dysuria suggests cystitis. Hematuria and a flank mass would make a neoplasm or polycystic kidney likely.

    The initial workup should include a CBC, urinalysis, urine culture, chemistry panel, flat plate of the abdomen to assess the presence of stones and kidney size, and personal examination of the urinary sediment. If a renal calculus is suspected, an IVP is ordered immediately and a urologist consulted. A three-glass test will help localized the site of the bleeding. If there is blood in the initial specimen only, the urethra is probably the site of bleeding. If the blood is primarily in the final specimen, the bladder is most likely the site of bleeding. Equal blood discoloration in all specimens points to a renal lesion.

    If renal tuberculosis is suspected an AFB smear and culture is done. If collagen disease is suspected an ANA analysis and anti–double strand DNA antibody titer is ordered. If a renal carcinoma is suspected, a CT scan of the abdomen is probably the best study to order but the advice of the urologist ought to be sought. Ultrasonography is useful in differentiating cysts from tumors. If a bladder neoplasm is suspected, cystoscopy will be done. If renal artery embolism or thrombosis is suspected, renal angiography may need to be done to clearly make the diagnosis.

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    Source: Differential Diagnosis in Primary Care, 2007

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

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

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

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

    » READ BOOK EXCERPT ONLINE »

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

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

    After detecting hematuria, take a pertinent health history. If hematuria is macroscopic, ask the patient when he first noticed blood in his urine. Does it vary in severity between voidings? Is it worse at the beginning, middle, or end of urination? Has it occurred before? Is the patient passing clots? To rule out artifactitious hematuria, ask about bleeding hemorrhoids or the onset of menses, if appropriate. Ask if there’s pain or burning with hematuria episodes.

    Ask about recent abdominal or flank trauma. Has the patient been exercising strenuously? Note a history of renal, urinary, prostatic, or coagulation disorders. Then obtain a drug history, noting anticoagulants or aspirin.

    Begin the physical examination by palpating and percussing the abdomen and flanks. Next, percuss the costovertebral angle (CVA) to elicit tenderness. Check the urinary meatus for bleeding or other abnormalities. Using a chemical reagent strip, test a urine specimen for protein. A vaginal or digital rectal examination may be necessary.

    » READ BOOK EXCERPT ONLINE »

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

    Calcium imbalance: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Confirming diagnosis  A serum calcium level less than 8.5 mg/dl confirms hypocalcemia; a level more than 10.5 mg/dl confirms hypercalcemia. (However, because approximately one-half of serum calcium is bound to albumin, changes in serum protein must be considered when interpreting serum calcium levels. A common conversion formula is calcium corrected = calcium actual + 0.8 x [4.0 – albumin level]. Ionized calcium levels are 4.65 to 5.28 mg/dl and are a measure of the fraction of serum calcium in ionized form.)

    The Sulkowitch urine test shows increased calcium precipitation in hypercalcemia. In hypocalcemia, an electrocardiogram (ECG) reveals lengthened QT interval, prolonged ST segment, and arrhythmias; in hypercalcemia, shortened QT interval and heart block. (See Diagnosing hypercalcemia, pages  916 and 917.)

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

    Polycystic kidney disease: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    A family history and a physical examination revealing large bilateral, irregular masses in the flanks strongly suggest polycystic kidney disease. In advanced stages, grossly enlarged and palpable kidneys make the diagnosis obvious. In patients with these findings, the following laboratory results are typical:

    ❑ Excretory urography reveals enlarged kidneys, with elongation of pelvis, flattening of the calyces, and indentations caused by cysts. Excretory urography of the neonate shows poor excretion of contrast medium.

    ❑ Ultrasound and computed tomography scan show kidney enlargement and the presence of cysts; tomography demonstrates multiple areas of cystic damage. Ultrasonography is the preferred imaging technique because it’s less expensive, doesn’t require contrast or radiation exposure, and is easily and safely performed on children and pregnant females.

    ❑ Urinalysis and creatinine clearance tests are nonspecific tests that evaluate renal function and reveal urine protein or blood in the urine.

    Diagnosis must rule out the presence of renal tumors.

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

    Chronic renal failure: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Diagnosis of chronic renal failure is based on clinical assessment, a history of chronic progressive debilitation, and gradual deterioration of renal function as determined by creatinine clearance tests. The following laboratory findings also aid in diagnosis:

    ❑ Blood studies show elevated blood urea nitrogen, serum creatinine, and potassium levels; decreased arterial pH and bicarbonate; and low hemoglobin (Hb) level and hematocrit (HCT).

    ❑ Urine specific gravity becomes fixed at 1.010; urinalysis may show proteinuria, glycosuria, erythrocytes, leukocytes, and casts, depending on the etiology.

    ❑ X-ray studies include kidney-ureter-bladder films, excretory urography, nephrotomography, renal scan, and renal arteriography.

    ❑ Renal or abdominal computed tomography scan, magnetic resonance imaging, or ultrasound indicate changes associated with chronic renal failure, including abnormally small size in both kidneys.

    ❑ Kidney biopsy allows histologic identification of the underlying pathology.

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

    Renal calculi: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Diagnosis is based on the clinical picture and the following tests:

    ❑ Computed tomography scan or magnetic resonance imaging are highly sensitive for identifying hydronephrosis and detecting small renal and urethral stones.

    ❑ Excretory urography may be used for diagnosis of obstruction by urinary calculus.

    ❑ Kidney-ureter-bladder X-rays reveal most renal calculi.

    ❑ Calculus analysis shows mineral content.

