--- module: 051-01 language: en chapter: 51 title: "Urinary Tract Disease, Obstruction, Stones, Continence, and Urological Assessment" module_title: "Foundations" source_sha256: dab7d86331b652dc3bbaf247d84f925bb282407ef21072a45257e4425398083a --- # Urinary tract disease: foundations ## Orientation ### Collecting systems to ureters to low-pressure reservoir ### Bladder contraction with outlet relaxation empties ### Disease impairs drainage, storage, voiding, continence ### Immediate priorities #### Infected obstruction, acute retention, anuria #### Severe bleeding, testicular emergencies #### Rapidly deteriorating renal function ## History and localisation ### Ureteric colic #### Peristalsis works against obstruction #### Fluctuating flank pain radiating to groin #### Restless movement, unlike peritoneal stillness ### Constant flank pain with fever: upper-tract infection #### Older or immune-suppressed may lack features ### Lower urinary symptom domains #### Storage: frequency, urgency, nocturia #### Voiding: hesitancy, weak stream, straining #### Post-void: incomplete emptying, after-dribble #### Quantify intake and volumes, not assume prostate ### Haematuria history #### Anticoagulation reveals bleeding, not sole cause #### Painless visible blood: assess for malignancy ### Medicines and retention #### Anticholinergics, opioids, sympathomimetics #### Diuretics and sedatives worsen incontinence ### Baseline renal function and solitary kidney ## Examination ### Observations, hydration, perfusion, sepsis ### Abdomen: masses, hernias, enlarged bladder ### Costovertebral tenderness supportive, not specific ### Genitalia with consent, privacy, chaperone ### Testicular pain #### Lie, swelling, cremasteric response #### Never delay surgical review for torsion ### Digital rectal examination #### Size correlates poorly with obstruction #### Normal examination does not exclude cancer #### No vigorous massage in acute prostatitis ### Neurological examination for cord or cauda equina ## Urinalysis and microbiology ### Dipstick findings need context #### Haem: red cells, haemoglobin, or myoglobin #### Nitrite needs nitrate reduction and dwell time #### Pyuria means inflammation, many causes ### Midstream or catheter port, not bag ### Culture in pregnancy, recurrence, complicated cases ### Asymptomatic bacteriuria usually untreated #### Treating colonisation causes harm and resistance ## Urinary tract infection ### Cystitis: dysuria, frequency, no systemic illness #### Vaginal symptoms suggest alternatives ### Pyelonephritis: fever, flank pain, bacteraemia ### Antibiotics by syndrome, severity, cultures ### Failure: obstruction, abscess, resistance, adherence ### Catheters bypass defence and form biofilm #### Diagnose from symptoms, not cloudy urine #### Prevention: avoid, asepsis, closed system, remove ## Obstruction and retention ### Raised upstream pressure #### Lower filtration and impaired concentration #### Infection and eventual atrophy ### Bilateral or solitary kidney: painless anuria ### Retention may be painless if chronic #### Measure post-void residual by ultrasound ### Difficult catheterisation needs experienced help #### Blind attempts create false passages ### Post-obstructive diuresis #### Retained salt and water, or impaired concentration #### Replace a considered proportion ## Urinary stones ### Supersaturation modified by volume, pH, inhibitors ### Imaging #### Non-contrast computed tomography highly sensitive #### Ultrasound avoids radiation in pregnancy ### Analgesia, antiemetics, correct deficit #### Forced fluid does not push the stone ### Infection plus obstruction is an emergency #### Antibiotics and stent or nephrostomy #### Definitive treatment after stabilisation ### Prevention by urine volume and cause #### Keep dietary calcium to limit oxalate uptake ## Haematuria and urological cancer ### Confirm, then seek glomerular features ### Clots suggest non-glomerular bleeding #### Clots can obstruct outflow ### Imaging and often cystoscopy by age and risk ### Bladder cancer linked to smoking, occupation ### Prostate-specific antigen is organ-specific ## Incontinence and neurogenic bladder ### Mechanisms #### Stress: abdominal pressure beats urethral closure #### Urgency, overflow, functional, often mixed ### Diary, residual volume, selective urodynamics ### Treat reversible contributors first ### Pelvic-floor training first-line for stress ### Antimuscarinics: dry mouth, confusion, retention ### Neurogenic: low-pressure storage protects kidneys