UROLOGY SYMPTOMATOLOGY

By DR. Soumya Banerjee

PAIN
• Dysuria is pain while passing urine refers to the discomfort localised to the
outlet of the bladder which is experienced during voiding – typically described as
a sensation akin to passing razor blades or glass. It is due to an infection in the
lower urinary tract or bladder cancer or carcinoma in situ (CIS) of the bladder.
• Renal pain is usually caused by distension of the renal capsule and is felt as a
constant, gnawing pain in the loin/renal angle.
• Ureteric colic (often incorrectly referred to as renal colic) is different from renal
pain and is typified by the lateralised, colicky pain experienced by someone who
has a ureteric calculus. Ureteric colic can radiate to the groin or lower still to the
testicle/labium but does not radiate to the back of the leg. Ureteric colic can be
caused by something other than a stone in the ureter, such as a blood clot or,
rarely, a sloughed renal papilla.
• *If the history is carefully taken, it will be apparent that some patients
simultaneously experience both ureteric colic and renal pain.
• Suprapubic bladder pain, which is experienced when the
bladder is full and is relieved by micturition, is typical of
interstitial cystitis, an idiopathic benign inflammatory disorder of
the bladder typically seen in middle-aged females. Disease
processes in the bladder, e.g. infection or inflammation, can
produce suprapubic pain.
• Testicular pain is a common symptom in men, especially in
early middle-age.
• Sudden severe testicular pain in younger men (<40 years old)
should be treated as a medical emergency and the patient
assessed so that a diagnosis of acute testicular torsion can be
excluded.
• Hydrocoeles and epididymal cysts usually do not cause
significant pain but can have an increasing pressure effect as
they enlarge. A dragging sensation in the scrotum which gets
worse towards the end of the day is typical of the discomfort
associated with a varicocoele, often on the left side.
• Investigation of testicular pain in the young adult male/middle-aged
male is frequently negative, resulting in a highly unsatisfactory
diagnostic label of ‘idiopathic testicular pain’ which is subsequently
managed with the input of other clinicians, most commonly pain
management specialists.
• Patients undergoing vasectomy are routinely counselled of the
approximate 10% risk of testicular pain in the short term following
surgery but more importantly the 1% chance of chronic testicular
pain in the longer term.
• Perineal pain is often a feature of a complex of symptoms typically
seen in middle-aged men who, by a process of exclusion, are
diagnosed as suffering from acute or chronic prostatitis.
• With prostatitis, perineal pain may be accompanied by suprapubic
pain, low back pain which radiates to the legs, penile pain as well as
frequency of micturition and dysuria.
• Perineal pain is an ominous symptom after previous treatment for a
pelvic malignancy, often signifying recurrent pelvic disease.
Summary – Pain from the
Urinary Tract
• Renal pain is not synonymous with renal colic
• Renal colic is a misnomer and should be referred to as
ureteric colic
• Renal pain can be distinguished from ureteric colic by
careful history taking
• Renal pain and ureteric colic may be experienced
simultaneously
• Ureteric colic may radiate to the groin/testicle/labium
• Ureteric colic does not radiate to the chest or the back
of the leg
LOWER URINARY TRACT SYMPTOMS (LUTS)

The International Continence Society (ICS) provides the internationally accepted definitions for
symptoms relating to lower urinary tract function:
• Frequency is the complaint by the patient who considers that he/she voids too often during the
day. The patient may report needing to void more frequently than is their usual habit or more
frequently than they consider is socially acceptable.
• Nocturia is the complaint that the individual needs to wake at night at least once to void.
• Strangury is a sensation of constantly needing to void. Typically, the patient describes having to
stand/sit for long periods with the sensation that micturition is imminent. Strangury is most
commonly due to a lower urinary tract infection (UTI).
• Urgency is a sudden compelling desire to pass urine which is difficult to defer.
• Urge incontinence (UI) is involuntary urinary leakage, often large volume, immediately preceded
by the sensation of urgency. Urgency and episodes of urge incontinence are often associated with
an overactive bladder or a bladder neuropathy.
• Stress incontinence is involuntary urinary leakage whichoccurs when the intra-abdominal
pressure rises. This is most common in females who have had vaginal deliveries who describe
small-volume urinary leakage associated with activity such as coughing, laughing, sneezing or
exercising.
• Nocturnal enuresis is involuntary loss of urine during sleep. A common cause in an elderly male
is chronic retention of urine with overflow incontinence.
• Hesitancy is the term used when an individual describes difficulty in initiating micturition,
resulting in a delay in the onset of voiding after the individual is ready to pass urine. This can be
several seconds to several minutes and is often a symptom of bladder outlet obstruction.
• Reduced urinary stream is usually reported compared with previous performance or in
comparison with the performance of others. This is often a symptom of bladder outlet obstruction.