    CONFIRMING DIAGNOSIS Excretory urography confirms the diagnosis and determines size and location of calculi.

    ❑ Kidney ultrasonography is an easily performed, noninvasive, nontoxic test to detect obstructive changes such as hydronephrosis.

    ❑ Urine culture of midstream sample may indicate UTI.

    ❑ Urinalysis may be normal, or may show increased specific gravity and acid or alkaline pH suitable for different types of stone formation. Other urinalysis findings include hematuria (gross or microscopic), crystals (urate, calcium, or cystine), casts, and pyuria with or without bacteria and white blood cells.

    ❑ A 24-hour urine collection is evaluated for calcium oxalate, phosphorus, and uric acid excretion levels.

    ❑ Serial blood calcium and phosphorus levels detect hyperparathyroidism and show increased calcium level in proportion to normal serum protein.

    Increased blood uric acid levels may indicate gout as the cause. Diagnosis must rule out appendicitis, cholecystitis, peptic ulcer, and pancreatitis as potential sources of pain.

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

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

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

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

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

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

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

    Introduction: Renal and Urologic Disorders: Physical examination for renal disease
    (Professional Guide to Diseases (Eighth Edition))

    The first step in physical examination is careful observation of the patient’s overall appearance, because renal disease affects all body systems. Examine the patient’s skin for color, turgor, intactness, and texture; mucous membranes for color, secretions, odor, and intactness; eyes for periorbital edema and vision; general activity for motion, gait, and posture; muscle movement for motor function and general strength; and mental status for level of consciousness, orientation, and response to stimuli. (See Common renal symptoms.)

    Renal disease causes distinctive changes in vital signs: hypertension due to fluid and electrolyte imbalances and hyperactivity of the renin-angiotensin system; a strong, fast, irregular pulse due to fluid and electrolyte imbalances; hyperventilation to compensate for metabolic acidosis; and an increased susceptibility to infection due to overall decreased resistance. Palpation and percussion may reveal little because the kidneys and bladder are difficult to palpate unless they are enlarged or distended.

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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

    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.

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

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

    After detecting hematuria, take a pertinent health history. If hematuria is macroscopic, ask the patient when he first noticed blood in his urine. Does it vary in severity between voidings? Is it worse at the beginning, middle, or end of urination? Has it occurred before? Is the patient passing any clots? To rule out artifactual hematuria, ask about bleeding hemorrhoids or the onset of menses, if appropriate. Ask if pain or burning accompanies the episodes of hematuria.

    Ask about recent abdominal or flank trauma. Has the patient been exercising strenuously? Note a history of renal, urinary, prostatic, or coagulation disorders. Then obtain a drug history, noting the use of anticoagulants or aspirin.

    Begin the physical examination by palpating and percussing the abdomen and flanks. Next, percuss the costovertebral angle (CVA) to elicit tenderness. Check the urinary meatus for bleeding or other abnormalities. Using a chemical reagent strip, test a urine specimen for protein. A vaginal or digital rectal examination may be necessary.

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

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

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

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

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

    Physical examination

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

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

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

    A thorough history is of utmost importance!

    A. General aspects

    1. Type of hematuria (macro/gross or microscopic).

    2. Relationship to urination or timing of hematuria. The three-container method will help to separate the micturition into three portions with an initial, middle, and final portion.

    Predominantly, initial hematuria results from anterior urethral disease; final hematuria results from disease of the bladder neck or posterior urethra; and hematuria throughout the stream suggests a disease site higher in the bladder, ureter, or kidney.

     3. Urine color. Color can be affected by the following: Phenazopyridine (orange); nitrofurantoin (brown); rifampin (yellow-orange); l-dopa, methyldopa, and metronidazole (reddish-brown); phenolphthalein in laxatives, red beet and rhubarb consumption, food coloring, and vegetable dyes (red).

     4. Clots, especially wormlike clots, suggest a location above the bladder neck.

     5. Associated symptoms (e.g., recent sore throat, fever, chills, and flulike symptoms) may be the first sign of IgA nephropathy or postinfectious glomerulonephritis. Urinary frequency, dysuria, fever, chills, and urgency point to an infectious process. Diminished urine flow and abdominal pain or flank pain radiating into the groin can indicate the presence of urinary tract obstruction (Chapter 10.5). Vaginal discharge or bowel movement changes may hint at a nonurinary tract cause such as a foreign body (especially in children). A rash, joint pain, photosensitivity, flulike symptoms, and Raynaud’s phenomenon point to a collagen vascular disease.

     B. Past medical history should lead to a suspicion of parasites (e.g., Schistosoma heamatobium) if the patient has traveled to endemic areas; of bladder tumor if there was exposure to chemical carcinogens (e.g., aniline dyes), or tobacco smoke. Other causes of hematuria detected in the history include drug ingestion and anticoagulation, and medical problems such as prostatic hypertrophy, diabetes mellitus (nephrosclerosis), analgesic medication abuse (renal papillary necrosis), nephrolithiasis, trauma (including vigorous masturbation), chemotherapy exposure with cyclophosphamide (chemical cystitis), antibiotic use (interstitial nephritis), previous urinary tract malignancies suggesting recurrence, and sickle cell disease (papillary necrosis).

     C. Family history. Delineate any family history of polycystic kidney disease, sickle cell trait and disease, nephrolithiasis, various glomerular diseases, tuberculosis, and benign familial hematuria. The combination of renal failure, deafness, and hematuria suggests Alport’s hereditary nephritis.

