Typical renal pain is felt as a dull and constant ache in the back just below the ribs and next to the vertebras. This pain often spreads along the lower ribs toward the umbilicus or lower abdominal quadrant. It may be expected in the renal diseases that cause sudden distention of the renal capsule. Acute pyelonephritis (infection of the kidney), with its sudden swelling and acute obstruction of the ureter (with its sudden renal back pressure) both cause this typical pain. It should be pointed out, however, that many urologic renal diseases are painless because their progression is so slow that sudden distention of the capsule of the kidney does not occur. Such diseases include cancer, chronic pyelonephritis, staghorn calculus, tuberculosis, polycystic kidney, and hydronephrosis due to chronic obstruction of the ureter.
Pain in the ureter is typically caused by acute obstruction (passage of a stone or a blood clot). In this instance, there is back pain from distention of the renal capsule combined with severe colicky pain that radiates from the back down toward the lower anterior abdominal quadrant, along the course of the ureter. In men, it may also be felt in the bladder, scrotum, or testicle. In women, it may radiate into the vulva. The severity and colicky nature of this pain are caused by the increased spasm of the ureter as it attempts to rid itself of a foreign body or to overcome obstruction.
The physician may be able to judge the position of a ureteral stone by the history of pain and the site of referral. If the stone is lodged in the upper ureter, the pain radiates to the testicle, since the nerve supply of this organ is similar to that of the kidney and upper ureter. With stones in the mid portion of the ureter on the right side, the pain is referred to the right lower abdominal quadrant and may therefore simulate appendicitis; on the left side, it may resemble diverticulitis or other diseases of the descending or sigmoid colon. As the stone approaches the bladder, inflammation and edema of the opening into the bladder, and symptoms of bladder irritability such as urinary frequency and urgency may occur. It is important to realize, however, that in mild ureteral obstruction, there is usually no pain, either in the kidney or the ureter.
The over distended bladder of the patient in acute urinary retention causes agonizing pain in the suprapubic area. Other than this, however, constant suprapubic pain not related to the act of urination is usually not of urologic origin.
The patient in chronic urinary retention due to bladder neck obstruction or neurogenic bladder may experience little or no suprapubic discomfort even though the bladder reaches the level of the umbilicus.
The most common cause of bladder pain is infection; the pain is usually not felt over the bladder but is referred to the urethra and is related to the act of urination. Terminal dysuria (burning at the end of urination) may be a major complaint in severe cystitis (infection of the bladder).
Direct pain from the prostate gland is not common. Occasionally, when the prostate is acutely inflamed, the patient may feel a vague discomfort or fullness in the area between the genitals and the anus, or in the rectal area. Low backache is occasionally experienced as referred pain from the prostate but is not a common symptom of prostatitis. Inflammation of the prostate gland may cause dysuria (burning with urination), frequency, and urgency.
Testicular pain due to trauma, infection, or torsion of spermatic cord is very severe and is felt locally, although there may be some radiation of the discomfort along the spermatic cord into the lower abdomen. Uninfected hydrocele, spermatocele, and tumor of the testis do not commonly cause pain. A varicocele may cause a dull ache in the testicle that is increased after heavy exercise. At times, the first symptom of an early indirect inguinal hernia may be testicular pain (referred pain). Pain from a stone in the upper ureter may be referred to the testicle.
Acute infection of the epididymis is the only painful disease of this organ and is quite common. The pain begins in the scrotum, and some degree of neighborhood inflammatory reaction involves the other testicle as well, further aggravating the discomfort. In the early stages of epididymitis, pain may first be felt in the groin or lower abdominal quadrant. (If on the right side, it may mimic appendicitis.)
SYMPTOMS RELATED TO THE ACT OF URINATION
Many conditions cause symptoms of "cystitis". These include infections of the bladder, bladder inflammation due to chemical or radiation reactions, interstitial cystitis, prostatitis, psychoneurosis, torsion or rupture of an ovarian cyst, and foreign bodies in the bladder. Often, however, the patient with chronic cystitis notices no symptoms of bladder irritability. Irritating chemicals or soap on the urethra may cause cystitis-like symptoms of painful urination, frequency, and urgency. This has been specifically noted in young girls taking frequent bubble baths.
Frequency, Nocturia, & Urgency
The normal capacity of the bladder is about 400 cc. Urinary frequency may be caused by urine remaining the bladder, which decreases the functional capacity of the bladder. When the lining of the bladder becomes inflamed (for example, due to infection, foreign body, stones, tumor), the capacity of the bladder decreases sharply. This decrease is due to 2 factors: the pain resulting from even mild stretching of the bladder and the loss of bladder flexibility resulting from inflammation and swelling. When the bladder is normal, urination can be delayed if circumstances require it, but this is not so in acute cystitis. Once the diminished bladder capacity is reached, any further distention may be agonizing, and the patient may lose bladder control, if not able to reach a bathroom immediately. During very severe acute infections, the desire to urinate may be constant, and each voiding may produce only a few milliliters of urine. Day frequency without nocturia (urination at night), and acute or chronic frequency lasting only a few hours suggest nervous tension.
