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Chapter 31 • Urinary Incontinence 381
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U/A and urine culture, as well as determination of
blood urea nitrogen and creatinine levels.
Interference with the nerve supply to the bladder can
result in neurogenic bladder, obstruction, and consequent
overow incontinence, caused by an imbalance between
detrusor muscle contraction and urethral sphincter relaxation. Functional incontinence can also be congenital or
acquired, such as with meningomyelocele or spinal cord
injury, or can be a surgical complication from radical
prostatectomy. On examination, the anal sphincter may
be lax. Neurological testing may reveal decits.
Incontinence from Reversible Factors
Medications
Sedatives, hypnotics, diuretics, anticholinergic agents,
a-adrenergic agents, and calcium channel blockers
can cause incontinence. a-Adrenergic agonists and
b-adrenergic agonists increase sphincter tone and may
cause retention; they can also cause urge incontinence.
Anticholinergics, prostaglandin inhibitors, calcium
channel blockers, and narcotic analgesics decrease
detrusor tone and can produce incontinence. Diuretics
can cause incontinence because of increased production of urine, and CNS depressants such as hypnoticsedatives can interfere with functional ability.
Urinary Tract Infection
The patient with a UTI has symptoms of lower or upper tract infection, such as burning, dysuria, frequency,
urgency, ank pain, and fever. The urine may have a
foul odor. The patient may exhibit suprapubic or costovertebral angle (CVA) tenderness. In infants, a fever
with no localizing signs frequently indicates UTI.
Urine analysis and culture can conrm the diagnosis of
a lower UTI (see Chapter 32).
Vaginitis
Vaginitis produces incontinence as a result of local
irritation. Atrophic vaginitis indicates a loss of estrogen and a concomitant loss of the vesicourethral angle, which predisposes women to stress incontinence.
Provocative stress testing can demonstrate stress incontinence. Microscopy, molecular testing, or culture
can conrm vaginal infection (see Chapter 34).
pain and fecal soiling. On examination, stool may be
felt in the colon and/or ampulla.
Change in Mental or Functional Status
Depression, dementia, and confusion can all produce
incontinence (see Chapter 8). Restricted mobility can
result in incontinence because of loss of functional
ability.
Diabetes Insipidus
In DI, the kidneys are unable to concentrate urine because
of a deciency in the hypothalamic production of ADH
(central DI) or a renal unresponsiveness to ADH (nephrogenic DI). The result is polyuria, which may cause incontinence. The patient also exhibits polydipsia. Urine specic gravity will be less than 1.015.
Diabetes Mellitus
DM often presents with excessive uid intake and
urination. The excess uid volume can result in
incontinence, particularly in older adults with chronic
health problems, restricted mobility, or compromise
in mental or functional health. Urinalysis can screen
for glycosuria. Follow-up testing should check fastin g b lood glu cose lev e ls and hem oglob i n A1c
measurement.
Mixed Incontinence
Patients who experience incontinence as the result of
several anatomical, physiological, or functional factors
are considered to have mixed incontinence.
Enuresis from Organic Causes
Genitourinary Causes
Genitourinary disorders that can produce enuresis
include UTI, ectopic ureter, iatrogenic damage to the
external sphincter, and urethral obstruction. Physical
examination is usually normal. Fever and abdominal
tenderness may be present with a UTI. Anatomical
genitourinary abnormalities may signal an ectopic
ureter. Diagnostic testing includes urinalysis, urine
culture, and specic gravity to rule out infection
and DM. Referral for further evaluation may be
necessary.
Constipation and Fecal Impaction
Constipation or fecal impaction can produce obstructive overow incontinence by mechanical pressure on
the urethra. The patient may experience abdominal
Neurological Causes
Nervous system involvement can also produce enuresis. Lumbosacral disorders affect bladder innervation
and may cause enuresis. Head injury or brain tumor
382 Chapter 31 • Urinary Incontinence
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can cause polyuria and polydipsia. Interference with
the nerve supply to the bladder causes neurogenic
bladder and obstruction, which can result in enuresis.
