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
Urine cloudiness:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask about symptoms of UTI, such as dysuria; urinary urgency or frequency; and pain in the flank, lower back, or suprapubic area. Also ask the patient if he has had recurrent UTIs or recent surgery or treatment involving the urinary tract.
Obtain a urine specimen to check for pus or mucus. (See How to perform the three-glass urine test, page 777.) Using a reagent strip, test for blood, glucose, and pH. Palpate the suprapubic area and flanks for tenderness.
If you note cloudy urine in a patient with an indwelling urinary catheter, especially if he also has a fever, remove the catheter immediately (or change it if the patient must have one in place).
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
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
Nocturia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin by exploring the history of the patient’s nocturia. When did it begin? How often does it occur? Can the patient identify a specific pattern? Precipitating factors? Also, note the volume of urine voided. Ask the patient about any change in the color, odor, or consistency of his urine. Has the patient changed his usual pattern or volume of fluid intake? Next, explore associated symptoms. Ask about pain or burning on urination, difficulty initiating a urine stream, costovertebral angle tenderness, and flank, upper abdominal, or suprapubic pain.
Determine if the patient or his family has a history of renal or urinary tract disorders or endocrine and metabolic diseases, particularly diabetes. Is the patient taking a drug that increases urine output, such as a diuretic, a cardiac glycoside, or an antihypertensive?
Focus your physical examination on palpating and percussing the kidneys, the costovertebral angle, and the bladder. Carefully inspect the urinary meatus. Inspect a urine specimen for color, odor, and the presence of sediment.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Polyuria:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Because the patient with polyuria is at risk for developing hypovolemia, evaluate fluid status first. Take vital signs, noting increased body temperature, tachycardia, and orthostatic hypotension (a 10-mm Hg decrease in systolic blood pressure upon standing and a 10-beats per minute increase in heart rate upon standing). Inspect for dry skin and mucous membranes, decreased skin turgor and elasticity, and reduced perspiration. Is the patient unusually tired or thirsty? Has he recently lost more than 5% of his body weight? If you detect these effects of hypovolemia, you’ll need to infuse replacement fluids.
If the patient doesn’t display signs of hypovolemia, explore the frequency and pattern of the polyuria. When did it begin? How long has it lasted? Was it precipitated by a certain event? Ask the patient to describe the pattern and amount of his daily fluid intake. Check for a history of visual deficits, headaches, or head trauma, which may precede diabetes insipidus. Also check for a history of urinary tract obstruction, diabetes mellitus, renal disorder, chronic hypokalemia or hypercalcemia, or psychiatric disorder (both past and present). Find out the schedule and dosage of any drugs the patient is taking.
Perform a neurologic examination, noting especially any change in the patient’s level of consciousness. Then palpate the bladder and inspect the urethral meatus. Obtain a urine specimen and check its specific gravity.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urethral discharge:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient when he first noticed the discharge, and have him describe its color, consistency, and quantity. Does he experience pain or burning on urination? Does he have difficulty initiating a urine stream? Does he experience urinary frequency? Ask the patient about other associated signs and symptoms, such as fever, chills, and perineal fullness. Explore his history for prostate problems, sexually transmitted disease, or urinary tract infection. Ask the patient if he has had recent sexual contacts or a new sexual partner.
Inspect the patient’s urethral meatus for inflammation and swelling. Using proper technique, obtain a culture specimen. (See Collecting a urethral discharge specimen, page 778.) Then obtain a urine specimen for urinalysis, culture and, possibly,, a three-glass urine test. (See How to perform the three-glass urine test.) Palpation of the male patient’s prostate gland may be necessary.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urinary incontinence:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If can control urination occasionally, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he’s ever sought treatment for incontinence or found a way to deal with it himself.
Obtain a medical history, especially noting urinary tract infection (UTI), prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies and childbirths she has had.
After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious signs of inflammation or an anatomic defect. Have female patients bear down, and note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urinary frequency:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient how many times a day he voids and how this compares to his previous pattern of voiding. Also ask about the onset and duration of the increased frequency and about any associated urinary signs or symptoms, such as dysuria, urgency, incontinence, hematuria, discharge, or lower abdominal pain during urination.
Also ask about neurologic symptoms, such as muscle weakness, numbness, and tingling. Explore the patient’s medical history for UTIs or other urologic problems, recent urologic procedures, and neurologic disorders. Ask a male patient about a history of prostatic enlargement. Ask a female patient of childbearing age whether she is or could be pregnant.
Obtain a clean-catch midstream urine specimen for urinalysis and culture and sensitivity tests. Then palpate the patient’s suprapubic area, abdomen, and flanks, noting any tenderness. Examine the urethral meatus for redness, discharge, or swelling. The physician may palpate the prostate gland of a male patient.
If the patient’s history or symptoms suggest a neurologic disorder, perform a neurologic examination.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urinary hesitancy:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient when he first noticed hesitancy and if he has ever had the problem before. Ask about other urinary problems, especially reduced force or interruption of the urine stream. Ask if he has ever been treated for a prostate problem, a UTI, or a urinary tract obstruction. Obtain a drug history.
Inspect the patient’s urethral meatus for inflammation, discharge, and other abnormalities. Examine the anal sphincter and test sensation in the perineum. Obtain a clean-catch urine specimen for urinalysis and culture and sensitivity tests. A male patient requires prostate gland palpation. A female patient requires a gynecologic examination.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urinary urgency:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient about the onset of urinary urgency and whether he’s ever experienced it before. Ask about other urologic symptoms, such as dysuria and cloudy urine. Also ask about neurologic symptoms such as paresthesia. Explore his medical history for recurrent or chronic UTIs and for surgery or procedures involving the urinary tract.
Obtain a clean-catch urine specimen for urinalysis and culture and sensitivity tests. Note urine character, color, and odor, and use a reagent strip to test for pH, glucose, and blood. Then palpate the suprapubic area and both flanks for distention and tenderness. If the patient’s history or symptoms suggest neurologic dysfunction, perform a neurologic examination.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Dysuria:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A good general history is critical and can help direct further questions.
A. Distinguishing between symptoms of “internal” dysuria and “external” dysuria is often helpful. Internal dysuria is where the discomfort seems to be centered inside the body and begins before or with the initiation of voiding. External dysuria is when the discomfort appears after voiding has initiated. Symptoms of internal dysuria suggest inflammation of the bladder or urethra, whereas those of external dysuria suggest vaginitis, vulvar inflammation, or external penile lesions.
B. Careful questioning about other associated symptoms and risk factors is the key to sorting out the diagnosis. The history of a new sex partner may support an STD cause. Diaphragm usage may support a bladder infection as well as associated symptoms of frequency, urgency, voiding small volumes, hematuria, and abrupt onset. Gradual onset is more suggestive of urethritis and external causes. Other symptoms of suprapubic pain, costovertebral angle tenderness, fever, flank pain, and so on should be asked about and can direct the diagnostic workup.
