Diagnosis of Urinary stones
Diagnostic Test list for Urinary stones:
The list of medical tests
mentioned in various sources as
used in the diagnosis of Urinary stones
includes:
Urinary stones Diagnosis: Book Excerpts
Tests and diagnosis discussion for Urinary stones:
When you have a urinary problem, your doctor may use a cystoscope to
see the inside of your bladder and urethra. The urethra is the tube that
carries urine from the bladder to the outside of the body. The cystoscope
has lenses like a telescope or microscope. These lenses let the doctor
focus on the inner surfaces of the urinary tract. Some cystoscopes use
optical fibers (flexible glass fibers) that carry an image from the tip of
the instrument to a viewing piece at the other end. The cystoscope is as
thin as a pencil and has a light at the tip. Many cystoscopes have extra
tubes to guide other instruments for procedures to treat urinary problems (Source: excerpt from Cystoscopy and Ureteroscopy: NIDDK)
Diagnostic Tests for Urinary stones: Online Medical Books
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Review excerpts from medical books online, free, without registration,
for more information about diagnostis of Urinary stones.
DYSURIA:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there fever? A significant fever would suggest either pyelonephritis, particularly in females, or acute prostatitis in males.
- 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.
- 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.
- 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.
- 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
Dysuria:
Differential Diagnosis
(In a Page: Signs and Symptoms)
Lower urinary tract etiologies (male)
–Infectious cystitis: E. coli (#1 cause), Staphylococcus saprophyticus, Proteus, Klebsiella, Enterococcus
–Acute prostatitis
–Benign prostatic hypertrophy
–Epididymitis/urethritis: Chlamydia,
gonorrhea, E. coli, staphylococcus aureus
–External infections (e.g., herpes)
–Allergic reaction to contraceptives, soaps,
lotions
–Malignancy (urethral or bladder cancer)
–Urethral strictures Lower urinary tract etiologies (female)
–Infectious cystitis: E. coli (#1 cause), Staphylococcus saprophyticus, Proteus, Klebsiella, Enterococcus
–Acute urethritis: Chlamydia, gonorrhea
–Vaginitis: Candida, herpes
–Atrophic vaginitis
–Allergic reaction to contraceptives, soaps,
lotions
–Malignancy: Urethral cancer, bladder
cancer
–Urethral strictures
–Vaginitis (Trichomonas, bacterial vaginosis)
-
Upper urinary tract etiologies
–Pyelonephritis: Fever, chills, nausea, vomiting, and CVA tenderness
–Urolithiasis: Acute onset of dysuria with associated flank pain, with or without hematuria
Reiter's syndrome
–Genital ulcers, conjunctivitis, and arthritis
Noninfectious cystitis (e.g., drugs, radiation, granulomatous, allergic)
Behçet syndrome
–Oral and genital ulcers, arthritis, and uveitis
Trauma
Rectal fissure
Psychogenic (e.g., conversion disorder)
Workup and Diagnosis
-
History and physical examination
-
Male genital exam with gonorrhea/chlamydia test, culture, Gram stain
–Tender, boggy, swollen prostate suggests prostatitis
(avoid prostatic massage, because of risk of bacteremia)
–Tender epididymitis and testicles suggest infection
–Generally enlarged prostate associated with nocturia and
increasing frequency suggests BPH - Female genital exam with KOH prep, wet mount, Gram
stain, and DNA tests/culture as indicated
–Thin, papery vaginal tissue suggests atrophic vaginitis
–Candida discharge is thick, cheesy, and white; pruritic
–Chlamydia discharge is scant, watery and gradual onset
–Gonorrhea discharge is profuse, yellow-green with
abrupt onset, intracellular gram-negative diplococci
–Bacterial vaginosis discharge is pruritic, with clue cells on wet mount and a fishy odor with KOH (whiff test)
–Trichomonas discharge is frothy, grey-green, with pruritis and mobile organisms on wet mount
-
Urinalysis should be done in all patients
–Hematuria suggests urolithiasis, pyelonephritis, or cystitis; painless hematuria suggests bladder cancer
–Positive nitrites, leukocyte esterase, or WBCs with suprapubic tenderness suggests uncomplicated cystitis
-
Urine culture is indicated if positive urinalysis and in pregnant women, diabetic or immunocompromised patients, or males with urethral discharge
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Source: In a Page: Signs and Symptoms, 2004
Urinary Stream (Decreased):
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
Benign prostatic hyperplasia
-
–Most common cause of decreased urinary stream in men >40
Urethral stricture
–May be congenital or acquired
-
Chronic urethritis
–May be secondary to stricture or chronic infection
Prostate cancer
–More frequent in men >40
-
Neuropathic bladder
–Spinal cord trauma
–Herniated disc
–Multiple sclerosis
–Spina bifida
–CVA
–Parkinson's disease
–Nerve injury secondary to pelvic surgery
-
(e.g., prostatectomy)
-
