COMPLAINT OF THE UROLOGY PATIENT

1. Urinary Symptoms A. Irritative urinary symptoms Burning, urgency, frequency. Caused by irritation of the sensory autonomic nerves underneath
the bladder mucosa in the trigone. Nerve irritation is either: (i) mechanical from stone friction with the trigonal mucosa while the patient is moving during day time causing diurnal frequency with burning and urgency; or (ii) inflammatory from cystitis causing the same symptoms day and night.

B. Obstructive urinary symptoms Lesions in the bladder neck or urethra, e.g. stone, stricture, congenital urethral valve, BPH,
prostate carcinoma etc. These lesions can cause either partial or complete obstruction:

Partial obstructive urinary symptoms Hesitancy, weak stream, straining, interruption of the stream, bifurcation of the stream, terminal dribbling. Complete obstructive urinary symptom Acute retention of urine. Also review chapter on Retention of Urine. C. Other urinary symptoms Red urine Hematuria; review chapter on Hematuria. Drug induced; e.g. Rifampicin antibiotic. Certain food products; e.g. beetroot ( ). Turbid urine Pyuria; turbid urine from presence of excessive pus cells in the urine. Phosphaturia; phosphate crystals precipitate in alkaline urine causing turbid urine. Uricosuria; uric acid crystals dissolve in body temperature. However, they precipitate in room
temperature causing turbid urine. For this reason, urine rich in uric acid crystals is clear when freshly voided, and becomes turbid after a few minutes when reaching room temperature.

Incontinence and leak of urine

Review chapter on Incontinence and Leak of Urine.

Anuria No micturition and no desire to micturate in association with an empty bladder from cessation of the kidneys to produce urine. Pre-renal anuria; if the patient is in shock.

 Renal anuria; after acute tubular necrosis or end stage renal failure. Post-renal anuria; after iatrogenic ligation of both ureters during a difficult hysterectomy or
complete impaction of a ureteral stone draining a solitary kidney. Post- renal anuria is a urological complication, and is managed by the urologist.

2. Urethral Discharge Not Related to Micturition A. Bleeding per urethra (bloody discharge) - Caused by bleeding from a lesion in the male distal urethra (penile or bulbous urethra); i.e. from a lesion distal to the external urethral sphincter. - Common causes: injury of the bulbous urethra, impacted stone in the penile urethra, warts in the penile urethra. - Presentation: patient notices a blood stain in his underwear. B. Purulent discharge - Caused by venereal diseases; e.g. Gonorrhea or Chlamydea. - Presentation: patient notices a yellow stain in his underwear. C. Prostatorrhea - Caused by hypersecretion from the para-urethral glands in young adults who are sexually active and are sexual abstinent (paraurethral gland secretion contributes to the
normal semen fluid. Even though the paraurethral glands are present at the level of the prostatic urethra, their draining ducts pierce the pelvic diaphragm to open in the bulbous urethra distal to the external urethral sphincter).

- Presentation: a colorless viscid stain is noticed emerging from the urethral meatus. 3. Renal Pain A. Renal colic A newly formed small stone in the kidney is showered with urine flow to the ureter. During its descent, the ureteric muscle (at any level) undergoes sudden reflex spasm around the stone which is considered a foreign body. The stone becomes impacted in the ureter in spite of its small size. Muscle spasm coupled with mucosal edema from mechanical irritation of the mucosa results in complete stone impaction. Hyperperistalsis of the ureteric muscle occurs proximal to the stone in an attempt to overcome the obstruction. Renal colic is caused by ureteral spasm at the level of the stone + ureteral hyperperistalsis above the stone. Severe renal colic requires hospitalization.

B. Dull aching renal pain A newly formed small stone in the kidney can be hooked to the mucosa of the renal pelvis or ureter if its surface is rough and irregular. The hooked stone is not showered down with the urine flow. It acts as a nucleus that invites continuous precipitation of urine crystals over it. The stone enlarges slowly, and eventually reaches a size where it becomes too large to be showered distally along the ureter. Partial obstruction of the ureter by the stone results in progressive hydroureter + hydronephrosis. Chronic distention of the renal capsule from hydronephrosis causes persistent mild to moderate chronic dull aching renal pain. 4. Scrotal Symptoms A. Pain - Acute epididymo-orchitis (review chapter on Urinary Tract Infection). - Testicular torsion (review chapter on Urinary Tract Infection). - Direct blow of a testis, e.g. by a ball during a game of football. B. Swelling noticed by the patient - Hydrocele. - Spermatocele. - Testicular tumor (review chapter on Testicular Tumors). C. Absent testis - Cryptorchidism (review chapter on Anomalies). - Congenitally absent testis (review chapter on Anomalies). 5. Symptoms Not Related to Urology - Headache from reno-vascular hypertension (cause: renal artery stenosis). - General weakness, nausea, vomiting from uremia (cause: renal failure from advanced
bilateral hydronephroses).

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