1. Urinary Symptoms
Dr. Atef Galal

2. U r in a r y im p o r t a n t s y m p t o m s
U p p e r u r in a r y t r a c t L o w e r u r in a r y t r a c t G e n e ra l s y m p to m s
s y m p to m s s y m p to m s
P a in O b s t r u c t iv e In c o n t in e n c e Ir r ia t it iv e C h a n g e in u r in e Fever
H e m a t u r ia C o lo u r U r e m ia
S w e llin g T u r b id it y M a jo r o r g a n f a ilu r e
S tr e a m D ru g
p a in fre q u e n c y u rg e n c y S .O .I.E m p t y in g

3. Pain
Pain is usually associated with either
urinary tract obstruction or
inflammation.
• Edema and distention of the capsule
surrounding the organ. Thus,
pyelonephritis, prostatitis, and
epididymitis are typically quite
painful.

4. Pain
Tumors in the GU tract usually do not
cause pain unless they produce
obstruction or extend beyond the
primary organ to involve adjacent
nerves.
Pain associated with GU malignancies is
usually a late manifestation and a sign of
advanced disease.

5. Pain
Pain of renal origin is usually located in
the ipsilateral costovertebral angle just
lateral to the sacrospinalis muscle and
beneath the 12th rib.
The pain may radiate across the flank
anteriorly toward the upper abdomen
and umbilicus and may be referred to
the testis or labium.

6. Pain
Pain of renal origin may be associated
with gastrointestinal symptoms
because of:
• Reflex stimulation of the celiac
ganglion
• Proximity of adjacent organs (liver,
pancreas, duodenum, gallbladder, and
colon).

7. Pain
Renal pain may be confused with pain of
intraperitoneal origin:
• Perforated duodenal ulcer or pancreatitis may
radiate into the back, but the site of greatest
pain and tenderness is in the epigastrium.
• Intraperitoneal origin pain radiates into the
shoulder.
• Patients with intraperitoneal pathology prefer
to lie motionless to minimize pain.

8. Pain
Renal pain may be confused with
radicular pain (resulting from irritation
of the costal nerves,T10–T12)
• It has a similar distribution (from the
costovertebral angle across the flank toward
the umbilicus.
• Is not colicky.
• Intensity may be altered by changing
position.

9. Pain
Ureteral pain is usually acute and
secondary to obstruction.
It results from acute distention of the
ureter and by hyperperistalsis and spasm
of the smooth muscle of the ureter
Usually produced by a stone or blood
clot.

10. Pain
Site of ureteral
obstruction can be
determined by location
of referred pain

11. Pain
Midureteral obstruction:
• Referred McBurney's point
simulating appendicitis on rt. side
• On the left side is referred over the left
lower quadrant and resembles
diverticulitis.
• Also, may be referred to the scrotum
in the male or the labium in the female.

12. Pain
Lower ureteral obstruction:
• Produces symptoms of vesical
irritability, (frequency, urgency, and
suprapubic discomfort)
• May radiate along the urethra in men
to the tip of the penis.

13. Pain
Vesical Pain :
• Produced either by overdistention or
inflammation.
• Inflammatory conditions of the bladder
usually produce intermittent
suprapubic discomfort.
• It is severe when the bladder is full
and relieved by voiding.
• Strangury: sharp, stabbing suprapubic
pain at the end of micturition.

14. Pain
Dysuria:
• Is painful urination that is usually caused by
inflammation.
• This pain is usually not felt over the bladder
but is commonly referred to the urethral
meatus.
• Pain occurring at the start of urination may
indicate urethral pathology, whereas pain
occurring at the end of micturition
(strangury) is usually of bladder origin.

15. Pain
Prostatic Pain:
• It is usually secondary to inflammation
with edema and distention of the
capsule.
• It is poorly localized.
• Patient may complain of lower
abdominal, inguinal, perineal,
lumbosacral, or rectal pain.
• It is frequently associated with irritative
urinary symptoms.

16. Pain
Penile Pain:
• Pain in the flaccid penis is usually
secondary to inflammation in the
bladder or urethra and is
experienced maximally at the
meatus.
• Pain in the erect penis is usually due
to Peyronie's disease or priapism.

17. Pain
Scrotal Pain:
• Scrotal pain may be primary or referred.
• Primary pain arises from within the
scrotum and is usually secondary to
acute epididymitis or torsion of testis
or testicular appendices.
• Edema and pain associated with acute
epididymitis and torsion, it is difficult to
distinguish these two conditions.