Physical examination
The physical examination is essential in narrowing the diagnosis. It helps to rule out pyelonephritis and other systemic infections in patients with dysuria, allowing the physician to search for the less severe causes. Fever, flank tenderness, and suprapubic tenderness are useful findings. A careful genital examination (speculum in women, foreskin retraction and prostate examination in uncircumcised men) can point to specific localized causes. The genital examination also allows collection of samples for testing. Attention to localized lesions (e.g., HSV lesions), discharge (yeast, bacterial vaginosis, gonorrhea, and trichomoniasis) and trauma also help make the diagnosis.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Nocturia:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
Possible causes of nocturia include:
A. Increased urine output. The history should include questions concerning the following causes of increased urine output:
1. Excess intake of fluids
2. Drugs (i.e., caffeine, alcohol, diuretics, nonsteroidal antiinflammatory drugs, calcium channel blockers, lithium)
3. Diabetes mellitus (Chapter 14.1)
4. Diabetes insipidus (central or nephrogenic)
5. Hypercalcemia (Chapter 17.4)
6. Peripheral edema (from any cause) (Chapter 2.3)
7. Congestive heart failure (Chapter 7.5)
8. Renal disease
9. Aging (1)
B. Sleep-related nocturia. Disrupted sleep will cause a patient to arise and empty a partially filled bladder. Causes of disrupted sleep include:
1. Use of a short-acting sedative hypnotic
2. Pain (acute or chronic)
3. Dyspnea (from pulmonary or cardiac disease) (Chapter 8.7)
4. Anxiety or depression
5. Drugs that interfere with the sleep cycle (2)
6. Parkinson’s disease
C. Dementia
D. Sleep apnea (3)
E. Urinary tract dysfunction. Causes of lower urinary dysfunction include:
1. Lower urinary tract infection
2. Small bladder capacity
3. Detrusor hyperactivity
4. Prostatic hypertrophy
5. Urinary retention for any reason
6. Decreased bladder compliance (interstitial cystitis, radiation, tuberculosis) (2)
7. Sensory stimulation in a paraplegic
8. Neurogenic bladder (spastic or atonic) from multiple sclerosis, cerebrovascular accidents, herniated disks, or spinal cord injury
9. Obstetric, gynecologic, or urologic disease or injury
10. Chronic obstructive pulmonary disease (COPD) (4)
11. Fecal impaction
Physical examination
The extent of the physical examination will be guided by the history. Essential for all patients is a genitourinary examination to identify lower urinary tract abnormalities such as bladder distention, cystocele, or rectocele. Examination of the heart, lungs, and extremities will identify pulmonary, cardiac disease, and peripheral edema. A rectal examination (with sphincter contraction during the examination) will identify sphincter laxity, fecal impaction, tumors, and prostate abnormalities. Absence of the anal wink (S4-5) or bulbocavernosus reflex (S2-3) can indicate spinal cord pathology. (In older patients, the absence of these reflexes is not always pathologic.) An expanded neurologic examination will be necessary in patients with other neurologic symptoms.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Urethral Discharge:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A detailed medical history is essential for the evaluation of UD. The essential symptoms addressed at the time of interview are (a) dysuria, (b) urethral discharge, (c) itching at the urethra, (d) hematuria, (e) rectal symptoms, (f) contact with infectious agents, and (g) sexual history. The characteristics of UD are noted in relation to color, quantity, odor, consistency, frequency, and relationship to urination. Profuse, yellowish UD occurring 3 to 7 days after sexual exposure is characteristic of GC. GC infection is more common in men than in women. In 1997, 324,901 cases of gonorrhea were reported to the Centers for Disease Control, with a case rate of 122/100,000 (1). Clear to white, scanty, or mucopurulent UD (23% to 55%) that develops gradually at least a week after exposure, with waxing and waning in intensity, suggests chlamydial infection. This is the most common sexually transmitted disease (STD) in the United States, with 3 million new cases occurring annually (2). As many as 85% of women with chlamydial infections and 40% of infected men are asymptomatic (3). Sexual history should include sexual behaviors, condom usage, number of sexual partners, recent sexual contacts, and the orifices used for sexual contacts. Consistent usage of condoms prevents sexually transmitted urethritis. Oral sex increases UD from oral flora infections.
Physical examination
A. Focused physical examination (PE) should include vital signs, and urologic and rectal examination. In men, this should include examination of the penis, perimeatal region (for evidence of erythema), urethral meatus, scrotum, testicles, epididymis, prostate, and perianal and inguinal region. Stains present on the patient’s underwear may indicate the characteristics of the discharge, which is particularly useful in a patient who has urinated shortly before examination. Recent micturition can eliminate much inflammatory discharge. Sometimes it is necessary to examine the patient in the morning before voiding to enhance the diagnosis. Perform a complete gynecologic and urologic examination in women.
B. Abdomen. Completely examine the abdomen to rule out intraabdominal pathology, including masses and inflammation, obstruction, or distention of organs.
C. Additional physical examination should include the skin and other systems, as needed. If a patient is suspected of gonococcal infection, it may be essential to check the patient’s joints, skin, throat, eye and other organs.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Urinary Incontinence:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Voiding history. It is important to fully characterize the patient’s problem by taking a detailed history, including the duration of the symptoms, timing of voluntary or involuntary voiding, amounts voided involuntarily, and the relationship to voluntary voiding. Focus on the following areas:
1. Need for pads or diapers (measure of severity)
2. Loss of urine with coughing or laughing (suggests stress type)
3. Inability to hold urine after having the urge to urinate (suggests urge type)
4. Pain or discomfort (suggests infection or inflammation) (Chapter 10.1)
5. Inability to fully empty bladder (suggests obstruction)
6. Decreased urinary stream (suggests obstruction)
7. What impact does UI have on the patient’s life?
8. What does the patient think is going on?
B. Major medical problems. Does the patient have any known condition that is associated with UI? These include diabetes, heart failure, menopause, and neurologic problems. Does the patient have other genitourinary symptoms? In female patients, be sure to take a detailed obstetric history.
C. Medication history. Since medications are a major cause of incontinence, a thorough medication history is essential. Offending agents include diuretics, older antidepressants, antihypertensives, narcotics, and alcohol.
D. Special concern. Central and nephrogenic diabetes insipidus can present with UI because of increased urine output (many liters per day). These patients frequently have a concomitant polydypsia that closely matches their water loss (Chapter 14.5). Consider this diagnosis when the patient gives a history of voiding large volumes of urine.
Physical examination
The physical examination is often normal in cases of UI. Focus efforts in an attempt to uncover the underlying cause(s):
A. General. Is the patient physically capable of getting to the toilet?
B. Mental status. Can the patient understand and act on the urge to void?
C. Neurologic, including the anal reflex; focal signs suggest a neurologic cause.
D. Abdominal examination. Is the bladder distended?
E. Rectal or prostate. Does the patient have a fecal impaction or an enlarged prostate?
F. Pelvic examination. Look for atrophic vaginitis, uterine prolapse, or a pelvic mass.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
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
Polyuria:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Urinary tract infection
❑ Diabetes mellitus
❑ Diuretic therapy
❑ Bladder outlet obstruction
❑ Nephrogenic diabetes insipidus
❑ Central diabetes insipidus
❑ Primary polydipsia
Diagnostic Approach
Polyuria is output of 3 L or more daily, and should be differentiated from urinary frequency and nocturia. Nocturia is most commonly due to drinking fluids before sleep, but is also associated with congestive heart failure, cirrhosis, nephrotic syndrome, chronic renal failure and diuretics. Mechanisms of polyuria include: loss of renal concentrating ability (parenchymal disease); decreased bladder capacity; solute diuresis of glucose (diabetes), urea (hypercatabolic states), mannitol, or radiocontrast; postobstructive and post-ATN nephropathy; and decreased responsiveness of the tubule to aldosterone with sodium diuresis (cystic renal disease, Bartter syndrome, or resolving ATN).