Bladder neck contracture
–May be congenital or acquired
(e.g., post-prostatectomy)
Urethral or bladder foreign body
Bladder stones
Bladder neck cancer
Urethral cancer
Urethral polyp
Posterior urethral valves
–Frequently presents with recurrent UTIs
Workup and Diagnosis
-
History and physical examination, including abdomen, back, genitalia (palpate penis for areas of tenderness or induration), digital rectal examination, neurologic exam
–Note previous urinary tract instrumentation and STDs
–Exploration of urethra with catheter to check for obstruction and postvoid residual (normal <100 mL)
Initial labs include urinalysis (pyuria indicates secondary infection), urine culture and sensitivity, CBC (may reveal leukocytosis in infection, anemia in chronic disease), BUN/creatinine (elevated in acute renal failure, such as obstruction), and electrolytes
Consider PSA, which is elevated in prostate cancer and prostatitis; may be mildly elevated in BPH
Consider urine cytology and alkaline phosphatase (elevated in metastatic prostate cancer)
Uroflowmetry: Calculate urine flow rate during timed void (normal 20–25 mL/second; <10 indicates obstruction)
Consider renal ultrasound to rule out hydronephrosis and stones
Consider abdominal/pelvic CT scan to detect stones and workup cancer
Consider cystoscopy (to rule out cancer and anatomic problems), retrograde urethrography (to assess for strictures), voiding cystourethrogram (pressure/volume curves), transrectal ultrasound with needle biopsy (prostate CA), and/or intravenous pyelogram (stones and anatomic abnormalities)
>>
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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)
>
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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.
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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.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Urinary hesitancy:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient when he first noticed hesitancy and if he’s ever had the problem before. Ask about other urinary problems, especially reduced force or interruption of the urine stream. Ask if he’s ever been treated for a prostate problem or urinary tract infection or obstruction. Obtain a drug history.
Inspect the patient’s urethral meatus for inflammation, discharge, and other abnormalities. Examine the anal sphincter and test sensation in the perineum. Obtain a clean-catch sample for urinalysis and culture. In a male patient, the prostate gland requires palpation. A female patient requires a gynecologic examination.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Bladder distention:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If distention isn’t severe, begin by reviewing the patient’s voiding patterns. Find out the time and amount of the patient’s last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva’s or Credé’s maneuver to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.
Explore the patient’s history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Ask about his drug history, including his use of over-the-counter drugs.
Take the patient’s vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can’t be palpated through the abdominal wall.) Inspect the urethral meatus, and measure its diameter. Describe the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Dysuria:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient complains of dysuria, have him describe its severity and location. When did he first notice it? Did anything precipitate it? Does anything aggravate or alleviate it?
Next, ask about previous urinary or genital tract infections. Has the patient recently undergone an invasive procedure, such as cystoscopy or urethral dilatation, or had a urinary catheter inserted? Also, ask if he has a history of intestinal disease. Ask the female patient about menstrual disorders and use of products that irritate the urinary tract, such as bubble bath salts, feminine deodorants, contraceptive gels, or perineal lotions. Also ask her about vaginal discharge or pruritus.
During the physical examination, inspect the urethral meatus for discharge, irritation, or other abnormalities. A pelvic or rectal examination may be necessary.
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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
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
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
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
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
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
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.
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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.
» 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
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