Urinary Problems
The causes of oliguria
The major complaints possible are:
1. PAIN OR BURNING SENSATION
-Pain or burning sensation while passing urine-the signifies
urinary tract infection. Increased frequency of passing urine
may also be there.
-It is desirable to confirm the diagnosis with microscopic
examination of urine. In urine infection pus cells will be
present.
Treatment of urinary tract infection
-If this is not associated with fever likely to be – lower
urinary tract infection – treat with Amoxicillin or co-
trimoxazole or ciprofloxacin for 5 to 7 days.
-If this is associated with fever (which means that
infectionmay have spread to kidneys) then treatment is with
Amoxicillin or trimoxazole should go on for 14 days.
Ciprofloxacin is another good choice for UTI give for 14
days.
-Always advise to drink plenty of water so that there is a
high output of urine.
When to refer
-In males after a single episode & in females with recurrent
UTI refer to the CHC for ultrasound to rule out urinary
stones.
-If fever does not subside within three days
2. EXCESSIVE URINE FLOW
-The commonest cause is drinking lots of water. This is
normal.
-The next common cause is DM. A urine sugar test would
confirm this. If it is positive refer it to a doctor in the
community health care center to confirm the diagnosis, to
check for complications and to start the drugs.
Subsequently it can be followed up at the primary health
care centre.
-Rarely there are other causes of excessive urine flow like
diabetes insipidus and some types of kidney disorders for
which person would need to go to a tertiary care hospital.
3.DECREASED URINE FLOW
-The commonest cause is lack of drinking water and hot
weather. Correct by drinking lot of water.
-If it is not corrected by drinking water occurs along with
swelling of the feet and/or face then consider oliguria (<400
ml/24hr) and anuria (<50ml/24hr).
may be renal, cardiac or others.
-Test the urine for albumin (if albumin is present heating
the urine will cause it to turn white). If albumin is present it
likely to be a renal problem.
-If the urine if dark coloured and microscopic examination
of urine shows red or white blood cells this is also due to a
kidney problem.
-If urine is scanty and there is breathlessness on lying
down with JVP elevated with pedal oedema with or without
basal lung crepitations – a heart problem is likely.
4.PAIN WHILE PASSING URINE OR LOWER
ABDOMINAL PAIN WITH HAEMATURIA
-This may be due to stones. Refer to a tertiary care centre
with facilities for managing this.
-If there is no decrease in pain advise to drink large
amounts of water regularly.
5. PAINLESS HAEMATURIA
-suspect malignancy – refer to urologist for further tests.
6.RETENTION OF URINE
-Refer to higher centre equipped for surgery.
-One can relieve bladder distension by putting catheter.
-Percutaneous drainage – draining the urine from the
bladder from the supra-pubic area before referring – if the
distension is excessive and painful.
-If needed Suprapubic Cystostomy can be done in CHC
before sending to district hospital.
*In all cases with urinary symptoms urine examination
including urine microscopy is a must.
PEDAL OEDEMA (SWOLLEN FEET)
1.Clinical pattern: Unilateral, painful, may be pitting, with
redness and heat
Likely Diagnosis: Lymphangitis, -maybe early filarial
oedema, cellulitis
Action required: start an antibiotic-amoxicillin 500mg 8
hourly – may add metronidazole. If open ulcers are
present. Inj procaine penicillin is an alternative.
2.CP: unilateral or bilateral, painful, non-pitting
LD: deep vein thrombosis
AR: Inj heparin 5000 units subcutaneously to be repeated
every 6 hours with clotting time to be kept within 2 to 2.5
times the normal.
-treatment of infections. Especially if there is impetigo a
course of penilcillin is indicated.
REFER to district hospital if urine flow decreases further or
if hypertension is not controlled.

3.CP: usually unilateral or asymmetrical, does not pit on 2.NEPHROTIC SYNDROME

pressure, long standing
LD: late filariasis, elephantiasis
4.CP: bilateral, pitting, with generalized swelling – face,
abdomen.
LD: differentiate between these four conditions:
kidney/heart/liver disease, severe anaemias
This too is due to glomerular disease that can be primary
or secondary. The type of lesion that is most common in
children and most responsive to treatment in both adults
and children is called minimal testing disease.
DIAGNOSIS
-proteinuria more than 3.5mg in 24 hours

5.CP: bilateral pedal oedema associated with pregnancy -hypo-albuminaemia, hyperlipidaemia

often normal but to rule out pre-eclampsia by checking
blood pressure and urine for abdomen. -oedema

LD: normal, secondary to anaemia, pre-eclampsia TREATMENT

-in all adults a renal biopsy is indicated. If this is not

available one would have to treat this presumptively as we
RENAL DISEASE treat minimal change disease. But as most cases in adults
are not steroids becomes a problem in the absence of a
1.ACUTE NEPHRITIS biopsy report.

This is clinical syndrome due to glomerular disease which
may be a primary disease or secondary to a systemic
process. Note that sickle cell disease can also present as
nephropathy.
Diagnosis: - Clinical presentation: oliguria,
haematuria,facial puffiness, occasionally pedal oedema
-On examination: patient has hypertension, urine
examination which shows proteinuria and RBCs
Investigation : the presence of RBC casts in urine is
diagnostic- however one can diagnose acute nephritis even
in its absence.
-in young children since minimal change disease is more
common one could treat presumptively for the same and
biopsy only if there is no response.
-Treatment for minimal change disease is with
prednisolone 1mg/kg/day. To be given till proteinuria
normalizes and then tapered over three months. Failure to
response usually indicates that it is not minimal lesion. If
after tapering steroids there is relapse then restart
prednisolone. If steroid dependence develops refer to
tertiary centre for cytotoxic drugs. If there is non-response
develops also refer to tertiary care centre.

Treatment :

GENERAL GUIDELINES

-bed rest at home

-adequate fluids – taking care that excess is not given

which would increase oedema but not enough is given to
ensure at least 400ml of urine per day. If one can estimate
the previous days urine volume – a water intake of that
plus about 800 to 1000ml would be adequate

-salt restriction- especially if oedemas present

DRUG TREATMENT

-a tablet of furosemide may be tried if there is water logging

and hypertension. Not to be given if there is no obvious
evidence of fluid excess

-other antihypertensive is required