18. Pain
• Chronic scrotal pain is usually related to
noninflammatory conditions; hydrocele,
varicocele.
• It is generally characterized as a dull, heavy
sensation that does not radiate.
• Pain arising in the kidneys or
retroperitoneum may be referred to the
testicles.
• Dull pain associated with an inguinal hernia
may be referred to the scrotum.
• It may also result from inflammation of the

19. Hematuria
2-Hematuria:
• Is the presence of blood in urine;
• >3 red blood cells per (HPF) is
significant.
Hematuria of any degree should
never be ignored
Hematuria in adults, should be
regarded as a symptom of
malignancy until proved

20. Hematuria
In evaluating hematuria,
several questions should
always be asked:
• Is the hematuria gross or
microscopic?
• At what time during urination
does the hematuria occur?
• Is the hematuria associated with

21. Hematuria
Timing of Hematuria:
• Initial hematuria: arises from the
urethra.
• Total hematuria: from the
bladder or upper urinary tracts.
• Terminal hematuria: is usually
secondary to inflammation in the
area of the bladder neck or
prostatic urethra.

22. Hematuria
Association with Pain:
• If it is associated with
inflammation or obstruction it
will be painfull
• Or from upper urinary tract
with obstruction of ureters
with clots or calculus.

23. Hematuria
Presence of Clots:
• The presence of clots usually
indicates a more significant
degree of hematuria, and,
accordingly, the probability of
identifying significant urologic
pathology increases.

24. Hematuria
Shape of Clots:
• (wormlike) clots, particularly if
associated with flank pain,
identifies the hematuria as
coming from the upper urinary
tract.

25. Irritative Symptoms:
Frequency:
• The normal adult voids five or six
times per day, with a volume of
approximately 300 mL with each
void.
• Urinary frequency is due either
to increased urinary output
(polyuria) or to decreased
bladder capacity.

26. Irritative Symptoms:
Frequency:
• Polyuria should be evaluated for
diabetes mellitus, diabetes insipidus,
or excessive fluid ingestion.
• Causes of decreased bladder
capacity include: increased
sensitivity and decreased
compliance; pressure from extrinsic
sources; or anxiety

27. Irritative Symptoms:
Nocturia: is nocturnal frequency.
• Normally, adults arise no more than once at
night to void.
• Nocturia may be secondary to increased urine
output or decreased bladder capacity.
• Nocturia without frequency may occur in the
patient with congestive heart failure, in the
geriatric patient.

28. Irritative Symptoms:
Frequency:
• Frequency during the day without nocturia
is usually of psychogenic origin and related
to anxiety.

29. Obstructive Symptoms
1-Decreased force of urination
• Is usually secondary to bladder
outlet obstruction
• Most patients are unaware of a
change in the force and caliber of
their urinary stream.
• These changes usually occur
gradually and go generally
unrecognized by most patients.

30. Obstructive Symptoms
2-Difficulty:
• Urinary hesitancy :
• Refers to a delay in the start of micturition.
• Intermittency:
• Refers to involuntary start-stopping of the
urinary stream.
• Postvoid dribbling:
• Refers to the terminal release of drops of urine
at the end of micturition.
• This is secondary to a small amount of residual urine in
either the bulbar or the prostatic urethra.

31. Obstructive Symptoms
3-Straining:
• Refers to the use of abdominal musculature to
urinate.
• Normally, it is unnecessary for a man to
perform a Valsalva maneuver except at the end
of urination.
• Increased straining during micturition is a
symptom of bladder outlet obstruction.

32. Obstructive or irritative
Symptoms
It is important for the urologist to distinguish irritative from
obstructive lower urinary tract symptoms.
This most frequently occurs in evaluating men with BPH.
Although BPH is primarily obstructive, it produces changes in
bladder compliance that result in increased irritative symptoms.
In fact, men with BPH more commonly present with irritative
than obstructive symptoms, and the most common presenting
symptom is nocturia.
The urologist must be careful not to attribute irritative symptoms
to BPH unless there is documented evidence of obstruction.
In general, lower urinary tract symptoms are nonspecific and may
occur secondary to a wide variety of neurologic conditions as well
as to prostatic enlargement (Lepor and Machi, 1993).

