Renal Pain

Pain of renal origin is usually located in the ipsilateral costovertebral angle just lateral to the sacrospinalis muscle and beneath the 12th rib. Pain is usually caused by acute distention of the renal capsule, generally from inflammation or obstruction. The pain may radiate across the flank anteriorly toward the upper abdomen and umbilicus and may be referred to the testis or labium. A corollary to this observation is that renal or retroperitoneal disease should be considered in the differential diagnosis of any man who complains of testicular discomfort but has a normal scrotal examination. Pain due to inflammation is usually steady, whereas pain due to obstruction fluctuates in intensity. Thus the pain produced by ureteral obstruction is typically colicky in nature and intensifies with ureteral peristalsis, at which time the pressure in the renal pelvis rises as the ureter contracts in an attempt to force urine past the point of obstruction.

Pain of renal origin may be associated with gastrointestinal symptoms because of reflex stimulation of the celiac ganglion and because of the proximity of adjacent organs (liver, pancreas, duodenum, gallbladder, and colon). Thus renal pain may be confused with pain of intraperitoneal origin; it can usually be distinguished, however, by a careful history and physical examination. Pain that is due to a perforated duodenal ulcer or pancreatitis may radiate into the back, but the site of greatest pain and tenderness is in the epigastrium. Pain of intraperitoneal origin is seldom colicky, as with obstructive renal pain. Furthermore, pain of intraperitoneal origin frequently radiates into the shoulder because of irritation of the diaphragm and phrenic nerve; this does not occur with renal pain. Typically, patients with intraperitoneal pathology prefer to lie motionless to minimize pain, whereas patients with renal pain usually are more comfortable moving around and holding the flank.

Renal pain may also be confused with pain resulting from irritation of the costal nerves, most commonly T10-T12. Such pain has a similar distribution from the costovertebral angle across the flank toward the umbilicus. However, the pain is not colicky in nature. Furthermore, the intensity of radicular pain may be altered by changing position; this is not the case with renal pain.

Ureteral Pain

Ureteral pain is usually acute and secondary to obstruction. The pain results from acute distention of the ureter and by hyperperistalsis and spasm of the smooth muscle of the ureter as it attempts to relieve the obstruction, usually produced by a stone or blood clot. The site of ureteral obstruction can often be determined by the location of the referred pain. With obstruction of the midureter, pain on the right side is referred to the right lower quadrant of the abdomen (McBurney point) and thus may simulate appendicitis; pain on the left side is referred over the left lower quadrant and resembles diverticulitis. Also, the pain may be referred to the scrotum in the male or the labium in the female. Lower ureteral obstruction frequently produces symptoms of vesical irritability including frequency, urgency, and suprapubic discomfort that may radiate along the urethra in men to the tip of the penis. Often, by taking a careful history, the astute clinician can predict the location of the obstruction. Ureteral pathology that arises slowly or produces only mild obstruction rarely causes pain. Therefore ureteral tumors and stones that cause minimal obstruction are seldom painful.

Vesical Pain

Vesical pain is usually produced either by overdistention of the bladder as a result of acute urinary retention or by inflammation. Constant suprapubic pain that is unrelated to urinary retention is seldom of urologic origin. Furthermore, patients with slowly progressive urinary obstruction and bladder distention (e.g., diabetics with a flaccid neurogenic bladder) frequently have no pain at all despite residual urine volumes over 1L.

Inflammatory conditions of the bladder usually produce intermittent suprapubic discomfort. Thus the pain in conditions such as bacterial cystitis or interstitial cystitis is usually most severe when the bladder is full and is relieved at least partially by voiding. Patients with cystitis sometimes experience sharp, stabbing suprapubic pain at the end of micturition, and this is termed strangury. Furthermore, patients with cystitis frequently experience pain referred to the distal urethra that is associated with irritative voiding symptoms such as urinary frequency and dysuria.