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Source: Field Guide to Bedside Diagnosis, 2007
Proteinuria:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Diabetes
❑ Drugs/toxins
❑ Acute tubular necrosis
❑ Glomerulonephritis
❑ Orthostatic
❑ Systemic lupus erythematosus
❑ Toxemia
❑ Polycystic kidneys
❑ Interstitial nephritis
❑ Renal vein thrombosis
❑ Multiple myeloma
❑ Amyloidosis
Diagnostic Approach
Proteinuria may present on urinalysis or as edema caused by reduced oncotic pressure from serum albumin loss. The dipstick detects albumin in concentrations of 30 mg/dL (Sensitivity 70%, Specificity 92%, Likelihood ratio 8.8), or 300 to 500 mg of proteinuria per day. False positives may be seen with dehydration and hematuria, both of which can be detected with the dipstick (specific gravity and hemoglobin). False negatives can occur when the protein is a low molecular weight tubular protein (not albumin), e.g., immunoglobulin light chains in myeloma or beta-2 microglobulin. In nephrotic syndrome more than 3.5 grams per day of proteinuria occurs.
Systemic disease should be suspected in the presence of fever, rash, or arthritis.
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Source: Field Guide to Bedside Diagnosis, 2007
Urinary Incontinence:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Cystitis
❑ Benign prostatic hypertrophy
❑ Pelvic floor relaxation
❑ Drugs
❑ Prostatitis
❑ Diabetes
❑ Cough
❑ Multiple sclerosis
❑ Spinal cord compression
❑ Decreased cortical inhibition
❑ Vesicovaginal fistula
Diagnostic Approach
On examination, test for stress-induced leakage with a full bladder, palpate for bladder distension after voiding, and check for post-void residual. Do a pelvic examination looking for pelvic floor laxity, atrophic vaginitis, urethritis, or pelvic mass, and a rectal examination for tone, fecal impaction, and prostate nodule. Check perineal sensation and neurosacral reflexes including volitional anal contraction, anal wink (anal contraction in response to a light scratch of the perineal skin), and bulbocavernosus reflex (anal contraction in response to a light squeeze of the penis or clitoris). An intact reflex arc but absent perineal sensation suggests a cord lesion or multiple sclerosis.
Urge incontinence: Due to detrusor overactivity. Urine loss is accompanied by a strong desire to void. Incontinence is preceded by a warning of seconds to minutes. Leakage is periodic but frequent, and nocturnal incontinence is common. Voluntary control of the anal sphincter is intact, and sacral sensation and reflexes are preserved. The post-void residual is low. It is usually a result of detrusor instability caused by stroke, Alzheimer dementia, brain tumor, Parkinson disease, bladder outlet obstruction, spinal cord lesion, or interstitial cystitis.
Reflex incontinence: Due to an excessive pressure response to bladder filling. Voiding occurs without stress or warning. Sacral reflexes are preserved, but voluntary sphincter control and perineal sensation are impaired. Post-void residual is increased. Usually caused by a spinal cord lesion, incontinence may be mimicked by cortical damage with decreased awareness of signals to void.
Stress incontinence: Due to failure of the sphincter to remain closed during bladder filling. Incontinence of small amounts of urine occurs with increased abdominal pressure (e.g., coughing, laughing, sneezing). Stress-induced detrusor instability is suggested by a 5 to 15 second delay between stress and leakage, and by nocturnal leakage.
Overflow incontinence: Due to impaired detrusor contractility and/or bladder outlet obstruction. There is frequent leakage of small amounts of urine, hesitancy, decreased flow, and incomplete emptying. The post-void residual is increased, and the bladder is palpable. Common mechanisms include bladder outlet obstruction caused by benign prostatic hypertrophy or urethral stricture; decreased detrusor tone due to a herniated disc; or peripheral neuropathy caused by diabetes, pernicious anemia, tabes, or cauda equina.
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Source: Field Guide to Bedside Diagnosis, 2007
Urinary tract infection, lower:
Diagnosis
(Handbook of Diseases)
Characteristic clinical features and a microscopic urinalysis showing red blood cells and white blood cells greater than 10/high-power field suggest lower UTI.
❑ A clean-catch, midstream urine specimen revealing a bacterial count of more than 100,000/ml confirms the diagnosis. Lower counts do not necessarily rule out infection, especially if the patient is voiding frequently, because bacteria require 30 to 45 minutes to reproduce in urine.
Careful midstream, clean-catch collection is preferred to catheterization, which can reinfect the bladder with urethral bacteria.
❑ Sensitivity testing determines the appropriate therapeutic antimicrobial agent.
❑ Voiding cystoureterography or excretory urography may detect congenital anomalies that predispose the patient to recurrent UTIs.
❑ If patient history and physical examination warrant, a blood test or a stained smear of the discharge rules out a sexually transmitted disease.
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Source: Handbook of Diseases, 2003
Bladder distention:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Ask the patient about voiding patterns, the time and amount of the last voiding, and the amount of fluid he consumed since the last voiding. Does he have a history of difficulty when urinating? Ask whether Valsalva’s maneuver or Credé’s maneuver is required to initiate urination. Does he experience an urgent need to urinate? Does the urge to urinate arise without warning? Is urination painful or irritating? Ask about the force and continuity of the urine stream and whether the bladder is empty after voiding.
Assess the patient’s history for the presence of a urinary tract obstruction or infections, venereal disease, lower abdominal or urinary tract trauma, systemic or neurologic disorders, and neurologic, intestinal, or pelvic surgery. Note medication history, including the use of over-the-counter or recreational drugs.
Physical examination
Take the patient’s vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can’t be palpated through the abdominal wall.) Inspect the urethral meatus. Document the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Bladder distention:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If distention isn’t severe, begin by reviewing the patient’s voiding patterns. Find out the time and amount of the patient’s last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva’s or Credé’s maneuver to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.
Explore the patient’s history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Note his drug history, including his use of over-the-counter drugs.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Dysuria:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient complains of dysuria, have him describe its severity and location. When did he first notice it? Did anything precipitate it? Does anything aggravate or alleviate it?
Next, ask about previous urinary or genital tract infections. Has the patient recently undergone an invasive procedure, such as cystoscopy or urethral dilatation, or had a urinary catheter placed? Also, ask if he has a history of intestinal disease. Ask the female patient about menstrual disorders and use of products that irritate the urinary tract, such as bubble bath salts, feminine deodorants, contraceptive gels, and perineal lotions. Also ask her about vaginal discharge and pruritus.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Nocturia:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Explore the history of the patient’s nocturia. When did it begin? How often does it occur? Can the patient identify a specific pattern or precipitating factors? Also, note the volume of urine voided. Ask the patient about any change in the color, odor, or consistency of his urine. Has the patient changed his usual pattern or volume of fluid intake? Next, explore associated symptoms. Ask about pain or burning on urination, difficulty initiating a urine stream, costovertebral angle (CVA) tenderness, and flank, upper abdominal, or suprapubic pain.
Determine if the patient or his family has a history of renal or urinary tract disorders or endocrine and metabolic diseases, particularly diabetes. Is the patient taking a drug that increases urine output, such as a diuretic, a cardiac glycoside, or an antihypertensive?
