The First Lecture
Urinary Symptoms and Signs
The main renal functions are:
n Excretion of soluble waste products
n Regulation of the composition of the body fluids
n Production and secretion for several substances (renin, erythropoietin, cholecalciferol)
Symptoms
Pain
n Ureteral colic: flank pain, spasmodic, colicky, that often originates in the costovertebral angle and radiates around the trunk to the left inferior quadrant and the external genitalia on the same side; the patient is restless and there is no position for relieving it.
n Kidney pain in chronic kidney disease, due to gradual distension of the renal capsula; is dull, aching, and steady; it is felt near the costovertebral angle and may radiate anterior, to the umbilicus.
n Acute or chronic pain in the hypogastric area - due to bladder disorders; in bladder infection the pain is dull, steady, in sudden distension is with a very high intensity.
Edema
n Hypoalbuminemic ("nephrotic edema") - appears due to a decrease in the oncotic blood pressure. It is white, easy pitting, downy, with a normal temperature of the skin.
n Due to salt and water retention in chronic renal disorders; it is less pitting, with a gradual onset and with a muddy colour.
Micturition disorders
Frequent urination
n Polyuria: more than 1500 ml/day. The micturition are not very frequent, but with a very big amount of urine.
Can appear in physiological conditions (big amount of fluid intake, alcoholics, diuretics, tea, coffee) or in some pathological states (diabetes mellitus/ insipidus, chronic renal diseases).
Nocturia - refers to urinary frequency during nighttime
n Polakiuria means frequent urination, but with a low amount of urine.
It is always pathologic: prostatic enlargement, bladder stones/ cancer, urinary tract infection.
n Urinary incontinence means involuntary loss of urine.
Enuresis - by children after 5yr, during nighttime.
In neurological conditions such as stroke, spinal cord compression, dementia, multiple sclerosis, stress incontinence.
In anatomical abnormalities like the perineal rupture (e.g. after delivery).
n Dysuria denotes a difficult urination. Can be described like:
Hesitancy in starting the urinary stream-
Straining
It denotes a bladder neck obstruction: prostate enlargement, bladder stones, uterine fibroma, and gravid uterus.
n Pain during urination is in most cases like a burning sensation and appears in
Urethritis, cystitis, urethral obstruction
n Pain after urination is steady, in most of the cases in the hypogastrum. Appears sometimes in:
Bladder stones, cystitis, seminal vesiculitis
n Urinary urgency- it is an intense and immediate sensation to void
Urethritis, cystitis,
Urinary retention means urinary accumulation in the bladder because of the impossibility to evacuate it.
The bladder is usually painful because it is distended suddenly (acute retention of urine). It appears like a suprapubic mass, with the convexity superior, elastic and painful at deep palpation.
In chronic retention- the bladder distension is gradually, painless, only with sensation of hypogastric fullness.
n The most common causes are:
Urethral stricture/ stone
Prostate enlargement
Acute prostatitis
Paraplegia, myelitis
Anuria/ Oliguria mean a reduction/ cessation of the urinary output.
n Oliguria- 24 hr. urinary output is 50-500ml
n Anuria- 24 hr. urinary output is< 50
Acute renal failure: us. suddenly and unexpectedly
Chronic renal failure- a gradual decrease of the urinary flow, during years/ decades.
Discolored Urine
n Colorless
Low concentration, that can appear in very diluted urine
n Cloudy white
Phosphates in alkaline urine; the cloud disappears with acid addition.
Bacteriuria (pus- urinary tract infection)
Chyle in the urine (neoplasic disorders).
n Yellow
Highly concentrated normal urine
Pyrimidine, tetracycline ingestion
n
Urobilinogen in high concentration
Pyrimidine ingestion
n Blue Green
Methylene blue, Phenol, Indigo carmine ingestion
n Black/ Brown
Bilirubin in high concentration, with yellow froth;
Hematine (Hemoglobin in acid urine)
Methemoglobin
Melanin- malign melanoma, appears after exposure to sunlight
Porphyrin- appears after exposure to sunlight
Homogentisic acid
Red color of the urine can appear due to many compounds. It is very important to differentiate between hematuria and other causes that change in red the urine color.
Examples of substances that can change the color in red: rhubarb, aloes, blackberries, pyrimidine, phenophtalein, rifampicin ingestion, aniline dyes, blackberries
n Myoglobinuria- the excretion of Mb, from damaged muscle; it also color in red the urine.