Interference in innervation can occur from congenital
or acquired causes. Diagnostic testing includes urinalysis, urine culture, and specic gravity to rule out infection and DM. Referral for further evaluation may be
necessary. Some children with sleep apnea have been
found to have an increased atrial natriuretic factor, inhibiting the renin-angiotensin-aldosterone pathway,
causing enuresis.
Enuresis from Nonorganic Causes
Primary Enuresis
Primary enuresis occurs when a child has never
achieved consistent dryness. The normal developmental patterns of micturition follow a characteristic pattern in children but at an individual rate. The usual
progression depends on the maturation of the CNS;
generally, the following stages are seen:
n Birth to 6 months. Bladder emptying is an uninhib-
ited reex action.
n 6 to 12 months. Bladder emptying is less frequent
because of CNS inhibition of reex action.
n 1 to 2 years. Child consciously perceives bladder
fullness; CNS inhibition increases.
n 3 to 5 years. At age 5 years, most children are
aware of bladder fullness; they develop the ability
to inhibit the need to void both voluntarily and unconsciously.
Primary enuresis may represent a developmental delay
or maturational lag. Often there is a family history of
enuresis. The enuresis usually is only nocturnal. The
incidence is higher in boys than in girls and usually
resolves as the child matures. Physical examination is
normal. Diagnostic testing includes urinalysis, urine
culture, and specic gravity to rule out other causes.
Developmental (Secondary) Enuresis
Developmental enuresis, which is secondary, may be
related to changes or stresses in a child’s life. It can also
occur as the result of genital trauma, infection, distended colon, or fecal impaction. The enuresis occurs in
a child who has had a period of dryness of more than
6 months. Diagnostic testing includes urinalysis, urine
culture, and specic gravity to rule out other causes.
Small Bladder
An anatomically small bladder can also produce enuresis. The child voids frequently but not in excessive
volume. Physical examination is normal. Diagnostic
testing includes urinalysis, urine culture, and specic
gravity to rule out other causes.
Sickle Cell Anemia
Children with sickle cell anemia have a concentrating
defect and may experience enuresis because of volume excess. Physical examination ndings are consistent with the sickle cell disorder. Diagnostic testing
includes urinalysis, urine culture, and specic gravity.
DIFFERENTIAL DIAGNOSIS OF Common Causes of Urinary Incontinence
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Incontinence from Anatomical Causes
Stress
incontinence
Urge
incontinence
Small-volume incontinence with
coughing, sneezing, laughing,
running; history of prior pelvic
surgery
Uncontrolled urge to void;
large-volume incontinence;
history of CNS disorders, such
as stroke, multiple sclerosis,
parkinsonism
Pelvic floor relaxation; cystocele,
rectocele; lax urethral
sphincter; loss of urine with
provocative testing; atrophic
vaginitis
Normal examination U/A and culture;
U/A and culture; PVR
normal
PVR normal; office
cystometrography:
,300-350-mL volume;
BUN, creatinine,
urodynamic testing
Chapter 31 • Urinary Incontinence 383
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Urinary Incontinence—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Overflow
incontinence
Incontinence from Reversible Factors
Medications Hypnotics, diuretics,
Urinary tract
infection
(UTI)
Vaginitis Itching, odor Discharge, atrophic vaginitis,
Constipation/
fecal
impaction
Change in
mental or
functional
status
Diabetes
insipidus (DI)
Diabetes
mellitus (DM)
Enuresis from Organic Causes
Genitourinary
causes
Neurological
causes
Enuresis from Nonorganic Causes
Primary
enuresis
Developmental
(secondary)
enuresis
Small bladder Void frequently, not in excessive
Sickle cell
anemia
BUN, blood urea nitrogen; CNS, central nervous system; KOH, potassium hydroxide; PVR, postvoid residual; U/A, urinalysis.