• Intermittency is the term used when the individual describes urine flow which stops and starts, on
one or more occasions, during micturition.
• Straining is the muscular effort used in order to initiate, maintain or improve the urinary stream.
• Incomplete emptying is the sensation that at the end of micturition bladder fullness persists.
• Post micturition dribble (PMD) is the term used when an individual describes the involuntary
loss of urine immediately after he/she has finished passing urine. This is a common symptom in the
ageing male when the bulbar urethra fails to empty itself of urine at the completion of micturition.
PMD is a symptom which is not usually remedied by a transurethral resection of the prostate.
• In general terms, LUTS are classified as either storage LUTS
(frequency, nocturia, urgency and UI); voiding LUTS (hesitancy, a
reduced stream, straining) or post-micturitional LUTS (incomplete
emptying and PMD).
• Storage LUTS result from failure of the bladder to act as a
functioning reservoir for urine and are commonly seen in patients
with an overactive bladder or a bladder neuropathy.
• Voiding and post-micturitional LUTS are commonly seen in
males with bladder outlet obstruction (BOO); however, a male with
BOO may also have storage LUTS as the thickened detrusor muscle
resulting from outlet obstruction becomes overactive, resulting in the
combination of symptoms. The term ‘prostatism’ is now obsolete.
LUTS are frequently investigated with urodynamics .
Summary - Lower urinary tract
symptoms (LUTS)
• Are classified as storage, voiding or post-micturitional
• Storage LUTS are frequency, nocturia, urgency and urge
incontinence
• Storage LUTS are typical of an overactive bladder
• Voiding LUTS are hesitancy, a reduced stream and
straining
• Voiding LUTS are typical of bladder outlet obstruction
• Some patients may have storage and voiding LUTS in
combination
• Are often investigated with urodynamics
HAEMATURIA
• Haematuria occurs when there is blood in the urine.
• This is now classified as visible haematuria (VH) or non-
visible haematuria (NVH). Older terminology referred to
macroscopic (or frank or gross) haematuria and microscopic
(or dipstick) haematuria.
• Degree and frequency of haematuria.
• Enquiry should be made about the timing of the blood in
relation to the urinary stream;
• - initial (urethral pathology),
• -throughout the stream (bladder or upper tracts),
• - terminal (bladder neck or prostatic pathology).
• A patient with haematuria should be investigated regardless of whether
they are taking anticoagulant therapy.
• The concern for the urologist is that the haematuria, especially if
painless, is due to an underlying neoplasm of the urinary tract, usually a
bladder or renal tumour.
• Causes of haematuria include Trauma, Infection and Neoplasm (think of
TIN) at all levels of the urinary tract.
• Haematuria in association with loin pain and a palpable loin mass defines
the classic triad of symptoms and signs of a renal tumour although this
triad is seen in less than 10% of patients presenting with a renal tumour.
• Apart from young females with a proven UTI, most patients with
haematuria, whether visible or non-visible, will be investigated urgently
at a haematuria clinic where they will have a renal ultrasound scan (USS)
and a flexible cystoscopy as a minimum. The cancer detection rate
depends on the degree of haematuria, being approximately 20% in those
patients with visible haematuria but very much lower in those with non-
visible haematuria (<5%).
Summary - Haematuria
• Nowadays, is classified as visible haematuria (VH) or
nonvisible haematuria (NVH)
• A list of potential causes for haematuria can be rapidly
generated by considering trauma (T), infection (I) and
neoplasm (N) at all levels of the urinary tract from
kidney to urethra (TIN )
• Haematuria is investigated with a renal USS and a
flexible cystoscopy as a minimum
Discolouration of the urine
• Many drugs and foodstuffs have been reported to produce abnormal discolouration of the urine. Most
colours have been reported but the most frequently encountered clinically are red/orange and brown.
• Clearly, haematuria is the commonest cause for red urine; however, the presence of haem in the urine
also produces red discolouration and generates a positive dipstick test.
• Red urine discolouration due to haemoglobinuria may present in haemolytic disorders such as ‘march
haematuria’, classically seen in dehydrated soldiers after prolonged marching.
• Likewise, myoglobinuria due to myocyte destruction, e.g. caused by rhabdomyolysis after crush injury,
can also result in red discolouration of the urine.
• Disordered haem production, seen in porphyria, can result in red discolouration that may change to
brown or purple with exposure to sunlight.
• Several medications can cause red/orange discolouration of the urine, most commonly rifampicin,
isoniazid or phenazopyridine with tears and other bodily fluids generally also discoloured. Others include
chlorpromazine, thioridazine, senna and laxatives containing a phenolphthalein component.
• Consumption of large quantities of beetroot can result in red discolouration of the urine. This
discolouration is due to the excretion of betalain (betacyanin) pigments such as betanin.