Crush syndrome
Exercise myoglobinuria (McArdle disease)
Heroin addiction
Quail meat in some persons
Hemoglobinuria defines the presence of extracelular Hb in the urine. In can appear into:
Hemoglobin casts (brown masses, large cylindrical aggregates)
Intravascular hemolysis (blood transfusions, extensive burns, severe exercise, exposure to cold, paroxysmal nocturnal hemoglobinuria, malaria, typhus fever, bites of poisonous snakes, spiders)
Hemolysis in the bladder (urine very diluted)
Hematuria defines the presence of red blood cells in the urine. It can appear like:
n Gross hematuria (macroscopic hematuria) - when can be seen without microscope.
n Microscopic hematuria - when the erythrocytes can be detected only with the microscope.
n The three glasses test -can help to identify the site of bleeding. The patient is asked to urinate in three glasses; the doctor appreciate after that in which glass appear gross hematuria:
Initial hematuria (hematuria in the first glass) - site of hemorrhage is probably in the urethra.
Terminal hematuria (hematuria in the last glass) - the site of bleeding is from the trigon region of the bladder (the last region that is emptied).
Total hematuria (hematuria in three glasses) - the bleeding is most likely from the kidney; the proof -erythrocyte casts in the urine.
Causes ("the five t")
n Tumor
n Trauma
n Thrombocytopenia
n Infections
n Stones
Urine Chemistry
n Blood- us. not present
n Glucose- us. not present
n Ketone bodies- present in the urine of healthy individuals only during fasting; the presence in diabetic patients define severe metabolic imbalance.
n Protein- not present in normal urine above 150 mg/24 hr
n Bilirubin- not present in the normal urine; only conjugated BR can be excreted
n pH= 4.6 -8
n Concentration and dilution- normal between 1003 - 1030 (specific gravity)
isostenuria 1010
Urinary sediment can contain:
n
In acid urine: cystine, uric acid;
In alkaline urine: calcium phosphate, calcium oxalate;
n Cells: erythrocytes, leukocytes, epithelial cells (from the urinary tract);
n Bacteria
n Casts= cylindrical elements formed by protein clots, that traps any tubular contents within the matrix.
Hyaline - made only from proteins; are the only type that can appear in normal individual's urine.
Granular- made from proteins and few epithelial, degenerated cells;
Waxy- with lipoproteins and mucoproteins; in chronic renal failure;
Fatty - with lipids inside; are characteristic for nephrotic syndrome;
Pigmented - with hemoglobin/ myoglobin, bilirubin and appear when these compounds are present in the urine;
Cellular- casts that includes various types of cells: erythrocytes, leukocytes, epithelial cells.
Microorganisms
Paraclinic exploration methods
n Plain Rx
n I.V.Urography
n Echography
n Scintigraphic scan
n Doppler US for renal vessels
n
n MRI
n angio-MRI
The Palpation of the Kidneys
The patient is lying on a bed, while the examinator is placed on his/ her right side.
For the right kidney
The left hand is behind the patient, parallel with the 12-th rib, the fingertips in the costovertebral angle; the right hand is placed lateral and parallel to the rectus muscles; the left hand is pushing from posterior to anterior and in the same time the right hand is pushing down, from anterior to posterior, during a deep inspiration. The kidney will be felt between the two hands. A normal right kidney can be palpable.
For the left kidney
The maneuver is like for the right kidney, with the difference that the right hand is placed posterior and the left hand anterior. Usually a normal left kidney is not palpable.
In fat patients the maneuver is the same, with the exception that the patient is in lateral decubitus (so the abdominal fat will go down and the flank will be easily to palpate).
In children and very thin persons the maneuver can be done with only one hand (the 2-5 fingers on the posterior and the thumb will press from anterior the abdominal wall).
Enlarged kidneys:
ptosis
hydronephrosis
cysts
tumors
The urethral points are some areas where the urether is projected in the lumbar region or on the abdominal wall.
The costovertebral point is in the angle between the last rib and the vertebral column.
The costomuscular point is in the angle between the last rib and the lumbar muscles. The percussion with the medial aspect of the hand in this point (the Giordano maneuver) can provoke/ increase pain in kidney stones, pyelonephritis, and kidney abscess.
The superior anterior point is at the meeting point between the umbilical orizontal line and a vertical line through the 12-th ribs' tip.
The medium uretheral point is at the juncture between the external third of the bispinous line and the internal third.
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