University of Nigeria Virtual Library Serial No. AGUGUA, N.E.N - - PDF document

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Serial No. Author 1 AGUGUA, N.E.N Author 2 Author 3 Title

Presentation of Urinary Tract Disorders

Keywords Description

Presentation of Urinary Tract Disorders

Category Publisher Publication Date Signature

Ojionuka Arinze B.

Digitally signed by Ojionuka Arinze B. DN: CN = Ojionuka Arinze B., C = US, O = University of Nigeria, Nsukka, OU = Innovation Centre Reason: I have reviewed this document Date: 2007.02.18 20:16:15 -08'00'

CHAPTER 37 PRFSENTATION OF URINARY TRACT DISORDERS The history in urinarv tract disorders is usually h r l p f ~ ~ l

wlr~lt~ the physical examinat~on is oftcn not. Thc synipfonls arc tl!c*rcrr>re doubly importanl; first, to warn the patient somcthiog 15 ntriiss :irrtl second, t o guide the clinician towards the working diagnosis and inctdcntally the nccewry diagnostrc tests such as endoscopy, lalm-atory tests or radiography.

• 1. Pain

is one of the most important ?yn~ptonis in the Irrlnaty

• tract. By its very nature, thc second stage and occasionally tlic

final diagnosis ran he mads. A dull ache in the loin of'lc11 arising from a stretch of thc renal pelvis. renal cnpsulrn or pvri- nephr~c tissues, suggests cithcr renal parenchym:rl dise;~sc (tumour orbpyclo-nephritis) or a chronic drsorder of the pelvi- calyceal tree (tumour. hydronephrosis or stone). Rcnal colic, due to sudden obstruction of the ureter or renal pelvic;, may be due to a stone or blood clot. It is a severe nauseating pait1 either felt in the loin Ifrom the renal pelvis) or it radiates froin the loin to the groin, testis or labium major (from the ureter). Tile patient "rolls around" in agony and the pain 1s worsened by any sudden jerks or jolts. Most adult patients can diajinose the oppressive pain of acute hladder distention in urmary

• - --P
• retention. Strangury (an acute suprapubic pain radiating to the

urethra and into the perineum) suggests irr~tation

• f the urinary

bladdcr, In particular the trigone.

A child in strangury often

grasps the tip of the penis - a very useful sign indeed. Prrint~nl p,iln which 15 commonly an mtense burning pain in the perineum

IS su~gcstive

• f prostatic inflammatory disease.

Pclvlc pain

(hie to a rongestcd proslate is felt over the sacrum. Localinxl, burning pain

In thc urclhra, ddrinp micturition, sugpests urethritis from e~thcr gonorrhoea or non-specific infection.

2, Frequency of micturition

is the second impcvlant symptom. It may be pronouncrd during the day or night or at both times.

Whcn mechi~nical

in ori!:in (i.e. reduccd urinary blacldcr capacity? tlir causes ~ncludc:

w a) Pregnancy and other pelvic tumours comprcssion. producing external h) Inflanimatory filmsis with eithcr qhrinkage of the urinary I>latldcr wall or Inwrhrmg

• f the threshold of the bladdcr and

r~rethr,~l strctcli rcccptors arising from a stone, trigonitis, prostat~t~c

• r urt.tllrit~s.

C)

A Ir~mour

• r Inrgc calc~~lus
• ccupying space in the urinary

hladdcr.

• 1 he frcqr~cncy of rn~cturi

tion in prostatic enlargement (bcn~t'n

• l nisl~pn:~~lt)

may occur e~ther by thc distortion of the ctrcttli rcwptor\ of' the tr~gonc ;~nd bladder neck causing a

f a l w llrgc.ticy to rlrin;itc8 or bv rnrchanical obstrtlctjon wltli

~ncomplctt' crnptylng of thc urinary bladder. Thus difficulty lo \tctrt (lic$~t:rnc-v)

and difficulty to stop (tcnninal dribbling)

,1rcX common \ymplorns of benign prostatic hypertrophy.