• The commonly used antibiotics nitrofurantoin and metronidazole can lead to the urine being discoloured
brown.
• Brown urine due to high-circulating bilirubin is also a feature of obstructive jaundice.
Haematospermia
• This refers to blood, which can be bright red or a brown
colour, seen in the seminal fluid.
• It is most commonly due to benign inflammatory
change in the prostate but occasionally can be the
presenting symptom of a prostate cancer.
• A digital rectal examination (DRE) should be performed
alongside a prostate-specific antigen (PSA) test and a
transrectal US (TRUS) should be considered.
• In most cases, haematospermia is self-limiting.
Pneumaturia The urethral syndrome
• This is air, or more correctly • In this condition, typically
gas, in the urine. Patients seen in young females,
typically describe frothy urine,
bubbles in the urine or a
symptoms suggestive of a
stream which intermittently UTI are reported but with
stops then starts again. negative bacteriology. It
• The commonest cause is an is sometimes remedied by
underlying colovesical fistula, a simple cystoscopy and
usually due to primary urethral dilatation.
pathology in the rectum or
sigmoid colon.
SYMPTOMS RELATED TO THE
EXTERNAL GENITALIA
Testis
• A testis may be absent from the scrotum in patients with undescended or ectopic testes.
• In boys <5 years, a common cause of testicular pain and swelling is a torted hydatid of
Morgagni (appendix testis). Often in these young males the scrotal skin is transparent
enough to allow visualisation of a small, bluish swelling at the superior pole of the testis.
• In a young male suspected of having a testicular torsion, examination of the normal i.e.
contralateral testis may reveal a horizontal lie or ‘clapper bell testis’, raising the level of
clinical suspicion. If torsion is suspected, immediate testicular exploration is mandatory
and if confirmed, bilateral testicular fixation is performed.
• Patients with Klinefelter’s syndrome typically have bilateral small, firm testes in addition to
the other signs typical of this condition.
• A hydrocoele is an accumulation of fluid between the testis and the tunica vaginalis and in
the younger male can be associated with a patent processus vaginalis. On opening into a
hydrocoele, the fluid is typically a yellow colour.
• A testis which cannot be felt in a tense hydrocoele in the age groups at risk of testis
cancer needs to be assessed by USS preoperatively.
Epididymis
• Epididymal pathology is rare in the prepubertal male. In the sexually
active male, acute epididymitis (often due to chlamydia) with
significant pain and swelling needs to be distinguished from acute
testicular torsion. If there is any doubt, scrotal exploration is
undertaken.
• Tiny cysts are frequently detected in young males undergoing testicular
USS but in the vast majority of patients these do not require attention.
• Epididymal cysts can form similar scrotal swellings to hydrocoeles but
can be distinguished by the fact that the testis can often be felt
separately. They contain clear or white fluid. Both hydrocoeles and
epididymal cysts transilluminate on clinical examination.
• Genitourinary tuberculosis (TB) can result in bilateral nodular induration
of the epididymes.
 Spermatic Cord
Penis
• Peyronie’s disease is an idiopathic
condition in which fibrosis develops in
• Ten per cent of males
the corpora cavernosa of the penis. The have a left-sided
‘plaque’ of Peyronie’s fibrosis is usually
palpable in the midline anywhere from
varicocoele and a smaller
the base of the penis to just behind the left testis. Masses are
corona. It gives rise to painful angulation
of the penis on erection. occasionally found
• Penile fracture occurs when there is associated with the
trauma to the erect penis. Classically, spermatic cord, which on
there is an audible crack and immediate
penile detumescence and the patient removal are found to be
presents with gross bruising of the
penile shaft skin.
lipomas, mesotheliomas
or sarcomas.
Prepuce
(foreskin)
• Phimosis occurs when the
distal foreskin is tight and will
not allow the foreskin to retract.
• Paraphimosis occurs when a
poorly retractile foreskin
becomes trapped in the
retracted state and cannot be
replaced. Significant oedema of
the foreskin results, making
replacement of the foreskin
increasingly difficult.
• Depigmentation and scarring of
the distal prepuce occurs in
balanitis xerotica obliterans
(BXO).
Glans penis Urethra
• In the younger male, • Hypospadias occurs when there is
genitourinary warts due to failure of the urethra to completely
human papilloma virus (HPV) close on the ventral aspect and
epispadias occurs when there is failure
infection may be observed. In of closure on the dorsal surface.
the older male, red raised
• A urethral diverticulum in a female
patches on the glans penis or the can be a cause for recurrent UTIs and
inner aspect of the prepuce due is notable for its capacity to fill and
to Zoon’s balanitis or CIS empty at cystoscopy.
(erythroplasia of Queyrat or • A urethral caruncle is a minor prolapse
Bowen’s disease) are of the urethral mucosa in a female
distinguished only on penile and usually requires no treatment.
biopsy.
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