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Urinary symptoms

Medicine > Endocrine & metabolic

Differential Diagnosis Schema 🧠

Lower Urinary Tract Symptoms (LUTS)

  • Benign prostatic hyperplasia (BPH): Common in older men, presents with hesitancy, weak stream, incomplete emptying, and nocturia.
  • Overactive bladder: Characterised by urgency, frequency, and nocturia, often without infection; can be idiopathic or related to detrusor overactivity.
  • Urinary tract infection (UTI): Presents with dysuria, frequency, urgency, and suprapubic pain; more common in women.
  • Bladder outlet obstruction: Can be due to BPH, urethral stricture, or bladder neck stenosis, leading to hesitancy, weak stream, and incomplete emptying.
  • Bladder stones: May present with pain, haematuria, and LUTS, especially if the stone is mobile within the bladder.
  • Bladder cancer: Often presents with painless haematuria, but may also cause LUTS in advanced cases.
  • Prostatitis: Presents with pelvic pain, dysuria, frequency, and sometimes systemic symptoms like fever.
  • Interstitial cystitis: Chronic condition with bladder pain, urgency, and frequency, often without infection.
  • Urethral syndrome: Chronic dysuria and frequency without evidence of infection, often in women.
  • Foreign body in the bladder or urethra: Can cause pain, haematuria, and LUTS depending on the location and size of the object.
  • Neurological disorders: Conditions like multiple sclerosis, spinal cord injury, or diabetic neuropathy can lead to LUTS due to bladder dysfunction.
  • Medications: Diuretics, alpha-blockers, or anticholinergics can exacerbate or cause LUTS.
  • Pregnancy: Increased frequency and urgency due to pressure on the bladder, common in the third trimester.
  • Pelvic organ prolapse: In women, can cause LUTS due to mechanical obstruction or irritation of the bladder.

Upper Urinary Tract Symptoms

  • Kidney stones: Presents with acute flank pain, haematuria, and sometimes nausea or vomiting; pain may radiate to the groin.
  • Pyelonephritis: Infection of the kidney, presenting with fever, chills, flank pain, and dysuria; often with systemic symptoms.
  • Renal colic: Severe pain due to ureteral obstruction, often caused by kidney stones, with associated haematuria and nausea.
  • Hydronephrosis: Dilation of the renal pelvis due to obstruction, can be asymptomatic or cause flank pain and haematuria.
  • Renal tumour: May present with haematuria, flank pain, and a palpable mass; often asymptomatic in early stages.
  • Glomerulonephritis: Presents with haematuria, proteinuria, hypertension, and sometimes nephrotic syndrome symptoms.
  • Polycystic kidney disease: Inherited disorder causing multiple renal cysts, presenting with hypertension, haematuria, and flank pain.
  • Renal infarction: Rare, presents with acute flank pain, haematuria, and sometimes hypertension; requires urgent evaluation.
  • Papillary necrosis: Associated with analgesic abuse, sickle cell disease, or diabetes; presents with haematuria and flank pain.
  • Renal artery stenosis: May present with hypertension resistant to treatment and possible renal impairment.
  • Renal vein thrombosis: Presents with flank pain, haematuria, and sometimes nephrotic syndrome.
  • Chronic kidney disease: May present with vague symptoms such as fatigue, swelling, and changes in urination patterns.

Key Points in History 🥼

Symptom Onset and Duration

  • Onset: Acute onset may suggest infection, stones, or trauma, while chronic onset may indicate a progressive condition like BPH or CKD.
  • Duration: Long-standing symptoms are more likely related to chronic conditions, while sudden changes may indicate an acute process.
  • Progression: Determine if symptoms are worsening, stable, or fluctuating to assess the underlying condition.
  • Precipitating factors: Consider any recent events, medications, or lifestyle changes that could have triggered symptoms.
  • Relieving factors: Identify any actions or treatments that alleviate symptoms, such as medications or positional changes.
  • Associated activities: Note whether symptoms are related to specific activities, such as urination, physical exertion, or sexual activity.

Associated Symptoms

  • Dysuria: Painful urination may suggest UTI, urethritis, or bladder irritation.
  • Haematuria: Visible blood in the urine can indicate stones, tumours, trauma, or glomerular disease.
  • Fever and chills: Suggests an infectious cause, such as pyelonephritis or prostatitis.
  • Flank pain: Often associated with renal colic, pyelonephritis, or kidney stones.
  • Pelvic pain: May indicate bladder conditions, prostatitis, or interstitial cystitis.
  • Urinary frequency: Increased frequency can suggest UTI, overactive bladder, or diabetes.
  • Urgency: A sudden, intense need to urinate often points to overactive bladder, UTI, or interstitial cystitis.
  • Nocturia: Frequent urination at night can be related to BPH, overactive bladder, or chronic kidney disease.
  • Incomplete emptying: Sensation of incomplete bladder emptying may indicate bladder outlet obstruction or detrusor underactivity.
  • Weak stream: Suggests obstruction, such as from BPH or urethral stricture.
  • Incontinence: Loss of bladder control can be related to stress incontinence, urge incontinence, or overflow incontinence.
  • Systemic symptoms: Fatigue, malaise, or weight loss may suggest a more serious underlying condition like cancer or chronic infection.