3

llarmaitlria umlplctcc the triad of the main urinary tract \vrnptorn$ It IS ~rnportant to estahlrsh wliethcr it is uniform lincmatur~a

• r merc strt.akinp of the urinc with blood as this

#

dctcrminrs the ari;iton~ical levcl of the bleeding. Thus, a un~forrnly blood-stained urine indicates a bleeding point in the uplwr urinary tract (renal carcinoma. glonierulonephritis o r carcinoma). C'onsp~cuous blood a t the end of micturition (termi- nal h;~eni;~turta sugpcsts a calculus or bladder tumour. Ilowever,

: i calculus may hc associated with mirroscopic haematuria.

Many otlicr important symptorns may occur, though less

• conilnonly. Thcy includc:
• 4. Polyurr;~. whcrc thcre is a definitv increase in the rate of produc-

tion o f urinc ;IS In d~itlwtc~ ins~p~dus.

5 . In;~hility

to pass ~ ~ r i n c which must hc separated from anuria.

In anuria. tl~cr-c

is failure of the kidney to produce urine. lnahililv to pass urinc is often duc to b1;ldder outlet obstruction.

f~

For~l \nielling dirty urine uwally suggrsts an infection. Pnc11rn3turi;1 (gas in the urinc) occurs in a vcsico-colic fi.;tula

• t bcn~pn

(d~vcrt lcr~li~r discasc) or mal~gnant (carcinoma of colon

• r rccttlrn ) origin.

Su\t a ti.w hmic remark5 abo~lt thv d~agnostic tests in urology!

Presentation of Urinary Tmc t Discorders 23 1

.

They are essentially four:

.

I

I . Laboratory teats: The urological surgeon and the nephmlngifit

have unfortunately successfully disembercd thcss tsstr fc.r the

r

credit of neither. Thc urological surgeon is intoresteil prinrclrily in rcmediable structural abnormalities while the nephro10gi:it concentrates mainly on the functional disordcis of thc urinary

• tract. Thus the surgeon would request for:

a) Urinalysis: microscopy (red cclls, white cclls, casts, bacteria,

tumour cells). bacterial culture i,e. a qurtntitative hactt:riitl

• count. (>I O5 organismslml) sul:gests infection).

b) Blood tests (i) the blood urea provides an idea of [lie crude renal function. (ii) Serum acid phosphatase

(elevated in

prostatic carcinoma). (iii) Serum calcium (in suspected hyperpara- thyroidism). (iv) Serum creatinine clearance (providcs a precise test of renal function) etc.

#

• 2. Endoscopy:

Cysto-urethroscopy inspects the whole mucosal surface of the urinary bladder and urethra; it also allows the catheterization of the ureter to collect urine, confirm its patency and allows its injection with a contrast medium.

• 3. Radiography:

a) The single most important test in urinary disorders is intravenous urography (the traditional term "pyelography" is certainly an incomplete description). In this test, an intravenously injected iodine - containing contrast medium is rapidly cleared in a concentrated form by the normal

• kidneys. It outlines the renal calyces and pelves, the uretcrs,

and the urinary bladder. The rate of clearance of the contrast material (urografin, Hypaque etc.) is a test of renal

• function. The function of the two kidneys, ofttcn a cruc~al

decision before operation on the kidneys, can thus be com- pared. In addition, the volume of residual urine in Ihe bladder (a test of the ability of .the bladder to empty cow- pletcly) can be assessed in the post-voiding films taken m1lch later in the process of intrav(:, ous urngraphy (IV IJ). (-1~. 1-ly,

any proven allcrgy t o iodine iniposes extra care in doing the

.