Diseases that cause fibrosis of the bladder are accompanied by frequency of urination. Examples of such diseases are tuberculosis, radiation cystitis, interstitial cystitis, and schistosomiasis. The presence of stones or foreign bodies causes bladder irritability, but an accompanying infection is almost always present.
Nocturia may be a symptom of kidney disease related to a decrease in the kidney function with an inability to concentrate the urine. Nocturia can occur in the absence of disease in persons who drink excessive amounts of fluid in the late evening. Coffee and alcoholic beverages, because of their specific diuretic effect, often produce nocturia if consumed just before bedtime. In older people who are ambulatory, some fluid retention may develop secondary to mild heart failure or varicose veins. When lying down at night, this fluid is mobilized, leading to nocturia in these patients.
Painful urination is usually related to acute inflammation of the bladder, urethra, or prostate. At times, the pain is described as "burning" on urination and is usually located in the tip of the penis in men. Women usually localize the pain to the urethra. The pain is present only with voiding and disappears soon after urination is completed. More severe pain sometimes occurs in the bladder just at the end of voiding, suggesting that inflammation of the bladder is the likely cause. Pain also may be more marked at the beginning of or throughout the act of urination. Dysuria often is the first symptom suggesting urinary infection and is often associated with urinary frequency and urgency.
Strictly speaking, enuresis means bedwetting at night. It is considered normal during the first 2 or 3 years of life but becomes troublesome, particularly to parents, after that age. It may be due to delayed development of nerves and muscles in the urethra and bladder, but it may present as a symptom of organic disease (for example, infection, narrowing of the urethra and neurogenic bladder). If wetting occurs also during the daytime, however, or if there are other urinary symptoms, investigation of the cause is essential. In adult life, enuresis may be replaced by nocturia for which no bodily illness can be found.
Symptoms of Bladder Outlet Obstruction
Hesitancy in initiating the urinary stream is one of the early symptoms of obstruction of the bladder. As the degree of obstruction increases, hesitancy is prolonged and the patient often strains to force urine through the obstruction. Prostate obstruction and narrowing of the urethra are common causes of this symptom.
Loss of Force and Decrease of Caliber of the Stream
Progressive loss of force and caliber of the urinary stream is noted as resistance in the urethra increases despite the increase in bladder pressure.
Terminal dribbling becomes more and more noticeable as obstruction progresses and is a most distressing symptom.
A strong, sudden desire to urinate is caused by hyperactivity and irritability of the bladder, resulting from obstruction, inflammation, or bladder disease of neurological origin. In most circumstances, the patient is able to control temporarily the sudden need to void, but loss of small amounts of urine may occur (urgency incontinence).
Acute Urinary Retention
Acute retention is the sudden inability to urinate. The patient experiences increasingly agonizing pain just above the pubic bone, associated with severe urgency and may dribble only small amounts of urine.
Chronic Urinary Retention
Chronic urinary retention may cause little discomfort to the patient even though there is great hesitancy in starting the stream and marked reduction of its force and caliber. Patients can also experience constant dribbling of urine (paradoxic incontinence), which may be likened to water pouring over a dam.
Interruption of the Urinary Stream
Interruption may be abrupt and accompanied by severe pain radiating down the urethra. This type of reaction strongly suggests the presence of bladder stones.
Sense of Residual Urine
The patient often feels that urine is still in the bladder even after urination has been completed.
Recurring episodes of acute cystitis suggest the presence of residual urine.
There are many reasons for incontinence. The history often gives a clue to its cause.
The patient may lose urine without warning; this may be a constant or periodic symptom. The more obvious causes include congenital defects and fistulas. Injury to the sphincter of the urethra may occur during resection of the prostate or childbirth. Congenital or acquired neurological diseases may lead to improper functioning of the bladder and incontinence.
When slight weakness of the sphincters is present, urine may be lost due to physical strain (for example, coughing, laughing, rising from a chair). This is common in women who have weakened muscle support of the bladder neck and urethra due to multiple births. Occasionally, neurological bladder problems can cause stress incontinence.
Urgency may be so precipitate and severe that there is involuntary loss of urine. Urge incontinence not infrequently occurs with acute cystitis, particularly in women, since women seem to have relatively poor anatomic sphincters. Urge incontinence is a common symptom of an upper motor neuron lesion.
