THE RENAL SYSTEM SIGNS AND SYMPTOMS

Dr. Anna-Maria Andronescu June 2009

HISTORY TAKING = IMPORTANT ROLE

PRIOR HISTORY PAST MEDICAL HISTORY

ACUTE INFECTIONS CHRONIC INFECTIONS TOXIC SUBSTANCES MECANICAL SECUNDARY TO OTHER DISEASESR BOLI

FAMILY HISTORY

PAST MEDICAL HISTORY

ACUTE INFECTIONS

(Especially HEMOLITIC STREPTOCOCCUS)

TONSILITTIS; SCARLET FEVER POSTSTREPTOCOCCAL SYNDROME; PNEUMONIA ENDOCARDITIS

CHRONIC INFECTIONS

TUBERCULOSIS SIFILIS MALARIA AMILOYDOSIS

PAST MEDICAL HISTORY TOXICS

DRUGS:

aminoglycosides, amphotericin, lithium, ciclosporin and tacrolimus, paracetamol (in overdose), non-steroidal anti-inflammatory drugs (underperfused kidney),

METALS: COPPER, CHROMIUM, MERCURY DIETARY: Calcium-rich food. INCOMPATIBLE BLOOD TRANSFUSION

MECANICAL
CRUSHING TRAUMAS; RENAL EMBOLISM or THROMBOSIS; EXTRINSIC COMPRESSIONS

SECUNDARY TO OTHER DISEASES

Hypertension, Diabetes, PARATHYROIDS diseases

FAMILY HISTORY

RENAL MALFORMATIONS POLYCYSTIC KIDNEY DISEASE CYSTINURIA INSIPIDUS DIABETES RENAL TUBULAR ACIDOSIS TUBULAR NEPHROPATIES

SIGNS AND SYMPTOMS

RENAL PAIN II. DIURESIS disturbances III. URINATION disturbances IV. URINE ABNORMALITIES V. RENAL EDEMA VI. GENERAL MANIFESTATIONS
I.

RENAL PAIN

RENAL COLIC CHRONIC LOIN PAIN PERINEAL PAIN STRANGURY

RENAL COLIC
1.

ONSET: SUDDEN TRIGGERS: VIBRATIONS, PHYSICAL ACTIVITY, RAPID WALKING LOCATION: RENAL ANGLE (usually UNILATERALLY); RADIATION: LOINSFLANKSFOSSASGROINSGENITALIA; INTENSITY and DURATION: SEVERE, SUSTAINED AGRAVATED by: PALPATION, COUGH, SNEEZING AMELIORATED by: HEAT ASSOCIATED with:

2. 3. 4. 5. 6. 7.

RESTLENESS, PALOR, COLD SWEATING NAUSEA, VOMITINGS TACHYCARDIA, ANGINAL PAIN, ILEUS, MICTURITION disturbances

RENAL COLIC

RENAL COLIC
CAUSES:

KIDNEY STONES BLOOD CLOTS PUS CLOTS PAPILLARY NECROSIS NEOPLASTIC TISSUE URETERAL STRICTURES KIDNEY PTOSIS KIDNEY MALFORMATIONS EXTRINSIC ACUTE OBSTRUCTIONS

RENAL COLIC
DIFFERENTIAL DIAGNOSIS :

APPENDICULAR COLIC ILEITIS BILIARY COLIC PANCREATITIS, DUODENAL ULCER GENITALS DISEASES VERTEBRAL PAIN MUSCULAR PAIN ACUTE ABDOMEN

CHRONIC RENAL PAIN

ONSET LOCATION
RADIATION INTENSITY DURATION AGRAVATION RELIEVING

SLOWLY, INSIDIOUS LOINS

MILD MODERATE CONTINUOUS (NO colicky) seldom on PALPATION, SUDDEN MOVES NO ANTALGIC POSTURES

CHRONIC RENAL PAIN CAUZE:

