CHAPTER XLVIII DIAGNOSIS OF DISEASES OF THE URINARY ORGANS In investigating any case of disease of the urinary organs the surgeon should proceed systematically, and should arrange the symptoms and signs of these affections in four classes. He should first investigate the patient's pain, then study the act of micturition, next examine the urine passed, and, lastly, proceed to investigate directly the urinary passages, the bladder, and the kidneys.
<Callout type="important" title="Important">Pain is associated with nearly all diseases of the urinary organs. It owns the same causes and has the same general significance here as elsewhere, but the seat, time, and character of the pain are of considerable diagnostic importance.</Callout> Pain may be either local, i.e. felt at the seat of the lesion, or referred, i.e. felt at a distance from it. The referred pains in urinary cases are recognized by the absence of all other signs of disease at the painful parts, and also by the special seats of these pains. They are experienced at the end of the penis, usually just behind the glans— which is found quite normal — being "referred" there from the neck of the bladder (fundus vesicte) or pelvis of the kidney; or they are felt in the testicle, groin, and down the thigh, being "referred" to these regions from the kidney, the pelvis of the kidney, and the ureter; this may be associated with retraction of the testicle. These 'referred pains' are especially caused by the irritation of calculi and foreign bodies.
In children the pain 'referred' to the end of the urethra is shown by the patient pulling at the penis, often drawing out the foreskin to a considerable length, or by scratch- in-' at the vulva. Of the local pains it is only necessary to say that pain in the prostate is felt in the pedueum and rectum, and is excited by the passage of large and hard motions, or by the contact of the finger in the rectum; pain in the bladder is felt above the pubes, deep in the perineum, and sometimes in the groins and sacrum; renal pain is felt m the loin, passing down to the groin.
When the pain is felt— The pain may be spontaneous, i.e. quite independent of movement on the part of the patient, of micturition, erection, or defecation; such pain may be due to inflammation, to the contact of foreign bodies and calculi, to the growth of tumours, or to over-distension. Many painful conditions do not give rise to 'spontaneous pain.'
When pain is increased during micturition it shows that either the contraction of the bladder or the passage of the urine along the urethra is painful, and we therefore meet with this symptom in acute cystitis, acute prostatitis, urethritis, stricture of the urethra, chancre or epithelioma of the meatus, and in very tight phimosis.
When pain is increased at the end of micturition it shows that the contraction of the bladder down upon its neck is painful, and we therefore meet with his in stone in the bladder, in prostatitis, and in ulceration of the base of the bladder from any cause, and in the bladder felt only at the end of a prolonged micturition, may be caused by adhesion of the bladder to surrounding structures.
<Callout type="warning" title="Warning">Pain from movable kidney or from renal calculus rarely comes on when the patient is at rest, particularly when recumbent, as at night; the pain of movable kidney is relieved by the recumbent position, especially if, in addition, upward pressure is made from the iliac fossa to the false ribs.</Callout> When the pain is increased by defecation it shows that the painful part is at the base of the bladder or the prostate. The pain is, of course, more marked when the motions are large and hard. Erection of the penis causes pain, either by stretching an inflamed urethra, by adding to the congestion of an inflamed prostate, or, when part of the erectile tissue cannot expand, by the great tension to which it is subjected. It is an indication, therefore, of urethritis, of prostatitis, or of an obliteration of part of the corpus spongiosum or corpus cavernosum.
<Callout type="tip" title="Tip">When the cause is a stretching of the urethra, a tight pain is felt all along the under-surface of the penis, and the organ is more or less curved down; when it is prostatitis, the erection of the penis is perfect, and the pain is felt deep in the perineum; when it is obliteration of part of the erectile tissue, the penis is sharply bent to one or other side or directly downwards.</Callout>
The act of micturition.— In health, when the urine has distended the bladder to a certain extent, a stimulus is transmitted to a centre in the lumbosacral enlargement of the spinal cord and there reflected along motor nerves to the muscular coat of the bladder, and at the same time the contraction of the sphincter muscles is inhibited. This reflex centre is under the control of the will, and the act can be excited or inhibited by the will, which also can increase the expelling force by throwing into contraction the abdominal muscles.
The resistance to be overcome is that offered by the urethra, and the shape of the issuing stream is determined by the meatus urinarius. A knowledge of these facts enables us to understand how the act may be modified. Nearly all the affections of the urinary organs cause frequency of micturition.