IVLJ thcrchy avoiding morhid o r fatal complications. Kctrogratlc pyclography is the direct injection of contrast rncrlium inlo the ureters through a cat-heter introduced at cy5to-urettiroscopy. It provides a more illuminating picture than Lliv IV1J. Cliclst X-ruy:

A chest X-ray may rule out lung and rib nirtastasis fl-cv-n renal and prostatic carcinoma. Skeletal X-rays may he indicated in patients with bone pain o r proven c;rrcinoma ol' thc. prostlrte. h'onr Scan: uwa!ly picks up skoletal metastasis before the c o n v c ~ ~ t i o n ; ~ ? X-rays d o in proslatic carcinoma. l-lowever

arcs of' ;~hnoriilal

bone scan shoulcl be X-rayed for confirma- tion. (:vsto-ur.ctlrrogror~li~~ is the tlircct injection of contrast iiit.tliuni i n t o the urethra ;md urinary bl:itlder. It is a ~lseful tcst ill hladdrr outlet obstructions. The landmark of the prostatic ~lrethra is the vcrumontnnrlm. This area. on the

posterior wsii, rcccives the ostia of the prostatic ducts, the

common tjactlla1:ory ducts and the prostatic utricle. The prostatic uretlir:~ is reddened and congested in prostatitis. 'I'he median lobe of the prostate gland may be seen on cystoscopy t o causc obstructive uropathy whereas the prostatr gland may feel normal

• n rectal exaniina-

tion.

Ci~re-r~ro~rupl~y

rlsrlally studics, via an X-ray image-intensifier ;111tl

;I v~(Ieo-I;~pr

dcvicv, IIIC dyti;~niic events in the 1.1rinary l.ract such as :rltcrations in urinc flow ctc.

Kennl nrtc~riowrnphy gives direct inforniation of the renal

architecture by demonstrating the renal arteries and their

Imnches, avascu1::r (cysts) or vascular (neoplastic) lesions

• f thr. kii1nt:y.

Krnal Sc(rrtnir7x after IV in,jcction of a radio-isotope nucleidr

also provides direct inforniation about renal blood and urinary flow.

• 4. Riopsv is rssrntially diagnostic in neoplastic and other renal
• Icsions. The met hods applicable include:

;I)

Trans-rcct;ll o r trans-perincal biopsy of thc prostate by a fine riccdlc o r a tru-cut apparatus.

17) I-:ndoscopic biopsy of the urinary bladder and prostate.

. * . .

Pr~sentation qf Urinary Tract Discorders 233

e

c) Percutaneous nerdle biopsy in suspected widespread lesions

• f the kidney (dif'use glomerular or tubular lesions. clirotiic

pyelonephritis). The wise student would build on this preliminary s c i ~ f f ~ l t j

• t'

information noting:

1 , the indlcations and contrn-indications of the various diagnostic:

tests;

• 2. the various disturhances of micturation and the actiolopical

lesions, hacniaturia inclusive;

• 3. tlie urolog~cal

procedures a) ahlafwe: partial and unilateral nephrrctorny, nephro- urctercctoniy, bilateral ncphrectorny, partial and complete cystectomy

b) rrronstrurtiw. uretl~roplasty, uretcro-ilcostorny, tlcocysto- phsty, renal transplantation etc.), and c ) re1ic.f' of' ohstntction e . pro\tatectomy (tramvr~ical, retropuhlic, perineal, or transurethral) and uretero -

01

pyelohthotoniy ). The indlcations must bc clearly known. And for completion: "Sir (Madam) thls patient has palnlcss haematuria arting from the upper urinary tract as shown hy the uniform staining of tlie urinc etc., etc.

A malignant neoplasm of

the kidney is the most probable cause as shown by tlie presence of an irregular, hard, non-tender, fixed mass in the left loin. (2nd stage diagnosis). The certain diagnosis (based on the history. physical examination and diagnostic t a t , in particular biopsy)

i~ a renal cell carcinoma.

Finally, in anatomical trrrns, the upper urinary tract extends from the kidney t o the urctcro-vesical junctioll; the niid-tract extends from the urctcro-ves~cal junction t o the internal urina,

y

(bladder) mcatus and tlie lower urinary tract from the internal unnary meatus t o the external urinary mratlis.