    Physical examination

    should focus on signs of systemic disease (fever, rash, lymphadenopathy, joint swelling, and abdominal or pelvic mass), and underlying medical or renal disease (hypertension, edema). Multiple telangiectasias and mucous membrane lesions indicate hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease). An abdominal mass in children requires exclusion of Wilms tumor.

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

    Dysuria: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Lower urinary tract infection

    ❑ Acute pyelonephritis

    ❑ Urethritis

    ❑ Vaginitis

    ❑ Acute prostatitis

    ❑ Urethral calculus

    ❑ Reiter syndrome

    Diagnostic Approach

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

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

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

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

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    Source: Field Guide to Bedside Diagnosis, 2007

    Hematuria: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Urinary tract infection

    ❑ Nephrolithiasis

    ❑ Anticoagulation

    ❑ Long distance running

    ❑ Renal trauma

    ❑ Bladder cancer

    ❑ Renal cell cancer

    ❑ Transitional cell cancer

    ❑ Glomerulonephritis

    ❑ Interstitial cystitis

    ❑ Hemorrhagic cystitis

    ❑ Hemoglobinuria

    ❑ Endocarditis

    ❑ Polycystic kidney disease

    ❑ Renal artery embolism

    ❑ Renal vein thrombosis

    ❑ Endometrial implants

    ❑ Wegener granulomatosis

    ❑ Goodpasture syndrome

    Diagnostic Approach

    A reasonable cutoff for discriminating benign from serious causes of hematuria is 10 RBCs/HPF. The urine dipstick detects as few as 1 to 2 RBCs/HPF. Analysis of the urine sediment is crucial. White cells and bacteria are indicative of cystitis whereas white cell casts are seen in pyelonephritis. Red cell casts and dipstick proteinuria indicate glomerulonephritis. Red cells from a glomerular source tend to be distorted. A positive dipstick for hemoglobin but no RBCs in the urinalysis suggests the presence of myoglobin or free hemoglobin derived from intravascular hemolysis. Menstrual blood contamination needs to be considered in the differential of microscopic hematuria.

    Initial hematuria suggests a urethral source; terminal hematuria, the prostatic urethra, trigone, or base; and total hematuria, the kidney, ureter, or bladder. Massive hematuria is usually associated with bladder neoplasm, benign prostatic hypertrophy, or trauma. Bright red urine suggests a lower urinary source. Passage of bulky disc-like or fragmented clots implies the bladder as source, long shoestring clots suggest a ureteral origin, and pyramidal clots are from the renal pelvis. Glomerular sources virtually never produce clots (due to the presence of tissue plasminogen activators in the glomeruli and tubules). With a presentation of painless total hematuria, a urinary tract cancer is found in 20%.

    Flank pain associated with hematuria may result from the passage of stones or clots. Hypertension suggests renal disease. Rash, fever, arthralgia/arthritis, or hemoptysis suggests a connective tissue disease or vasculitis. Beets, blackberries, and rhubarb, as well as pyridium, rifampin, phenothiazines, and anthracyclines, can produce red urine without blood.

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    Source: Field Guide to Bedside Diagnosis, 2007

    Calcium imbalance: Diagnosis
    (Handbook of Diseases)

    A serum calcium level below 4.5 mEq/L confirms hypocalcemia; a level above 5.5 mEq/L confirms hypercalcemia. (However, because about half of serum calcium is bound to albumin, changes in serum protein must be considered when interpreting serum calcium levels.)

    In patients with hypercalcemia, urine test results show an increase in urine calcium precipitation. In those with hypocalcemia, an electrocardiogram (ECG) reveals a lengthened QT interval, a prolonged ST segment, and arrhythmias; in those with hypercalcemia, an ECG reveals a shortened QT interval and heart block.

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    Source: Handbook of Diseases, 2003

    Polycystic kidney disease: Diagnosis
    (Handbook of Diseases)

    A family history and a physical examination revealing large bilateral, irregular masses in the flanks strongly suggest polycystic kidney disease. In advanced stages, grossly enlarged and palpable kidneys make the diagnosis obvious. (See Visualizing the polycystic kidney.) In patients with these findings, the following laboratory results are typical:

    ❑ Excretory urography or retrograde ureteropyelography reveals enlarged kidneys, with elongation of the renal pelvis, flattening of the calyces, and indentations caused by cysts. Excretory urography of the neonate shows poor excretion of contrast medium.

    ❑ Ultrasonography, tomography, and radioisotope scans show kidney enlargement and cysts. Computed tomography scan and magnetic resonance imaging show multiple areas of cystic damage.

    ❑ Urinalysis and creatinine clearance tests (nonspecific tests that evaluate renal function) indicate abnormalities.

    CLINICAL TIP: Diagnosis must rule out the presence of renal tumors.

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    Source: Handbook of Diseases, 2003

    Renal failure, acute: Diagnosis
    (Handbook of Diseases)

    The patient’s history may include a disorder that can cause renal failure. Blood test results indicating intrinsic acute renal failure include elevated urea nitrogen, creatinine, and potassium levels; low bicarbonate and hemoglobin (Hb) levels; and low pH and hematocrit (HCT).

    Urine specimens show casts, cellular debris, decreased specific gravity and, in glomerular diseases, proteinuria and urine osmolality close to serum osmolality. The urine sodium level is less than 20 mEq/L if oliguria results from decreased perfusion and more than 40 mEq/L if it results from an intrinsic problem.

