Basic Clinical Urology

3CHAPTER 2 UROLOGIC SYMPTOMSUrology (genito-urinary surgery) focuses on the surgical and medicaldiseases of the male and female urinary tract organs (kidneys, adrenals,ureters, urinary bladder, and urethra), and the male reproductive system(testes, epididymis, vas deferens, seminal vesicles, prostate and penis).The general classification of urologic symptoms is shown in figure 1.Complaints are reported in the patient own words e.g. I have passed someblood in my water; he or she wets the bed; he has difficulty duringurination and feeling as he cannot empty his bladder completely.You should always trust the patient. If the patient is quite certain that hehas a testicular swelling, and you are not able to feel it, proceed accordingto his complaint.Figure1. Classification of Urologic SymptomsUro-genitalUrological Pain Voiding disordersChanges in characters of urine Swelling Discharge/fistula Symptoms of chronic kidney diseaseMale genitalErectile dysfunctionEjaculatory disordersHematospermiaPeyronie's diseasePriapismInfertilitySystematic lMetastatic

4PAINPain within the genitourinary tract usually arises from obstructionor inflammation. Referred pain is common. Acute inflammation ofparenchyma produces severe pain and fever e.g. pyelonephritis, prostatitisand epididymo-orchitis. Tumors usually do not cause pain unless theyproduce obstruction or extend to adjacent nerves.1- Renal pain: Renal or flank pain is a visceral pain that results from obstruction ofurine flow with distension of the collecting system or the renalcapsule. Pain due to inflammation is dull, aching and steady. It is felt in the posterior renal (costo-vertebral) angle, below the lastrib and lateral to the sacrospinalis muscle (Figure 2). Pain may radiate anteriorly toward the umbilicus. It may be associated with gastrointestinal symptoms e.g. nausea andvomiting. Differential diagnosis:Radicular pain:- It results from irritation of costal nerves most commonly T10-T12.- Not colicky- It is felt in the renal angle and radiates towards the umbilicus.- The intensity is altered by changing the position.2- Ureteral colic: A ureteral stone is the most common cause leading to hyperperistalsis and ureteral colic. The most severe pain a human-kind can experience. Patients with ureteral colic are usually moving around in agony,and holding the flank (the rolling sign) while patients with intraperitoneal pathology prefer to lie motionless. Ureteral pain is colicky, intermittent, and occurring in waves. The site of maximum intensity varies with the site of obstruction. Ureteral colic is usually accompanied by renal pain due todistension of the renal pelvis.

5Figure 2. Renal pain is felt in theposterior costo-vertebral angle andradiates anteriorly towards theumbilicus (grey). Ureteral colicdistribution and referral is illustratedin black. The nerve supply of the upper ureter is by T 10; hence pain may bereferred to the umbilicus. Lower down pain is felt at progressivelylower levels. Pain is originating at the costo-vertebral angle and radiating aroundthe trunk into the lower quadrant of the abdomen, or possibly intothe anterior aspect of upper thigh and testicle or labium (figure 2). Pain in mid-ureter simulates appendicitis or diverticulitis. The lower ureter sends sensory nerves common with pelvic organs.Pain is felt as suprapubic discomfort with vesical irritability(urgency, frequency) and radiates along urethra to tip of penis. Often associated with restlessness, nausea, vomiting, sweating, andcollapse. Associated fever chills and hematuria may exist. Pain is aggravated by jogging movements such as car journeys.3- Bladder pain: Acute urine retention: The sudden inability to urinate inspite of thedesire to do so. Pain is severe, bursting, felt in the suprapubic area.The bladder is full and over-distended due to complete obstruction. Chronic retention is painless and dribbling is noted as overflowincontinence. Cystitis: Suprapubic burning pain is severe when the bladder is fulland is relieved partially by voiding. It is associated with frequencyand dysuria. Sharp stabbing suprapubic pain at the end ofmicturition is termed strangury. Constant suprapubic pain that is not related to acute retention isseldom of urologic origin.

