Clinical Symptomatology And Manifestations In Renal Diseases
Kidney Diseases Manifestations
As in any other branch of medicine, a properly conducted full clinical examination is absolutely essential for diagnosis.
Difficult and painful micturition is called dysuria. The pain may be a burning sensation in the urethra and tip of the penis or colicky or dull pain over the suprapubic area. Infection of the lower urinary tract, stones, foreign bodies and new growths of the bladder or urethra are the common causes for dysuria.
It is the sudden and strong desire to micturate. It may be so severe that the patient may void involuntarily. This is a prominent symptom in inflammatory lesions of the trigone of the bldder or posterior urethra. Precipitancy may occur in neurological disorders (bilateral upper motor neuron lesion), but this is not associated with pain.
This refers to a painful desire to pass urine even though the bladder is empty. This is caused by severe lower urinary infections.
Frequency of micturation
This is the desire to pass urine more frequently than normal. The normal bladder can hold up to 500ml of urine without discomfort. Normally, adults pass urine once is 4-5 hours, during day time and they do not have to wake up from sleep for micturition. Considerable variation occurs even in normal subjects. Increased frequency may occur when the bladder capacity is reduced as a result of chronic inflammatory lesions, tumour invasion, neurogenic overstimulation and longstanding obstruction. In such conditions, the quantity of urine during each voiding is reduced. This should not be mistaken for the increased frewuency of micturition which occurs with polyuria.
Retention of Urine
This term refers to inability to pass urine (which has already collected in the bladder). This is often due to mechanical blockade to the urethra or neurogenic factors. Common causes include phimosis, urethral valves, bladder neck obstruction by enlarged protstate, vesical and urethral stones or bladder tumours.
Incontinence of Urine
This is inability of the bladder to hold the urine. In total incontinence, there is continuous urinary leakage and bladder is unable to hold any amount of urine. This occurs when the external urethral sphincter is paralysed or injured.
When the bladder is filled beyond its capacity and dribbling occurs thereafter, it is called overflow incontinence. If dirbbling of urine occurs as a result of sudden rise of intra-abdominal pressure as in coughing or sneezing, it is called “stress incontinence”.
In our next discussion, we will continue with other symptoms such as enuresis, alterations in the volume of urine, oliguria, polyuria, nocturia, pain and many more.
Enuresis Or Bed Wetting
Enuresis, Oliguria And More
Unintentional voiding of urine, usually during sleep is called enuresis. This is normal in infants till the age of 2 years. If it occurs in older age groups, it may be due to a delay in the development of bladder control, or loss of control due to obstruction, infection or neurogenic dysfunction.
Alterations in the volume of urine
The daily output in normal persons varies from 500 to 2500ml depending on the fluid intake and climatic factors-two-thirds passed during day and one-third during night. Estimation of the volume of urine is great help in monitoring the development and progress of renal disease.
Reduction in the daily urinary volume below 400ml is called Oliguria. However, when the output is less than 100ml, the term anuria is used. When there is complete failure of formation of urine. Common causes of oliguria are dehydration, congestive cardiac failure, shock, acute glomerulonephritis and early stages of acute renal failure. Anuria may supervene on prolonged shock and acute renal failure. When absolute anuria occurs rapidly in a previously healthy subject, mechanical obstruction to the urinary passages should be suspected and surgical causes excluded.
Increase in urine volume above 3000ml in 24 hours is called polyurina. It may occur as a result of inability of the kidney to concentrate the urine (e.g. chronic nephritis and diabetes insipidus), osmotic diuretic states like diabetes mellitus, psychological causes like compulsive polydipsia or the use of diuretics.
Nocturia (or Nycturia)
This term denotes the urge to urinate at night, leading to interruption of the patient’s sleep. This is an early symptom in diabetes mellitus, early congestive heart failure, or chronic renal insufficiency. More of urine is passed at night than during daytime. This may be the result of mobilization of dependent edema fluid during recembency. Inappropriate timing of the administration of diuretics also may give rise to this symptom.
More symptoms such as pain, Hematuria, turbidity of urine, pneumaturia, Edema and infective lesions will be reviewed in the next article.
Hematuria, Edema And Others
Pain arising from the excretory organs
The quality, severity and character of the pain varies depending on the site of disease, type of onset and other factors. The pain arising from the kidney is of dull aching type usually confined to the loin and also felt in the lumbar region. Distension of the kidney and increase in intracapsular pressure give rise to dull pain. Rarely tumours may be responsible.
Lesions obstructing the outflow tract (Pelvis and ureters) give rise to colicky pain. Renal colic or ureteric colic is characterized by an abrupt onset of sharp stabbing and excruciating pain associated with sweating, prostration, vomiting, shock and occasionally collapse. The colic occurs with varying frequency and in the intervals, the patient may be symptom free. The pain is maximally felt over the loin and it radiates to the root of the penis or suprapubic area.
Pain arising from the bladder is characterized by dull continuous discomfort in the suprapubic area. Urethral pain is often burning in type. Prostatic pain is often felt as a vague discomfort and fullness in the perineum.
Hematuria (presence of blood in urine) may be macroscopic or microscopic. It may be due to medical causes such as glomerulonephritis and hemorrhagic disorders or surgical causes such as tumours or urolithiasis. The three glass test in which urine is collected separately at the start, middle and end of micturition helps in locating the site of bleeding. In glomerulonephritis, the urine is uniformly blood-stained. Hematuria accompanied by pain arising from the kidney, ureter or bladder is generally suggestive of a surgical cause. Reddish colour of urine can be imparted by several substances and this should not be mistaken for hematuria e.g, drugs like phenazopyridine, phenolphthalein, dyes like anthocyanins in beetroot and berries and vegetable dye used for colouring. Microscopy of urine is an easy and sure method to distinguish hematuria by the presence of erythrocytes. At times, hemoglobinuria may give rise to reddish colour of urine. This can be distinguished from hematuria by centrifuging the urine. In hemoglobinuria, the supernatant is coloured whereas in pure hematuria, the erythrocytes settle at the bottom, leaving the supernatant free. Presence of hemoglobin in the urine can be confirmed spectroscopically.
Turbidity of Urine
Pus, blood or crystals may impart turbidity to the urine.
This term denotes the presence of gas in urine. It may occur as a result of fistulous communication between the bowel and urinary tract or infection of the bladder by gas- forming organisms.
Acute glomerulonephritis and nephritic syndrome are characterized by fluid puffiness of the eyelids and face occurring especially on waking up from sleep is suggestive, other areas where the areolar tissue is loose such as the scrotum and breasts also show edema. In nephritic syndrome, the edema is more pronounced over dependent parts.
Infective lesions of the urinary tract
In active infection, fever is a prominent symptom. In pyelonephritis, the fever is intermittent and accompanied by chills and rigor. In chronic urinary infections, fever may not be prominent. Tumours of the kidney such as hypernephroma may give rise to irregular fever at times.
© 2014 Funom Theophilus Makama