    Other studies include renal ultrasonography, kidney-ureter-bladder radiography, cautious use of excretory urography, renal scan, retrograde pyelography, and nephrotomography.

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    Source: Handbook of Diseases, 2003

    Renal failure, chronic: Diagnosis
    (Handbook of Diseases)

    Clinical assessment, a history of chronic progressive debilitation, and gradual deterioration of renal function as determined by creatinine clearance tests lead to a diagnosis of chronic renal failure.

    The following laboratory findings also aid in diagnosis:

    ❑ Blood studies show elevated blood urea nitrogen, creatinine, and potassium levels; decreased arterial pH and bicarbonate levels; and low hemoglobin (Hb) levels and hematocrit (HCT).

    ❑ Urine specific gravity becomes fixed at 1.010; urinalysis may show proteinuria, glycosuria, erythrocytes, leukocytes, and casts, depending on the cause.

    ❑ Renal or abdominal X-ray, abdominal computed tomography scan, magnetic resonance imaging, or ultrasonography shows reduced kidney size.

    ❑ X-ray studies include kidney-ureter-bladder radiography, excretory urography, nephrotomography, renal scan, and renal arteriography.

    ❑ Kidney biopsy allows histologic identification of underlying pathology.

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    Source: Handbook of Diseases, 2003

    Renal calculi: Diagnosis
    (Handbook of Diseases)

    The complete clinical picture along with the following diagnostic tests allows a diagnosis:

    ❑ Excretory urography, retrograde pyelography, abdominal computed tomography scan, or abdominal or kidney magnetic resonance imaging reveals tumors or obstructions of the ureter. These tests help confirm the diagnosis and determine size and location of calculi.

    ❑ Kidney-ureter-bladder X-rays reveal most renal calculi.

    ❑ Calculus analysis shows mineral content.

    ❑ Kidney ultrasonography, an easily performed noninvasive, nontoxic test, helps detect obstructive changes, such as unilateral or bilateral hydronephrosis.

    ❑ Urine culture of midstream specimen may indicate urinary tract infection.

    ❑ Urinalysis may be normal or may show increased specific gravity and acid or alkaline pH suitable for different types of stone formation. Other urinalysis findings include hematuria (gross or microscopic), crystals (urate, calcium, or cystine), casts, and pyuria with or without bacteria and white blood cells.

    ❑ A 24-hour urine collection is evaluated for calcium oxalate, phosphorus, and uric acid excretion levels.

    ❑ Serial blood calcium and phosphorus levels help detect hyperparathyroidism and show an increased calcium level in proportion to the normal level of serum protein.

    ❑ Blood protein level measures the level of free calcium unbound to protein.

    ❑ Blood chloride and bicarbonate levels may show renal tubular acidosis.

    ❑ Increased blood uric acid levels may indicate gout as the cause.

    Diagnosis must rule out appendicitis, cholecystitis, peptic ulcer, and pancreatitis as potential sources of pain.

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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.

    » READ BOOK EXCERPT ONLINE »

    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.

    » READ BOOK EXCERPT ONLINE »

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

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

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

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

    » READ BOOK EXCERPT ONLINE »

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

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

    After detecting hematuria, take a pertinent health history. If hematuria is macroscopic, ask the patient when he first noticed blood in his urine. Does it vary in severity between voidings? Is it worse at the beginning, middle, or end of urination? Has it occurred before? Is the patient passing any clots? To rule out artifactitious hematuria, ask about bleeding hemorrhoids or the onset of menses, if appropriate. Ask if there’s any pain or burning with the episodes of hematuria.

    Ask about recent abdominal or flank trauma. Has the patient been exercising strenuously? Note a history of renal, urinary, prostatic, or coagulation disorders. Then obtain a drug history, noting any anticoagulants or aspirin.

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

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

    Urinary Tract Infection (UTI)

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

    • Urethritis

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

    • Cystitis

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

    • Pyelonephritis

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

    • Chemical Irritation

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

    • Diaper Dermatitis

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

    • Trauma

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

    • Psychogenic

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

    Diagnostic Approach

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

    Urinalysis

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

    • Urine Culture

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

    Table 15.1. Criteria for Diagnosis of Urinary Tract Infections

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

    Radiologic Imaging

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

    » READ BOOK EXCERPT ONLINE »

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

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

    Hematuria without Proteinuria

    Glomerular Disorders

    Acute Postinfectious Glomerulonephritis

  • Usuallypresents within 1–2 wks after streptococcal pharyngitisor skin infection.
  • Rare before 3 yrs of age.
  • Disease spectrum varies from asymptomaticmicroscopic hematuria with normal renal function to acute renalfailure.
  • Clinical manifestations include fever,abdominal or flank pain, edema, hypertension, and oliguria. Urinecolor is often reddish brown, and red cell casts are usually seen.Proteinuria may or may not occur. In almost all cases, C3 levelis decreased. Supporting evidence of preceding streptococcal infectioncan include positive throat culture, positive streptozyme, or elevatedantistreptolysin O titer.
  • C3 level should return to normal withinabout 8 wks after onset of illness. Proteinuria can last for 6 mosand microscopic hematuria for 1–2 yrs, but virtually allchildren recover.

    • Immunoglobulin A Nephropathy

  • Also knownas Berger disease.
  • Can occur at any age, but peak incidenceis in adolescence and young adulthood.
  • Usually presents with recurrent attacksof gross hematuria, which may be associated with upper respiratorytract infections.
  • Microscopic hematuria can occur betweenepisodes of gross hematuria. Mild proteinuria also may occur, particularlyearly in the course. Renal function tends to be normal. Hypertension,nephrotic syndrome, and rapidly progressive course are unusual findings.
  • Serum concentration of C3 is normal,and this helps to distinguish this disorder from acute postinfectiousglomerulonephritis. Immunoglobulin A is major immunoglobulin inmesangial deposits on renal biopsy.