6 Interstitial Cystitis or Bladder Pain Syndrome (IC/BPS):Interstitial Cystitis is currently not a scientifically accurate termbecause many patients have no interstitial pathology and nobladder inflammation. IC/BPS may be associated with urinaryurgency, frequency, and nocturia, and sterile urine culture. Thosewith IC/BPS may have symptoms that overlap with other urinarybladder disorders such as urinary tract infection and overactivebladder,4- Prostate pain: It is due to acute inflammation. Localized in the perineum and referred to lower back and rectum. Acute prostatitis is associated with fever, frequency, dysuria oracute retention and tenesmus.5- Penile pain: Pain in the flaccid penis is usually due to bladder or urethralinflammation or a stone. Paraphimosis: The uncircumcised foreskin is trapped behind theglans penis Priapism: Painful, persistent, purposeless penile erection6- Testicular pain: Primary pain is due to acute epididymo-orchitis, torsion of thetestis or trauma. In patients with testicular discomfort and a normal scrotalexamination, renal or retroperitoneal disease should be considered. Referred in renal or ureteric colic. Hydrocele, varicocele and testicular tumor may be associated withscrotal discomfort.7- Urethral pain: Burning or scalding during micturition is usually due toinflammation or a stone. Dysuria is pain or burning during micturition usually caused byinflammation.

7VOIDING FUNCTION AND DYSFUNCTIONNORMAL VOIDINGMicturition is urine disposal from the bladder to outside through theurethra. The process is voluntary in adults and depends upon learnedbehavior, while in infants it is an involuntary reflex. Micturition occurs ascoordination between the vesico-urethral unit and the nervous system.A) Filling or storage phase:During bladder filling the sympathetic tone predominates (T10 to L2through the hypogastric nerve). Alpha-receptors increase the muscle tonein the bladder outlet, while beta- receptors in the bladder body relax thedetrusor. Pudendal nerve (somatic S2-4) causes contraction of the striatedexternal urethral sphincter. The normal adult bladder can hold up to 500ml of urine. We become aware of the need to void at 150 ml. At 400 mlwe are seeking an appropriate toilet.B) Voiding or emptying phase:When the bladder is full stretch receptors are activated and signals aretransmitted to the sacral cord. The pelvic nerve (parasympathetic, S2-4)endings release acetylcholine and the detrusor contracts. Inhibitoryimpulses from the CNS to the sympathetic and pudendal nerves relax thebladder neck and external urethral sphincter to allow continuous,complete emptying of the bladder in a single setting. A strong warning isgiven to men not to hold urine in. As soon as you feel the need to go,excuse yourself from whatever you are doing and find a bathroom.The process of normal urination is defined as follows:A. Initiation:A human can start the act of urination even when the bladder is not full.Animals void only when the bladder is full. A human can postponevoiding of a full bladder until he can find a socially suitable place, go toit, adopt it and then start to pass urine.B. Maintenance:The normal urinary stream is continuous and free of pain, with adequateforce, form and caliber.C. Termination:A human can void all urine with no post-voiding residual.

8VOIDING DISORDERSDIFFICULTY(A) Difficulty in relation to voiding:1- Difficulty to start:Hesitancy: The need to wait before urine stream is voluntarilyinitiated.Urgency is defined by the ICS (International Continence Society) asthe complaint of a sudden compelling desire to pass urine which isdifficult to defer.Urge incontinence: A sudden severe urge to void with involuntaryloss of urine. It is caused by bladder muscle contraction.Overactive bladder (OAB) is a symptom complex, defined by the ICSas urgency, usually accompanied by frequency and nocturia, withor without urge incontinence, in the absence of infection or otherobvious pathology. Food and Drug Administration (FDA) definedOAB as "symptoms of urgency, urge urinary incontinence, andfrequency." The symptoms have a differential diagnosis includinginfection, stone, tumor and neurological disorders, which need tobe excluded. Urgency is the hallmark symptom of OAB.2- Difficulty to maintain: Stream abnormalities include:Intermittency: Involuntary stop and start of urine stream.Weak stream: Decreased force and caliber of stream.Bifurcation or spraying of streamStraining is the use of abdominal muscles to increase intra-abdominalpressure to urinate. Straining will help to void urine in case ofurethral stricture. However, in prostatic obstruction, theincreased intra-abdominal pressure will lead to more obstructionby occlusion of the posterior urethra.3- Difficulty to terminate:Sense of incomplete emptying: A feeling that the bladder is notcompletely emptied at the end of urination.Strangury: Incomplete emptying with sharp stabbing suprapubic pain.