Prostatic Pain

Prostatic pain is usually secondary to inflammation with secondary edema and distention of the prostatic capsule. Pain of prostatic origin is poorly localized, and the patient may complain of lower abdominal, inguinal, perineal, lumbosacral, penile, and/or rectal pain. Prostatic pain is frequently associated with irritative urinary symptoms such as frequency and dysuria, and, in severe cases, marked prostatic edema may produce acute urinary retention.

Penile Pain

Pain in the flaccid penis is usually secondary to inflammation in the bladder or urethra, with referred pain that is experienced maximally at the urethral meatus. Alternatively, penile pain may be produced by paraphimosis, a condition in which the uncircumcised penile foreskin is trapped behind the glans penis, resulting in venous obstruction and painful engorgement of the glans penis (see later). Pain in the erect penis is usually due to Peyronie disease or priapism (see later).

Testicular Pain

Scrotal pain may be either primary or referred. Primary pain arises from within the scrotum and is usually secondary to acute epididymitis or torsion of the testis or testicular appendices. Because of the edema and pain associated with both acute epididymitis and testicular torsion, it is frequently difficult to distinguish these two conditions. Alternatively, scrotal pain may result from inflammation of the scrotal wall itself. This may result from a simple infected hair follicle or sebaceous cyst, but it may also be secondary to Fournier gangrene, a severe, necrotizing infection arising in the scrotum that can rapidly progress and be fatal unless promptly recognized and treated.

Chronic scrotal pain is usually related to noninflammatory conditions such as a hydrocele or a varicocele, and the pain is generally characterized as a dull, heavy sensation that does not radiate. Because the testes arise embryologically in close proximity to the kidneys, pain arising in the kidneys or retroperitoneum may be referred to the testes. Similarly, the dull pain associated with an inguinal hernia may be referred to the scrotum.

Gross versus Microscopic Hematuria

The significance of gross versus microscopic hematuria is simply that the chances of identifying significant pathology increase with the degree of hematuria. Thus patients with gross hematuria usually have identifiable underlying pathology, whereas it is quite common for patients with minimal degrees of microscopic hematuria to have a negative urologic evaluation.

Timing of Hematuria

The timing of hematuria during urination frequently indicates the site of origin. Initial hematuria usually arises from the urethra; it occurs least commonly and is usually secondary to inflammation. Total hematuria is most common and indicates that the bleeding is most likely coming from the bladder or upper urinary tracts. Terminal hematuria occurs at the end of micturition and is usually secondary to inflammation in the area of the bladder neck or prostatic urethra. It occurs at the end of micturition as the bladder neck contracts, squeezing out the last amount of urine.

Association with Pain

Hematuria, although frightening, is usually not painful unless it is associated with inflammation or obstruction. Thus patients with cystitis and secondary hematuria may experience painful urinary irritative symptoms, but the pain is usually not worsened with passage of clots. More commonly, pain in association with hematuria usually results from upper urinary tract hematuria with obstruction of the ureters with clots. Passage of these clots may be associated with severe, colicky flank pain similar to that produced by a ureteral calculus, and this helps identify the source of the hematuria.

Presence of Clots

The presence of clots usually indicates a more significant degree of hematuria, and, accordingly, the probability of identifying significant urologic pathology increases.

Shape of Clots

Usually, if the patient is passing clots, they are amorphous and of bladder or prostatic urethral origin. However, the presence of vermiform (wormlike) clots, particularly if associated with flank pain, identifies the hematuria as coming from the upper urinary tract with formation of vermiform clots within the ureter.

It cannot be emphasized strongly enough that hematuria, particularly in the adult, should be regarded as a symptom of malignancy until proved otherwise and demands immediate urologic examination. In a patient who presents with gross hematuria, cystoscopy should be performed as soon as possible, because frequently the source of bleeding can be readily identified. Cystoscopy will determine whether the hematuria is coming from the urethra, bladder, or upper urinary tract. In patients with gross hematuria secondary to an upper tract source, it is easy to see the jet of red urine pulsing from the involved ureteral orifice.

