Urinary Symptoms

 

• Dysuria

  Pain on urination (aka uralgia). It is an 'irritative' bladder symptom, along with urgency, frequency, and nocturia.

  Causes

  Infection:

  • UTI (usually cystitis), STI (usually urethritis).
  • Men: prostatitis, balanitis.
  • Women: vaginitis.

  Inflammation:

  • Atrophic vaginitis.
  • Interstitial cystitis (aka painful bladder syndrome).
  • Reiter's syndrome.
  • Drug-induced: cystitis (cyclophosphamide, allopurinol, danazol, ketamine) or urethritis (NSAIDs).

  Obstruction:

  • Stones in urethra or bladder.
  • Benign prostatic hyperplasia.

  Cancer:

  • Prostate
  • Bladder

• Urinary frequency

  Can be due to polyuria or frequent small amounts. Often accompanied by urinary urgency.

  Causes of frequent small amounts:

  • UTI
  • Overactive bladder.
  • Stress incontinence.
  • Kidney stones, especially in distal ureters where they irritate the bladder.
  • Reduction in bladder capacity from age, bladder cancer, prostate cancer, pregnancy, fibroids, or faecal impaction.
  • Neurogenic bladder, especially the spastic bladder of an upper motor neuron lesion.

• Polyuria

  >3 litres urine in 24hrs.

  Causes

  DICK PHD:

  • Diabetes mellitus or insipidus.
  • IV fluid excess.
  • ↑Ca2+
  • Kidney disease e.g. polyuric phase of AKI.
  • Psychogenic
  • Heart failure.
  • Diuretics, including drugs with diuretic side effects like alcohol and coffee.

• Oliguria

  Urine production <0.5 ml/kg/hour.

  Causes

  • Acute kidney injury (AKI).
  • Urinary obstruction.
  • Urinary retention.

• Urinary retention

  Incomplete bladder emptying. Can be chronic or acute, the latter involving a complete inability to urinate.

  Causes

  • Urinary obstruction: commonly prostate enlargement, genitourinary prolapse, urinary tract stones, or faecal impaction. In addition to the physical blockage, bladder overfilling in turn leads to distention and further dysfunction.
  • Inflammation: balanitis, prostatitis, vulvovaginitis, vaginal lichen planus.
  • Neurogenic bladder: peripheral lesions causing a flaccid bladder (e.g. cauda equina syndrome) or a central lesion causing detrusor-sphincter dyssynergia.
  • Drugs: anticholinergics, opioids, epidural, tricyclic antidepressants, sympathomimetics.
  • Painful retention in genital herpes.

  Signs and symptoms

  • ↓Urine output.
  • Suprapubic tenderness.
  • Can lead to hydronephrosis.

  Investigations

  • Urinalysis
  • Bloods: FBC, U&E, glucose.
  • US: bladder scan to check for post-void residual, and kidney scan for hydronephrosis.
  • Other imaging may be needed later e.g. CT (mass, stones), MRI (neurological).

  Management

  • Catheterise
  • Treat underlying cause.

• Urinary obstruction

  Symptoms

  • Difficulty passing urine: reduced flow, straining to void, hesitancy, dribbling. In severe cases, retention.
  • Paradoxically, can also lead to overflow incontinence and urgency.

  Causes

  These may cause compression or blockage at various points along the urinary tract.

  Intraluminal:

  • Stones
  • Clot
  • Foreign body.

  Intramural:

  • Tumour
  • Polyps
  • Urethral or ureteric stricture.
  • Neurogenic bladder.
  • Congenital urethral valves.
  • Pinhole meatus.

  Extramural:

  • These may compress the bladder neck, ureters, or urethra, causing obstruction, but some can also compress the bladder to cause frequency/incontinence.
  • Prostate: BPH, cancer.
  • Gynae: prolapse (cystocele, rectocele), ovarian cyst, fibroids, uterine cancer.
  • Faecal impaction.
  • Colorectal cancer.
  • Phimosis

  If the patient is catheterised always consider catheter blockage first, by flushing the catheter.

• Neurogenic bladder

  Neurological pathology can affect both detrusor and sphincter function.

  Causes and symptoms

  Peripheral (lower motor neuron):

  • Flaccid bladder (or detrusor areflexia) → retention ± overflow
  • Causes: diabetes, cauda equina and conus medullaris, slipped disc, HIV, Guillain Barré, alcohol, vitamin B12 deficiency, tabes dorsalis.

  CNS (upper motor neuron):

  • Brain lesions → spastic bladder (or detrusor hyperreflexia) → urge incontinence. In the initial shock phase post-stroke or CNS injury, there may be flaccidity and retention.
  • Causes: stroke, MS, cord lesion, MND, spina bifida, Parkinson's, tabes dorsalis.
  • Some spinal cord lesions cause both detrusor hyperreflexia and ↑sphincter tone (detrusor-sphincter dyssynergia), leading to urgency symptoms but difficulty emptying bladder fully.
  • Spinal cord damage at S2-4 may cause a flaccid bladder.

• Altered urine appearance

  • Cloudy: UTI (pus), non-pathological phosphate precipitation in alkaline urine.
  • Frothy: protein (nephrotic syndrome).
  • Pneumaturia (bubbles): UTI, enterovesical fistula (diverticulitis, Crohn's).
  • Haematuria: cancer, inflammation, or stones at any level e.g. UTI, kidney stones, glomerulonephritis.