Urinary symptoms

Haematuria

The presence of blood in the urine (haematuria) is always abnormal and may be the only indication of pathology in the urinary tract (Fig. 63.1). Tiny amounts of blood that are insufficient to stain the urine (microscopic haematuria) may be detected by dipstick testing as part of a routine health check. A substantial haemorrhage into the urinary tract will give the urine a red or brownish tinge (macroscopic haematuria) and the patient may pass blood clots. False positive stick tests and the discoloured urine caused by beetroot and certain drugs (e.g. dindevan, pynidium and furadantin) can be distinguished from haematuria by the absence of red blood cells on urinary microscopy.

Haematuria may be intermittent or persistent. Blood appearing at the beginning of the urinary stream indicates a lower urinary tract cause, while uniform staining throughout the stream points to a cause higher up. Terminal haematuria is typical of severe bladder irritation by stone or by infection. If the patient experiences pain with haematunia, the characteristics of the pain may help to identify the source of the bleeding. Commonly. there is no pain.

None of these variations in the presentation of haematuria is sufficient in itself to diagnose the cause of bleeding, and all patients with haematuria need investigation even if they are taking anticoagulant drugs. In a significant proportion, all tests will be negative: the chance of finding a urological cause in patients under 40 years of age who are found to have microscopic haematunia is particularly small. However, bleeding into the urinary tract may be caused by an occult nephropathy so it is important to check for hypertension in these patients.

Pain

Renal pain

Inflammation and acute obstruction to the flow of urine from the renal pelvis are liable to cause pain that is typically felt as a deep-seated, sickening ache in the loin. It is probably the result of stretching the capsule of the kidney. However, calculi in the kidney can also be painful in the absence of infection, although they may be too small or peripherally placed to cause obstruction. Slow-growing masses such as tumours or cysts are not usually painful unless they are very large. When the cause is inflammatory, there may be local deep tenderness and occasionally spasm of the psoas muscle.

Ureteric colic

This is an acute pain felt in the loin and radiating to the ipsilateral iliac fossa and genitalia. The patient often rolls around in agony as waves of excruciating sharp pain are imposed upon a continuing background of discomfort. Con­trast this with the patient suffering from penitoneal pain who lies still to avoid exacerbating the pain by movement.

Ureteric colic is caused by the passage of a foreign body, usually a stone. The site of the pain can be a guide to the progress of the stone: the more the pain radiates into the groin, the more distal the stone. Local tenderness is much less than would be expected from the severity of the pain.

Bladder pain

Bladder pain is felt as a suprapubic discomfort made worse by bladder filling. In men, a sharp pain misleadingly referred to the tip of the penis may be the result of irritation of the trigone of the bladder. Severe inflammation of the bladder can cause an extreme wrenching discomfort at the end of micturition. This symptom of bladder stone was recognised by the old lithotomists who called it strangury.

Prostatic and seminal vesicle pain

This is felt as a penetrating ache in the perineum and rectum. There may be associated discomfort in the groin. The patient is characteristically exasperated and depressed by pain that has a peculiarly relentless nature. Pelvic pain is often blamed on ‘chronic prostatitis’ but it occurs in both men and women and is notoriously difficult to treat successfully.

Urethral pain

Urethral pain is a scalding or burning felt in the vulva or penis especially during voiding.

Altered bladder function

The normal bladder has two distinct phases of function. During the filling phase the bladder acts as a reservoir to collect urine until it is emptied in the voiding phase. Inappropriate

contraction of the bladder detrusor muscle during filling (instability) is perceived as a sensation of urgency to pass urine. The patient may have frequency of micturition and a tendency to urge incontinence. Sleep may be disturbed by nocturia. Instability may be idiopathic in both sexes or part of the bladder response to outflow obstruction, notably in men with enlargement of the prostate. When detrusor instability has a demonstrable neurological cause, it is known as hyperreflexia.

Symptoms of impaired emptying are most commonly the result of bladder outflow obstruction, but detrusor failure or atony presents a similar picture. The patient has difficulty initiating voiding (hesitancy) and the stream is variable or slow. Abdominal straining improves the weak flow. When the act of micturition is completed there may be a feeling that urine remains in the bladder so the patient tries again (.pis-en­deux). With time, the bladder becomes chronically overfilled and is unable to act as an effective reservoir. Urine spills out, typically at night when sleep halts constant trips to the lavatory (chronic retention with overflow).