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Polyuria:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Explore the frequency and pattern of the polyuria. When did it begin? How long has it lasted? Was it precipitated by a certain event? Ask the patient to describe the pattern and amount of his daily fluid intake. Is the patient unusually tired or thirsty? Has he recently lost more than 5% of his body weight? Check for a history of visual deficits, headaches, or head trauma, which may precede diabetes insipidus. Also check for a history of urinary tract obstruction, diabetes mellitus, renal disorder, chronic hypokalemia or hypercalcemia, or psychiatric disorder (both past and present). Find out the schedule and dosage of any drugs the patient is taking.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urethral discharge:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient when he first noticed the discharge, and have him describe its color, consistency, and quantity. Does he experience pain or burning on urination? Does he have difficulty initiating a urine stream? Does he experience urinary frequency? Ask the patient about other associated signs and symptoms, such as fever, chills, and perineal fullness. Explore his history for prostate problems, sexually transmitted disease, or urinary tract infection. Ask the patient if he has had recent sexual contacts or a new sexual partner.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary incontinence:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If he is occasionally able to control urination, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he has ever sought treatment for incontinence or found a way to deal with it himself.
Obtain a medical history, especially noting urinary tract infection (UTI), prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies she has had and how many childbirths.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary frequency:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient how many times per day he voids. How does this compare to his previous pattern of voiding? Ask about the onset and duration of the abnormal frequency and about any associated urinary signs or symptoms, such as dysuria, urgency, incontinence, hematuria, discharge, or lower abdominal pain with urination.
Ask also about neurologic symptoms, such as muscle weakness, numbness, or tingling. Explore his medical history for UTI, other urologic problems or recent urologic procedures, and neurologic disorders. With a male patient, ask about a history of prostatic enlargement. If the patient is a female of childbearing age, ask whether she is or could be pregnant.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary hesitancy:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient when he first noticed hesitancy and if he has ever had the problem before. Ask about other urinary problems, especially reduced force or interruption of the urine stream. Ask if he has ever been treated for a prostate problem or UTI or obstruction. Obtain a drug history.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary urgency:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient about the onset of urinary urgency and whether he has ever experienced it before. Ask about other urologic symptoms, such as dysuria and cloudy urine. Also ask about neurologic symptoms such as paresthesia. Examine his medical history for recurrent or chronic UTIs or for surgery or procedures involving the urinary tract.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Dysuria:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Urinary Tract Infection (UTI)
UTI existswhen a significant number of bacteria are present in urine or whenthe urinary tract is infected with a virus. Infection can involveurethra, bladder, or renal parenchyma.E. coli is most common pathogen inall age groups. Other pathogens include gram-negative enteric bacteria(Klebsiella, Proteus, Pseudomonas, and Enterobacter species) andgram-positive bacteria (Enterococcus species, coagulase-negativeStaphylococcus, group B Streptococcus, S. aureus).Only virus likely to be encounteredas urinary tract pathogen is adenovirus, which causes acute hemorrhagiccystitis.Manifestations vary with age. In neonatesclinical features include fever or temperature instability, poorfeeding, decreased activity, and vomiting. Fever, vomiting, anddecreased weight gain may occur in infants. In children and adolescents,common findings include fever, dysuria, frequency, urgency, vomiting,abdominal pain, and flank pain. In all age groups urine may be cloudyand foul smelling.Pyuria and microscopic or gross hematuriamay be found. Positive urine culture is diagnostic. Urethritis
In girlsvulvovaginitis is a common cause of urethritis. See Chap. 71, Vaginal Discharge.Occasionally, dysuria occurs with labialadhesions, which are readily seen on physical exam. Proposed mechanismis pooling of urine behind adhesion and inadequate cleansing ofurethra.In boys urethritis occurs most commonlyin adolescents. N. gonorrhoeae and C. trachomatis are the most commonpathogens in this age group.Gonorrhea usually presents with creamyurethral discharge and dysuria 2–7 days after sexual contact.Gram-stained smear of discharge that shows gram-negative intracellulardiplococci is diagnostic, whereas positive culture of urethral dischargeis confirmatory.Infection with C. trachomatis may ormay not produce mild mucoid discharge, and dysuria is usually mild.Positive urine culture is diagnostic.When herpes simplex virus causes urethritis,vesicles are usually seen on genital exam. Cystitis
Infectionof bladder with bacteria is common in girls but infrequent in boys.Long male urethra and bactericidal prostatic secretions may be responsiblefor lower incidence in boys.Children with cystitis may have dysuria,urinary frequency, urgency, suprapubic tenderness, and occasionallyfever.If dysuria persists in sexually activeindividuals and urine bacterial culture is negative, urine shouldbe cultured for C. trachomatis.Adenovirus infection of bladder cancause severe dysuria and bloody urine (hemorrhagic cystitis). Usualurine culture for bacteria is sterile. Pyelonephritis
Childrenwith acute pyelonephritis do not have dysuria unless cystitis isalso present. They are usually more ill and have higher fever thanthose with urethritis or cystitis.Parenchymal infection should be suspectedin febrile child with flank pain and tenderness who may or may notbe toxic.Renal scintigraphy using technetium99m–dimercaptosuccinic acid can show renal cortical involvementin most cases. Chemical Irritation
Chemicalirritants, which include detergents, fabric softeners, perfumedsoaps, and bubble baths, are common causes of transient urethritis.History and physical exam are diagnostic. Diaper Dermatitis
Diaper dermatitiswith or without Candida infection can cause meatal inflammation withulcer formation in boys and urethral inflammation in girls.History and physical exam are diagnostic. Trauma
Any injuryto urethra (e.g., minor trauma, foreign body placed in urethra,or child abuse) can produce dysuria. Hematuria with or without bacteriuriaalso may occur.History and physical exam are oftendiagnostic.Urethrogram or cystogram may be necessaryif there is history of trauma and persistent hematuria. Pelvic radiographymay reveal radiopaque foreign body. Psychogenic
Dysuria may occur for psychologic reasonswithout any pathologic process involving genitourinary tract. Diagnostic Approach
History and physical exam are usually diagnosticof trauma, vulvovaginitis, labial adhesions, chemical irritation,and diaper dermatitis. Otherwise, suspect UTI and perform UA andurine culture. Urinalysis
Presenceof WBCs (>10/high-power field) in sediment ofcentrifuged specimen of urine suggests but is not diagnostic ofUTI. Neither is positive leukocyte esterase test (urine dipstick), whichindicates presence of WBCs in urine.Positive nitrite test using nitritestrip (Griess test) on urine dipstick is highly sensitive and specificfor detection of gram-negative bacteria (e.g., E. coli, Klebsiella,and Proteus species). Positive reaction usually indicates 105 CFUs/mL.False-positive reactions are uncommon if urine is fresh; however,if urine is not examined immediately, test result may be positivebecause of bacteria growing at room temperature. False-negativereactions may occur when there has been inadequate time for bacterialproliferation (random collection rather than first morning specimen)or when infection is due to Enterococcal species and some Staphylococcaland Pseudomonas species that do not convert nitrate to nitrite.Presence of ≥1 bacteria/oilimmersion field of unspun urine (unstained or Gram stain) from clean-catchmidstream specimen correlates with urine colony count of >105 CFUs/mL80–95% of the time. Urine Culture