Although inflammatory conditions may result in hematuria, all patients with hematuria, except perhaps young women with acute bacterial hemorrhagic cystitis, should undergo urologic evaluation. Older women and men who present with hematuria and irritative voiding symptoms may have cystitis secondary to infection arising in a necrotic bladder tumor or, more commonly, flat carcinoma in situ of the bladder. The most common cause of gross hematuria in a patient older than age 50 years is bladder cancer.

Irritative Symptoms

Frequency is one of the most common urologic symptoms. The normal adult voids five or six times per day, with a volume of approximately 300 mL with each void. Urinary frequency is due to either increased urinary output (polyuria) or decreased bladder capacity. If voiding is noted to occur in large amounts frequently, the patient has polyuria and should be evaluated for diabetes mellitus, diabetes insipidus, or excessive fluid ingestion. Causes of decreased bladder capacity include bladder outlet obstruction with decreased compliance, increased residual urine, and/or decreased functional capacity due to irritation, neurogenic bladder with increased sensitivity and decreased compliance, pressure from extrinsic sources, or anxiety. By separating irritative from obstructive symptoms, the astute clinician should be able to arrive at a proper differential diagnosis.

Nocturia is nocturnal frequency. Normally, adults arise no more than twice at night to void. As with frequency, nocturia may be secondary to increased urine output or decreased bladder capacity. Frequency during the day without nocturia is usually of psychogenic origin and related to anxiety. Nocturia without frequency may occur in the patient with congestive heart failure and peripheral edema in whom the intravascular volume and urine output increase when the patient is supine. Renal concentrating ability decreases with age; therefore urine production in the geriatric patient is increased at night, when renal blood flow is increased as a result of recumbency. In general, nocturia may be attributed to nocturnal polyuria (nocturnal urine overproduction) and/or diminished nocturnal bladder capacity (Weiss and Blaivas, 2000). Nocturia may also occur in people who drink large amounts of liquid in the evening, particularly caffeinated and alcoholic beverages, which have strong diuretic effects. In the absence of these factors, nocturia signifies a problem with bladder function secondary to urinary outlet obstruction and/or decreased bladder compliance.

Dysuria is painful urination that is usually caused by inflammation. This pain is usually not felt over the bladder but is commonly referred to the urethral meatus. Pain occurring at the start of urination may indicate urethral pathology, whereas pain occurring at the end of micturition (strangury) is usually of bladder origin. Dysuria is frequently accompanied by frequency and urgency.

Obstructive Symptoms

Decreased force of urination is usually secondary to bladder outlet obstruction and commonly results from benign prostatic hyperplasia (BPH) or a urethral stricture. In fact, except for severe degrees of obstruction, most patients are unaware of a change in the force and caliber of their urinary stream. These changes usually occur gradually and go generally unrecognized by most patients. The other obstructive symptoms noted later are more commonly recognized and are usually secondary to bladder outlet obstruction in men due to either BPH or a urethral stricture.

Urinary hesitancy refers to a delay in the start of micturition. Normally, urination begins within a second after relaxing the urinary sphincter, but it may be delayed in men with bladder outlet obstruction.

Intermittency refers to involuntary start-stopping of the urinary stream. It most commonly results from prostatic obstruction with intermittent occlusion of the urinary stream by the lateral prostatic lobes.

Postvoid dribbling refers to the terminal release of drops of urine at the end of micturition. This is secondary to a small amount of residual urine in either the bulbar or the prostatic urethra that is normally “milked back” into the bladder at the end of micturition (Stephenson and Farrar, 1977). In men with bladder outlet obstruction, this urine escapes into the bulbar urethra and leaks out at the end of micturition. Men will frequently attempt to avoid wetting their clothing by shaking the penis at the end of micturition. In fact, this is ineffective, and the problem is more readily solved by manual compression of the bulbar urethra in the perineum and blotting the urethral meatus with a tissue. Postvoid dribbling is often an early symptom of urethral obstruction related to BPH, but, in itself, seldom necessitates any further treatment.

