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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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428 SYMPTOM SORTER
Painless frank haematuria is an ominous sign indicating possible malignancy.
Beware of recent onset of recurrent cystitis with haematuria in the elderly. e underlying
cause may be a bladder tumour, especially if the haematuria (micro- or macroscopic) does
not settle with treatment of the infection.
Renal tumours can sometimes present with renal colic, as blood clots in the ureters mimic
the eects of stones. A useful clue is that the bleeding may precede the pain.
Haematuria requires emergency admission if there is signicant blood loss or clot retention.
Remember the possibility of chronic ketamine abuse in young people.
NOTES:
https://t.me/med1917
429
DYSURIA
The GP Overview
Dysuria is a very common symptom which is likely to be welcomed by the busy duty doctor,
given that the diagnosis and management are usually straightforward. It’s worth bearing in
mind, though, that there are occasional causes other than ‘cystitis’, especially in recurrent or
unresolving cases. A lso, genuine repeated infections can sometimes be a sign of some underlying
problem.
Differential diagnosis
COMMON
lower UTI (commonly referred to as ‘cystitis’)
upper UTI (i.e. acute pyelonephritis)
STD
peri-urethral inammation (i.e. vulvitis in females and balanitis in males)
painful bladder syndrome (aka urethral syndrome, interstitial cystitis)
OCCASIONAL
chemical urethritis (e.g. from soap/bubble bath – common problem but unusual to present
to the GP)
bladder stone
prostatitis
trauma (including child abuse)
urethral stricture
RARE
bladder tumour
Behcet’s syndrome
schistosomiasis
tuberculosis
benign prostatic hypertrophy/overactive bladder (common problems but rarely present with
dysuria)
endometriosis
ketamine-associated ulcerative cystitis
https://t.me/med1917
430 SYMPTOM SORTER
Ready Reckoner
Lower UTI Upper UTI STD Peri-urethral
inammation
Painful bladder
syndrome
Systemic upset No Yes No No No
Recurring problem Possible Possible No Possible Ye s
MSU positive Possible Possible No No No
Vaginal/urethral discharge No No Possible Possible No
Visible external abnormality No No Possible Ye s No
Investigations
LI KE LY: Urinalysis, MSU, swabs and other investigations for STD.
POSSIBLE: Vulval/vaginal swab (for non-STD causes), cystoscopy and abdominal ultrasound,
hospital based urological investigations, gynaecological investigations.
SMALL PRINT: FBC, ESR/CRP, EMU, serological testing.
Urinalysis: If nitrite positive, very likely UTI, if only leucocytes positive probable UTI, but
if nitrite and leucocyte negative UTI very unlikely; UTI may also cause proteinuria and
haematuria; positive ndings in various other scenarios (e.g. leucocytes positive in STD, TB,
peri-urethral inammation, blood positive in stone and tumour).
MSU: To conrm any suspected infection; sterile pyuria in STD, TB, peri-urethral
inammation; microscopy may reveal schistosomiasis eggs.
STD investigations: In suspected STD, usually arranged in local GUM clinic.
Other vulval/vaginal swab: In the presence of a discharge when STD not suspected (e.g. to
conrm thrush).
Cystoscopy and ultrasound: May be necessary in recurrent UTI to exclude any underlying
problem, or in persistent or recurrent dysuria when the diagnosis is unclear (may reveal, for
example, bladder stone, enlarged prostate or bladder tumour).
Hospital based urological investigations (e.g. for young children with recurrent or severe
UTI).
FBC, ESR/CRP: Raised white cell count and inammatory markers in acute prostatitis;
eosinophilia in schistosomiasis.
EMU: ree EMUs for microscopy and culture for suspected TB.
Serological testing: For suspected schistosomiasis.
Gynaecological investigations: Usually in secondary care, if endometriosis suspected.
TOP TIPS
In a clear case of lower UTI in women under 65, it is reasonable to make the diagnosis – with
appropriate safety netting – without urinalysis or MSU.
https://t.me/med1917
DYSURIA 431
Remember peri-urethral inammation as a potential cause. is is particularly common
in children who are oen presented as ‘another water infection’ when, in fact, they have
balanitis or vulvitis.
A ‘negative’ (for growth) MSU packed with pus cells is not ‘normal’. ere are many possible
explanations, including STD, peri-urethral inammation and TB.
Re-test the urine aer treatment of lower UTI if there is visible or non-visible haematuria,
and consider further investigations if the haematuria persists.