    • Henoch-Schönlein Nephritis

  • Common causeof vasculitis in childhood.
  • Clinical features include abdominalpain, purpura on buttocks and lower legs, transient arthritis/arthralgiaof large joints, microscopic hematuria, and gastrointestinal bleeding.
  • Diagnosis is usually clinical.
  • Renal biopsy is indistinguishable fromimmunoglobulin A nephropathy.
  • Some children develop chronic nephropathywith progression to end-stage renal disease.

    • Alport Syndrome

  • Primaryfeature is recurrent gross hematuria or asymptomatic microscopichematuria. A number of affected children also have sensorineuralhearing loss. Later in life, individuals develop progressive renalinsufficiency.
  • Usual form of genetic transmissionis X-linked, although autosomal-dominant and autosomal-recessiveforms occur. X-linked phenotype is due to mutation in the gene foralpha-5 chain of basement membrane collagen.

    • Membranoproliferative Glomerulonephritis

  • Most commonin the second decade of life. 3 histologic types (I, II, III) havebeen described.
  • Presentation is variable: gross ormicroscopic hematuria with or without proteinuria or nephrotic syndrome.Hypertension is common, and renal function may be decreased.
  • Serum C3 level is usually low. C3 nephriticfactor may be present, especially in type II. Different types canonly be distinguished by renal biopsy.

    • Systemic Lupus Erythematosus

  • Chronicmultisystem autoimmune disease that is most common in adolescent girls.
  • Characteristic findings include fever,arthritis, weight loss, and nephritis. Hematuria and proteinuriaare common urinary findings. Antinuclear antibody is usually positiveand serum C3 is usually low.
  • Antibody to double-stranded DNA isdiagnostic. Renal biopsy usually shows proliferative glomerulonephritiswith immunoglobulin G and C3 deposits.

    • Familial Benign Hematuria (Thin Basement Membrane Nephropathy)

  • Autosomal-dominantdisorder in which hematuria is usually microscopic. Positive familyhistory of hematuria and absence of proteinuria suggest diagnosis.Electron microscopy shows thinning of glomerular capillary basementmembrane.
  • Although thought to be benign, reportby Dische et al. (1985) described thin basement membrane nephropathyin several individuals who developed progressive renal disease.Further study is required to determine whether this disorder isreally benign.

    • Nonfamilial Benign Hematuria

    In many children, diagnostic studies do notreveal the cause of hematuria. These children are categorized ashaving benign nonfamilial hematuria. After months or years, hematuriafrequently disappears. Although this disorder is often benign, somechildren may have slowly developing glomerulonephritis. As longas hematuria exists, these patients should be tested at 6-mo intervalsto determine whether proteinuria develops.

    Nonglomerular Disorders

    Urinary Tract Infection

  • Common symptomsare dysuria, frequency, urgency, fever, abdominal pain, flank pain,and vomiting. Microscopic or gross hematuria can occur along withpyuria and bacteriuria.
  • Positive urine culture confirms thediagnosis.
  • See Chap.15, Dysuria.

    • Trauma

  • Blunt orpenetrating injury to kidney or any portion of urinary tract cancause gross or microscopic hematuria.
  • With minor trauma and microscopic hematuriain asymptomatic individuals, renal U/S should be performedto search for anatomic abnormality (e.g., hydronephrosis or renalcyst) because minimal trauma rarely causes hematuria in normal kidneys.Otherwise, CT is radiologic study of choice.
  • Urethral trauma may occur followingcrush-type injury from fractured pelvis or direct injury, and urethrographymay be diagnostic.

    • Exercise

    Vigorous exercise can produce gross or microscopichematuria, which usually resolves within 1–2 days.

    Hydronephrosis

    In children with hydronephrosis, microscopicor gross hematuria may occur following mild flank or abdominal trauma.Renal U/S may be performed initially.

    Renal Vein Thrombosis

  • Predisposingfactors include perinatal asphyxia, dehydration, septicemia, shock,and coagulopathies (e.g., protein C deficiency).
  • Gross hematuria usually occurs alongwith palpable unilateral or bilateral flank masses.
  • Renal U/S with Doppler methodsis diagnostic.

    • Hemoglobinopathies

  • HemoglobinopathiesSA, SC, SS, CC, AC, and sickle beta-thalassemia can produce renalbleeding and microscopic or gross hematuria.
  • Hemoglobin electrophoresis is diagnosticand should be performed in any African-American child with hematuriaof unknown cause.

    • Idiopathic Hypercalciuria

  • Microscopicor gross hematuria may occur with increased urinary calcium excretion withoutevidence of urinary stone disease. However, hypercalciuria is riskfactor for development of urolithiasis.
  • Urine calcium:creatinine ratio (mg:mg)of greater than normal for age can screen for this disorder (Matoset al., 1997). If spot ratio is greater than normal, 24-hr urinecalcium excretion should be measured. Calcium excretion of >4mg/kg/day is indicative of hypercalciuria.