<Callout type="important" title="Important">This may be due to increased stimulation of the bladder by abnormal urine or by calculi and foreign bodies; by undue irritability of the bladder, as in all forms of cystitis and prostatitis; by a small size of the bladder, so that a few ounces of urine distend it; by failure to empty the bladder, when, as in the last case, the addition of a small quantity of urine to that retained in the bladder distends it to the full; by irritation of other parts of the urinary apparatus, as in renal calculus, pyelitis, acute distension of the pelvis of the kidney, urethritis, and phimosis; by instability of the centre in the spinal cord, whereby it responds to stimuli of too feeble force—this is seen in the nocturnal 'incontinence' of children, and in the effects of sexual excess; and, lastly, by stimuli from the brain, as in some cases of hysteria and some forms of 'nervousness.'</Callout>
Unconscious micturition. — Micturition should be a conscious act; it may be unconscious, through an interruption in the flow of sensation in the cord, or through the reflex centre responding to a stimulus not powerful enough to excite sensation, as is seen in the nocturnal 'incontinence' of children; or by the bladder leaking, as occurs in cases of great overdistension from atony, when the sphincter action is interfered with and urine leaks or dribbles out into the urethra; this leaking must be distinguished from the expulsive act of micturition.
Unconscious micturition is often spoken of as 'involuntary.' The surgeon must not mistake frequency of micturition or unconscious micturition for 'incontinence of urine,' a condition only met with in extroversion of the bladder, in large recto-vesical or vesico-vaginal fistula, and in paralysis.
The force of the stream depends upon the expelling power of the bladder and abdominal muscles, and the obstruction offered by the urethra; this force is estimated by the distance to which the stream can be propelled from the body: it may be increased by very powerful contraction of the bladder, as is sometimes seen in vesical calculus; it is diminished by atony of the bladder, hypertrophy of the prostate, or tight stricture.
The size and shape of the stream depend upon conditions in the urethra. When there is stricture the stream may not fully distend the meatus, and then will not be shaped by it, but will be twisted or bifid. The stream may be reduced to a mere succession of drops. The duration of micturition is increased by stricture, by atony of the bladder, and by enlargement of the prostate.
Patients often complain of a difficulty in beginning to pass water: this may be owing to an interference with the nervous mechanism, and it is a very frequent symptom of prostatic enlargement; a similar difficulty in 'leaving off,' or a dribbling continuing after the close of the voluntary act, is seen in cases of enlarged prostate with atony of the bladder and 'residual' urine, and in advanced cases of urethral stricture.
A sudden interruption of the act is a rare symptom caused by a stone or a growth in the bladder blocking up the neck.
XLVIII] RETENTION OF URINE 679 The escape of urine from other orifices than that of the urethra is evidence of urinary fistula, which will be named according to its position, viz. perineal, scrotal, rectal, vaginal, etc.
Retention of urine is a condition characterized by inability to empty the bladder. It may be complete or partial, and as the latter is often associated with involuntary or frequent micturition it is overlooked by the patients, and may be mistaken by the surgeon unless he remembers that in the great majority of cases dribbling arises from overflow.
Complete retention has to be distinguished from suppression, ruptured bladder, and extravasation of urine. It is characterized by the presence of a full bladder, as felt per rectum and above the pubes, and usually by a painful desire to pass water, while the introduction of a catheter is followed by the escape of a large quantity of urine, relief of the pain, and disappearance of the bladder tumour.
In the other conditions there is no bladder tumour, and, on passing a catheter into the bladder, either no urine or only a small quantity of bloody urine is drawn off. In suppression of urine the bladder is empty, there is no swelling from the escape of urine, and after a time there are characteristic general signs, such as coma and convulsions; in rupture of the bladder there is a history of an accident, or of long previous retention with a sense of sudden yielding; and in extravasation of urine there is the characteristic swelling in the perineum, scrotum, penis, and abdominal wall.
{See p. 632.) Partial retention is characterized by frequency of micturition, by less force in the stream, and often by dribbling of urine or inability to prevent the escape of a few drops of urine during coughing or effort. These symptoms are worse at night; after the patient has tried to empty his bladder, the catheter draws off the residual urine.
The causes of retention are nervous, muscular, or obstructive. Nervous retention is caused by inhibition of the micturition centre by some strong stimulus, such as that caused by an operation on the rectum or urinary organs, or even by any injury or operation, by severe pain in the act of micturition, as in acute urethritis, and also by hysteria and 'nervousness.' The retention sometimes seen in acute overdistension may be due to exhaustion of the lumbar centre. Compression of the brain and contusion of the cervical and dorsal spinal cord are other causes of 'nervous' retention.
This form of retention is characterized by its suddenness, its completeness, its evident relation in most cases to an injury or operation, and by the absence of all 'obstruction.' Muscular retention is due to overdistension of the bladder paralysing the muscle, to atony of the bladder, and perhaps to prostatic growths interfering with the action of the muscle. It is characterized by being chronic (except in cases of acute distension), generally partial, or attended with 'dribbling,' and by the feeble power with which the urine flows from a catheter; indeed, the bladder may be quite unable to expel its contents, and the surgeon may have to force out the urine by pressure above the pubes.
