Urology Quiz: Renal Obstruction and Pain

Clinical Chemistry Case Study Notes

• Case Summary: A clinical case study involving genitourinary symptoms and diabetes mellitus.

• Genitourinary Symptoms:

  • Pain originates from obstruction or inflammation within the genitourinary tract.
  • Referred pain is common.
  • Acute inflammation of the parenchyma (e.g., pyelonephritis, prostatitis, epididymo-orchitis) causes severe pain and fever.
  • Tumors usually do not cause pain unless they obstruct or inflame surrounding structures.
  • Renal pain: visceral pain caused by urine flow obstruction or distension of the renal capsule; often dull, aching, and steady, located in the posterior renal angle, below the last rib, and radiating to the anterior, toward the umbilicus.
  • Ureteric pain: severe, colicky, intermittent pain occurring in waves, caused by a ureteral stone; pain is felt in the costo-vertebral angle, radiating around the trunk into the lower quadrant of the abdomen or possibly into the upper thigh.
  • Bladder pain: acute urine retention causes sudden inability to urinate despite desire to do so; painful, bursting pain in the suprapubic area; chronic retention leads to painless dribbling or overflow incontinence. Cystitis involves burning suprapubic pain, while prostate pain is acute inflammation, localized in the perineum, and referred to lower back and rectum; associated with fever, frequency, dysuria, or acute retention/tenesmus.
  • Urethral pain: burning sensation during urination usually due to inflammation or stone.
  • Testicular pain: primary pain is due to acute epididymo-orchitis, torsion of the testis, or trauma; referred pain is also possible in renal or ureteric colic, and hydrocele, varicocele, or testicular tumor.
  • Penile pain: in the flaccid penis, is usually due to bladder or urethral inflammation or stone. Priapism is painful, persistent, purposeless penile erection; causes include sickle cell disease, pelvic tumors, pelvic infections, genital trauma, spinal cord trauma, and medications (e.g., alprostadil, fluoxetine, prazosin, clozapine, warfarin, heparin).
  • Dysuria: painful or difficult urination; can be associated with infections (UTIs, prostatitis, STDs/urethritis, vaginitis, and vulvitis), stones, or urethral lesions.
  • Voiding difficulty: a sign of outflow obstruction, e.g., enlarged prostate or urethral stricture.
  • Other features of outflow obstruction include straining to void, poor stream, urinary retention, and incontinence (lack of voluntary control over urination), hesitancy (difficulty starting urination).
  • Frequency: Increased urine production (e.g., diabetes mellitus, insipidus, polydipsia, diuretics, alcohol, renal tubular disease, adrenal insufficiency), or passage of small amounts of urine frequent (e.g., cystitis, urethritis, neurogenic bladder), bladder compression or outflow obstruction (e.g., pregnancy, bladder tumour, enlarged prostate). Polyuria (increased urine volume > 3L/24h) can result from factors like over-enthusiastic IV fluids, diabetes mellitus or insipidus, hypercalcemia, psychogenic polydipsia, or the polyuric phase of acute tubular necrosis recovery. Oliguria (<400mL/24h or <0.5mL/kg/hour) is a sign of shock or acute kidney injury. Anuria is <50mL/24h; in a catheterized patient with sudden anuria, consider catheter blockage; slow decline of oliguria to anuria suggests renal dysfunction. Cloudy urine suggests pus (UTI), but can also be normal phosphate precipitation in alkaline urine.
  • Urinary changes (continued): pneumaturia (bubbles in urine) may occur with UTI due to gas-forming organisms or signal an enterovesical (bowel-bladder) fistula from diverticulitis, Crohn’s disease or neoplastic disease of the bowel; nocturia (frequent urination at night) suggests irritative bladder, diabetes mellitus, or UTI; haematuria (blood in the urine)indicates neoplasia or glomerulonephritis.
  • Genitourinary symptoms: vaginal discharge (normal discharge is white or clear, non-offensive, and varies with menstrual cycle; profuse and fishy smelling discharge in bacterial vaginosis, without itch or soreness; vulval itch and soreness, thick white, non-offensive discharge in vulvovaginal candidiasis; infection with aforementioned organisms may not cause symptoms.).

• Diabetes Mellitus (DM):

  • DM is a group of metabolic disorders with a common phenotype of hyperglycemia.
  • DM causes arises from a complex interaction of genetics and environmental factors.
  • Factors contributing to hyperglycemia depend on the cause of DM and include: reduced insulin secretion, decreased glucose utilization, and increased glucose production.
  • Clinical Features: hyperglycemia, polyuria (excess urination), glycosuria (glucose in urine), polydipsia (thirst), polyphagia (increased hunger), weight loss.
  • Complete medical history should include emphasis on weight, exercise, family history of DM, and risk factors for cardiovascular disease. In established DM patients, HbA1c levels, self-monitoring blood glucose results, knowledge about DM, and frequency of hypoglycemia should be assessed during physical exam (including retinal exam, blood pressure, and urine analysis, foot exam).

