COMMON URINARY

SYMPTOMYousaf Khan

Renal Dialysis LecturerIPMS, KMU

POLYURIA: Persistent large increase in urine output. Excessive or abnormally large production or passage

of urine (>3 L per day in adults).

Micturition: in which there is passage of small amount of urine with increased frequency.

Polyuria is due to free water excretion or due to excessive solute excretion.

CAUSESPhysiological Excessive intake of fluid Cold climate Anxiety Pro rich dietPathological Endocrine Renal Systemic Psychiatric Drugs Iatrogenic

EXCESSIVE SOLUTE EXCRETION Due to excretion of increased non absorbable

solutes(such as glucose) – SOLUTE DIURESIS Urine output > 3 L per day Urine osmolality > 300 msmol/L

Causes: Glycosuria is uncontrolled daibetes mellitus Mannitol administration High protein diet causing increase urea production and

excretion. Excessive sodium loss in cystic renal disease Renal tubular demage Bartter syndrome: excessive urinary potassium loss –

hypokalemia and hypotension.

FREE WATER EXCRETION Due to excretion of increased water(from a defect in

ADH production or renal responsiveness) – WATER DIURESIS

Urine output >3 L per day Urine is dilute (<250 mosmol/ L)

Causes – polydipsia Central diabetes insipidus ( central or nephrogenic).

INCREASE FREQUENCY OF MICTURITION Frequent passage of small volume of urine without

an increase in total volume

Causes: Renal : pyelonephritis Ureter : stone Bladder: cystitis and BPH Urethera: urethitis Gynecological: vaginitis and pregnancy Psychological: depression and tension

PROTEINURIA Normal urinary protein excretion should be < 150

mg/day. Abnormal proteinuria was defined as excretion of

protein > 150 mg/day. Heavy proteinuria > 1g/dl – indicate glomerular

origin Mild to moderate – tubular defect

CAUSES Primary renal disease Glomerulonephritis

Secondary Renal disease Systemic disease : diabetes, hypertension and

amyloidosis Drugs: captopril, penicillamine, heroin and NSAID Infection: Hepatitis B, infective endocarditis, malaria,

AIDS Allergy: Vaccine, bee sting

TYPE OF PROTEINURIAFunctional proteinuria: Stresses – no renal disorder, 1g/d. Causes: exercise, fever, severe hypertension, burns,

postoperative and acute alcohol abuse.

Orthostatic proteinuria: when a patient is standing but not when recumbent, benign

condition usually occurring below the age 30.

Isolated proteinuria: Defined as proteinuria without hematuria or reduction in

glomerular filtration rate (GRF) In most cases, patient is asymptomatic Urine sediment is unremarkable Causes: diabetes mellitus and amyloidosis

Overload proteinuria: From production of excessive amounts of filterable protein Such bence – jones protein in multiple myeloma, myoglobinuria in rhabdomyolysis.

Tubular proteinuria: From inability of damage tubule to reabsorb normally filtered

proteins. Causes: acute tubular necrosis, toxic injury, drug induced

interstitial nephrititis,

Microalbuminuria Normal < 30 microgram / per minute. Dipstick can detect – concentration is more than 100 mg/L. Albumin excretion > 20 microgram / min or 30 -300 mg/24. Indicator of diabetic nephropathy.

EVALUATION OF PATIENT WITH PROTEINURIA

24- hour urinary proteins > 3.5 g/24 h – nephrotic range

Measurement of urinary proteinUrine dipsticknegativetrace between 15-30mg/dl1+ 30-100 mg/dl2+ 100-300mg/dl3+ 300-1000mg/dl4+ >1000mg/dl

Albumin – creatinine ratio: Ratio b/w urinary protein concentration and urinary

creatinine concentration. 30 mg of albumin per gram of creatinine is

considered abnormal

Renal Biopsy: Proteinuria is associated with renal insufficiency

particularly if it is acute in onset.

MANAGEMENT Reducing proteinuria may also reduce progression of

renal disease Low protein diet Treatment of underlying cause.

HEMATURIA Causes: Renal causes may be glomerular or non glomerular in originGlomerular causes: IgA nephropathy Nephritic syndorm Post – streptococcal glomerulonephrititis Membranoproliferative glomerulonephrititis

Non – glomerular causes: Renal cyste Renal stone, interstitial nephritis Renal tumors

Extra – renal causes: Ureter: stone and papiloma Bladder: trauma, stone, hemorrhagic cystitis urethra; trauma infection, tumors and stone Blood disorderDrugs: Anticoagulants Analgesic abuse Cyclophosphomide antibiotics

GROSS HEMATURIA Non – glomeular in origin In the absence of infection gross hematuria from a

lower urinary tract is most commonly. Due to from transitional cell carcinoma of bladder. Blood in start of voiding comes from urethra Blood diffusely present through out the urine comes

from the bladder or above. Blood only at the end of micturition suggest

bleeding from prostate or bladder base

MICROSCOPIC HEMATURIA Glomerulonephritis Renal T.B Collagen disease e.g SLE Malignant hypertension Blood disorder Infective endocarditis Benign prostatichyperplasia

INVESTIGATION Urine analysis: protienuria and cast suggest renal in origin Urine culture and sensitivity, urine cytology, IVP,

ultrasound kidney, and ultra sound abdomen.

Condition which may mimic hematuria Hemoglobinuria: urine gives a positive chemical test for

hemoglobine, but no red cells are detectable.

Myoglobinuria: no red cell are seen but chemical tests for hemoglobin are positive. Myoglobin can bee distinguished by spectrometry.

Acute intermittent porphyria: fresh urine appears normal but on standing for some hours a dark red color develops.

URINARY RETENSION The inability to voluntarily void urine

CATEGORIES OF URINARY RETENTION Obstructive Infectious & Inflammatory Pharmacologic Neurologic Other

CAUSES OF URINARY RETENTIONOBSTRUCTIVE Benign prostatic hyperplasia Strictures Bladder calculi Faecal Impactation Phimosis Benign/malignant pelvic masses Organ prolapse Pelvic mass – gynae malignancy Uterine fibroid / ovarian cyst Foreign bodies

INFECTIOUS AND INFLAMMATORYCAUSES Prostatitis Prostatic abscess Cystitis Acute vaginitis Herpes simplex virus

PHARMACOLOGIC CAUSES Drugs with anticholingeric properties eg:

tricylic antidepressants (amitriptyline) Opioids NSAIDs in men Antiparkinsonian agents (levodopa) Antipsychotics (chlopromazine) Muscle relaxants (Baclofen)

NEUROLOGIC CAUSEAUTONOMIC OR PERIPHERAL NERVE Diabetes mellitus,BRAIN Tumour, Parkinson’s disease,SPINAL CORD Haematoma / abscess

OTHER CAUSES Post-op complications

Pregnancy-associated retention

Trauma eg: penile fracture or laceration

Idiopathic detrusor failure

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