    • Urolithiasis

  • Causes inchildren include urinary tract infection, hypercalciuria, hyperuricosuria, cystinuria,and primary hyperoxaluria.
  • When urinary stone is being passed,abdominal or flank pain (renal colic) and microscopic or gross hematuriaare usual findings.
  • Diagnostic investigations should includeUA; urine culture; blood urea nitrogen; and serum measurements ofcalcium, phosphorus, uric acid, and creatinine.
  • CT is recommended to search for underlyingdisease and localize any obstruction.
  • When calculi are recovered from urine,their biochemical contents should be analyzed. If they are unrecoverablefrom urinary tract, determination of calcium:creatinine ratio inrandom urine specimen should be performed. Ratio greater than normalfor age can screen for hypercalciuria. More precise test is measurementof 24-hr urine calcium excretion.
  • If these tests are negative, 24-hrurinary excretion of cystine, oxalate, and uric acid should be performed.

    • Polycystic Kidney Disease

    Autosomal-Recessive

  • Gene hasbeen mapped to chromosome 6.
  • Common findings in neonates are grossor microscopic hematuria, bilateral flank masses, hypertension,and azotemia.
  • Renal U/S usually revealslarge echogenic kidneys. Cysts are microscopic and not seen by imaging.
  • Liver disease is congenital hepaticfibrosis.
  • Diagnosis is usually clinical and radiologic.

    • Autosomal-Dominant

  • Rarely encounteredin childhood.
  • At least 3 different genetic mutationshave been found.
  • Gross or microscopic hematuria, unilateralor bilateral abdominal masses, and hypertension are common findings.
  • Abdominal U/S shows enlargedpolycystic kidneys and hepatic cysts.
  • Diagnosis is usually based on clinicaland radiographic findings.

    • Renal Tuberculosis

  • Usuallydoes not occur until primary disease has been established over several years.
  • Usually associated with tuberculouscystitis, which can produce suprapubic pain and dysuria.
  • Gross or microscopic hematuria andpyuria are characteristic.
  • Mantoux test is usually positive.
  • Usual urine culture for bacteria isnegative, whereas urine culture positive for acid-fast organismsis diagnostic.

    • Vascular Malformations

  • Arteriovenousmalformations of kidney can present with gross hematuria.
  • Renal U/S and CT may locatemalformation. Renal angiography is definitive.

    • Foreign Body in Urethra or Bladder

  • Foreignbody in urethra or bladder usually produces urethral or suprapubicpain, dysuria, and hematuria.
  • Abdominal radiography may reveal radiopaqueforeign body. Cystoscopy can confirm diagnosis.
  • It is important to note that a foreignbody in the vagina can produce bleeding that may be mistaken forhematuria.

    • Neoplasm

  • A numberof genitourinary neoplasms occur in the pediatric population.
  • Wilms tumor, most common renal tumorin children, usually presents as abdominal or flank mass that doesnot cross midline unless it is very large. Gross hematuria occursin small number of cases. Renal U/S or CT shows renal massthat distorts collecting system.
  • Renal hemangioma is rare lesion thatcan present with recurrent gross hematuria. Diagnosis is confirmedby renal angiography.
  • Renal carcinoma is rare in pediatricpopulation, but renal U/S can demonstrate mass lesion.
  • Bladder tumors are exceedingly rarein children, but suprapubic mass is sometimes palpable. Most commonbladder tumor is rhabdomyosarcoma, which can present with hematuriaor acute urinary retention. Abdominal U/S, CT, and cystoscopyare useful in locating and defining extent of tumor.
  • In all cases of genitourinary tractneoplasms, histologic diagnosis is definitive.

    • Bleeding Disorders

    Although gross or microscopic hematuria mayoccur with bleeding disorders (hemophilias, thrombocytopenia, disseminatedintravascular coagulation), it is uncommon to have isolated hematuriaas only manifestation. See Chap.53, Recurrent Infection.

    Drugs

    A number of drugs (penicillins, sulfonamides,cephalosporins, rifampin, tetracycline, cisplatin, lithium) maycause gross or microscopic hematuria. Cyclophosphamide may causehemorrhagic cystitis.

    Hematuria with Proteinuria

  • Hematuriawith proteinuria may occur with several glomerular renal disordersas discussed previously:

  • Acute postinfectious glomerulonephritis
  • Immunoglobulin A nephropathy
  • Henoch-Schönlein nephritis
  • Alport syndrome
  • Membranoproliferative glomerulonephritis
  • Systemic lupus erythematosus
  • Other glomerular renal diseases thatusually present with hematuria and proteinuria are discussed inthis section.

    • Membranous Nephropathy

  • Most commonduring second decade of life and usually presents with nephroticsyndrome. Microscopic hematuria is more common than gross hematuria.
  • Renal biopsy confirms diagnosis.

    • Glomerulonephritis of Chronic Infection

  • Disordersassociated with glomerulonephritis of chronic infection includeendocarditis and ventriculoatrial shunt infections.
  • Clinical features are those of acuteglomerulonephritis, namely edema, hypertension, and renal insufficiency.Serum C3 is often decreased.

    • Idiopathic Rapidly Progressive Glomerulonephritis

  • Uncommondisease in children; often preceded by viral illness.
  • Affected children have acute onsetof hematuria, proteinuria, oliguria or anuria, and azotemia.
  • Serum C3 level is normal or mildlydecreased. Many children progress to end-stage renal disease withina few weeks or months without treatment.
  • Renal biopsy and clinical course arediagnostic.

    • Hemolytic-Uremic Syndrome

  • Typicalform follows prodromal illness consisting of fever, vomiting, abdominal pain,and, often, bloody diarrhea. This is followed in 5–10 daysby hemolytic anemia with fragmented red cells, thrombocytopenia,and acute renal injury with hematuria, proteinuria, and often oliguriaor anuria.
  • Most common pathogen is E. coli 0157:H7.