Straining refers to the use of abdominal musculature to urinate. Normally, it is unnecessary for a man to perform a Valsalva maneuver except at the end of urination. Increased straining during micturition is a symptom of bladder outlet obstruction.

It is important for the urologist to distinguish irritative from obstructive lower urinary tract symptoms. This most frequently occurs in evaluating men with BPH. Although BPH is primarily obstructive, it produces changes in bladder compliance that result in increased irritative symptoms. In fact, men with BPH more commonly present with irritative than obstructive symptoms, and the most common presenting symptom is nocturia. The urologist must be careful not to attribute irritative symptoms to BPH unless there is documented evidence of obstruction. In general, lower urinary tract symptoms are nonspecific and may occur secondary to a wide variety of neurologic conditions, as well as to prostatic enlargement (Lepor and Machi, 1993). In this regard, two important examples are mentioned. Patients with high-grade flat carcinoma in situ of the bladder may present with urinary irritative symptoms. The urologist should be particularly aware of the diagnosis of carcinoma in situ in men who present with irritative symptoms, a history of cigarette smoking, and microscopic hematuria. In our personal experience, we cared for a 54-year-old man who presented with this history and was treated for BPH for 2 years before the diagnosis of bladder cancer was established. Once the correct diagnosis was made, the patient had developed muscle-invasive disease and required a cystectomy for cure.

The second important example is irritative symptoms resulting from neurologic disease such as cerebrovascular accidents, diabetes mellitus, and Parkinson disease. Most neurologic diseases encountered by the urologist are upper motor neuron in etiology and result in a loss of cortical inhibition of voiding with resultant decreased bladder compliance and irritative voiding symptoms. The urologist must be extremely careful to rule out underlying neurologic disease before performing surgery to relieve bladder outlet obstruction. Such surgery not only may fail to relieve the patient’s irritative symptoms but also may result in permanent urinary incontinence.

Since its introduction in 1992, the American Urological Association (AUA) symptom index has been widely used and validated as an important means of assessing men with lower urinary tract symptoms (Barry et al, 1992). The original AUA symptom score is based on the answers to seven questions concerning frequency, nocturia, weak urinary stream, hesitancy, intermittency, incomplete bladder emptying, and urgency. The International Prostate Symptom Score (I-PSS) includes these seven questions, as well as a global quality-of-life question (Table 3–1). The total symptom score ranges from 0 to 35 with scores of 0 to 7, 8 to 19, and 20 to 35 indicating mild, moderate, and severe lower urinary tract symptoms, respectively. The I-PSS is a helpful tool both in the clinical management of men with lower urinary tract symptoms and in research studies regarding the medical and surgical treatment of men with voiding dysfunction.

Table 3–1 International Prostate Symptom Score

The use of symptom indices has limitations, and it is important for the physician to discuss the patient’s responses with him. It has been demonstrated that a grade 6 reading level is necessary to understand the I-PSS, and some patients with neurologic disorders and dementia may also have difficulty completing the symptom score (MacDiarmid et al, 1998). In addition, the symptom score and obstructive and irritative voiding symptoms are nonspecific, and the symptoms may be caused by a variety of conditions other than BPH. Similar symptom scores have been demonstrated to be present in age-matched men and women between 55 and 79 years of age (Lepor and Machi, 1993). Despite these limitations, the I-PSS is a simple adjunct in assessing men with lower urinary tract symptoms and may be used in the initial evaluation of men with lower urinary tract symptoms, as well as in the assessment of treatment response.

Incontinence

Urinary incontinence is the involuntary loss of urine. A careful history of the incontinent patient will often determine the etiology. Urinary incontinence can be subdivided into four categories.

Enuresis

Enuresis refers to urinary incontinence that occurs during sleep. It occurs normally in children up to 3 years of age but persists in about 15% of children at age 5 and about 1% of children at age 15 (Forsythe and Redmond, 1974). Enuresis must be distinguished from continuous incontinence, which occurs in the day and night and which, in a young girl, usually indicates the presence of an ectopic ureter. All children older than age 6 years with enuresis should undergo a urologic evaluation, although the vast majority will be found to have no significant urologic abnormality.