Paradoxic incontinence is loss of urine due to chronic urinary retention or secondary to a flaccid bladder. The intravesical pressure finally equals the urethral resistance; urine then constantly dribbles forth.
OLIGURIA AND ANURIA
Urinating less than 500cc of urine in 24 hours or not urinating at all (anuria) may be caused by acute renal failure (due to shock or dehydration), fluid imbalance, or obstruction of both ureters.
The passage of gas in the urine strongly suggests a fistula between the urinary tract and the bowel. This occurs most commonly in the bladder or urethra but may be seen also in the ureter or near the kidney. Colon cancer, diverticulitis with abscesses, colitis and trauma cause most bladder fistulas. Congenital abnormalities account for most fistulas between the urethra and the bowel. Certain bacteria, by the process of fermentation, may liberate gas on rare occasions.
Blood in the urine (hematuria) is a danger signal that cannot be ignored. Kidney or bladder tumors, stones and infections are a few of the conditions in which hematuria is typically present. It is important to know whether urination is painful or not, whether the hematuria is accompanied by symptoms of bladder irritability, and whether blood is seen in all or only a portion of the urine stream.
Bloody Urine in Relation to Symptoms and Disease
Hematuria (blood in the urine) associated with renal colic suggests a stone in the ureter, although a clot from a bleeding renal tumor can cause the same type of pain.
Hematuria is not uncommonly associated with nonspecific, tuberculous, or schistosomal infection of the bladder. The bleeding is often towards the end of urination, although it may be present throughout urination. Stones in the bladder often cause hematuria, but infection is usually present, and there are symptoms of obstruction of the bladder, neurogenic bladder, or cystocele.
Dilated veins may develop in the bladder due to enlargement of the prostate. These may rupture when the patient strains to urinate, resulting in hematuria.
Hematuria without other symptoms (silent hematuria) must be regarded as a symptom of tumor of the bladder or kidney until proved otherwise. It is usually not continuous; bleeding may not recur for months. Less common causes of silent hematuria are staghorn kidney stones, polycystic kidneys, benign prostatic hyperplasia, renal cyst, and sickle cell disease. Joggers and people who engage in sports frequently develop temporary hematuria.
Time of Hematuria
Learning whether the hematuria is partial or total (present throughout urination) is often of help in identifying the site of bleeding. Total hematuria has its source at or above the level of the bladder (for example, stone, tumor, tuberculosis, nephritis).
OTHER OBJECTIVE MANIFESTATIONS
Discharge from the Urethra
Discharge from the urethra in men is one of the most common urologic complaints. This is usually caused by gonorrhea or Chlamydia. The discharge is usually accompanied by local burning on urination or an itching sensation in the urethra.
Skin Lesions of the External Genitalia
An ulceration of the penis may represent syphilis, chancroid, herpes, or cancer. Venereal warts of the penis are common.
Visible or Palpable Masses
The patient may notice a visible or palpable mass in the upper abdomen that may represent renal tumor, hydronephrosis, or polycystic kidney. Lumps in the groin may represent spread of tumor of the penis or a reaction to a sexually transmitted disease. Painless masses in the scrotum are common and include hydrocele, varicocele, spermatocele, chronic epididymitis, hernia, and testicular tumor.
Inflammation of the prostate or seminal vesicles can cause hematospermia (bloody ejaculation).
COMPLAINTS RELATED TO SEXUAL PROBLEMS
Many people have urinary complaints due to psychological or emotional problems. In others, bodily symptoms may increase in severity because of tension. It is important, therefore, to seek clues that might give evidence of emotional stress.
In women, the relationship of menstruation to pain in the ureters or bladder should be determined. Menstruation may exacerbate both organic and functional bladder and kidney difficulties.
Many patients recognize that the state of their "nerves" has a direct effect on their symptoms. They often realize that their "cystitis" develops after a tension-producing or anxiety-producing episode in their personal or occupational environment.
Sexual Difficulties in Men
Men may complain directly of sexual difficulty, but often they are ashamed of discussing loss of sexual power. The main sexual symptoms include impaired quality of erection, premature loss of erection, absence of ejaculation with orgasm, premature ejaculation, and even loss of desire. Men should discuss these symptoms openly and in detail with their physician
Sexual Difficulties in Women
Women who have the psychosomatic cystitis syndrome almost always admit to an unhappy sex life. They notice that urinary frequency, or pain in the vagina or urethra often occurs on the day following the incomplete sexual act. Many of them recognize the inadequacy of their sexual experiences as one of the underlying causes of urologic complaints. If the patient's physician does not ask for additional information regarding these complaints, then patients must volunteer this information to the physician and ask for assistance.