GLOMERULONEPHRITIS INTERSTITIAL NEPHRITIS RENAL INFARCTUS EXTRARENAL INFLAMMATIONS RENAL MALFORMATIONS POLYCYSTIC KIDNEY DISEASE RENAL PTOSIS

PELVIC PAIN
a) b) c)

ONSET LOCATION RADIATION

VARIABLE LOWER ABDOMEN GROINS and GENITALIA

d)
e) f) g)

INTENSITY
DURATION AGGRAVATION RELIEVING

MODERATE SEVERE
PERSISTENT PALPATION (RECTAL, VAGINAL)
NO ANTALGIC POSTURES

STRANGURY
a) b)
c)

ONSET LOCATION
RADIATION

SUDDEN/SLOWLY SUPRAPUBIC To the URETRAL MEATUS

DULL, PRESSURE LIKE/AGONIZING

d) e) f) g)

INTENSITY DURATION AGGRAVATION ASSOCIATION

UNTIL OBSTACLE IS REMOVED MICTURITION

a repeated, urgent desire to urinate frequently

DIURESIS DISTURBANCES

POLYURIA OLIGURIA ANURIA NOCTURIA

DIURESIS = INGESTA (0,5-1L) SWEATINGS BREATHING N = 1.5 2 L/DAY METABOLISM DEFECATION

DIURESIS DISTURBANCES - POLYURIA

PASSING A LARGER VOLUME OF URINE THAN NORMAL

PHYSIOLOGICAL: - COLD ENVIRONMENT - EMOTIONAL STRESS - LIQUID INGESTION (ALCOHOL) PATHOLOGICAL: - INFECTIONS - ACUTE RENAL FAILURE - CHRONIC RENAL FAILURE - HEART RHYTHM DISTURBANCES - DIURETICS - DIABETES MELITUS - DIABETES INSIPIDUS - psychogenic polydipsia (polydipsia = excessive drinking)

DIURESIS DISTURBANCES - OLIGURIA

DIURESIS < INGESTA 1000 Passing a smaller volume of urine than normal REDUCE URINE VOLUME until 400 500 ml/day CAUSES:

PHYSIOLOGICAL:

- EXCESSIVE HEAT EXPOSURE

- INTENSE SWEATINGS - LACK OF FLUIDS INGESTION - DRY DIET

DIURESIS DISTURBANCES - OLIGURIA

CAUSES:

PATHOLOGICAL: - COLICA RENALA - OBSTRUCTII TUBULARE - NEFROPATII INTERSTITIALE - PIELONEFRITE - IRA - IRC - VARSATURI - Sd. DIAREEICE - RETENTII HIDROSALINE - hipoTA - ENDOCRINE: ADH, PROGESTERON

DIURESIS DISTURBANCES - ANURIA

DIURESIS < 150 ml/24 ore

always PATHOLOGICAL
- ACUTE RENAL FAILURE - CHRONIC RENAL FAILURE - persistent HYPOTENSION - severe HYPOVOLEMIAS - severe HIDROELECTROLITICS IMBALANCES - severe BLOOD ACID-BASE IMBALANCES

DIURESIS DISTURBANCES - NOCTURIA

REVERSAL OF NORMAL DAY/NIGHT VOIDING PATTERN

NORMAL RATIO DAY:NIGHT = 3:1 CAUSES:

RENAL POLYURIA INCOMPLETE URINARY TRACT OBSTRUCTION EXTRARENAL HEART FAILURE LIVER CIRRHOSIS

MICTURITION DISTURBANCES

FREQUENCY RARE MICTURITIONS DYSURIA PAIN ON URINATION URINARY RETENTION URINARY INCONTINENCE URGENCY

FREQUENCY
Increased frequency of micturition without an increase in the total urine volume
CAUSES: POLYURIA ALCOHOL, FLUIDS INGESTION EDEMAS DIABETES INSIPIDUS DIABETES MELITUS KIDNEY FAILURE