Acute prostatitis is probably under-diagnosed. Suspect it if a man presents with UTI-type
features plus sudden onset of obstructive urinary symptoms and systemic upset. If managed
in the community, these men require two weeks of antibiotic.
Take care when triaging – pressure of work may mean a rushed assessment. Remember that
dysuria might be just one part of an acute pyelonephritis, so enquire specically about fever,
rigors and systemic upset. ese patients will need to be seen and may need admission.
Remember that recurrent lower UTIs occasionally have an underlying cause. In particular,
beware the older patient with little or no previous history of UTIs suddenly experiencing
recurrent or persistent problems – there could be an underlying bladder tumour.
Do not overlook the possibility of an STD which is commonest in, though not restricted
to, the younger age groups. Ask about this possibility, other relevant symptoms, and sexual
history.
Remember to investigate children with recurrent or severe UTI according to prevailing
guidance.
Bear in mind that unexplained dysuria in children may occasionally be a sign of abuse.
UTIs are much less common in men – refer for investigation if recurrent.
Remember the possibility of chronic ketamine abuse in young people.
https://t.me/med1917
432
EXCESSIVE URINATION
The GP overview
Polyuria is a highly subjective symptom and one which presents rather less oen than urinary
frequency (which is dealt with separately, see p. 431). Most of the causes of polyuria listed here
are also, by implication, causes of polydipsia – the only causes of true polydipsia not included
are those due to dehydration.
Differential diagnosis
COMMON
diabetes mellitus (DM)
diuretic therapy
chronic kidney disease (CKD)
hypercalcaemia (e.g. osteoporosis treatment, multiple bony metastases, hyperparathyroidism)
alcohol
OCCASIONAL
potassium depletion: chronic diarrhoea, diuretics, primary hyperaldosteronism
relief of chronic urinary obstruction
drugs: lithium carbonate, demeclocycline, amphotericin, glibenclamide, gentamicin
cranial diabetes insipidus (hypothalamo-pituitary tumour, skull trauma, sarcoidosis or
histiocytosis X)
Cushing’s disease from excessive corticosteroid doses and ACTH-secreting bronchial
carcinoma
sickle-cell anaemia
early chronic pyelonephritis
RARE
psychogenic polydipsia (compulsive water drinking)
supraventricular tachycardia
DIDMOAD syndrome (diabetes insipidus, diabetes mellitus, optic atrophy, deafness:
autosomal recessive)
familial cranial diabetes insipidus (autosomal dominant inheritance)
familial nephrogenic diabetes insipidus (males only: X-linked recessive)
Fanconi syndrome
https://t.me/med1917
EXCESSIVE URINATION 433
Ready reckoner
DM Diuretic therapy CRF Alcohol
High Ca
2+
Marked thirst Ye s No No No Ye s
Other abnormalities on urinalysis Possible No Possible No No
Abdominal pain and vomiting Possible No No No Ye s
Episodic No Possible No Ye s No
Anorexia/weight loss Yes No Possible No Possible
Possible investigations
LI KE LY: Urinalysis, fasting glucose or HbA1c.
POSSIBLE: FBC, U&E, serum calcium.
SMALL PRINT: Blood lm, further specialist investigations (see below).
Urinalysis: Glucose and possible ketones in diabetes; possible haematuria and proteinuria
with renal problems; specic g ravity very low in d iabetes insipidus and psychogenic polydipsia.
Fasting glucose or HbA1c: To conrm diabetes mellitus.
FBC: Normochromic anaemia in CKD; lm for sickle-cell anaemia.
U&E: To detect potassium deciency and abnormalities suggesting CKD.
Serum calcium: Elevated in hypercalcaemia.
Further specialist investigations: Many of the aforementioned causes will need further
investigation in secondary care to establish underlying aetiology (e.g. ultrasound and renal
biopsy in CKD, water deprivation test for diabetes insipidus, CT scan if possible pituitary
lesion, and so on).
TOP TIPS
Take time to clarify the symptoms. It is essential to dierentiate polyuria from frequency, as
the causes are very dierent.
Remember alcohol as a possible cause, especially in young males. Patients can be surprisingly
slow to make quite obvious connections.
Refer for more detailed investigation if the symptoms are clear-cut and baseline tests draw
a blank.
https://t.me/med1917
434 SYMPTOM SORTER
Diabetes mellitus is not the only cause of polyuria with thirst. If urinalysis is negative for
sugar, consider diabetes insipidus or hypercalcaemia.
