The Urinary Tract

General questions for a urinary history include: "Do you have any difficulty passing your urine?" "How often do you go?" "Do you have to get up at night? How often?" "How much urine do you pass at a time?" "Is there any pain or burning?" "Do you ever have trouble getting to the toilet in time?" "Do you ever leak any urine? Or wet yourself involuntarily?" Does the patient sense when the bladder is full and when voiding occurs?

Ask women if sudden coughing, sneezing, or laughing makes them lose urine. Roughly half of young women report this experience even before bearing children. Occasional leakage is not necessarily significant. Ask older men "Do you have trouble starting your stream?" "Do you have to stand close to the toilet to void?" "Is there a change in the force or size of your stream, or straining to void?" "Do you hesitate or stop in the middle of voiding?" "Is there dribbling when you're through?"

What color is the urine? Has it ever been reddish or brown?

Disorders in the urinary tract may cause pain in either the abdomen or the back. Bladder disorders may cause suprapubic pain. In bladder infection, pain in the lower abdomen is typically dull and pressurelike. In sudden overdistention of the bladder, pain is often agonizing; in contrast, chronic bladder distention is usually painless.

Infection or irritation of either the bladder or urethra often provokes several symptoms. Frequently there is pain on urination, usually felt as a burning sensation. Some clinicians refer to this as dysuria, while others reserve the term dysuria for difficulty voiding. Women may report internal urethral discomfort, sometimes described as a pressure, or an external burning from the flow of urine across irritated or inflamed labia. Men typically feel a burning sensation proximal to the glans penis. In contrast, prostatic pain is felt in the perineum and occasionally in the rectum.

Commonly, there are other associated symptoms. Urinary urgency is an unusually intense and immediate desire to void, sometimes leading to involuntary voiding or urge incontinence. Urinary frequency, or abnormally frequent voiding, may occur. Ask about any related fever or chills, blood in the urine, or any pain in the abdomen, flank, or back (see the next page). Men with partial obstruction to urinary outflow often report hesitancy in starting the urine stream, straining to void, reduced caliber and force of the urinary stream, or dribbling as voiding is completed.

Three additional terms describe important alterations in the pattern of urination. Polyuria refers to a significant increase in 24-hour urine volume,

See Table 9-6, Frequency, Nocturia, and Polyuria (p. 357).

Involuntary voiding or lack of awareness suggests cognitive or neurosensory deficits.

Stress incontinence from decreased intraurethral pressure (see below)

Common in men with partial bladder outlet obstruction from benign prostatic hyperplasia; also seen with urethral stricture

Hematuria, or blood in the urine

Pain of sudden overdistention in acute urinary retention

Painful urination with cystitis or urethritis

Also consider bladder stones, foreign bodies, tumors; also acute prostatitis. In women, internal burning in urethritis, external burning in vulvovaginitis

Urgency in bladder infection or irritation. In men, painful urination without frequency or urgency suggests urethritis.

Abnormally high renal production of urine in polyuria. Frequency roughly defined as exceeding 3 liters. It should be distinguished from urinary frequency, which can involve voiding in high amounts, seen in polyuria, or in small amounts, as in infection. Nocturia refers to urinary frequency at night, sometimes defined as awakening the patient more than once; urine volumes may be large or small. Clarify any change in nocturnal voiding patterns and the number of trips to the bathroom.

Up to 30% of older patients are concerned about urinary incontinence, an involuntary loss of urine that may become socially embarrassing or cause problems with hygiene. If the patient reports incontinence, ask when it happens and how often. Find out if the patient has leaking of small amounts of urine with increased intra-abdominal pressure from coughing, sneezing, laughing, or lifting. Or is it difficult for the patient to hold the urine once there is an urge to void, and loss of large amounts of urine? Is there a sensation of bladder fullness, frequent leakage or voiding of small amounts but difficulty emptying the bladder?

As described earlier, bladder control involves complex neuroregulatory and motor mechanisms (see p. 319). A number of central or peripheral nerve lesions may affect normal voiding. Can the patient sense when the bladder is full? And when voiding occurs? Although there are four broad categories of incontinence, a patient may have a combination of causes.

In addition, the patient's functional status may have a significant impact on voiding behaviors even when the urinary tract is intact. Is the patient mobile? Alert? Able to respond to voiding cues and reach the bathroom? Is alertness or voiding affected by medications?

Blood is the urine, or hematuria, is an important cause for concern. When visible to the naked eye, it is called gross hematuria. The urine may appear without polyuria during the day or night in bladder disorder or impairment to flow at or below the bladder neck

See Table 9-7, Urinary Incontinence (pp. 358-359).

Stress incontinence with increased intra-abdominal pressure from decreased contractility of urethral sphincter or poor support of bladder neck; urge incontinence if unable to hold the urine, from detrusor overactivity; overflow incontinence when the bladder cannot be emptied until bladder pressure exceeds urethral pressure, from anatomic obstruction by prostatic hypertrophy or stricture, also neurogenic abnormalities

Functional incontinence from impaired cognition, musculoskeletal problems, immobility

Kidney pain

Ureteral pain

Ureteral pain frankly bloody. Blood may be detected only during microscopic urinaly-sis, known as microscopic hematuria. Smaller amounts of blood may tinge the urine with a pinkish or brownish cast. In women, be sure to distinguish menstrual blood from hematuria. If the urine is reddish, ask about ingestion of beets or medications that might discolor the urine. Test the urine with a dipstick and microscopic examination before you settle on the term hematuria.