Quantitative culture of properly collectedurine specimen establishes diagnosis of UTI, and susceptibilitytesting can be performed. Table15.1, based on data from many studies, is useful guidefor diagnosis of UTI. Table 15.1. Criteria for Diagnosis of Urinary Tract Infections
| Method of Collection | Colony Counta (Pure Culture) | Probability of Infection (%) |
| Suprapubic aspiration | Gram-negative bacilli: any number | >99 |
| Gram-positive cocci: > a few thousand | |
| Catheterization | >105 | 95 |
| 104–105 | Infection likely |
| 103–104 | Suspicious; repeat |
| <103 | Infection unlikely |
| Clean-voided (male) | >104 | Infection likely |
| Clean-voided (female) | 3 specimens: >105 | 95 |
| 2 specimens: >105 | 90 |
| 1 specimen: >105 | 80 |
| 5 × 104–105 | Suspicious; repeat |
| 104 to 5 × 104 | Symptomatic; suspicious; repeat |
| 104 to 5 ×104 | Asymptomatic; infection unlikely |
| <104 | Infection unlikely |
Radiologic Imaging
Differencesof opinion exist concerning usefulness of radiologic studies inevaluation of children with UTI. Studies are performed to searchfor anatomic abnormalities that may predispose to infection andalso to identify presence of vesicoureteral reflux.In our hospital when infant or childhas first UTI, initial studies include renal U/S in both girlsand boys followed by a radionuclide voiding cystourethrogram ingirls and contrast voiding cystourethrogram in boys.Use of renal cortical scintigraphyis controversial, but it can help diagnose acute pyelonephritisand identify renal scarring. >>
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Proteinuria:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Functional/Transient Proteinuria
Fever, exercise, extreme cold, cardiac failure,seizures, and emotional stress can cause transient proteinuria.Diagnosis is usually made by history, physical exam, and clinicalcourse. Proteinuria measured on dipstick is usually <2+. Postural Proteinuria (Orthostatic)
Occurs when patient is in upright position,not recumbent. Can be transient or persistent and is unusual before7 yrs of age. Long-term prognosis is benign. Nephrotic Syndrome
Characterizedby proteinuria, hypoproteinemia, edema, and hyperlipidemia.Congenital (Finnish type) form, whichis autosomal recessive, presents during first 3 mos of life. Mostcommon cause in children is minimal change disease, which most commonlyoccurs at 2–6 yrs of age. Other causes include focal glomerulosclerosis,mesangial proliferative glomerulonephritis, lupus nephritis, anddrug exposure (captopril, lithium, penicillamine, procainamide,NSAIDs).Initial episode of nephrotic syndromeas well as relapses often follow viral URIs. First sign of generalizededema may be ankle or eyelid edema, and pleural effusions and ascitesalso may occur. UA usually reveals +3 or +4 proteinuria.Although microscopic hematuria can occur, gross hematuria is unusual.Serum albumin is usually <2 g/dL, whereas serumcholesterol and triglycerides are increased. Renal function maybe normal or impaired.In children <6 yrs of age,in whom minimal change disease is most likely, corticosteroids canbe given as diagnostic and therapeutic trial. Lack of therapeuticresponse with persistence of proteinuria for >4–6wks is indication for renal biopsy. Tubulointerstitial Disease
Reflux Nephropathy
Occurs asconsequence of vesicoureteral reflux, which is abnormal retrogradeflow of urine from bladder into upper urinary tract.Proteinuria, hypertension, and chronicrenal insufficiency may occur. History of recurrent urinary tractinfection is frequent.Combination of renal U/S,voiding cystourethrography, and renal scintigraphy is commonly usedto evaluate reflux and its effects. Reflux may be graded from Ito V, with V being most severe.Diagnosis is usually clinical and radiologic. Tubulointerstitial Nephritis
Syndromewith inflammation and damage of tubular and interstitial structuresand relative sparing of glomerular and vascular structures.Common causes include infection (mostcommonly pyelonephritis and streptococcal infections), drugs (penicillins,sulfonamides, cephalosporins, phenytoin, thiazides, furosemide,allopurinol, amphotericin B, NSAIDs), and idiopathic.Clinical manifestations vary from mildazotemia to oliguric renal failure. Proteinuria may occur aloneor with hematuria (usually microscopic).Renal biopsy is necessary for definitivediagnosis, unless serum creatinine begins to decrease followingwithholding of suspected offending agents. Fanconi Syndrome
This autosomal-dominantdisorder whose gene locus has been mapped to chromosome 15q15.3is characterized byGeneralized dysfunction of proximal tubuletransport causing excessive urinary excretion of amino acids, glucose,phosphate, bicarbonate, and other solutesVitamin D–resistant metabolicbone disease (rickets in children) Clinical features include aminoaciduria,proteinuria, glycosuria, hypokalemia, hypophosphatemia, metabolicacidosis, rickets, and impaired growth.This syndrome also may be associatedwith cystinosis (most common), galactosemia, hereditary fructoseintolerance, tyrosinemia, Wilson disease, Lowe syndrome, lead poisoning,and drugs (aminoglycosides, cisplatin, valproic acid). Ischemic Tubular Injury
Acute tubularnecrosis usually occurs as result of prerenal failure or after severehypoxic insult.UA may be unremarkable or show low-gradeproteinuria and granular casts. There is inability to conserve sodiumand water.Renal U/S shows normal-sizedkidneys with loss of corticomedullary differentiation, and renalscintigraphy demonstrates decreased renal function. Benign Persistent Proteinuria
Persistentproteinuria without evidence for postural proteinuria or renal disease.Renal biopsy is normal or shows minimalnonspecific changes.This is a diagnosis of exclusion.Even though this is a benign disorder,follow-up is important because focal glomerulosclerosis may presentsimilarly. Diagnostic Approach
First stepin evaluation of a child with proteinuria is to determine if thereare any predisposing factors for transient or functional proteinuria(e.g., fever or strenuous exercise).If history is negative for these factorsand dipstick protein is persistently ≥1+, next step isto do complete UA and determine protein:creatinine ratio in a firstmorning spot urine specimen.If results of UA are normal and protein:creatinineratio is in normal range, diagnosis is postural proteinuria andno further studies are necessary.If results of UA are otherwise abnormalor first morning protein:creatinine ratio is above normal, furtherstudies are necessary. Serum electrolytes, creatinine, albumin,and cholesterol as well as blood urea nitrogen should be measured,and renal U/S should be performed. C3 and antinuclear antibody shouldbe considered.If diagnosis remains uncertain andno chemical or radiographic evidence of renal disease exists, renalbiopsy may be performed or child may tentatively be considered tohave benign persistent proteinuria. If renal biopsy is not performedor is normal, child should be monitored at 6-mo intervals for urinaryand chemical changes indicative of renal disease. >>>
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Urinary Incontinence:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Maturational Delay
Most commoncause of primary urinary incontinence is lag in maturation of normal inhibitingmechanism of urine control. There is often family history of incontinence.Many children may achieve daytime controlbut still experience incontinence during sleep.This is a diagnosis of exclusion inan otherwise normal child who has no evidence of organic disease,no history of stress-related or psychologic disturbance, and normalUA and urine culture.At 5–10 yrs of age, spontaneouscure rate of nocturnal enuresis is about 15%/yr. Stress-Related Causes
Stress is frequent cause of secondary incontinence.Examples of stress-related factors are illness, separation, birthof sibling, attending new school, death of family member, divorcein family, and other personal and family problems. Once problemis recognized, proper support and counseling usually help with itsresolution. Urinary Tract Disorders
