SEMIOLOGY IN UROLOGY

HOW DOES THE PATIENT COME TO SEE THE DOC?
‡ Anamnesis: very important ‡ Modern medicine: nobody has time ‡ Personal records (medical history, lab values etc.) ‡ All signs and symptoms

PAIN IN UROLOGY
LUMBAR PAIN
‡ Localization ‡ Irradiation ‡ Intensity ‡ Associated digestive symptoms, ‡ Associated urinary symptoms ± micro-hematuria

PAIN IN UROLOGY
LUMBAR PAIN ± differential diagnosis
‡ ‡ ‡ ‡ ‡ ‡ Biliary colic Ulcer, pancreatitis Acute appendicitis Salpingitis, depherentitis Pleural and pulmonary diseases Very intense pain, in hypoxia /anoxia / obstruction or torsion of the intestine

PAIN IN UROLOGY
LUMBAR PAIN ± differential diagnosis
‡ One side pain ± more important ‡ Elderly male patients receiving treatment for a rheumatic disease Metastasis in prostate cancer ‡ Pain in urinary lithiasis
± Urinary changes ± Echo: the patient has to undress Zoster Zone

‡ Renal colic with fever

PAIN IN UROLOGY
HYPOGASTRIC PAIN
‡ Young woman, polakiuria, ³muddy´ urine cystitis ‡ Woman, polakiuria, without pyuria, symptoms resisting at antibiotics candidsis / Hyperreactive bladder /vaginal infection / endocrine disorders / lithiasis

PAIN IN UROLOGY
PERINEUM PAIN
‡ Young man prostatitis ‡ Woman gynecological problems

PAIN IN SCROTUM
‡ Young man, very intense pain 6 hours!!! ‡ Testicular hydatide torsion ‡ Acute Orhchyepididimitis ‡ Viral orchytis testicular torsion ±

HEMATURIA
‡ Is it hematuria ?
± Drugs that color the urin: piramidon, nitrofurantoin ± cumarol ± Bilirubinuria ± jaundice ± Hemoglobinuria

‡ Hematuria localization
± Cystoscopy (in anesthesis)

HEMATURIA
‡ Etiology:
± Neoplastic diseases ± Lithiasis ± hematuria with pain ± tuberculosis ± persistent micro-hematuria

‡ Bladder tumors :
± Painless whimsical hematuria, age > 40 years ± Investigations: echo, urography, CT, MRI

PYURIA: ³muddy´ urine at evacuation
‡ Renal diseases
± Lithiasis ± Tuberculosis

‡ Bladder diseases
± Infections, bladder lithiasis ± Prostatic disease

‡ Urinalysis ‡ Treatment: acidifying the urine

URINATION (MICTION) CHANGES
‡ Polakiuria: frequent and low quantitative urination ‡ Dysuria: difficult miction ‡ Thin urinary jet

DYSURIA: difficult miction
‡ Children: subvesical diseases
± Vesical cervix sclerosis ± Posterior urethral Valves ± Phimosis ± Urethral meatus stenosis

‡ Pathophysiology:
± After miction residue dilation + incontinence hydronephrosis acute urine retention

DYSURIA IN MEN
‡ Young men:
± Acute prostatitis: fever ± Urethral stenosis

‡ Elderly men:
± Prostate adenoma ± Prostate cancer ± Vesical cervix sclerosis ± Urethral stenosis ± Perianal infections

DYSURIA IN WOMEN
‡ Leziuni organice
± Uterus cervix neoplasm ± cytology ± Urethra neoplasm ± Vesical cervix sclerosis ± Central nervous system disorders ± multiple sclerosis ± Diabetes mellitus ± After radical surgery

DIURESIS CHANGES
‡ Normal urinary volume: 800-2000 ml/24h ‡ Diuresis monitoring: 24h 5 zile ‡ Polyuria (>3 l/day): diabetes insipidus, diabetes mellitus, chronic renal failure ± compensatory mechanism, increased water intake ‡ Anuria: no urine in the bladder ± Prerenal causes: prolonged hypotension, shock ± Renal causes: drugs, infections ± Postrenal causes: urinary tract obstruction

BLADDER FUCTIONS

‡ Urine reservoir

‡ Urine output
± Bladder contraction ± Sphincter relaxation

ANATOMIC DIFFERENCES WOMAN / MAN

URINARY INCONTINENCE CAUSES:
‡ C.N.S. disorders
± Tabes, multiple sclerosis, Alzheimer¶s, cerebral hemorrhage, Parkinson¶s ± Vertebral traumas with medulla interest ± Radical surgery

‡ Enuresis in children

CAUSES
‡ Congenital Causes:
± Epispadias gr. III ± Bladder extrophy ± Ectopic urether opening

‡ Traumas:
± Fistula (vesical-vaginal, urether-vaginal, complex) - Incontinence after prostatectomy

EMBRIOLOGIE

FUNCTIONAL INCONTINENCE
‡ Very frequent ‡ Causes:
± Bladder
‡ Hyperactive ‡ hypocontractile

± Vesical cervix
‡ Obstruction ‡ Incompetence

FUNCTIONAL INCONTINENCE
‡ Hyperactive bladder
± ± ± ± Idiopathic Infections Bladder tumors Bladder lithiasis

‡ Hypocontractile bladder
± Tumor compressions on the spine ± Diabetes ± Connective tissue replacement (chronic obstructions)

