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Common urinary histories

Frequency / dysuria / nocturia

Exploring symptom

  • Timeframe
    • Duration
    • Onset (sudden or gradual)
    • Progression
    • Timing (intermittent or continuous)
  • Urination
    • Try to quantify urinary volume and frequency
    • Any catheter

Relevant system reviews

  • General
    • Fever, sweats, rigors
  • Urological
    • Storage: frequency, volume, urgency, nocturia, incontinence
    • Infection: dysuria, haematuria, odour
    • Prostatic/voiding (if male): hesitancy, poor flow/dribbling, feeling of incomplete emptying

Differential diagnoses and clues

Urological:

Cystitis-Dysuria (‘burning pain on urination’)
-Frequency and urgency
Urethritis-Dysuria
-Purulent urethral discharge
Pyelonephritis-Dysuria and loin pain
-Fever/chills/rigors
-Vomiting
Benign prostatic hyperplasia-Poor flow and terminal dribbling
-Hesitancy
-Overflow incontinence 
-Elderly male

Others:

Other differentialsAnxiety, Detrusor instability, Bladder/lower urethral calculus, Prostatitis, Pregnancy, Drugs (e.g. diuretics, excess caffeine)

Haematuria

Exploring symptom

  • Timeframe
    • Duration
    • Onset (sudden or gradual)
    • Progression
    • Timing (intermittent or continuous)
  • Haematuria
    • Try to quantify bleeding
    • Thick blood or discoloured urine
    • Any clots? – increase risk of urinary retention
    • Catheterised?
    • Anaemia symptoms (tiredness, breathlessness on exertion)

Relevant system reviews

  • General
    • Fever, sweats, weight loss, rashes, joint pain/swelling
  • Urological
    • Storage: frequency, volume, urgency, nocturia, incontinence
    • Infection: dysuria 
    • Prostatic/voiding (if male): hesitancy, poor flow/dribbling, feeling of incomplete emptying

Differential diagnoses and clues

Urological:

Bladder transitional cell carcinoma-Painless haematuria
-History of aromatic amine exposure (e.g. dye washers, painters, decorators)
Renal cell carcinoma-Flank pain/mass
-May have fever/hypertension/weight loss
Urethral trauma, e.g. by catheter-History of catheter use or trauma
UTI-Frequency/dysuria/urgency
Urethritis-Dysuria
-Purulent urethral discharge
Calculi-Loin to groin pain

Others: 

UrologicalGlomerulonephritis, Benign prostatic hyperplasia/prostate cancer, Polycystic kidney disease, Schistosomiasis, Urinary tract, TB
MiscellaneousHaematological e.g. anticoagulation, sickle cell, coagulopathy, Strenuous exercise, Infective endocarditis, Drugs (e.g. sulphonamides, cyclophosphamide, NSAIDs), Menstruation, Rhabdomyolysis

Polyuria

Exploring symptom

  • Timeframe
    • Duration
    • Onset (sudden or gradual)
    • Progression
    • Timing (intermittent or continuous)
  • Polyuria
    • Try to quantify urinary volume and frequency
    • Try to quantify fluid intake
    • Other symptoms

Relevant system reviews

  • General
    • Fever, sweats, weight loss, malaise, rashes, joint pain/swelling
  • Urological
    • Storage: urgency, nocturia 
    • Infection: dysuria, haematuria, odour 
    • Prostatic/voiding (if male): hesitancy, poor flow/dribbling, feeling of incomplete emptying

Differential diagnoses and clues

Endocrine:

Diabetes mellitus-Polydipsia/thirst and polyuria
-Weight loss and tiredness
-Visual disturbance
Diabetes insipidus-Polydipsia/thirst and polyuria

Urological:

Chronic kidney disease-Non-specific symptoms, e.g. fatigue, weakness, pruritus, dyspnoea

Others:

Other differentialsUTI, Cushing’s syndrome, Psychogenic polydipsia, Drugs (e.g. diuretics, alcohol, lithium, tetracyclines), Postobstructive diuresis (life-threatening complication of relieving urinary obstruction)

Incontinence

Exploring symptom

  • Timeframe
    • Duration
    • Onset (sudden or gradual)
    • Progression
    • Timing (intermittent or continuous)
  • Incontinence
    • Pattern of incontinence, e.g. loss with effort or no control at all
    • Can they feel when they need to urinate
    • Try to quantify urinary volume and frequency
    • Bowel habit (any constipation?)

Relevant system reviews

  • Urological
    • Storage: frequency, volume, urgency, nocturia 
    • Infection: dysuria, haematuria, odour
    • Prostatic/voiding (if male): hesitancy, poor flow/dribbling, feeling of incomplete emptying

Differential diagnoses and clues

Urological:

Stress incontinence-Incompetent sphincter-Small losses with effort, e.g. coughing, bending, exertion
-Risk factors: multiple pregnancies, post-menopause, pelvic floor trauma
Urge incontinence-Detrusor instability
-Spinal cord pathology (e.g. cord compression, cord injury, MS)
-Urge to pass urine followed by uncontrollable bladder emptying 
Overflow incontinence-Prostatic hypertrophy
-Stricture or stone
-Spinal cord pathology
-Dribbling and poor stream
-Hesitancy
-Elderly male or history of obstruction
Mixed incontinence-Mix of above types
True incontinence-Vesicovaginal or ureterovaginal fistula-Continuous urine leak

Others:

Other differentialsPost-prostatectomy or other pelvic surgery, Bladder stone / tumour, Fistula, Psychogenic

Retention

Exploring symptom

  • Timeframe
    • Duration
    • Onset (sudden or gradual)
    • Progression
    • Timing (intermittent or continuous)
  • Retention
    • Any constipation
    • Previous catheterisation

Relevant system reviews

  • Urological
    • Storage: frequency, volume, urgency, nocturia, incontinence 
    • Infection: dysuria, haematuria, odour
    • Prostatic/voiding (if male): hesitancy, poor flow/dribbling, feeling of incomplete emptying

Differential diagnoses and clues

Urological:

Prostatic hypertrophy-History of hesitancy, poor flow and terminal dribbling
-Elderly male 
Urethral stricture-History of trauma or recurrent catheterisation
Bladder neck obstruction (e.g. tumour, calculus)-May have haematuria
UTI-Dysuria

Others:

UrinaryConstipation (common), Prostatitis, Pelvic mass, Genital Herpes, Clot retention (after bleed, e.g. from tumour), Phimosis
NeurologicalMS, Spinal cord injury/compression 
DrugsAnticholinergic drugs

Here are three questions

A 40 year old male patient presents with abdominal pain. Which features would make you suspicious of renal colic?

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What would be in your differential for this patient?

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Please describe the difference between urethritis, cystitis and pyelonephritis. Please name an infective cause of each.

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Now try some stations!

  1. Renal colic
  2. UTI
  3. Pyelonephritis
  4. Try more now!
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