Urinary Tract Infection
May causenighttime and daytime incontinence.Other common findings include fever,dysuria, urinary frequency, abdominal or flank pain, and vomiting.Positive urine culture confirms diagnosis(see Chap. 15, Dysuria). Dysfunctional Voiding Disorders
Voidingdysfunction occurs in many children who do not have known organiccause (e.g., neurologic disorder, injury, or malformation).Although some children have small-capacitybladder and experience urgency and often incontinence, others havehyperreflexic bladder with uninhibited detrusor contractions duringfilling. Still others have large hypotonic bladder that does notempty completely with voiding.Failure to empty bladder results inchronically distended bladder that is prone to urinary tract infectionand overflow incontinence.Urinary urodynamic testing is helpfulin determining abnormality in each case. Lower Urinary Tract Obstruction
Can producebladder distension and overflow incontinence. Poor urinary streamwith dribbling and excessive straining with urination are prominentfeatures.Specific causes include posterior urethralvalves, urethral duplication, or urethral cyst.Combination of tests including renalU/S, intravenous urography, and voiding cystourethrographyusually can confirm diagnosis. Retrograde urethrography is generallyrequired for adequate evaluation of urethral duplication. Ectopic Ureter in Girls
Ectopicureter may empty into bladder neck, urethra, vagina, or, rarely,uterus with continuous leakage of small amount of urine. Child hasnormal voiding habits but is frequently wet.Because of frequent occurrence of completeureteral duplication and associated renal parenchymal dysplasiain segment drained by ectopic ureter, renal U/S, intravenousurography, and voiding cystourethrography are useful in evaluation.If diagnosis remains uncertain afterthese studies, but ectopic ureter is still suspected, magnetic resonanceurography may be diagnostic. Cystoscopy can help identify ureteralorifice if it is in urethra, whereas vaginoscopy may be needed ifureter empties into vagina. Neurologic Disorders
Mental Retardation
Although children with mild mental retardationmay have voluntary control of urination, they may have incontinencefor behavioral reasons, while those with severe retardation usuallylack voluntary control of urination. Neurogenic Bladder
Lower extremityweakness, gait disturbance, fecal incontinence, decreased or absent perianalsensation, and lack of normal anal sphincter tone are common findingsin children with neurogenic bladder.Bladder size can be small, normal,or large, but usually it is small with thick wall.Evaluation of urinary tract may includerenal U/S, voiding cystourethrography, and urodynamic testing.Spinal dysraphism, a common cause ofneurogenic bladder in children, includes myelomeningocele, congenitaldermal sinus, diastematomyelia, and tethered cord syndrome.Myelomeningoceleand dermal sinus tract are visible on physical exam.Diastematomyelia is the splitting ofspinal cord at 1 or more vertebral levels, usually by bony or fibrousspur in spinal canal. The bone spicule may be detectable on spineradiography, but MRI is definitive imaging procedure.Tethering of spinal cord maintainsabnormally low position of cord and prevents its normal ascent.Lipoma, dermoid cyst, or dermal sinus tract are associated lesions,and MRI is diagnostic. Other causes of neurogenic bladderare sacral agenesis, spinal cord injury, and spinal cord tumors.Failure to palpate sacrum and coccyxsuggest sacral agenesis. Radiography of lumbosacral spine showsabsence of sacral segments.History of trauma exists with spinalcord injury.Tumors affecting spinal cord are discussedin Chap. 5, Back Pain. Abdominal or Pelvic Mass
Abdominal or pelvic mass (fecal impaction,mesenteric cyst, presacral teratoma) that impinges on bladder cancause urinary incontinence during running, laughing, coughing, orlifting. Abdominal or pelvic U/S is most useful screeningtest. Polyuria
Childrenwith diabetes mellitus may have incontinence, especially at night,if they have persistent hyperglycemia that is difficult to control.Other causes of polyuria are diabetes insipidus and psychogenicpolydipsia.Diabetes insipidus is associated withdefect in urine-concentrating ability. Random sample of urine withspecific gravity of >1.028 rules out concentration defect.Even specific gravity of >1.020 on random or early-morningurine sample is evidence of good concentrating ability and againstconcentrating defect.Children with persistent polyuria mayhave structural and functional changes in bladder, which contributeto voiding dysfunction.See Chap.47, Polyuria and Polydipsia. Primary Psychologic Disturbance
Urine incontinence occurs in some childrenwith primary psychologic problems (e.g., depression, a severe personalityor behavioral disorder, or psychosis). History, physical exam, clinicalobservation, and psychologic testing are diagnostic. Diagnostic Approach
Thoughtfullistening to parents and child usually reveals maturational, stress-related, orother psychologic factors that contribute to urinary incontinence.History, physical exam, UA (includingmeasurement of specific gravity), and urine culture screen for organicdisorders and are helpful in pinpointing the cause of urinary incontinence.Physical exam should include observation of any gait disturbance,exam of sacrum, and testing of perianal sensation, anal sphinctertone, and lower extremity strength, sensation, and reflexes.Abdominal U/S is useful forsuspected lower urinary tract obstruction, ectopic ureter, and abdominalor pelvic mass. Urinary urodynamic testing helps distinguish varioustypes of dysfunctional voiding disorders. CT and MRI are usefulin diagnosis of lesions that cause neurogenic bladder.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Polyuria and Polydipsia:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Diabetes Mellitus
By far,most common cause of polyuria and polydipsia in pediatric populationis diabetes mellitus.Most common form is insulin-dependentdiabetes mellitus (type 1), in which autoimmune destruction of betacells of pancreas causes diminished insulin secretion and hyperglycemia.Subsequent glucosuria produces osmotic diuresis with polyuria, polydipsia,and polyphagia.Second form is non–insulin-dependentdiabetes mellitus (type 2), which is characterized by insulin resistanceand usually relative insulin deficiency.Criteria for diagnosis of diabetesmellitus have been established by American Diabetes Association(1999) and include symptoms of diabetes mellitus plus plasma glucoseconcentration ≥200 mg/dL at any time of day regardlessof time of last meal or fasting plasma glucose concentration ≥126 mg/dL(fasting is defined as no caloric intake for ≥8 hrs). Diabetes Insipidus
2 formsof diabetes insipidus are antidiuretic hormone (ADH) deficiencyand ADH resistance.Primary clinical manifestations arepolyuria and polydipsia. Episodes of hypernatremic dehydration withhypotonic urine also may occur. Antidiuretic Hormone Deficiency (Central Diabetes Insipidus)
Kidney isunable to conserve water with ADH deficiency because of absenceor lack of release of ADH (arginine vasopressin).Genetic transmission of primary formis autosomal-dominant, and gene locus has been mapped to chromosome20p13.Secondary form includes lesions thatdamage neurohypophyseal system: head trauma, infection (meningitis,encephalitis), tumors (most commonly craniopharyngioma), Langerhanscell histiocytosis, and metastatic neoplasia (leukemia).Specific gravity of morning urine specimenshould be ≥1.018 in normal children without any overnight fluidintake. Presence of inappropriately dilute urine with hyperosmolarserum suggests ADH deficiency, and water deprivation test shouldbe performed under controlled supervised conditions.Inability to concentrate urine by waterdeprivation and resolution with administration of exogenous argininevasopressin confirm diagnosis. Antidiuretic Hormone Resistance (Nephrogenic Diabetes Insipidus)