• Complications of DM:

  • DM causes secondary pathophysiologic changes in multiple organ systems.
  • Leading causes of several issues in the US include end-stage renal disease (ESRD), nontraumatic lower extremity amputations, and adult blindness.
  • Also predisposes to cardiovascular diseases and is a likely leading cause of morbidity and mortality in the future.
  • Acute complications may include diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS).
  • Chronic complications include Ophthalmologic (diabetic retinopathy, macular edema), Renal (proteinuria, end-stage renal disease, type IV renal tubular acidosis), Neurologic (distal symmetric polyneuropathy, mononeuropathy, autonomic neuropathy), Gastrointestinal (gastroparesis, diarrhea, constipation), Genitourinary (cystopathy, erectile dysfunction, female sexual dysfunction).

• Classification of DM:

  • Classified based on the underlying pathogenic process of hyperglycemia, not on criteria like age or therapy.
  • Terms like IDDM (insulin dependent) and NIDDM (noninsulin dependent) are now discouraged as many Type 2 DM individuals require insulin eventually to control blood sugar.
  • Important types of DM include Type 1, Type 2, gestational DM, and monogenic diabetes syndromes.
  • Type 1 is characterized by autoimmune beta-cell destruction, usually before age 30, accounting for 5-10% of cases and characterized by hyperglycemia, breakdown of fats and proteins, and ketosis. Genetic predisposition (HLA DR3/DR4) and environmental factors (e.g., viral infections) are implicated in its development, and it is often diagnosed with ketoacidosis.
  • Type 2 DM arises from insulin resistance and/or dysfunction; develops more commonly in older individuals, and is associated with obesity, a history of diabetes in parents/siblings, being overweight/obese, physical inactivity, race/ethnicity of African American, Hispanic, American Indian.
  • Gestational DM: occurs during pregnancy, often from insulin resistance, and most women revert to normal glucose control after pregnancy. Screening and management approach differs in gestational DM compared to other types. Monogenic diabetes is a rare group that begins at a younger age, often in babies or children under 25, and is often associated with a strong family history of diabetes.

• Diagnostic Tests: -Diabetes may be diagnosed with HbA1c, FPG, 2-h P G values after OGTT. -Specific diagnostic criteria is utilized for gestational DM

• Criteria for Diabetes Diagnosis (4 options): -HbA1c ≥6.5%, FPG ≥126 mg/dL, 2hr PG ≥200 mg/dL during OGTT (75-g). Random PG ≥200 mg/dL in individuals with symptoms of hyperglycemia or hyperglycemic crisis.

• Diabetic Ketoacidosis (DKA):

  • Caused by insulin deficiency.
  • Associated with hyperglycemia, dehydration, acidosis.
  • Usually seen in Type 1 DM
  • Symptoms include nausea, vomiting, thirst, polyuria, abdominal pain, shortness of breath. Precipitating events may include inadequate insulin administration, infection, or certain drugs

• Hyperglycemic Hyperosmolar State (HHS):

  • Caused by prolonged insulin deficiency (with relative/absolute increase in glucagon).
  • Primarily in Type 2 DM.
  • Symptoms include polyuria, thirst, altered mental status.
  • Unlike DKA, HHS is often not accompanied by acidosis or significant ketonemia, though a small anion gap and ketones can occur in starvation-type HHS.

Case Study Examples

• Case 1: A 7-year-old boy presenting with nausea, vomiting, abdominal pain, thirst, and polyuria, blood glucose 300 mg/dL, glycosuria 3+, ketonuria 3+. Expected result: acidemia.
• Case 2: A 35-year-old woman with a 15-year history of diabetes, nausea, vomiting, early satiety, and weight loss of 9 kg. Blood glucose 238 mg/dL, HbA1c 8.5%, proteinuria 4 g/24h, serum albumin 2.4 g/dL, cholesterol 445 mg/dL. Likely diagnosis: Diabetic gastroparesis with malnutrition.
• Note:* The provided information is for educational purposes only and should not be used to diagnose or treat medical conditions. Always consult with a qualified healthcare professional.

This quiz covers key concepts related to renal obstruction and associated pain types. Participants will explore conditions like ureteral colic, prostatitis, and pyelonephritis, along with symptoms indicative of urinary issues. Test your knowledge on genitourinary pain and outflow obstruction.