Small-volume incontinence,
dribbling, hesitancy; in men
symptoms of enlarged prostate:
nocturia, dribbling, hesitancy,
decreased force and caliber of
stream; in neurogenic bladder:
history of bowel problems, spinal
cord injury, or multiple sclerosis
anticholinergic agents,
a-adrenergic agents, calcium
channel blockers
Dysuria, urgency, daytime
accidents
Abdominal pain Soiling; stool felt in colon and/or
Change in mental status; impaired
mobility; new environment
History of trauma to head; thirst,
frequency
Thirsty, increased frequency Weight loss U/A; serum glucose
UTI history; dribbling; urine
leakage
Head injury; spinal cord injury;
polydipsia, polyuria; sleep apnea
Child has never been dry; may
have family history
Child has been dry for 6 mo in
a row; changes or stresses in
child’s life
volume
Family history Findings related to sickle cell
Distended bladder; prostate
hypertrophy, stool in rectum;
fecal impaction; in
neurogenic bladder: evidence
of spinal cord disease or
diabetic neuropathy; lax
sphincter; gait disturbance
Normal except for findings re-
lated to other physical
conditions
Frequency, odor, fever U/A and culture
evidence of sexual abuse
ampulla
Impaired mental status; impaired
mobility
Weight loss U/A specific gravity
Fever, abdominal tenderness;
anatomical abnormalities
(ectopic ureter); examination
may be normal
Lax sphincter, spinal tuft, neu-
rological deficits; altered gait;
examination may be normal
Normal examination;
developmental delay
Examine for genital trauma or
abuse, infection, distended
colon, fecal impaction
None Bladder capacity 5 child’s
disease
U/A and culture; PVR
.100 mL; BUN,
creatinine; in
neurogenic bladder,
refer for testing
U/A to rule out urinary
tract problems; blood
chemistry to rule out
systemic problem
Gram stain, KOH, culture
None
U/A and culture; blood
chemistry
.1.015
U/A and culture; specific
gravity; referral for
testing
U/A and culture;
specific gravity; referral
for evaluation
U/A and culture; specific
gravity to rule out other
causes
U/A and culture; specific
gravity to rule out other
causes; screen for
glycosuria
age 1 2, for children
,11 yr
U/A and culture; specific
gravity
384 Chapter 31 • Urinary Incontinence
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REFERENCES AND READINGS
Abrams P, Andersson KE, Birder L, Brubaker L, Cardozo L, Chapple
C et al: Fourth international consultation on incontinence recommendations of the international scientic committee: Evaluation and
treatment of urinary incontinence, pelvic organ prolapse, and fecal
incontinence, Neurourol Urodyn 29:213, 2010.
Alper B, Curry S: Urinary tract infection in children, Am Fam Physician
72:2483, 2005.
American College of Obstetricians and Gynecologists: Urinary
incontinence in women, Obstet Gynecol 105:1533,2005.
Amir B, Farrell SA, Sub-Committee on Urogynaecology: SOGC
Committee opinion on urodynamics testing, J Obstet Gynaecol
Can 30:717, 2008.
Burkhart KS: Urinary incontinence in women: assessment and manage-
ment in the primary care setting, Nurse Pract Forum 11:192, 2000.
Culligan P, Heit M: Urinary incontinence in women: evaluation and
management, Am Fam Physician 62:2433, 2000.
Graham K, Levy J: Enuresis, Pediatr Rev 30:165, 2009.
Hay-Smith EJ, Bo Berghmans LC, Hendriks H, de Bie RA, van
Waalwijk van Doom ES: Pelvic oor muscle training for urinary
incontinence in women, Cochrane Database Syst Rev 1:
CD001407, 2001.
Hoebeke P, Bower W, Cooms D, Dejong T, Yang S: Diagnostic
evaluation of children with daytime incontinence, J Urol 183:699,
2010.
Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, Straus SE: What
type of urinary incontinence does this woman have? JAMA
299:1446, 2008.
Ma JF, Shortliffe LM: Urinary tract infection in children: etiology
and epidemiology, Urol Clin North Am 31:517, 2004.
Martin JL, Williams KS, Abrams KR, Turner DA, Sutton AJ,
Chapple C et al: Systematic review and evaluation of methods
of assessing urinary incontinence, Health Technol Assess 10:1,
2006.
Rogers RG: Urinary stress incontinence in women, N Engl J Med
358:1029, 2008.
Vapnek JM: Urinary incontinence: screening and treatment of urinary
dysfunction, Geriatrics 56:25, 2001.
Zorc J, Kiddoo D, Shaw K: Diagnosis and management of pediatric
urinary tract infections, Clin Microbiol Rev 18:417, 2005.