Background

  • Past medical history: Document any history of urological, nephrological, or gynaecological conditions that could influence symptoms.
  • Medication history: Review current medications, especially those known to affect bladder or renal function, such as diuretics, anticholinergics, or NSAIDs.
  • Family history: Consider any familial patterns of renal disease, urological cancer, or other related conditions.
  • Surgical history: Previous abdominal, pelvic, or urological surgeries may contribute to symptoms.
  • Obstetric history: In women, document pregnancies, childbirths, and any complications, as these can impact pelvic floor strength and bladder function.
  • Social history: Assess lifestyle factors such as alcohol use, smoking, and physical activity, which can impact urinary symptoms.
  • Psychological history: Include any history of mental health issues, as these can affect the perception and management of urinary symptoms.
  • Functional status: Determine the patient’s baseline mobility and any recent changes, as these can influence incontinence or LUTS.
  • Environmental factors: Consider factors such as access to toilet facilities, which can influence symptoms.
  • Occupational history: Certain occupations may predispose to dehydration, frequent holding of urine, or exposure to toxins.
  • Sexual history: Particularly relevant in younger patients, as STIs can present with urinary symptoms.
  • Dietary history: Caffeine, alcohol, and certain foods can irritate the bladder and exacerbate symptoms.
  • Fluid intake: High or low fluid intake can influence urinary frequency, urgency, and nocturia.
  • Allergies: Document any allergies, particularly to medications that might be used in treatment.
  • Recent treatments: Recent courses of antibiotics or other treatments that could influence current symptoms.

Possible Investigations 🌡️

Laboratory Tests

  • Urinalysis: To assess for infection, haematuria, proteinuria, or other abnormalities that might contribute to symptoms.
  • Urine culture: If a UTI is suspected based on symptoms or urinalysis findings.
  • Serum creatinine: To assess renal function, particularly in patients with suspected upper urinary tract involvement.
  • Blood glucose: To rule out diabetes as a contributing factor to urinary frequency or nocturia.
  • Prostate-specific antigen (PSA): In men, to assess for prostate pathology that may contribute to symptoms.
  • Serum electrolytes: To assess for electrolyte imbalances that may influence bladder function.
  • Thyroid function tests: To rule out hyperthyroidism, which can contribute to frequency and urgency.
  • CBC: To assess for anaemia or infection, which might exacerbate symptoms.
  • Urine cytology: May be indicated in patients with haematuria to assess for bladder cancer or other malignancies.
  • STD screening: Particularly in younger patients or those with high-risk sexual behaviour presenting with urinary symptoms.
  • Autoimmune screen: If there is suspicion of systemic autoimmune diseases such as lupus, which can involve the kidneys.
  • Liver function tests: If there is concern for systemic disease that could affect renal function.
  • Urine sodium and osmolality: May be useful in assessing renal concentrating ability, particularly in cases of polyuria or nocturia.

Imaging Studies

  • Renal ultrasound: To evaluate the kidneys and bladder for structural abnormalities, stones, or obstruction.
  • CT urogram: Provides detailed imaging of the urinary tract, useful in evaluating haematuria, stones, or suspected malignancy.
  • KUB X-ray (kidneys, ureters, bladder): Simple imaging to assess for stones or significant bladder distention.
  • Cystoscopy: Direct visualisation of the bladder, indicated for haematuria, recurrent UTIs, or suspicion of bladder cancer.
  • Urodynamic studies: To assess bladder function, including detrusor activity, bladder compliance, and sphincter function.
  • MRI of the spine: Indicated if there is suspicion of a neurological cause of urinary symptoms, such as spinal cord compression.
  • Intravenous pyelogram (IVP): Historically used to evaluate the urinary tract but largely replaced by CT urogram.
  • Voiding cystourethrogram (VCUG): To assess for vesicoureteral reflux or urethral abnormalities contributing to symptoms.
  • Pelvic ultrasound: Particularly in women, to evaluate for uterine, ovarian, or pelvic pathology that may influence symptoms.
  • Bladder diary: A non-invasive tool to track fluid intake, urination patterns, and episodes of incontinence over several days.

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Endocrine & metabolic