David Thurtle and Suzanne Biers
The approach to a new urological patient should be structured and concise. This approach should include initial resuscitation if necessary, and an assessment of the urgency or severity of the patient’s condition. Thereafter, a basic urological history, examination and initial investigations will help in accurately diagnosing and treating the patient.
Any acutely unwell or unstable patient should undergo initial rapid assessment and resuscitation using the ABCDE principles prior to formal assessment and investigation of urological problems, which can continue once the patient’s condition is stable and safe. The full ABCDE approach, suggested by the Resuscitation Council, is available in Appendix 2 (pages 185–190).
Common urological emergency presentations include voiding difficulty or urinary retention, pain and bleeding. It is important to be able to recognise and relate symptoms to potential pathology. Obtaining a ‘baseline’ urological history will be useful in evaluating the current condition and will help direct long-term management.
Lower urinary tract symptoms (LUTS) may be acute or longstanding. It is important to determine a patient’s previous urinary tract function to contextualise their acute symptoms and obtain a diagnosis. LUTS are broadly categorised into storage and voiding symptoms (Table 1.1). Make a direct enquiry into these symptoms (see Box 1.1 for a comprehensive tick box to follow when assessing LUTS), establish the timeframe of symptoms and any recent change.
Table 1.1 The classification of lower urinary tract symptoms.
•Incomplete bladder emptying
•Intermittent or slow stream
•Altered urine colour or smell
•Daytime frequency: number of times passing urine during the day – has this changed?
•Nocturia: number of times the patient wakes at night to pass urine – has this changed?
•Hesitancy: difficulty in initiating the void, or straining to void?
•Flow: weak, strong, intermittent?
•Incomplete emptying: the sensation of not emptying the bladder completely.
•Double voiding: urinating twice in quick succession. May be a sign of incomplete bladder emptying especially if the second void volume is reasonable.
•Strangury: pain or spasm at the end or immediately after voiding.
•Urgency: unable to hold on to urine/a strong desire to go to the toilet, which is difficult to defer.
•Urgency incontinence: involuntary leak of urine if unable to reach the toilet in time (triggers can include cold weather, going from sitting to standing, key in the door lock).
•Stress urinary incontinence: urine leak with cough, sneeze or exertion.
•Dysuria: stinging or burning on passing urine.
•Haematuria: blood in the urine.
•Pneumaturia: air bubbles in the urine (specific enquiry if a patient reports recurrent UTIs and has a history of previous pelvic cancer, surgery or radiotherapy). Indicates a possible fistula between the bowel and bladder or, less commonly, infection with gas-producing bacteria.
An acute onset of storage symptoms such as urinary frequency and urgency are often caused by urinary tract infection. Be vigilant for ‘red flag’ symptoms that may indicate the presence of significant underlying pathology (see Box 1.2). Urinary incontinence is the involuntary leakage of urine. Most commonly it is reported as a chronic symptom; however, new-onset incontinence (day or night) can be related to an overflow incontinence associated with urinary retention and occasionally associated upper urinary tract obstruction and renal impairment. It is helpful to categorise the type of incontinence:
•Stress incontinence: leakage associated with raised intra-abdominal pressure such as cough.
•Urgency incontinence: associated with a strong desire to void that cannot be deferred.
•Mixed incontinence: a combination of stress and urge urinary incontinence.
•Continuous incontinence: can be caused by a urinary tract fistula such as a vesicovaginal fistula.
•Overflow incontinence: more common in men and occurs in those with chronic urinary retention.
•Nocturnal enuresis/incontinence: in males this is a significant symptom and should alert you to the possible diagnosis of high-pressure chronic retention.
Box 1.2 Red flag-type symptoms that should alert the clinician to a possible significant pathology.
•Visible painless haematuria.
•Back or bone pain.
•New-onset lower limb weakness.
•Unexplained weight loss.
•Palpable pelvic mass.
A large proportion of urological presentations will be with pain. The Site, Onset, Character, Radiation, Alleviating factors, Timing, Exacerbating factors and associated Symptoms are important to establish (SOCRATES). Both loin pain and scrotal pain will often be presumed to be of urological origin, hence the focus on these below. Remember the concept of referred pain, which is commonly misleading in urological conditions (Box 1.3).
Box 1.3 Referred pain.
Referred pain relates to a pain felt at a distant site from the place of development. The sensation of pain from urological organs is often referred due to the embryological origin of these organs:
•Kidney pain: radiates to the back or hypochondrium.
•Ureteric pain: varies more than renal pain, and can be felt in the back, towards the abdomen or groins and in the external genitalia.
•Bladder pain: can be felt suprapubically or deeper in the pelvis. Some men report bladder pain referred to the tip of the penis with retention or infection.
•Prostate pain: often described as lower back pain, perineal, scrotal or abdominal pain; it is also sometimes described as penile tip pain.
•Penile pain: may be referred from the bladder. Pain from the penis itself is usually well localised.
•Testicular pain: pain can be referred from the distal ureters to the testes; pain originating from the testes is often felt in the lower abdomen on the ipsilateral side. If the pain is referred from the ureter, the testes are typically not tender on palpation.