Loss of Libido

Because androgens have a major influence on sexual desire, a decrease in libido may indicate androgen deficiency arising from either pituitary or testicular dysfunction. This can be evaluated directly by measurement of serum testosterone that, if abnormal, should be further evaluated by measurement of serum gonadotropins and prolactin. Because the amount of testosterone required to maintain libido is usually less than that required for full stimulation of the prostate and seminal vesicles, patients with hypogonadism may also note decreased or absent ejaculation. Conversely, if semen volume is normal, it is unlikely that endocrine factors are responsible for loss of libido. A decrease in libido may also result from depression and a variety of medical illnesses that affect general health and well-being.

Impotence

Impotence refers specifically to the inability to achieve and maintain an erection sufficient for intercourse. A careful history will often determine whether the problem is primarily psychogenic or organic. In men with psychogenic impotence, the condition frequently develops rather quickly secondary to a precipitating event such as marital stress or change or loss of a sexual partner. In men with organic impotence, the condition usually develops more insidiously and frequently can be linked to advancing age or other underlying risk factors.

In evaluating men with impotence, it is important to determine whether the problem exists in all situations. Many men who report impotence may not be able to have intercourse with one partner but will with another. Similarly, it is important to determine whether men are able to achieve normal erections with alternative forms of sexual stimulation (e.g., masturbation, erotic videos). Finally, the patient should be asked whether he ever notes nocturnal or early morning erections. In general, patients who are able to achieve adequate erections in some situations but not others have primarily psychogenic rather than organic impotence.

Failure to Ejaculate

An ejaculation may result from several causes: (1) androgen deficiency, (2) sympathetic denervation, (3) pharmacologic agents, and (4) bladder neck and prostatic surgery. Androgen deficiency results in decreased secretions from the prostate and seminal vesicles causing a reduction or loss of seminal volume. Sympathectomy or extensive retroperitoneal surgery, most notably retroperitoneal lymphadenectomy for testicular cancer, may interfere with autonomic innervation of the prostate and seminal vesicles, resulting in absence of smooth muscle contraction and absence of seminal emission at time of orgasm. Pharmacologic agents, particularly α-adrenergic antagonists, may interfere with bladder neck closure at time of orgasm and result in retrograde ejaculation. Similarly, previous bladder neck or prostatic urethral surgery, most commonly transurethral resection of the prostate, may interfere with bladder neck closure, resulting in retrograde ejaculation. Finally, retrograde ejaculation may develop spontaneously in diabetic men.

Patients who complain of absence of ejaculation should be questioned regarding loss of libido or other symptoms of androgen deficiency, present medications, diabetes, and previous surgery. A careful history will usually determine the cause of this problem.

Absence of Orgasm

Anorgasmia is usually psychogenic or caused by certain medications used to treat psychiatric diseases. Sometimes, however, anorgasmia may be due to decreased penile sensation owing to impaired pudendal nerve function. Most commonly, this occurs in diabetics with peripheral neuropathy. Men who experience anorgasmia in association with decreased penile sensation should undergo vibratory testing of the penis and further neurologic evaluation as indicated.

Premature Ejaculation

Men who complain of premature ejaculation should be questioned carefully because this is obviously a subjective symptom. It is common for men to ejaculate within 2 minutes after initiation of intercourse, and many men who complain of premature ejaculation in actuality have normal sexual function with abnormal sexual expectations. However, there are men with true premature ejaculation who reach orgasm within less than 1 minute after initiation of intercourse. This problem is almost always psychogenic and best treated by a clinical psychologist or psychiatrist who specializes in treatment of this problem and other psychologic aspects of male sexual dysfunction. With counseling and appropriate modifications in sexual technique, this problem can usually be overcome. Alternatively, treatment with serotonin reuptake inhibitors such as sertraline and fluoxetine has been demonstrated to be helpful in men with premature ejaculation (Murat Basar et al, 1999).