33. Symptom score
Since its introduction in 1992, the
American Urological Association (AUA)
symptom index has been widely used (
Barry et al, 1992).
The original AUA symptom score is based
on the answers to seven questions
concerning frequency, nocturia, weak
urinary stream, hesitancy, intermittency,
incomplete bladder emptying, and
urgency.

34. Symptom score
The total symptom score ranges
from 0 to 35 with scores of 0 to 7, 8
to 19, and 20 to 35 indicating mild,
moderate, and severe lower urinary
tract symptoms, respectively.

36. Incontinence
Urinary incontinence is the involuntary
loss of urine.
A careful history of the incontinent
patient will often determine the etiology.
It can be subdivided into four
categories:

37. 1-Continuous
Incontinence
Involuntary loss of urine at all times and in all
positions.
Commonly due to complete damage to the
sphincter or a urinary tract fistula that
bypasses the urethral sphincter, vesicovaginal
and ureterovaginal fistula
Ectopic ureter that enters either the urethra or
the female genital tract may cause urinary
incontinence.
It may be misdiagnosed for many years as a
chronic vaginal discharge.
Ectopic ureters never produce urinary
incontinence in males, because they always
enter the bladder neck or prostatic urethra
proximal to the external urethral sphincter.

38. 2-Stress Incontinence
Refers to the sudden leakage of urine with
coughing, sneezing, exercise, or other
activities that increase intra-abdominal
pressure.
Intra-abdominal pressure rises transiently
above urethral resistance, resulting in a
sudden, urine leakage.
It is most commonly seen in women
It is also observed in men following
prostatic surgery.

39. 3-Urgency incontinence
Is the precipitous loss of urine preceded
by a strong urge to void.
This is commonly observed in patients
with cystitis, neurogenic bladder, and
advanced bladder outlet obstruction with
secondary loss of bladder compliance.
It is important to distinguish urgency
incontinence from stress incontinence.

40. 4-Overflow urinary incontinence
(paradoxical incontinence), is secondary to
advanced urinary retention and high residual
urine.
the bladder is chronically distended and never
empties completely.
Urine may dribble out in small amounts as the
bladder overflows. This is particularly likely to
occur at night when the patient is less likely to
inhibit urinary leakage.
It is usually develop over a considerable length of
time, and patients may be totally unaware of
incomplete bladder emptying.

41. Enuresis
Refers to urinary incontinence that
occurs during sleep.
It occurs normally in children up to 3
years of age but persists in about 15%
of children at age 5 and about 1% of
children at age 15 (Forsythe and
Redmond, 1974).
All children over age 6 years with
enuresis should undergo a urologic
evaluation, although the vast majority

42. Impotence
Impotence refers specifically to the
inability to achieve and maintain an
erection sufficient for intercourse. A
careful history will often
determine whether the problem is
primarily psychogenic or organic.
Impotence

43. Impotence
In men with psychogenic impotence,
the condition frequently develops rather
quickly secondary to a precipitating
event such as marital stress or change
or loss of a sexual partner. In men with
organic impotence, the condition usually
develops more insidiously and
frequently can be linked to advancing
age or other underlying risk factors.

44. Impotence
In evaluating men with impotence, it is
important to determine whether the
problem exists in all situations. Many
men who report impotence may not be
able to have intercourse with one
partner but will with another. Similarly, it
is important to determine whether men
are able to achieve normal erections
with alternative forms of sexual
stimulation (e.g., masturbation, erotic
videos).

45. Impotence
Finally, the patient should be asked
whether he ever notes nocturnal or
early morning erections. In general,
patients who are able to achieve
adequate erections in some
situations but not others have
primarily psychogenic rather than
organic impotence.

46. Failure of Ejaculate
Anejaculation may result from
several causes: (1) androgen
deficiency, (2) sympathetic
denervation, (3) pharmacologic
agents, and (4) bladder neck and
prostatic surgery. Androgen
deficiency results in decreased
secretions from the prostate and
seminal vesicles

47. Failure of Ejaculate
causing a reduction or loss of seminal
volume. Sympathectomy or extensive
retroperitoneal surgery, most notably
retroperitoneal lymphadenectomy for
testicular cancer, may interfere with
autonomic innervation of the prostate and
seminal vesicles, resulting in absence of
smooth muscle contraction and absence of
seminal emission at time of orgasm.
Pharmacologic agents, particularly α-
adrenergic antagonists, may interfere with
bladder neck closure

48. Failure of Ejaculate
at time of orgasm and result in
retrograde ejaculation. Similarly,
previous bladder neck or prostatic
urethral surgery, most commonly
transurethral resection of the prostate,
may interfere with bladder neck closure,
resulting in retrograde ejaculation.
Finally, retrograde ejaculation may
develop spontaneously in diabetic men.