Obstructive retention may be traumatic or pathological. Fracture of the pelvis, subpubic dislocation of the hip, and rupture of the urethra are the injuries leading to it. The idiopathic causes are calculi and foreign bodies blocking the passage, inflammatory swelling or stricture of the wall of the urethra, and tumours pressing upon and blocking up the passage.
The obstruction from calculi, etc., is sudden; from inflammation it is acute and attended with other obvious signs, such as pain, swelling, and discharge; from stricture or tumour it is chronic, and is preceded by difficulty in micturition or diminution in the force or size of the stream. The history of the case and the age of the patient usually suffice to enable the surgeon to diagnose the case; the previous occurrence of urethral discharge, or of a small or feeble stream, of pain after micturition, or renal colic, or the operation of lithotripsy, is to be inquired for.
In children, retention is most often due to impaction of a calculus; in young men, to urethritis, prostatitis, or abscess; in middle-aged men, to stricture; and in elderly men, to hypertrophy of the prostate or to stone.
Examination of the urine. — An examination of the urine in disease of the kidneys or urinary passages should afford an answer to two questions — (1) Are the kidneys discharging their excretory functions properly? (2) Are any abnormal substances added to the urine?
The first question can, as a rule, be answered by determining the total daily excretion, its specific gravity, reaction, colour, and the amount of urea it contains. In some cases, in addition, it is of importance to estimate the amount of urea in the blood.
To answer the second question, test for the presence of albumin, blood, pus, and sugar; search for tube-casts; examine microscopically any deposit present, and examine the urine for organisms. Albuminuria may be due to the admixture of blood or pus with the urine, or to some condition of the kidneys, their blood-vessels, or the blood, leading to a filtration of blood-serum.
Wherever albuminuria is unattended with the presence of blood- or pus-cells in the urine, it is due to some fault in the renal excretion; this diagnosis is corroborated if 'tube-casts' of any kind are found. And where the amount of albumin is out of proportion to the number of blood- or pus-cells seen, the same inference is to be drawn.
<Callout type="warning" title="Warning">HEematuria is most certainly shown by the detection of blood-corpuscles in the urine. The surgeon must then decide the source of the blood, whether urethral, vesical, or renal.</Callout> If the blood escapes involuntarily and independently of the act of micturition, or passes with the first few drops of urine only, or if the escape of urine is preceded by the passage of a long clot the size and shape of the urethra, the blood is urethral. The most common causes of urethral hemorrhage are injury and catheterism.
When the blood flows only with the last drops of urine, it certainly comes from the prostate or neck of the bladder, and its cause will be
Key Takeaways
- Pain is a key symptom in diagnosing urinary diseases.
- Frequency of micturition can indicate various conditions, from inflammation to obstruction.
- Retention of urine has different causes and must be distinguished from other conditions like suppression or rupture.
Practical Tips
- Monitor pain patterns to identify the source of discomfort, whether local or referred.
- Use a catheter to determine if retention is complete or partial, as this can affect treatment options.
- Check for albuminuria and hematuria to assess kidney function and pinpoint the origin of blood in the urine.
Warnings & Risks
- Be cautious when interpreting pain symptoms, as they can be misleading without proper context.
- Avoid overdistending the bladder, which can lead to complications like urinary retention or overflow incontinence.
- Recognize that unconscious micturition is not the same as incontinence and requires careful diagnosis.
Modern Application
While many of the techniques described here are historical, the principles of pain assessment and urine examination remain crucial for triage and initial diagnosis. Modern medical technology has improved imaging and diagnostic tools, but understanding basic symptoms like frequency of micturition or presence of blood in urine can still be life-saving in survival situations where immediate access to advanced equipment is limited.
Frequently Asked Questions
Q: What are the key signs of urinary retention?
Urinary retention may present as a painful desire to urinate, inability to empty the bladder completely, and dribbling after micturition. A full bladder can be felt per rectum or above the pubes, and catheterization often reveals a large volume of urine.
Q: How does pain in urinary diseases differ from other types of pain?
Pain in urinary diseases is associated with specific organs like the kidneys, bladder, or prostate. It can be local or referred to distant areas such as the groin or testicles. The nature and location of the pain help differentiate it from other types.
Q: What are some common causes of hematuria?
Hematuria can result from urethral injury, prostatitis, kidney stones, or tumors. It is detected by finding blood corpuscles in the urine and requires further investigation to determine the exact source.