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).