9Post-voiding dribbling of urine: Release of drops of urine after completion of urination is due topooling of small amount of urine in the bulbar urethra (figure 3).Normally the last few drops of urine are expelled by contraction ofthe bulbo-cavernosus and bulbo-spongiosus muscles. Post-micturition dribble is fairly a common and benign symptom,and not closely related to outflow obstruction. Manual compression and evacuation of the bulbar urethra iseffective. Patient is advised to contract the sphincter muscles, andthen exert manual pressure on the perineum, immediately aftervoiding, to empty the bulbar urethra into the pendulous urethra fromwhich it will drain by gravity. Shaking the penis at end of micturition is ineffective. Management in the absence of other symptoms, normal flow rateand normal prostate feeling by DRE and PSA, is basicallyreassurance. It is an early symptom of BPH. A small amount of residual urine isnormally milked back into the bladder at the end of urinationwhereas in BPH, it escapes into the bulbar urethra and leaks out atthe end of micturition.Figure 3. Post-micturition dribbling is due to the pooling of smallamount of urine in the bulbar urethra (black).

11(B) Lower Urinary Tract Symptoms (LUTS): The term LUTS wasdeveloped to replace "prostatism" as a reminder that urinarysymptoms may have non-prostatic alternative causes, and to avoidtreating the prostate when the problem is elsewhere. Classification ofLUTS into irritative and obstructive group is shown in figure 4.Figure 4. Lower Urinary Tract SymptomsIrritative LUTSFrequencyUrgencyUrge incontinenceNocturiaObstructive LUTSHesitancyIntermittencyWeak prolonged streamStrainingIncomplete emptyingUrinary retentionOverflow incontinence(C) The American Urological Association symptom score (table 1)is widely used to assess men with LUTS. It includes sevenquestions. The total score ranges from 0 to 7, 8 to 19, and 20 to 35indicate mild, moderate and severe LUTS, respectively. TheInternational Prostate Symptom Score (I-PSS) is helpful in theclinical management of men with LUTS and in assessment oftreatment response. The international prostate symptom score(IPSS) gives a useful measure of both symptom severity anddegree of bothersomeness.Limitations of the AUA symptom score: Non-specific Patients with neurologic disorders and dementia may have difficultyin completion. Conditions other than BPH may have similar symptoms.

11 Similar scores were recorded in age-matched men and women over55 year.(D) LUTS in prostatic disorders: In uncomplicated BPH, LUTS are periodic and exaggerated by 5 Ws:Excess water, diuretics, caffeineWine: Alcohol causes excessive urine production.Cold weatherSexual excitement by women without reliefWithholdment of urination: Some people e.g. teachers and surgeons whodo not have time for regular bathroom breaks tend to hold urine. Thebladder can develop chronic overdistension leading to chronic emptyingproblems. An important item is the degree of bother that the symptoms cause. In prostate cancer most of cases are incidental, and when LUTSdevelop, they tend to be progressive.(E) The urologist must be careful not to attribute irritative symptoms toBPH unless there is documented evidence of obstruction.(F) Hematuria associated with irritative symptoms should direct theattention for the possible diagnosis of urothelial carcinoma in situ.(G) Another important example is irritative symptoms resulting fromneurologic disease, such as diabetes mellitus, cerebro-vascular accidents,and Parkinson's disease. The urologist should be careful to excludeneurologic disorders before performing surgery to relieve bladder outletobstruction. Surgery will fail to relieve irritative symptoms and mayresult in permanent incontinence.(H) Common causes of LUTS:Outflow obstruction: BPH, BNO, urethral stricture, meatal stenosis.Infection: Cystitis, prostatitis, urethral diveticulum.Impaired detrusor function: Neuromuscular dysfunction, detrusorinstability, impaired detrusor contractility.Neoplastic: Prostate cancer, bladder carcinoma in situ.Psychogenic