C H A P T E R
https://t.me/med1917
32
Urinary Problems in Females and Children
ommon adult female urinary concerns
include changes in usual urination patterns
C
nence), changes in urine appearance (color, clou
diness), and pain (dysuria, flank pain, or suprapubic
pain).
by infection, inammation, calculi (stones), congeni
tal malformation, or trauma. The majority of urinary
tract infections (UTIs) are caused by gramnegative
bacteria, predominantly Escherichia coli. The sexu
ally transmitted pathogens Chlamydia trachomatis,
Neisseria gonorrhoeae, and herpes simplex are
common causes of urethritis. Vaginitis can also cause
urinary symptoms in women. Urinary stones can
occur anywhere in the urinary tract and are common
causes of pain, bleeding, obstruction, and secondary
infection.
clinical disease of childhood, following respiratory
tract disorders. The symptoms of urinary tract dis
order may be vague or absent, making the diagnosis
easily overlooked. Infection may be present without
symptoms, with symptoms that are obviously re
lated to the urinary system, or with symptoms that
may divert attention to another organ system prob
lem. Abdominal masses in the newborn are most
frequently caused by renal enlargement, specifi
cally dysplastic kidney and/or congenital hydrone
phrosis. Vesicoureteral reflux (VUR) is the major
structural abnormality associated with UTI and
renal damage.
etrating, blunt, or crushing injuries, or by surgery or
instrumentation. Hematuria, oliguria, and pain are the
most common symptoms.
(frequency, urgency, nocturia, inconti
Urinary problems in adult females can be caused
In children, UTI is the second most common
Trauma to the urinary tract may be caused by pen
DIAGNOSTIC REASONING:
FOCUSED HISTORY
Are there systemic or upper urinary tract
symptoms present?
Key Questions
n Have you had a fever or chills?
n Have you had nausea or vomiting?
n Have you had acute pain in the abdomen or back?
n Are you positive for HIV infection? Are you receiving
chemotherapy?
n In an infant: Has the infant been irritable or had
anorexia or lethargy?
Fever and Chills
The presence of fever and chills suggests a systemic
inammatory response and indicates an acute condi
tion that should be treated aggressively. Suspect pyelo
nephritis or lithiasis of the upper urinary system. UTI
is the most common bacterial infection in febrile
infants and children who present without an obvious
source of infection.
Nausea and Vomiting
Nausea and vomiting often accompany upper UTI,
pyelonephritis, or lithiasis. Like fever and chills, these
symptoms suggest a systemic inammatory response and
indicate that the patient may be acutely ill. In newborns
and infants, nonspecic symptoms, such as vomiting,
diarrhea, and feeding difculties, may indicate UTI.
Acute Pain
Acute pain in the back or abdomen suggests upper UTI
and pyelonephritis. Flank pain occurs with stretching
of the renal capsule associated with parenchymal
385
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swelling, and may indicate infection, obstruction, or
primary renal disease.
Urinary tract stones may produce localized back
pain or excruciating pain that often radiates to the
thigh.
Immunocompromised Patients
Immunocompromised patients are susceptible to over
whelming infections by both common and atypical
organisms, and aggressive investigation is warranted.
Irritable Infant
UTI in neonates and infants is manifested in subtle
ways, such as irritability, anorexia, and weight loss.
Some infants with UTI present with bacteremia.
Is there hematuria?
Key Questions
n Have you had blood in your urine? When in the
stream does it occur?
n Do you have pain with urination?
n Do you have bleeding without urination?
n Have you done any strenuous exercise recently?
Hematuria
Redtobrown discoloration is commonly caused by
infection, trauma, or urinary tract stones. It can also be
caused by parenchymal renal disease, systemic dis
ease, medications, or coagulopathies.
Pyelonephritis or urinary tract stones are common
causes of gross (macroscopic) hematuria. Neoplasm,
trauma, and some medications can also produce
gross hematuria. Gross hematuria occurs in 60% to
90% of bladder tumors. Both bladder and renal neo
plasms are less common in women than in men.