DECREASED CAPACITY OF THE BLADDER CYSTITIS BLADDER STONES BLADDER TUBERCULOSIS TUMORS PELVIC COMPRESSION pregnancy, tumors, cysts

FREQUENCY
CAUSES:

IMPAIRED EMPTYING OF THE BLADDER

obstruction of bladder neck, proximal urethra

DECREASED CORTICAL INHIBITION OF BLADDER CONTRACTION

LOSS OF PERIPHERAL NERVE SUPPLY TO BLADDER

RARE MICTURITION
MICTURITION numbers 3/day

OLIGURIA INCREASED BLADDER CAPACITY

MEGALOCYSTIS (MEGABLADDER, MEGACYSTIS)

BLADDER DIVERTICULI

DYSURIA
DIFFICULTY VOIDING

Delay in initiating urine flow (HESITANCY)

Impaired urine flow Reduced force of the urinary stream

Double voiding (need to pass urine again within a few minutes of micturition)

Post-micturition dribbling

DYSURIA

NB: DIFFERENTIAL with PAIN ON URINATION pain in DYSURIA has lombar location and it is due to
vesico-ureteric reflux

CAUSES:

BLADDER: tumors, stones BLADDER NECK: UNDER BLADDER: URETHRAL: strictures PROSTATIC: benign hypertrophy, carcinoma EXTRA BLADDER PELVIC TUMORS NEUROLOGICAL DISEASES

PAIN ON URINATION

PREMICTURITION: BLADDER NECK conditions MICTURIONAL:

INITIALLY: bladder neck, proximal urethra TERMINALLY: cystitis

CONTINUOUS: urethritis

POSTMICTURION: prostatitis

URINARY RETENTION
ACUTE

COMPLETE
CHRONIC

INCOMPLETE

ACUTE COMPLETE URINARY RETENTION

OF SUDDEN ONSET SYMPTOMS: - urge to micturition - strangury - restlessness, anxiety

SIGNS: - inspection: bulging hypogastrium - palpation: tender, elastic, in tension, well defined mass - percussion: dullness with convex upper edge sometimes associated with dribbling incontinence

! differential with ANURIA URINARY CATHETERIZATION !

CHRONIC COMPLETE URINARY RETENTION

OF SLOW ONSET, IN EVOLUTION OF INCOMPLETE URINARY RETENTION

SIGNS and SYMPTOMS:

- FREQUENCY
- DYSURIA - CHRONIC STRANGURY - DRIBBLING INCONTINENCE

INCOMPLETE URINARY RETENTION

IMPAIRED EMPTYING OF THE BLADDER WITH RESIDUAL URINE IN THE BLADDER WITH BLADDER DISTENTION
VEZICOURETERIC REFLUX

NO BLADDER DISTENTION

SYMPTOMS:

- dysuria, frequency

clinical examination: Normal BLADDER DISTENTION

URINARY RETENTION
CAUSES

URETHRAL

BLADDER NECK
BLADDER PROSTATIC EXTRAURINARY (vicinity) EXTRAURINARY (at distance)

NEUROLOGICAL

EXAMINATION OF THE URINE

HAEMATURIA

PYURIA
PROTEINURIA

PNEUMATURIA
CHYLURIA

EXAMINATION OF THE URINE

Macroscopic Biochemical Microscopic Microbiological CULTURES SENSITIVES

CLARITY COLOR
ODOUR VOLUME

Specific Gravity pH
BLOOD PROTEIN

RBCs, WBCs BACTERIA

CASTS CRYSTALS

NITRITES

HAEMATURIA

The presence of red blood cells in the urine due to bleeding from the kidneys or urinary tract
CAN BE:

MICROSCOPIC (10001mil. erythrocytes/ml/min) MACROSCOPIC ( >1mil. erythrocytes/ml/min)