49. Failure of Ejaculate
Patients who complain of absence of
ejaculation should be questioned
regarding loss of libido or other
symptoms of androgen deficiency,
present medications, diabetes, and
previous surgery. A careful history will
usually determine the cause of this
problem.

50. Absence of Orgasm
Anorgasmia is usually
psychogenic or caused by certain
medications used to treat
psychiatric diseases. Sometimes,
however, anorgasmia may be due to
decreased penile sensation owing to
impaired pudendal nerve function.

51. Absence of Orgasm
Most commonly, this occurs in diabetics
with peripheral neuropathy. Men who
experience anorgasmia in association
with decreased penile sensation should
undergo vibratory testing of the penis
and further neurologic evaluation as
indicated.

52. Premature Ejaculation
Men who complain of premature ejaculation
should be questioned carefully because this is
obviously a very subjective symptom. It is
common for men to ejaculate within 2 minutes
after initiation of intercourse, and many men
who complain of premature ejaculation in
actuality have normal sexual function with
abnormal sexual expectations.

53. Premature Ejaculation
However, there are men with true premature
ejaculation who reach orgasm within less than
1 minute after initiation of intercourse. This
problem is almost always psychogenic
and best treated by a clinical psychologist or
psychiatrist who specializes in treatment of
this problem and other psychological aspects
of male sexual dysfunction. With counseling
and appropriate modifications in sexual
technique, this problem can usually be
overcome.

54. Premature Ejaculation
Alternatively, treatment with serotonin
re-uptake inhibitors, such as sertraline
and fluoxetine, have been
demonstrated to be helpful in men with
premature ejaculation (Murat Basar et
al, 1999).

55. Hematospermia
Hematospermia refers to the presence
of blood in the seminal fluid. It almost
always results from nonspecific
inflammation of the prostate
and/or seminal vesicles and
resolves spontaneously, usually
within several weeks. It frequently
occurs after a prolonged period of
sexual abstinence,

56. Hematospermia
and we have observed it several times
in men whose wives are in the final
weeks of pregnancy. Patients with
hematospermia that persists beyond
several weeks should undergo further
urologic evaluation, because, rarely, an
underlying etiology will be identified. A
genital and rectal examination should
be done to exclude the presence of
tuberculosis,

57. Hematospermia
a prostate-specific antigen (PSA) and a
rectal examination done to exclude
prostatic carcinoma, and a urinary
cytology done to exclude the possibility
of transitional cell carcinoma of the
prostate. It should be emphasized,
however, that hematospermia
almost always resolves
spontaneously and rarely is
associated with any significant
urologic pathology.

58. Pneumaturia
Pneumaturia is the passage of gas in
the urine. In patients who have not
recently had urinary tract
instrumentation or a urethral catheter
placed, this is almost always due to a
fistula between the intestine and
the bladder. Common causes
include diverticulitis,

59. Pneumaturia
carcinoma of the sigmoid colon,
and regional enteritis (Crohn's
disease). In rare instances, patients
with diabetes mellitus may have gas-
forming infections, with carbon dioxide
formation from the fermentation of high
concentrations of sugar in the urine.

60. Urethral Discharge
Urethral discharge is the most common
symptom of venereal infection. A
purulent discharge that is thick, profuse, and
yellow to gray is typical of gonococcal
urethritis; the discharge in patients with
nonspecific urethritis is usually scant and
watery. A bloody discharge is suggestive of
carcinoma of the urethra.

61. Fever and Chills
Fever and chills may occur with
infection anywhere in the GU tract but
are most commonly observed in
patients with pyelonephritis, prostatitis,
or epididymitis. When associated
with urinary obstruction, fever
and chills may portend septicemia
and necessitate emergency
treatment to relieve obstruction

62. Past Medical History
The past medical history is extremely
important because it frequently provides
clues to the patient's current diagnosis.
The past medical history should be
obtained in an orderly and sequential
manner.
Previous Medical Illnesses with
Urologic Sequelae

63. Past Medical History
There are obviously many diseases that may
affect the GU system, and it is important to
listen and record the patient's previous
medical illnesses. Patients with diabetes
mellitus frequently develop autonomic
dysfunction that may result in impaired
urinary and sexual function. A previous
history of tuberculosis may be important in a
patient presenting with impaired renal
function, ureteral obstruction, or chronic,
unexplained UTIs.

