Urology Problems
The
urinary tract includes the kidneys, ureters, bladder, (prostate), urethra, and
external genitalia. Symptoms perceived by patients reflect the embryological
origin as well as the current anatomy of these organs.
History
Any previous history of
urogenital problems, and a specific focus on:
• Colicky
pain: intense pain that
comes and goes suggests intermittent contraction of a hollow organ, e.g.
ureter. Patients with ureteric colic cannot find a comfortable position. Pain
may be referred to the genitals.
• Back
pain: the kidneys are
retroperitoneal.
• Ask
about urinary frequency, flow, blood or clots.
• Fever:
with chills and rigors
(shaking) suggests sepsis (Chapter 38).
• Dysuria:
burning pain when passing
urine implies urethral inflammation. Abnormal discharge from the genitals
suggests STI.
Examination
A patient with active renal colic
will move around, trying in vain to find a comfortable position; other causes
of intra-abdominal pain are usually alleviated by lying still. The abdomen
should be palpated for alternative causes of pain (e.g. abdominal aortic
aneurysm (AAA), cholecystitis) and the kidneys should be examined for
tenderness.
In a patient unable to void urine,
a palpable tender bladder that is dull to percussion suggests urinary
retention. The external genitalia should be examined if symptomatic, including
rectal examination if prostatitis is suspected.
Investigations
Bedside investigations
•
Ultrasound:
can rule out AAA.
•
Blood
glucose.
•
Swabs
from urethra/cervix if appropriate.
• Urine
dipstick testing is a rule-out test: if leucocytes, nitrites, blood and protein
are all negative, the urine does not need to be sent for culture, unless the
patient is immunosuppressed. If nitrites and leucocytes are negative, infection
is unlikely (-LR = 0.16), but if the
patient’s symptoms are very suggestive of UTI, the urine may be sent for
culture.
•
βhCG
•
Urine
microscopy – red cell casts imply glomerular bleeding, rather than bleeding
elsewhere in the urinary tract.
Laboratory investigations
•
FBC, U+E
•
LFTs,
amylase if abdominal pain.
Imaging
•
Ultrasound
is operator and body mass index dependent, can detect bladder size, ureteric
and renal pelvis dilatation resulting from obstruction but cannot reliably
detect stones.
•
CT KUB
(kidney, ureters, bladder) detects stones and other intra-abdominal pathology,
but involves significant radiation (300 CXR). MRI is an alternative that avoids
irradiation.
•
Contrast
radiography: intravenous urogram (IVU; 250 CXR) has been superseded by CT, but
X-ray KUB (75 CXR) can track radio-opaque stones.
Common diagnoses
Urinary tract infection/pyelonephritis
Females are more prone to UTIs
due to the short urethra. Drinking large quantities of water may help flush out
mild infection, but more serious infection needs treatment for 3 days with
antibiotics: trimethoprim or nitrofurantoin are common recommendations. Men
with UTIs and women with recurrent UTIs need antibiotics for 7 days and should
be reviewed in an outpatient clinic.
Pyelonephritis occurs when a UTI
ascends to the kidney(s). The patient is systemically unwell with fever,
loin/back pain, rigors, headache, nausea and vomiting. The kidney(s) are tender
on palpation. Emergency Department treatment includes antibiotics (e.g.
gentamicin), analgesia and intravenous fluids. Patients who respond to this may
be discharged with oral antibiotics (e.g. co-amoxycillin) and GP follow-up.
Urinary tract stones
Some patients, usually for
unknown reasons, form stones in their renal pelvis. If the stones pass into the
ureter, they cause intense colicky pain, ‘renal colic’ and microscopic
haematuria (90%).
NSAIDs, e.g. ketorolac i.v. or
diclofenac p.r., are rapidly effective at relaxing ureteric smooth muscle.
Morphine is useful for ongoing pain; pethidine (meperidine) should be avoided –
opiate- seeking should be suspected if it is requested.
CT confirms the diagnosis, and
informs treatment decisions. If there is a stone of less than 5 mm and the pain
has resolved, discharge patient on
regular NSAID or tamsulosin (an alpha blocking drug that also helps stones
pass) with outpatient clinic review.
Patients who are discharged
should be warned to return if they develop fever or further significant pain.
Otherwise, or if there is evidence of infection, urinary obstruction, renal
failure or single kidney, discuss with urology team.
Urinary retention
Urinary retention may occur due
to mechanical obstruction or neurological impairment, causing acute or chronic
retention that may cause renal damage. Ultrasound can confirm a large residual
volume of urine in the bladder after voiding.
Catheterisation should be
performed urgently to relieve obstruction and pain. If dipstick testing
indicates that the patient’s urine is likely to be infected, then
catheterisation should be covered by a single shot of gentamicin. If there are
blood clots in the bladder, a large irrigation catheter may be needed to flush
out the bladder.
If urinary retention occurs in a
patient with back pain, consider cauda equina compression (Chapter 17).
Constipation, e.g. from opiate analgesics, can cause urinary retention:
treating the constipation resolves the retention.
Sexually transmitted disease
Dysuria and/or discharge makes
STI more likely than torsion, but if there is any doubt, an ultrasound can
confirm normal testicular perfusion. Swabs should be taken and the patient
should be followed up in an STI clinic for contact tracing.
Diagnoses not to miss
Testicular torsion
Common in early adulthood, the
spermatic cord twists, causing testicular ischaemia. Torsion is diagnosed
clinically by a tender, high-riding testis: ultrasound may confirm the
diagnosis, but must not delay surgical exploration.
Infected obstructed kidney
The combination of urinary
obstruction and infection can rapidly destroy a kidney. Evidence of possible
infection should be sought in patients who have obstruction, e.g. stones, in
their urinary tract.
Prostatitis
UTIs are uncommon in men, and
prostatitis should be considered. The diagnosis is confirmed by a tender
prostate on rectal examination, after which urine is taken for culture.
Prolonged antibiotic treatment is necessary,
e.g. ciprofloxacin for 3 weeks.