The defectin this form of diabetes insipidus is inability of renal tubuleto respond to ADH.Primary form is usually due to X-linkeddisorder with defect in vasopressin receptor; however, autosomal-dominantand -recessive forms also occur.Secondary form is due to several disorders(renal dysplasia, medullary cystic disease, cystinosis, sickle celldisease, chronic renal failure, Fanconi syndrome, Bartter syndrome,hypercalcemia) and drugs (lithium, demeclocycline, methoxyflurane,amphotericin B, phenytoin) that produce renal concentrating defects. Primary Polydipsia
Is the excessiveingestion of water, when it is not needed to maintain fluid balance.Causes include compulsive water drinkingfor psychological reasons and frequent presentation of fluids toinfants. Another cause of primary polydipsia is hypothalamic damagethat affects thirst center but not ADH release.When overnight fluids are withheld,concentrated urine can be produced in the morning. Serum vasopressinlevels are low but increase to normal with fluid deprivation. Diagnostic Approach
Polyuriamust be distinguished from small volume urinary frequency, whichis common in pediatric practice. Children with polyuria often havenocturia and are unable to sleep through the night without wakingup to urinate. Most children with urinary frequency do not havepolyuria or a defect in urinary concentrating ability. Common causesof isolated urinary frequency are habit, attention-seeking behavior,and urinary tract infection.Random sample of urine with specificgravity of >1.028 and absence of polyuria rules out a concentrationdefect. Even urinary specific gravity of >1.020 on randomor early morning sample indicates sufficient urinary concentrationsuch that symptomatic diabetes insipidus is unlikely. Children whohave urine with a somewhat lower than normal specific gravity butwho can sleep through the night without passing urine do not needfurther evaluation.Presence of polyuria, dehydration,and high urinary specific gravity is evidence for osmotic diuresis,which is most commonly caused by diabetes mellitus. Dilute urineassociated with polyuria suggests diabetes insipidus or psychogenicpolydipsia. If blood glucose and urea nitrogen are normal, high serumosmolality with hyposmolar urine suggests ADH deficiency or resistance.Low serum osmolality with hyposmolar urine suggests primary polydipsia.With either ADH deficiency or resistance,urine specific gravity rarely exceeds 1.005 and urinary osmolalityrarely exceeds 200 mOsm/kg. Water deprivation test thatdemonstrates inability to concentrate urine indicates diabetes insipidusand distinguishes it from primary polydipsia. If urine remains hypotonicwith dehydration, next step is to determine response to exogenousvasopressin, which distinguishes ADH deficiency from resistance.With ADH deficiency, administration of vasopressin causes diminishingof symptoms and increase in urine specific gravity, whereas no responseoccurs with ADH resistance.With suspected renal disease, certaintests should be performed: CBC and differential; UA; urine culture;serum electrolytes, calcium, phosphorus, and creatinine; blood ureanitrogen; hemoglobin electrophoresis; and renal U/S. Othertests (e.g., determination of serum and urinary amino acids, voiding cystourethrography,and renal biopsy) may be necessary to define specific renal abnormality.Psychosocial history of emotional disturbance,including episodes of compulsive water drinking and formation ofconcentrated urine with fluid deprivation, are evidence for psychogenicpolydipsia. This disorder may sometimes be difficult to distinguishfrom hypothalamic thirst defect, and consultation with a pediatricendocrinologist is recommended.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Urine cloudiness:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask about symptoms of UTI, such as dysuria; urinary urgency or frequency; or pain in the flank, lower back, or suprapubic area. Also ask about recurrent UTIs or recent surgery or treatment involving the urinary tract. Obtain a complete drug history.
Obtain a urine specimen to check for pus or mucus. (See Performing the three-glass urine test, page 613.) Using a reagent strip, test for blood, glucose, and pH. Palpate the suprapubic area and flanks for tenderness.
If you note cloudy urine in a patient with an indwelling urinary catheter, especially with concurrent fever, remove the catheter immediately (or change it if the patient must have one in place).
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Bladder distention:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If distention isn't severe, begin by reviewing the patient's voiding patterns. Find out the time and amount of the patient's last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva's maneuver or Credé's method to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.
Explore the patient's history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Note his drug history, including his use of over-the-counter drugs and herbal medicines.
Take the patient's vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can't be palpated through the abdominal wall.) Inspect the urethral meatus, and measure its diameter. Describe the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Dysuria:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient complains of dysuria, have him describe its severity and location. When did he first notice it? Did anything precipitate it? Does anything aggravate or alleviate it?
Next, ask about previous urinary or genital tract infections. Has the patient recently undergone an invasive procedure, such as cystoscopy or urethral dilatation, or had a urinary catheter placed? Also ask if he has a history of intestinal disease. Ask the female patient about menstrual disorders and the use of products that irritate the urinary tract, such as bubble bath salts, feminine deodorants, contraceptive gels, or perineal lotions. Also ask her about vaginal discharge or pruritus.
During the physical examination, inspect the urethral meatus for discharge, irritation, or other abnormalities. A pelvic or rectal examination may be necessary.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Nocturia:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin by exploring the history of the patient's nocturia. When did it begin? How often does it occur? Can the patient identify a specific pattern or precipitating factors? Also, note the volume of urine voided. Ask the patient about changes in the color, odor, or consistency of his urine. Has the patient changed his usual pattern or volume of fluid intake? Next, explore associated symptoms. Ask about pain or burning on urination, difficulty initiating a urine stream, costovertebral angle (CVA) tenderness, and flank, upper abdominal, or suprapubic pain.
Determine if the patient or his family has a history of renal or urinary tract disorders or endocrine and metabolic diseases, particularly diabetes. is the patient taking a drug that increases urine output, such as a diuretic, a cardiac glycoside, or an antihypertensive?
Focus your physical examination on palpating and percussing the kidneys, CVA, and bladder. Carefully inspect the urinary meatus. Inspect a urine specimen for color, odor, and the presence of sediment.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Polyuria:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Because the patient with polyuria is at risk for developing hypovolemia, evaluate his fluid status first. Take his vital signs, noting an increased body temperature, tachycardia, and orthostatic hypotension (a 10 mm Hg decrease in systolic blood pressure upon standing and a 10 beats/minute increase in heart rate upon standing). Inspect for dry skin and mucous membranes, decreased skin turgor and elasticity, and reduced perspiration. Is the patient unusually tired or thirsty? Has he recently lost more than 5% of his body weight? If you detect these effects of hypovolemia, you'll need to infuse replacement fluids.
If the patient doesn't display signs of hypovolemia, explore the frequency and pattern of the polyuria. When did it begin? How long has it lasted? Was it precipitated by a certain event? Ask the patient to describe the pattern and amount of his daily fluid intake. Check for a history of visual deficits, headaches, or head trauma, which may precede diabetes insipidus. Also check for a history of urinary tract obstruction, diabetes mellitus, renal disorders, chronic hypokalemia or hypercalcemia, or psychiatric disorders (past and present). Find out the schedule and dosage of any drugs the patient is taking.