64. Past Medical History
Patients with hypertension have an increased
risk of sexual dysfunction because they are
more likely to have peripheral vascular
disease and because many of the
medications that are used to treat
hypertension frequently cause impotence.
Patients with neurologic diseases such as
multiple sclerosis are also more likely to
develop urinary and sexual dysfunction. In
fact, 5% of patients with previously
undiagnosed multiple sclerosis present
with urinary symptoms as the first

65. Past Medical History
As mentioned earlier, in men with bladder
outlet obstruction, it is important to be aware
of preexisting neurologic conditions. Surgical
treatment of bladder outlet obstruction
in the presence of detrusor
hyperreflexia may result in increased
urinary incontinence postoperatively.
Finally, patients with sickle cell anemia are
prone to a number of urologic conditions
including papillary necrosis

66. Past Medical History
and erectile dysfunction secondary to
recurrent priapism. There are obviously
many other diseases with urologic
sequelae, and it is important for the
urologist to take a careful history in this
regard.

67. Family History
It is similarly important to obtain a detailed
family history because many diseases are
genetic and/or familial in etiology. Examples
of genetic diseases include adult polycystic
kidney disease, tuberous sclerosis, von
Hippel–Lindau disease, renal tubular acidosis,
and cystinuria; these are but a few common
and well-recognized examples.

68. Family History
In addition to these diseases of known
genetic predisposition, there are other
conditions in which the precise pattern of
inheritance has not been elucidated, but
which clearly have a familial tendency. It is
well known that individuals with a family
history of urolithiasis are at increased risk for
stone formation. More recently, it has been
recognized that about 8% to 10% of men
with

69. Family History
prostate cancer have a familial form of
the disease that tends to develop
about a decade earlier than the more
common type of prostate cancer (Bratt,
2000). There are other familial conditions that
are mentioned elsewhere in the text, but
suffice it to state again that obtaining a careful
history of previous illnesses and a family
history of urologic disease can be extremely
valuable in establishing the correct diagnosis.

70. Medications
It is similarly important to obtain an
accurate and complete list of present
medications because many drugs
interfere with urinary and sexual
function. For example, most of the
antihypertensive medications
interfere with erectile function,
and

71. Medications
changing antihypertensive medications
can sometimes improve sexual
function. Similarly, many of the
psychotropic agents interfere with
emission and orgasm. In our own recent
experience, we cared for a man who
presented with anorgasmia. He had been to
several physicians without improvement in
this problem. When we obtained his past
medical history, he mentioned that he had
been taking

72. Medications
a psychotropic agent for transient depression
for several years, and his anorgasmia
resolved when this no longer needed
medication was discontinued. The list of
medications affecting urinary and sexual
function is exhaustive, but, once again, each
medication should be recorded and its side
effects investigated to be sure that the
patient's problem is not drug related. A listing
of common medications that may cause
urologic side effects is presented in

76. Cigarette smoking and consumption of
alcohol are clearly linked to a number of
urologic conditions. Cigarette
smoking is associated with an
increased risk of urothelial
carcinoma, most notably bladder
cancer, and it is also associated
with increased peripheral
vascular disease and erectile
dysfunction.

77. Chronic alcoholism may result in
autonomic and peripheral neuropathy
with resultant impaired urinary and
sexual function. Chronic alcoholism
may also impair hepatic metabolism of
estrogens, resulting in decreased
serum testosterone, testicular atrophy,
and decreased libido.
In addition to the direct urologic effects of
cigarette smoking and alcohol consumption,
patients who are actively smoking or

78. drinking at the time of surgery are at
increased risk for perioperative complications.
Smokers are at increased risk for both
pulmonary and cardiac complications. If
possible, they should discontinue smoking
at least 8 weeks before surgery to
optimize their pulmonary function (
Warner et al, 1989). If they are unable to do
this, they should at least quit smoking for 48
hours before surgery, because this will result
in a significant improvement in cardiovascular
function. Similarly,

79. chronic alcoholics are at increased risk for
hepatic toxicity and subsequent coagulation
problems postoperatively. Furthermore,
alcoholics who continue drinking up to the
time of surgery may experience acute
alcohol withdrawal during the
postoperative period that can be life-
threatening. Prophylactic
administration of lorazepam (Ativan)
greatly reduces the potential risk of
this significant complication.