Hematuria can be produced by local irritation in cys
titis. Platelet disorders and hemophilia can cause
both gross and microscopic bleeding. Urinary fre
quency or urgency, dysuria, or suprapubic pain sug
gests that the origin of hematuria is conned to the
lower urinary tract.
Initial hematuria (at the beginning of urination) sug
gests the urethra is the source, whereas terminal hema
turia (at the end of urination) suggests posterior urethra
or bladder base involvement. Total hematuria means
red blood cells are dispersed throughout the urinary
stream, characterizing origination in the kidney, ureter,
or bladder.
Pain
Hematuria without pain is usually caused by renal dis
ease or tumor of the bladder or kidney. Other causes of
painless hematuria include stones, polycystic kidney
disease, renal cysts, sickle cell disease, and hydrone
phrosis. When discomfort, such as renal colic, accom
panies hematuria, suspect a ureteral stone. Hematuria
with dysuria suggests bladder infection or lithiasis.
Bleeding Without Urination
Bladder lesions may produce bleeding independent of
micturition.
Strenuous Exercise
Transient hematuria is frequent after strenuous exer
cise, and the amount of bleeding is proportional to the
amount of exercise and the trauma sustained by
the urinary tract. Exerciserelated hematuria is caused
by direct trauma to the kidneys and bladder, as well as
by ischemic injury. It is caused by the shifting of blood
ow from the renal circulation to the heart, lungs,
and skeletal muscles during periods of high oxygen
demand.
Can the symptoms be localized to the lower
urinary tract?
Key Questions
n What are your primary symptoms (e.g., pain, fre
quency, urgency, small amounts of urine, nausea,
nocturia, itching)?
n Have you had any suprapubic pain?
n Do you have involuntary urination?
Primary Symptoms
Dysuria suggests inammation of the bladder neck or
urethra, usually caused by bacterial infection or irrita
tion that injures the bladder mucosa, leading to inam
matory changes, inltration, and edema. These changes,
from mild stretching of the bladder to a loss of bladder
elasticity, can result in urgency and frequency.
Dysuria is the cardinal symptom of uncomplicated
lower urinary tract infection (acute bacterial cystitis). In
children, it may also be the rst indication of an ana
tomical lesion such as obstruction of the urinary tract or
VUR. Other common symptoms include frequency,
mild nausea, nocturia, urgency, and voiding small
amounts. Fever is notably absent. Infants may have
strongsmelling urine and continuously damp diapers.
Chapter 32 • Urinary Problems in Females and Children 387
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Dysuria also suggests urethritis, especially if ac
companied by vaginal discharge. External dysuria, a
burning sensation as the urine passes the inamed
labia, suggests vulvovaginitis. Patients with vulvo
vaginitis may also report discharge, odor, or itching.
Women who have active herpes lesions may also expe
rience external dysuria. Young children with pinworms
(Enterobius vermicularis) may have dysuria and vagi
nitis because of the abrasions that result from periure
thral and perivaginal itching and scratching.
Interstitial cystitis produces diminished bladder
capacity along with symptoms of frequent painful uri
nation. Hematuria may be present. Increased frequency
can also occur as a result of stones or a tumor.
Suprapubic Discomfort and Urinary
Incontinence
Discomfort in the suprapubic area is indicative of blad
der involvement and urinary incontinence and is char
acteristic of bladder neck irritability caused by inam
mation. Local causes of incontinence can also include
pelvic relaxation and impaired bladder muscle activity.
Preschoolage children with UTIs frequently have
enuresis (see Chapter 31).
Could this be the result of trauma?
Key Questions
n Have you had any recent injury?
n Have you been hit recently?
n If a child: Have you noticed the child putting
foreign objects in his or her genitourinary tract?
Recent Injury
Injury or a blow to the ank area can produce hema
turia, originating from the kidney. Straddle injury
may result in abrasions and local inammation, caus
ing pain on urination. About 5% of childhood trauma
involves the kidney, making it a relatively uncommon
event. About 10% of the injured kidneys have under
lying abnormalities, such as hydronephrosis or a
horseshoe shape, making them more vulnerable to
injury.
Trauma
A victim of domestic violence may present with blood
in the urine secondary to trauma. Trauma may or may
not be associated with pain. Active children may not
remember trauma to the area.