    • Polyarteritis Nodosa

  • Necrotizingvasculitis that affects small and medium-sized arteries. Althoughcause is unknown, it may follow viral URI, streptococcal infection,or chronic hepatitis B infection.
  • Characteristic findings include fever,abdominal pain, hematuria, hypertension, purpura, arthritis, andstroke.
  • Lab findings include increased sedimentationrate, anemia, leukocytosis, proteinuria, and hypergammaglobulinemia.In some cases, antineutrophil cytoplasmic antibody is found.
  • Biopsy demonstrating the vasculitisis diagnostic.

    • Antiglomerular Basement Membrane Disease (Goodpasture Disease)

  • Associationof pulmonary hemorrhage and glomerulonephritis in which antibodies againstlung and glomerular basement membrane can be demonstrated.
  • Characteristic findings are hematuria,proteinuria, hemoptysis, and progressive renal failure. Serum C3level is normal.
  • Renal biopsy shows linear stainingof immunoglobulin G along glomerular basement membrane.

    • Focal Segmental Glomerulosclerosis

  • Clinicallyindistinguishable from minimal change nephrotic syndrome but shouldbe suspected when there has been inadequate response to standardcorticosteroid therapy.
  • Microscopic hematuria and occasionallygross hematuria may occur.
  • Renal biopsy is diagnostic.

    • Wegener Granulomatosis

  • Disorderof unknown cause characterized by vasculitis that affects upperand lower respiratory tract and kidneys.
  • Fever, malaise, weight loss, hemoptysis,dyspnea, hematuria, and proteinuria are characteristic findings.
  • Antineutrophil circulating antibodiesthat bind to proteinase 3 are specific for this disorder. Sinus,airway, lung, or kidney biopsy that shows necrotizing granulomatouslesions and presence of specific antineutrophil circulating antibodiesthat bind to proteinase 3 confirm the diagnosis.

    • Diagnostic Approach

  • First stepin diagnosis is to determine whether there is blood in urine. Althoughblood may produce pink, red, or brownish color of the urine, othersubstances also may produce same type of urinary discoloration.
  • Urine dipstick detects hemoglobin containedin red cells as well as free Hgb. It can detect as few as 1 or 2red cells per high-power field in uncentrifuged specimen. Microscopydetermines whether red cells are in urine and thus the presenceof hematuria.
  • Urine sample that tests positive ondipstick but negative on microscopy indicates presence of hemoglobinor myoglobin. Serum is pink in color with hemoglobinuria and normalin color with myoglobinuria.
  • Best way to distinguish myoglobin fromHgb is immunochemically. Red, orange, or brownish urine that isdipstick negative for blood indicates that certain foods (blackberries,beets), food dyes, urate crystals, or drugs (pyridium, desferoximine)are coloring urine. Urine containing porphyrin initially has normalcolor but changes to red on standing; dipstick is negative, andno red cells are seen on microscopy.

    • Hematuria without Proteinuria

  • Microscopichematuria without proteinuria is most commonly due to urinary tractinfection, trauma, acute postinfectious glomerulonephritis, immunoglobulinA nephropathy, familial benign hematuria, or nonfamilial benignhematuria.
  • Following history and physical exam,these tests should be performed initially: UA of child and familymembers (to diagnose familial benign hematuria), urine culture,serum creatinine, blood urea nitrogen, C3, calcium:creatinine ratio,and renal U/S. If results of these tests are normal, andproteinuria is consistently absent, most causes of hematuria havebeen excluded and further diagnostic studies (e.g., cystoscopy andrenal biopsy) are usually unnecessary.
  • Children categorized as having nonfamilialbenign hematuria because they have normal evaluation and no recognizablerenal disease may prove to have transient hematuria, but as longas hematuria occurs, these children should be followed for possibleoccurrence of proteinuria. Those with familial benign hematuriaalso should be followed.
  • In addition to above tests, diagnosticevaluation of gross hematuria should include CBC, platelet count,antistreptolysin O or streptozyme titer, and Hgb electrophoresis(in African-American children). Renal angiography may be necessaryif vascular malformation is suspected. If proteinuria occurs whenhematuria subsides, renal biopsy may be indicated.

    • Hematuria with Proteinuria

  • Glomerulonephritisshould be suspected in every child with hematuria and proteinuria.
  • Presence of red cell casts indicatesglomerular bleeding.
  • Results of tests for urinary protein(urine dipstick, sulfosalicylic acid test) are usually positivewith gross hematuria. Although dipstick protein reading of 3+ to4+ may signify glomerular disease with gross hematuria,lower reading may have diagnostic significance. See Chap. 50, Proteinuria, forprotein concentrations corresponding to dipstick readings.
  • To more reliably detect proteinuriaassociated with glomerular disease, urine should be tested whengross hematuria subsides.
  • Renal biopsy is required for specificdiagnosis unless there is evidence of unequivocal acute postinfectiousglomerulonephritis or family history of Alport syndrome. Biopsymay be necessary with acute postinfectious glomerulonephritis ifserum C3 level does not become normal within 2 mos, if proteinuriapersists for >6 mos, or to distinguish it from idiopathicrapidly progressive glomerulonephritis if presentation is that ofacute renal failure.