FUNCTIONAL INCONTINENCE
‡ Sphincter incompetence
± Effort incontinence in women ± Men: after TUR / surgery ± Diabetes mellitus

‡ Vesical cervix obstruction
± Dysuria ± in children ± Prostate adenoma, urethral stenosis, vesical cervix sclerosis ± in men ± Genital cancer, urethra stenosis, perianal phlegmon ± in women

ACUTE RENAL FAILURE
‡ Rapid decline in glomerular filtration rate ‡ Retention of nitrogenous waste products ‡ Perturbation of extracellular fluid volume and electrolyte and acid-base homeostasis ‡ Oliguria: frequent, but not invariable clinical feature ‡ Usually asymptomatic ‡ Most ARF is reversible

CLASSIFICATION AND MAJOR CAUSES OF ARF

PRERENAL ARF
I. A. B. C. D. II. A. B. III. A. B. C. IV. V. Hypovolemia Hemorrhage, burns, dehydration Gastrointestinal fluid loss (vomiting, diarrhea etc) Renal fluid loss (diuretics, diabetes mellitus) Sequestration in extravascular space (pancreatitis, peritonitis, burns etc) Low cardiac output Diseases of myocardium, valves and pericardium; arrhythmias, tamponade Other: pulmonary HTN, massive pulm. embolus, positive pressure mechanical ventilation Altered renal systemic vascular ratio Systemic vasodilatation: anti-HTN drugs, anesthesia Renal vasoconstriction: Ca, epinephrine, amphotericin B Cirrhoses with ascites Renal hypoperfusion Hyperviscosity syndrome: multiple myeloma, poycythemia

CLINICAL ASSESSMENT

‡ ‡ ‡ ‡ ‡

Thirst Orthostatic dizziness Orthostatic hypotension, tachycardia Decreased skin turgor Dry mucous membranes

LABORATORY FINDINGS
‡ Creatinine rises rapidly (within 24 to 48 hours) ‡ Peak creatinine levels: after 3-5 days, with return to baseline after 5-7 days (in ischemic ARF and atheroembolization the peak is later ± 7-10 days) ‡ Hyperkalemia, hyperphosphatemia, hypocalcemia, uric acid, CK-MM rhabdomyolisis ‡ Hyperuricemia, hyperkalemia, hyperphosphatemia, increased circulating levels of intracellular enzymes ± LDH ± acute urate nephropathy and tumor lysis syndrome following cancer chemotherapy.

INTRINSIC RENAL ARF
I.
A. B.

Renovascular obstruction (bilateral or unilateral)
Renal artery obstruction Renal vein obstruction: thrombosis, compression

II.
A. B.

Disease of glomeruli or renal microvasculature
Glomerulonephritis, vasculitis Hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, disseminated intravascular coagulation, toxemia of pregnancy, accelerated HTN, radiation nephritis, systemic lupus erythematosus, scleroderma

III.
A. B.

Acute tubular necrosis
Ischemia: as for prerenal ARF, obstetric complications Toxins (exogenous, endogenous)

IV.
A. B. C. D.

Interstitial nephritis
Allergic (drugs) Infection Infiltration (lymphoma, leukemia, sarcoidosis) Idiopathic

V. VI.

Intratubular deposition and obstruction Renal allograft rejection

CLINICAL ASSESSMENT
‡ Ischemia: following severe renal hypoperfusion and ARF persistence despite normalization of systemic hemodynamics ‡ Flank pain: occlusion of renal a./v., other parenchymal diseases ‡ Subcutaneous nodules, livedo reticularis, digital ischemia ± atheroembolizations ‡ Edema, HTN, ³active urine sediment´ (nephritic sdr.) ± acute GN or vasculitis ‡ Fever, arthralgias, pruritic erythematous rash after a new drug adm. ± allergic interstitial nephritis

POSTRENAL ARF

I.
I.

Ureteric
Calculi, blood clot, cancer, external compressions (retroperitoneal fibrosis)

II.
I.

Bladder neck
Neurogenic bladder, prostatic hypertrophy, calculi, cancer, blood clot

III.
I.

Urethra
Stricture, congenital valve, phimosis

CLINICAL ASSESSMENT
‡ Suprapubic and flank pain (bladder, renal collecting system and capsule distension) ‡ Colicky flank pain radiating to the groin ± acute ureteric obstruction ‡ History of nocturia, frequency, and hesitancy and enlargement or induration of the prostate ± prostatic disease ‡ Anticholinergic drugs, autonomic dysfunction ± neurogenic bladder

TREATMENT
‡ PRERENAL ARF
± Correct hypovolemia (packed red cells, isotonic saline) ± Correct dyselectrolytemias and acid-base status ± Correct / eliminate the cause

‡ INTRINSIC RENAL ARF
± Measures to attenuate the injury or hasten recovery in ischemic and nephrotoxic ARF (low-dose dopamine, loop-blocking diuretics, Ca ch. Blockers, alpha-blockers, antioxidants) ± GN, vasculitis: glucocorticoids, alkylating agents and/or plasmapheresis ± HTN, scleroderma: ACE inhibitors

DIALYSIS
‡ Absolute indications:
± Symptoms or signs of uremic sydrome ± Refractory hypervolemia, hyperkalemia, acidosis ± Blood urea levels > 100 mg/dl (not firm indication)

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