This phenomenon is partly why a genital examination should be performed on male patients presenting with lower abdominal pain, and an abdominal examination performed on those with testicular pain.
The most common causes of acute loin pain are ureteric colic and pyelonephritis, but the differential diagnosis is wide. Ureteric colic tends to come on within seconds or minutes, coming in waves of severe pain and the patient often reports being unable to get comfortable in any position. This colicky pain is often referred to the groin or the back, or down to the genitals. The location of the pain does not necessarily correlate with the location of the stone. Sensation to the ureters is from nerves derived from spinal cord segments between T12 and L2. The same dermatome is affected (T12–L2); therefore, pain can be experienced in the back, loins, scrotum or labia majora and anterior aspects of the upper thigh. Associated symptoms of urinary urgency, frequency and strangury or referred pain to the genitals can be suggestive of a calculus in the distal ureter within the bladder wall (intramural ureter). A list of differential diagnoses for loin pain is found in Chapter 2, page 29. By far the most important differential not to miss is a leaking abdominal aortic aneurysm.
Acute scrotal pain should raise suspicion of a testicular torsion, until proven otherwise (Chapter 4, page 69). Like any ischaemic pain, this is severe and continuous. Epididymo-orchitis tends to be a less severe, dragging pain of slower onset but the history should not be relied upon alone. It is important to establish the laterality and any previous similar history of pain. Some patients may have intermittent torsion, where the testis torts and spontaneously detorts. Do not be reassured by a history of scrotal trauma, as approximately 10% of those with torsion will report recent trauma. It is unclear whether scrotal trauma is a risk factor for torsion, or whether patients retrospectively attribute blame to an otherwise innocuous injury.
History of previous urological input or intervention
Past surgical history is always important to establish. Urological procedures in the past can suggest a propensity to a certain condition, such as a previous ureteroscopy in a recurrent stone former. Anyone undergoing instrumentation of the urethra or an endoscopic procedure will be at higher risk of urethral strictures. Ask patients whether they have ever had a previous catheter insertion, and whether it was inserted with any difficulty. Any recent urological instrumentation has an associated risk of urinary tract infection.
Past medical history
It is important to establish a patient’s general fitness, and to know about certain medical conditions, particularly any cause of renal impairment or propensity to disease, such as underlying malignancy, immune compromise or diabetes. A patient who has suffered from a urological condition in the past (such as stones, cystitis or epididymitis) will be at increased risk of suffering from the same disorder in the future.
Always establish early whether a patient has any allergies. A thorough medication history will help to establish a patient’s general health, clarify past medical history and provide vital information on potential interactions or contraindications to new medications. Some medications may be the cause of a patient’s urinary symptoms. Pay particular attention to medications known to cause nephrotoxicity (see Chapter 2, page 19, Box 2.2).
•A thorough ‘baseline’ urological history gives context to the acute presentation.
•Consider whether pain may be referred from a different site.
Unlike some specialties, it is harder to uncover many clues to the urological diagnosis from a general examination or examination of the peripheries. Nonetheless it is important to examine the patient generally and then focus more on the area of complaint. A chaperone should always be present when performing an intimate examination. It is good practice for the presence and name of a chaperone to be recorded in the medical notes.
Assess how unwell the patient is generally. Are they haemodynamically stable or are there any signs of systemic inflammatory response syndrome (SIRS) or sepsis (pages 12–15). Signs of cachexia, malnutrition, lethargy and pallor may be indicative of an underlying malignant process. Signs of fluid retention, altered skin pigmentation or excoriations may be suggestive of uraemia from renal failure. Gynaecomastia may be a sign of androgen deprivation therapy (used in prostate cancer) or oestrogen-producing testicular tumours (rare).
It is unusual for normal kidneys to be palpable. The kidneys should be examined by bimanual palpation, ‘ballotting’ the organ between both hands. The right is more commonly palpable as it is displaced inferiorly by the liver. A tender kidney should be obvious; percussion tenderness may also be present. Look at the skin over the flanks for any scars from previous open or percutaneous kidney operations, and any skin lesions that could be the cause of flank pain (such as shingles). Open nephrectomy may be performed via a ‘rooftop’ incision or a more lateral thoracolumbar incision. Laparoscopic port sites may be more difficult to see (see Figure 1.1 for further scars from urological surgery). Auscultation in the epigastrium for renal bruits, suggestive of renal artery stenosis, may be helpful. In trauma cases, look for patterns of bruising, other significant injuries and assess for rib fracture, which is associated with an increased risk of underlying renal trauma.
The empty bladder lies impalpable in the pelvis, posterior to the pubic symphysis. A palpable bladder is likely to have over 300ml of urine within it. The bladder may be tender in cystitis or acute retention. It is often easier to judge bladder size by percussion, with urine in the bladder dull to percussion, compared to gas-filled bowels.
A hand-held bladder scanner is a useful adjunct, though its accuracy can be variable. The most accurate assessment of bladder volume is a urinary catheter and drainage. The drained volume after catheter insertion should always be recorded in the medical notes.
Figure 1.1 Common urological scars and the potential operation for each.