    • » READ BOOK EXCERPT ONLINE »

    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

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

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

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

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

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

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

    After detecting hematuria, take a pertinent health history. If hematuria is macroscopic, ask the patient when he first noticed blood in his urine. Does it vary in severity between voidings? Is it worse at the beginning, middle, or end of urination? Has it occurred before? Is the patient passing clots? To rule out artifactitious hematuria, ask about bleeding hemorrhoids or the onset of menses, if appropriate. Ask if there's pain or burning with hematuria episodes.

    Ask about recent abdominal or flank trauma. Has the patient been exercising strenuously? Note a history of renal, urinary, prostatic, or coagulation disorders. Then obtain a drug history, noting anticoagulants or aspirin.

    Begin the physical examination by palpating and percussing the abdomen and flanks. Next, percuss the costovertebral angle (CVA) to elicit tenderness. Check the urinary meatus for bleeding or other abnormalities. Using a chemical reagent strip, test a urine specimen for protein. A vaginal or digital rectal examination may be necessary.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

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

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

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

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

    The clinical picture will point to the diagnosis in many cases. If there is a history of abdominal trauma, a contusion or laceration of the kidney or bladder should be suspected. Massive trauma anywhere prompts a tentative diagnosis of crush syndrome. Purpura or bleeding from other sites suggests a coagulation disorder. Severe colicky pain in the abdomen suggests kidney stone. A long history of hypertension suggests polycystic kidneys, renal artery stenosis, or glomerulonephritis. A history of fever and rheumatic valvular disease suggests SBE with renal embolism. Painless hematuria in an otherwise healthy looking adult suggests neoplasm, whereas painful hematuria with frequency and dysuria suggests cystitis. Hematuria and a flank mass would make a neoplasm or polycystic kidney likely. The initial workup should include a CBC, urinalysis, urine culture, chemistry panel, flat plate of the abdomen to assess the presence of stones and kidney size, and personal examination of the urinary sediment. If a renal calculus is suspected, an IVP is ordered immediately and a urologist consulted. A three-glass test will help to localize the site of the bleeding. If there is blood in the initial specimen only, the urethra is probably the site of bleeding. If the blood is primarily in the final specimen, the bladder is most likely the site of bleeding. Equal blood discoloration in all specimens points to a renal lesion. If renal TB is suspected, an acid-fast bacillus (AFB) smear and culture is done. If collagen disease is suspected, an ANA analysis and anti–double-strand DNA antibody titer is ordered. If a renal carcinoma is suspected, a CT scan of the abdomen is probably the best study to order, but the advice of a urologist ought to be sought. Ultrasonography is useful in differentiating cysts from tumors. If a bladder neoplasm is suspected, cystoscopy will be done. If renal artery embolism or thrombosis is suspected, renal angiography may need to be done to clearly make the diagnosis.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Urinary Tract Infections: Diagnosis
    (Pediatric Infectious Disease)

    Paramount to the diagnosis of urinary tract infection and any subsequent radiographic investigation is proper collection and examination of the urine. A bagged specimen is not appropriate for the diagnosis of urinary tract infection because it is easily contaminated by bacteria. In infants who are in diapers, an “in-and-out” catheterization is usually required. In toilet-trained children, a clean-catch specimen may be adequate if the child can be adequately prepped. Urine specimens that cannot be processed at once should be refrigerated at 4 °C. Urine kept at room temperature, for even a short period of time, can alter the results of leukocyte esterase and nitrate tests routinely done on dipstick examination.

    Analysis of a properly obtained urine specimen can provide a clue to the presence of infection. However, there remains considerable debate about the best test to perform. Urine dipstick for nitrate and leukocyte esterase, evaluation for bacteruria, and the presence of pyuria have all been used as screening tests for urinary tract infections.

    Nitrate detected by dipstick is positive in 50% of children with urinary tract infection. This relatively low figure may be related to the fact that the test requires bacteria to remain in the bladder for several hours, a condition that is less likely in children.

    The evaluation for pyuria is complicated by a variety of factors, including the precise number of white blood cells needed for presumptive diagnosis of infection and whether the urine specimen being evaluated is centrifuged before analysis. Hemocytometry is a method used to count white blood cells in body fluids such as spinal fluid and urine. In recent years, considerable study has been done on the use of hemocytometry in “enhanced urinalysis.” In this method, urine is obtained by catheter and evaluated as an uncentrifuged specimen. The enhanced urinalysis is considered positive if there are more than 10 white blood cells/mm 3 and any bacteria on Gram stain. The sensitivity of this method is 85%, with a specificity of 99%. The drawback to enhanced urinalysis is that the equipment needed may not be readily available. The traditional standard urinalysis uses centrifuged specimens, with pyuria being defined as at least 5 white blood cells per high-power field and the presence of any bacteria. The sensitivity of this method is 65%, with 92% specificity.

    In 1999, the American Academy of Pediatrics recommended dipstick evaluation, standard microscopy, and Gram stain as useful screens for urinary tract infection. Positive leukocyte esterase or nitrate on dipstick, greater than 5 white blood cells per high-power field on standard urinalysis, or a positive Gram stain of unspun urine is suggestive of urinary tract infection. These parameters continue to be evaluated, with some investigators commenting on the need to evaluate further the screening methods or even to eliminate urinalysis entirely. It should be understood that urine testing serves as a screen. A negative screen does not rule out urinary tract infection. Clinical correlation is always needed. In a febrile child who has a strong possibility of urinary tract infection, a negative urinalysis should be followed by a urine culture.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Infectious Disease, 2004


     » Next page: Signs of Kidney stones

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