Disorders of the urinary tract may also cause kidney pain, often reported as flank pain at or below the posterior costal margin near the costovertebral angle. It may radiate anteriorly toward the umbilicus. Kidney pain is a visceral pain usually produced by distention of the renal capsule and typically dull, aching, and steady. Ureteral pain is dramatically different. It is usually severe and colicky, originating at the costovertebral angle and radiating around the trunk into the lower quadrant of the abdomen, or possibly into the upper thigh and testicle or labium. Ureteral pain results from sudden distention of the ureter and associated distention of the renal pelvis. Ask about any associated fever or chills, or hematuria.

Important Topics for Health Promotion and Counseling

■ Screening for alcohol and substance abuse

■ Screening for colon cancer

Kidney pain occurs in acute pyelonephritis.

Renal or ureteral colic is caused by sudden obstruction of a ureter, as by urinary stones or blood clots.

Health promotion and counseling relevant to the abdomen include screening for alcoholism, risk of infectious hepatitis, and risk of colon cancer. Clues from social patterns and behavioral problems in the history and findings of liver enlargement or tenderness on physical examination often alert the clinician to possible alcoholism or risk of infectious hepatitis. Past medical history and family history are important when assessing risk of colon cancer.

The impact of alcohol and substance abuse on public health may be even greater than that of illicit drugs. Assessing patients for use of alcohol and other substances is a primary responsibility of all clinicians. The clinician should focus on detection, counseling, and, for significant impairment, specific recommendations for treatment. These interventions need not be time-consuming. Use the four CAGE questions, validated across many studies, to screen for alcohol dependence or abuse in all adolescents and adults, including pregnant women (see p. 413). Brief counseling interventions have been shown to reduce alcohol consumption by up to 25%.*

*U.S. Preventive Services Task Force: Guide to Clinical Preventive Services (2nd ed.). Baltimore, Williams & Wilkins, p. 572, 1996.

Focus on (1) sharing concern about the adverse effects of alcohol and education about harmful consequences, and (2) setting goals for behavioral change and follow-up. Tailor recommendations for treatment to the severity of the problem, ranging from support groups to inpatient detoxification to more extended rehabilitation.

Protective measures against infectious hepatitis include counseling about how the viruses are spread and the need for immunization. Transmission of hepatitis A is fecal-oral: fecal shedding in food handlers leads to contamination of water and foods. Illness occurs approximately 30 days after exposure. Hepatitis A vaccine is recommended for travelers to endemic areas, food handlers, military personnel, caretakers of children, Native Americans and Alaskan natives, and selected health care, sanitation, and laboratory workers. Vaccination is also recommended for homosexual contacts and injection drug users. For immediate protection and prophylaxis for household contacts and travelers, consider administering immune serum globulin.

Hepatitis B poses more serious threats to patients' health, including risk of fulminant hepatitis as well as chronic infection and subsequent cirrhosis and hepatocellular carcinoma. Transmission occurs during contact with infected body fluids, such as blood, semen, saliva, and vaginal secretions. Adults between the ages of 20 and 39 are most affected, especially injection drug users and sex workers. Up to a tenth of infected adults become chronically infected asymptomatic carriers. Behavioral counseling and serologic screening are advised for patients at risk. Because up to 30% of patients have no identifiable risk factors, hepatitis B vaccine is recommended for all young adults not previously immunized, injection drug users and their sexual partners, persons at risk for sexually transmitted disease, travelers to endemic areas, recipients of blood products as in hemodialysis, and health care workers with frequent exposure to blood products. Many of these groups should also be screened for HIV infection.

It is also important to screen patients for colorectal cancer, second highest of the malignancies in both prevalence and mortality. Risk factors include family history of colonic polyps, history of colorectal cancer or adenoma in a first-degree relative, and a personal history of ulcerative colitis, adenoma-tous polyps, or prior diagnosis of endometrial, ovarian, or breast cancer. The U.S. Preventive Services Task Force recommends annual testing of all persons over age 50 with the fecal occult blood test (FOBT), sigmoidoscopy, or both, but details several caveats.** The FOBT has a highly variable sensitivity (26%-92%), but good specificity (90%-99%). It produces many false positives related to diet, selected medications, and gastrointestinal conditions such as ulcer disease, diverticulosis, and hemorrhoids. The benefits of sigmoidoscopy are linked to the length of the sigmoidoscope and its depth of insertion. Detection rates for colorectal cancer and insertion depths are roughly as follows: 25%-30% at 20 cm; 50%-55% at 35 cm; 40%-65% at

**U.S. Preventive Services Task Force: Guide to Clinical Preventive Services (2nd ed.). Baltimore, Williams & Wilkins, pp. 89-103, 1996.

40-50 cm. Full colonoscopy or air contrast barium enema detects 80%-95% of colorectal cancers, but these procedures are more uncomfortable and colonoscopy is more expensive. When counseling patients about prevention, there is preliminary but inconsistent evidence that diets high in fiber may reduce risk of colorectal malignancy.

Preview: Recording the Physical Examination— The Abdomen

Note that initially you may use sentences to describe your findings; later you will use phrases. The style below contains phrases appropriate for most write-ups. Unfamiliar terms are explained in the next section, Techniques of Examination.

"Abdomen is protuberant with active bowel sounds. It is soft and nontender; no masses or hepatosplenomegaly. Liver span is 7 cm in the right midclavicular line; edge is smooth and palpable 1 cm below the right costal margin. Spleen and kidneys not felt. No costovertebral angle (CVA) tenderness."

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