Weight loss and cough in a smoker with polyuria suggests a possible ACTH-secreting
tumour. Arrange an urgent CXR.
If urinalysis reveals glucose and ketones in a known or new diabetic, arrange for urgent
assessment with a view to admission for stabilisation.
Renal disease is likely in patients with polydipsia who have blood and protein on urinalysis.
NOTES:
https://t.me/med1917
435
FREQUENCY
The GP overview
is means an increased frequency of micturition, and is usually associated with the passage
of small amounts of urine. It is not the same as increased production of urine (see ‘Excessive
urination’). It is a commonly presented problem, aecting women far more oen than men: e
average GP will deal with around 60 cases of cystitis (the main cause) each year.
Differential diagnosis
COMMON
infective cystitis
anxiety
overactive bladder syndrome
bladder calculus
lower urinary tract symptoms (LUTS) in men secondary to benign prostatic enlargement
OCCASIONAL
interstitial cystitis (non-infective)
prostatitis
pregnancy
ureteric calculus (in lower third of ureter precipitates reex frequency)
urethritis, pyelonephritis
iatrogenic (e.g. diuretics)
bladder neck hypertrophy
‘habit frequency’
RARE
pelvic space-occupying lesion, e.g. broid, ovarian cyst, carcinoma
secondary to pelvic inammation: PID, appendicitis, diverticulitis, adjacent tumour
bladder tumour (benign or malignant), prostate cancer
post-radiotherapy brosis (testicular, ovarian and prostatic cancer)
tuberculous cystitis/renal TB
brosis secondary to chronic sepsis from long-term catheter drainage
ketamine-associated ulcerative cystitis
https://t.me/med1917
436 SYMPTOM SORTER
Ready reckoner
Anxiety Infective
cystitis
Overactive bladder
syndrome
LUTS Bladder
calculus
Dysuria No Ye s No No Possible
Eased when prone No No No No Ye s
Hesitancy, slow ow No No No Ye s Possible
Nocturnal frequency No Ye s Ye s Possible No
Abnormal urinalysis No Ye s No Possible Ye s
Possible investigations
LI KE LY: Urinalysis, MSU, urinary frequency volume chart.
POSSIBLE: Urethral swab, PSA, uroowmetry, urodynamic studies, plain abdominal X-ray, renal
imaging, cystoscopy, CA-125.
SMALL PRINT: Pelvic ultrasound, U&E, pregnancy test and three EMUs for TB.
Urinalysis: Protein, nitrites, leucocytes and possible haematuria in infection; possible stone
or tumour if blood alone.
MSU: Microscopy may show abnormal epithelial cells, blood, pus and help identify pathogen
in infection.
Urinary frequency volume chart: May be useful in men with LUTS.
Swab any urethral discharge present for Chlamydia and gonorrhoea.
CA-125: May be useful if ovarian cancer suspected.
EMU: For pregnancy test; also three EMUs to check for TB if suspected (e.g. sterile pyuria).
U&E: Check if assessment suggests chronic sepsis or outow obstruction.
PSA: Consider this if LUTS in male.
Specialist tests include: Uroowmetry (for LUTS, urodynamic studies (for unstable bladder),
renal imaging and cystoscopy (for stones and tumours) and ultrasound (for pelvic masses or
if CA-125 elevated).
TOP TIPS
Frequency due to anxiety is typically long term, worse with stress and cold weather, and is
associated with a normal urinalysis.
It is reasonable to make an empirical diagnosis of overactive bladder syndrome in a
nonpregnant female with frequency in whom CA-125, pelvic examination and urinalysis
are entirely normal.
An unrecognised pregnancy may present with frequency – ask about periods, and do a
pregnancy test if a period has been missed.
https://t.me/med1917
FREUENCY 437
In the elderly, a bladder tumour may present as cystitis. If a new, recurring problem, or
haematuria attributed to the cystitis does not settle with antibiotics, consider referral.
Do not ignore sterile pyuria on the MSU – possible causes include urethritis and TB.
e adult patient with frequency who has persistent microscopic haematuria but no other
abnormalities on urinalysis may have a stone or tumour. Refer.
Appendicitis can cause mild frequency and pyuria. Do not be misled by the urinalysis into
an inappropriate diagnosis of UTI – act according to the clinical ndings.
UTI in infancy is a major cause of renal failure. Manage according to NICE guidance.
Remember the possibility of chronic ketamine abuse in young people.
NOTES:
https://t.me/med1917
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