Foreign Objects
Children have a propensity to put foreign objects in
any orice. Placing foreign objects in the vagina can
cause dysuria and pyuria.
Could this be genitourinary in origin?
Key Questions
n Are you sexually active? How frequently do you
engage in sexual activity?
n Have you had a new sexual partner recently?
n How many sexual partners do you have?
n Does your sexual partner have any symptoms?
n Do you use a diaphragm?
n Do you have any vaginal discharge?
n If a postmenopausal woman: Are you on hormone
replacement therapy?
Sexual Activity
Factors that contribute to the development of acute
bacterial cystitis include frequent sexual intercourse,
use of a diaphragm, and use of spermicidal gel for
contraception. Urethritis is associated with a history
of a new sexual partner, a partner with urethritis, and
multiple sexual partners. Masturbation may also
cause dysuria in girls, as a result of either local irrita
tion or the introduction of organisms that produce a
lower UTI.
Organisms from sexually transmitted infections can
cause urethritis when they are present in large numbers
in the urethra. A local inammatory response results.
C. trachomatis is the most common pathogen, al
though N. gonorrhoeae, Trichomonas vaginalis, and
herpes simplex can also cause urethritis. Active herpes
lesions can also produce dysuria as the urine passes
across the inamed external mucosa.
Diaphragm Use
Some women who use a diaphragm experience
mechanical compression of the urethra, with subse
quent urine retention that predisposes them to the
development of cystitis.
Vaginal Discharge and Hormone Therapy
Vaginal infections are a common cause of dysuria,
particularly in collegeage women. Atrophic vaginitis
can also cause dysuria. Postmenopausal women who
are not on hormone therapy are more likely to have
atrophic vaginitis.
388 Chapter 32 • Urinary Problems in Females and Children
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Urge To Urinate
Are there any specic risk factors to point me
in the right direction?
Women who ignore the urge to urinate or who post
pone urination are predisposed to the development of
bacterial cystitis. Urine in the bladder for a prolonged
Key Questions
n Have you had this or similar problems before? If
yes, when and how many times?
n Have you had recent catheterization or urinary tract
procedures performed?
n Is there a family history of kidney or urinary problems?
n Do you have diabetes?
n How much spicy food, caffeinated beverages/food,
carbonated beverages, or alcohol do you consume?
n How much water do you drink?
n Do you suppress the urge to urinate (postpone
period promotes bacterial growth.
to stop urination may have a UTI. Uncontrolled bladder
contractions against a closed bladder sphincter cause
the behavior. These children may develop vesicoure
teral reux and infection.
Bubble Bath and Hygiene Products
Common chemical irritants can cause dysuria without
infection. The most common irritant, particularly in
children, is found in bubble baths.
urination)?
n Do you use bubble baths, shampoos, feminine hygiene
products, powders, and soaps?
n Do you have constipation?
Constipation
Mechanical factors related to compression of the
bladder and bladder neck by a hard mass of stool
from constipation may cause UTI. There is also
History of Similar Problems
Patients with previous urinary problems are at risk for
chronic relapsing conditions, such as unresolved infec
a relationship between constipation and dysfunc
tional voiding accompanied by incomplete bladder
emptying.
tions, resistant strains of organisms, or reinfection.
Recent Instrumentation
Recent instrumentation in the urinary tract places the
patient at risk for infections.
Family History of Urinary Problems
Key Questions
n Have you had recent treatment for a sexually trans
n Have you been diagnosed with, but not treated for,
A family history of renal or urinary tract problems
places the patient at increased risk for urinary tract dis
orders. A family history of deafness or renal insuf
n Have you had excessive urination?
n Have you had a sore throat or been treated for strep
ciency suggests hereditary nephritis or Alport syndrome.
Girls who have a history of squatting or leg crossing
What else could this be?
mitted infection?
a sexually transmitted infection?
throat recently?
History of Diabetes Mellitus
Diabetes mellitus is associated with recurrent bacterial
cystitis.
Types of Food Consumed
Dysuria without pyuria can be caused by chemical irritants
such as spicy foods, caffeine, carbonation, and alcohol.