Perform a neurologic examination, noting especially any change in the patient's level of consciousness. Then palpate the bladder and inspect the urethral meatus. Obtain a urine specimen and check its specific gravity.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Urethral discharge:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when he first noticed the discharge, and have him describe its color, consistency, and quantity. Does he experience pain or burning on urination? Does he have difficulty initiating a urine stream? Does he experience urinary frequency? Ask the patient about other associated signs and symptoms, such as fever, chills, and perineal fullness. Explore his history for prostate problems, sexually transmitted disease, or urinary tract infection. Ask the patient if he has had recent sexual contacts or a new sexual partner. Obtain a complete drug history.
Inspect the patient's urethral meatus for inflammation and swelling. Using proper technique, obtain a culture specimen. (See Collecting a urethral discharge specimen.) Then obtain a urine specimen for urinalysis, culture, and possibly a three-glass urine specimen. (See Performing the three-glass urine test, page 613.) In the male patient, the prostate gland may have to be palpated.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Urinary incontinence:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If he can occasionally control urination, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he has ever sought treatment for incontinence or found a way to deal with it himself.
Obtain a medical history, especially noting urinary tract infection (UTI), prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies she has had and how many childbirths. A diary of voiding habits for a 24- to 48-hour period may provide useful information. Obtain a complete drug history.
After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious inflammation or anatomic defect. Have female patients bear down; note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Urinary frequency:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient how many times per day he voids. How does this compare with his previous pattern of voiding? Ask about the onset and duration of the abnormal frequency and about any associated urinary signs or symptoms, such as dysuria, urgency, incontinence, hematuria, discharge, or lower abdominal pain with urination.
Ask also about neurologic symptoms, such as muscle weakness, numbness, or tingling. Explore his medical history for urinary tract infection, other urologic problems or recent urologic procedures, and neurologic disorders. With a male patient, ask about a history of prostatic enlargement. If the patient is a female of childbearing age, ask whether she is or could be pregnant. Obtain a complete drug history.
Obtain a clean-catch midstream specimen for urinalysis and culture and sensitivity tests. Then palpate the patient's suprapubic area, abdomen, and flanks, noting any tenderness. Examine his urethral meatus for redness, discharge, or swelling. In a male patient, the physician may palpate the prostate gland.
If the patient's medical history reveals symptoms or a history of neurologic disorders, perform a neurologic examination.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Urinary hesitancy:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when he first noticed hesitancy and if he has ever had the problem before. Ask about other urinary problems, especially reduced force or interruption of the urine stream. Ask if he has ever been treated for a prostate problem or UTI or obstruction. Obtain a drug history.
Inspect the patient's urethral meatus for inflammation, discharge, and other abnormalities. Examine the anal sphincter and test sensation in the perineum. Obtain a clean-catch specimen for urinalysis and culture. In a male patient, the prostate gland requires palpation. A female patient requires a gynecologic examination.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Urinary urgency:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient about the onset of urinary urgency and whether he has ever experienced it before. Ask about other urologic symptoms, such as dysuria and cloudy urine. Also ask about neurologic symptoms, such as paresthesia. Examine his medical history for recurrent or chronic UTIs or for surgery or procedures involving the urinary tract. Obtain a complete drug history.
Obtain a clean-catch specimen for urinalysis and culture. Note urine character, color, and odor, and use a reagent strip to test for pH, glucose, and blood. Then palpate the suprapubic area and both flanks for distention and tenderness. If the patient's history or symptoms suggest neurologic dysfunction, perform a neurologic examination.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
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
NOCTURIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The workup of nocturia is essentially the same as the workup of
polyuria and urinary frequency . Obviously, the search for obstruction and infection are most
important. Venous pressure, circulation time, and pulmonary function studies to rule out congestive heart failure
should be done if the urinary tract is clean.
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Source: Differential Diagnosis in Primary Care, 2007
POLYURIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The diagnosis of polyuria depends largely on the association of other
symptoms. Polyuria, polyphagia, and polydipsia suggest diabetes mellitus and
hyperthyroidism. Polyuria with only polydipsia suggests psychogenic or
idiopathic diabetes insipidus; the Hickey–Hare test will differentiate the
two. Polyuria with polydipsia and weakness but with no significant weight
loss suggests hypercalcemia and possible hyperparathyroidism. Chronic
nephritis will be diagnosed by examination of the urine sediment and a
specific gravity that remains at 1.010. Nephrogenic diabetes insipidus can
be differentiated from neurogenic diabetes insipidus by the inability of the
kidney to respond to a pitressin injection.
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Source: Differential Diagnosis in Primary Care, 2007
PROTEINURIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The first step is to determine whether the proteinuria is caused by
infection. A urinalysis for WBCs and examination of a fresh drop of unspun
urine under the microscope for the bacteria are the fastest ways of
determining this. The urine can also be cultured. Next, determine if there
are red cells in the urine. This would indicate a more serious cause for the
proteinuria such as collagen disease, stone, glomerulonephritis, or neoplasm
and prompts the need for an IVP, cystoscopy, and urology consult.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
URETHRAL DISCHARGE:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The association of other symptoms and signs is helpful in narrowing the
list of possibilities. The discharge of acute urethritis is usually
associated with severe pain on micturation, whereas the discharge of prostatitis is often not. The discharge of
chronic prostatitis is usually painless and occurs most frequently on
arising. Urethral caruncles, papillomas, and carcinomas frequently have a
bloody discharge, at least intermittently. On examination, the physician can
detect induration of a urethral chancre, and the erythema of a balanitis is
obvious when the prepuce is retracted. The presence of arthritis or
conjunctivitis makes Reiter syndrome a distinct possibility, although
gonorrhea may do the same. The boggy prostate of prostatitis and the
increase of the discharge on massage will assist greatly in this diagnosis.
In the laboratory, a smear and culture are axiomatic in diagnosis, and one
must massage the prostate and milk the urethra if little discharge is found
on simple inspection. After massaging the prostate, the first portion of a
voided specimen should be examined, smeared, and cultured if no discharge is
apparent. Culture for Chlamydia if routine cultures are negative. Cystoscopy and
cystograms may be necessary, but the indications for these will be at the
discretion of the urologist, who should be consulted if routine treatment is
ineffective.
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Source: Differential Diagnosis in Primary Care, 2007
FREQUENCY AND URGENCY OF URINATION:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
This is no problem. Examine a drop of unspun urine under the
microscope. More than 1 or 2 motile bacteria per high-power field (HPF) is
diagnostic of UTI. Then culture the urine, catheterize for residual urine,
and do an IVP and voiding cystogram. A cystoscopy may be necessary. If these
are negative for abnormal findings, it is a good idea to collect a 24-hour
specimen; if the amount of urine exceeds 5 L, check the response to
pitressin. Special cultures for Chlamydia should be done if all else fails. The
workup of polyuria can
proceed further, if necessary.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
INCONTINENCE, URINARY:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
First, exclude stress incontinence with a pad test. Perineal pads are
weighed before and after walking and stress for 30 minutes. An increase in
weight identifies urine loss. Catheterization and examination, smear, and
culture of the urine are essential at the outset. Cystoscopy and cystometric
studies are often needed. Surgical repair of a cystocele or a
parasympathomimetic drug in cases of a flaccid neurogenic bladder and
propantheline bromide (ProBanthine), a parasympatholytic drug, for spastic
neurogenic bladders may be all that is necessary. A neurologist and
urologist often need to cooperate in the diagnosis and treatment of these
unfortunate individuals.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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