12Table 1. International Prostate Symptom Score (IPSS)Not at all1. Incomplete emptyingOver the past month, howoften have you had asensation of not emptyingyour bladder completely afteryou finished urinating?2. FrequencyOver the past month, howoften have you had to urinateagain less than two hours afteryou finished urinating?3. IntermittencyOver the past month, howoften have you found youstopped and started againseveral times when youurinated?4. UrgencyOver the past month, howoften have you found itdifficulttopostponeurination?5. Weak streamOver the past month, howoften have you had a weakurinary stream?6. StrainingOver the past month, howoften have you had to push orstrain to begin urination?7. NocturiaOver the past month, howmany times did you mosttypically get up to urinatefrom the time you went to bedat night until the time you gotup in the morning?Less than 1time in 5Less thanhalf thetimeAbout halfthe timeMore thanhalf the 45None1 Time2 time3 times4 times5 times uallysatisfied Anddissatisfied0123PatientscoreTotal IPSS ScoreQuality of life due to urinarysymptomsIf you were to spend the rest ofyour life with your urinarycondition just the way it is now,how would you feel about that?MostlyUnhappy Terribledissatisfied456

13FREQUENCYNormal adult voids 5-6 times per day and arises no more than twice atnight, with a volume of about 300 ml each.Frequency refers to increased number of times one feels the need tourinate. The patient passes frequent small amounts of urine.Causes include functional or organic decrease in bladder capacity: Inflammation: Edema and impaired elasticity Obstruction e.g. In BPH and urethral stricture, the high residual urinedecreases the effective functional bladder capacity. Stones Foreign body Tumors Neuropathic bladder Contracted bladder: Bilharziasis, TB, radiation, interstitial cystitis Pharmacological agents Psychogenic frequency: Anxiety ( no nocturia)- Frequency is expressed by finding out how often the patient pees by dayand by night, and can be easily written: D 5-6 / N 1-2, if the patienthas to void five to six times by day and once or twice at night.PolyuriaPolyuria is the passage of large volumes of urine with an increase inurinary frequency. It is accompanied with polydipsia (excessive thirst).Causes of polyuria: Endocrine: Diabetes mellitus, cranial diabetes insipidus, Cushings'syndrome, primary hyper-aldosteronism Renal: Chronic kidney disease, post-obstructive diuresis, nephrogenicdiabetes insipidus, early pyelonephritis Iatrogenic: Diuretics Alcohol Hypercalcemia Psychogenic: Compulsive water intake

14NocturiaNocturia is voiding during nocturnal sleep hours, preceded and followed bysleep. It is also defined by the ICS (International Continence Society) as thecomplaint of waking at night one or more times to void. Generally, nocturiamore than once is bothersome. Diagnosis is based on general medicalevaluation combined with voiding diary analysis (fluid intake and outputchart). This chart helps to avoid the misinterpretation betweenfrequency/nocturia and polyuria. The prevalence of nocturia in women(43%) is similar to that in men (37%). It is a little more common in youngerwomen and older men in whom causes other than BPH should be excluded.Causes of nocturiaSleepdisturbancesDiminishedbladder BehavioralFigure 5. Classification of Causes of NocturiaClassification of causes of nocturia (figure 5): Diminished bladder capacity: Causes of frequency. Nocturnal polyuria:- Peripheral edema (congestive heart failure, venous stasis, nephroticsyndrome, liver failure, hypo-albuminemia).- Renal concentrating ability decreases with advanced age.- The renal blood flow increases at night as a result of recumbency. Sleep disturbances: Obstructive sleep apnea Endocrine disorders: Diabetes mellitus, diabetes insipidus Behavioral: Excessive nighttime fluid intake especially coffee andalcoholics.

15Dysuria is painful micturition due to cystitis, urethritis, bladder stones ormalignancy.NOCTURNAL ENURESISBedwetting at night is physiologic during the first 3 years of life butbecomes troublesome to parents after that. It persists in 15% of childrenat age 5 and about 1% at age 15.a) Functional:It is secondary to delayed maturation of the vesico-urethralcomponents.b) Organic: Distal urethral stenosis in girls Posterior urethral valves in boys Infection Neuropathic bladderURINARY INCONTINENCEIncontinence: Neither men nor women

Medical history Surgical history History of trauma 29 29 40 41 Chapter 5 Family history 43 Chapter 6 Social history 44 Chapter 7 Systematic review 45 Chapter 8 Indirect urologic symptoms 46 Chapter 9