Decreased Fluid Intake
Decreased uid intake and concentrated urine pro
duce an irritant effect on bladder mucosa and may
cause dysuria without pyuria. It can also predispose
to the development of bacterial cystitis.
Sexually Transmitted Infections
Because vaginitis can cause urinary tract symp
toms in females, a sexually transmitted vaginitis
may be producing symptoms. Recent treatment
for a sexually transmitted infection may indicate
treatment failure, a coinfection that was not covered
by the prescribed drug, or a reinfection (see
Chapter 34).
Excessive Urination
The presence of polyuria suggests diabetes mellitus or
diabetes insipidus. Women with diabetes mellitus are
also prone to development of UTIs.
Chapter 32 • Urinary Problems in Females and Children 389
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Recent Streptococcal Infection
Poststreptococcal glomerulonephritis may develop
after a 1 to 3week latency period following pharyn
geal or skin infections with certain strains of group
A b hemolytic Streptococcus. The peak incidence is
at age 7.
DIAGNOSTIC REASONING:
FOCUSED PHYSICAL EXAMINATION
Note General Appearance
A patient who appears ill or who is pacing in pain is
likely to have an upper urinary tract problem, such as
pyelonephritis or urolithiasis. Patients with lower uri
nary tract problems usually do not present with signs
of systemic involvement, are free of fever, and gener
ally appear well. Neonates present with malaise, irrita
bility, and difculty feeding. Toddlers and preschoolers
appear ill with nausea, vomiting, and diarrhea.
Obtain Vital Signs, Height, and Weight
Failure to thrive is a common presenting sign of
urinary tract disease in neonates or young children.
Hypertension is seen in patients with nephritis.
Examine the Skin
Neonates with UTIs may present with jaundice.
Inspect the Perirectal Area
Inspect the skin and hair for inammation, lesions,
parasites, and dermatitis. Note inammation, presence
of lesions, or vaginal discharge. Observe for the pres
ence of labial adhesions that might predispose the child
to perineal bacterial colonization. Note personal hy
giene. External excoriation could be the cause of burn
ing or pain on urination. Note if there are any abra
sions, tears, or bruising present, which might indicate
trauma and/or sexual abuse.
Perform a Pelvic Examination If Indicated
A pelvic examination is essential if you suspect vaginitis
or vulvovaginitis as a cause of the urinary tract
symptom(s). On external examination, observe for blad
der or uterine prolapse. On internal examination, note
vaginal color, moistness, rugation, and characteristics of
discharge. Pale, dry mucosa with lack of rugation char
acterizes atrophic vaginitis in a mature woman. Vaginal
discharge not characteristic of physiological discharge
suggests a vaginal infection. (For discussion of vulvo
vaginitis, see Chapter 34.) Determine rectal tone. An
atonic anal sphincter suggests a neurogenic bladder. Rec
tal examination for fecal impaction is indicated if the
history suggests signicant constipation or encopresis.
Palpate and Percuss for Flank Pain and
at the Costovertebral Angle Bilaterally
Pain that is reproducible is indicative of renal capsule
distention and characterizes acute pyelonephritis or
acute ureteral obstruction.
Palpate and Percuss the Abdomen
Polycystic kidneys may produce abdominal disten
tion. A ank mass may indicate a hydronephrotic
kidney. Pain in the lower quadrant indicates lower
ureter involvement. Suprapubic tenderness is charac
teristic of lower UTI. Perform deep palpation to
identify kidneys or other abdominal masses. Normal
kidneys are usually not easily palpated. A distended
bladder rises above the symphysis pubis and is
characteristic of residual urine resulting from incom
plete bladder emptying. Palpation of an enlarged
bladder may cause pain. In hypertensive patients,
auscultate at the subcostal anterior abdomen for
bruits that could indicate a renovascular cause of
hypertension.
LABORATORY AND DIAGNOSTIC
STUDIES
The extent of diagnostic investigation is determined by
the history and the ndings of the examination. The
symptoms reported by the patient are taken into account
when ordering diagnostic tests to corroborate or verify the
diagnosis. General screening tests can be used to provide
additional data for patients with urinary tract problems.
Urine should be freshly voided and usually taken
midstream. If not examined immediately, the specimen
should be refrigerated because cells begin to disinte
grate after 1 to 2 hours.
Urine Dipstick
Reagent strips can be used to screen urine in the clini
cal setting.
Specific Gravity
Urine specic gravity depends on the patient’s
hydration. The urine pH also depends on the level
of hydration, as well as acidbase status, time of
390 Chapter 32 • Urinary Problems in Females and Children
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urine collection, diet, and drugs that may affect the
urine pH.
Leukocyte Esterase
The leukocyte esterase strip is calibrated to turn
purple in 60 seconds, indicating 5 or more white
blood cells in the urine. A positive test is indicative
of urethritis (75% to 90% sensitivity, 95% specic
ity). Urine that tests positive for leukocyte esterase
should be cultured for bacteria. Vaginal infection
with Trichomonas can produce false positive results;
diets high in vitamin C can produce false negative
results.
Nitrite
The nitrite strip is calibrated to turn pink within
30 seconds and signies nitrite produced by 105 or
more organisms/mL. Urine that tests positive for
nitrites should be cultured for bacteria. However,
note that some organisms that cause UTIs do not
convert nitrates to nitrites (e.g., Staphylococcus and
Streptococcus).
Protein
The normally small amount of protein excreted by a
healthy adult is usually not detectable by dipstick
analysis until the patient excretes 150 to 300 mg/day.
At this level, the patient will show trace amounts. In
healthy persons, urine contains no protein or only
trace amounts of proteins, which consists of albumin
and globulins from the plasma. Glomeruli usually
prevent the passage of protein from the blood to the
glomerular ltrate; therefore, the persistent presence
of protein in urine is a strong indication of renal
disease. If more than a trace amount of protein is
found, then a quantitative 24hour evaluation is nec
essary. False positive results can occur with alkaline
urine.
If the patient has trace levels of proteinuria, then
the use of 20% sulfosalicylic acid testing for protein
is appropriate. Add 8 drops of 20% sulfosalicylic acid
to a sample of fresh, concentrated urine. Protein con
centration is directly proportional to the degree of
white turbidity produced. The absence of white tur
bidity indicates a false positive result by dipstick
analysis.
A typical scale to indicate progressively increasing
amounts of protein is 11 (30 mg/dL), 21 (100 mg/dL),
31 (300 mg/dL), and 41 (500 to 1000 mg/dL). Peripheral
edema and ascites may be present in an adult who has
31 or 41 proteinuria, and is typically excreting 3 g
or more of protein per day. Proteinuria reported for a
single urinalysis is not an absolute guide in a differen
tial diagnosis because proteinuria may be glomerular or
tubular.
Glucose
Glucose in the urine is indicative of an elevated serum
glucose concentration greater than 200 mg/dL. If serum
glucose levels are normal while urine glucose level is
elevated, then proximal renal tubular damage should be
suspected.
Ketones
Ketones are detected earlier in the urine than in
the blood and may indicate starvation or diabetic
ketoacidosis.
Blood
Reagent strips are calibrated to detect the red blood
cells (RBCs) that are present. The strip detects heme at
0.05 to 0.3 mg of hemoglobin/dL (see later paragraph
titled Red Blood Cells).
Urinalysis with Microscopic Examination
Color
The urine should be clear to yellow, depending on
the concentration. The precipitation of calcium
phosphate or urates can turn the urine milky, espe
cially when stored in the refrigerator. Warming the
urine to body temperature causes these precipitated
salts to return to solution, removing the milky ap
pearance. Methylene blue and indigo blue can make
the urine blue. Vegetable dyes and paint from toys
ingested by young children can turn their urine vari
ous colors. Brown urine is often observed in glo
merulonephritis. Turbidity with a foul odor indicates
infection. Color changes of the urine may result
from various sources: hemoglobin from systemic
red blood cell lysis; myoglobin from damaged mus
cle cells or rhabdomyolysis; vegetable pigments
from food, such as red beets; pigments from drugs,
such as rifampin and phenazopyridine; or porphy
rins from porphyria.
Discoloration of the urine should be investigated
with microscopic examination to determine if RBCs or
any foreign substances are present. Pyuria results from
white blood cell (WBC) debris and leukocytes in the
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