Color of the haematuria:

RED or BROWN CAN LEAD to CLOTS and HAEMATIC DEPOSITS

HAEMATURIA
CAUSES

PRERENAL: HEMORRHAGIC conditions: coagulopathies thrombopathies, vasculopathies RENAL: glomerulonephrites, interstitial nephrites, tuberculosis, tumors, traumas, renal stones, polycystic kidney disease hypertensive nephrosclerosis, acute tubular necrosis, renal ischaemia (renovascular disease) schistosomiasis, urinary tract infection reflux nephropathy and renal scarring

POSTRENAL: URETER: stones, tumor, inflammation, vascular malformation, traumas BLADDER: tumor, stones, inflammation, polyp, foreign objects URETHRO-PROSTATIC: tumor, stones, inflammation strictures, foreign objects, malformation

HAEMATURIA

3 CUPS TEST:

INITIAL TERMINAL TOTAL

URETHRA, PROSTATE BLADDER KIDNEYS and URETER

HAEMATURIA
DIFFERENTIAL

CONCENTRATED urine increased specific gravity CONJUGATED BILIRUBIN RED-BROWN normalized when heated URATES drugs: L-Dopa

RED DRUGS (rifampicin, metronidazol)

FOOD: beetroot, blackberries

HAEMATURIA
DIFFERENTIAL

Like PORTO wine free haemoglobin myoglobin (traumatisme) like BURGUNDIA wine (darker shade overtime) porphyrins Blood from other sources than urinary tract (menorrhagia, metrorrhagia, traumas)

PYURIA
PRESENCE OF PUS CELL IN THE URINE

CAN BE:

MICROSCOPIC = LEUCOCYTURIA MACROSCOPIC - changes in urine aspect: LOSS of LUSTRE, TRANSPARENCY, MUCUS FRAGMENTS, PUS DEPOSITS - changes in odor of the urine

PYURIA
CAUSES

PRERENAL: septicemia, hematogenous dissemination of other systemic infections RENAL: tuberculosis, infected kidney stones, tumors, malformations, POSTRENAL:

STONES NEOPLASMS MALFORMATION CYSTITIS INVASIVE UROLOGICAL MANEUVERS BENIGN HYPERTROPHY/CANCER PROSTATE

PYURIA
DIFFERENTIAL

CLOUDY urines

URATES, PHOSPHATES
Clarifies when HEATED/ACID adding

CHYLURIA URETHRITIS VAGINITIS

PROTEINURIA
PRESENCE OF PROTEINS IN THE URINE

QUANTITY

MICROALBUMINURIA

30-300 mg/day

MEDIUM

300mg 3.5 g/day

HIGH

> 3.5 g/day

PROTEINURIA
CAUSES

PRERENAL (normal glomerular filter)

High protein levels in the blood (transfusions) Plasma cell dyscrazias

RENAL
abnormal glomerular permeability, decreased tubular reabsorbtion, tubular secretion
GLOMERULOPATHIES, TUBULOPATHIES

POSTRENAL

Massive epithelial desquamations + leucocyturia

PROTEINURIA
URINE PROTEIN ELECTROPHORESIS (UPEP)
1.

GLOMERULAR
SELECTIVE
NONSELECTIVE

2. 3.

TUBULAR ABNORMAL PROTEINS

GLOMERULAR PROTEINURIA
A.

SELECTIVE

mostly ALBUMIN GLOMERULOPATHIES with potential reversible evolution

B.

NONSELECTIVE

ALL PLASMA PROTEINS SEVERE, IRREVERSIBLE GLOMERULOPATHIES

TUBULAR PROTEINURIA

UPEP TAMM-HORSFALL 2 MICROGLOBULIN

CAUSES
TUBULAR INJURY of any cause

CHRONIC KIDNEY FAILURE

PYELONEPHRITIS HYPERTENSION

ABNORMAL PROTEINURIA

EXCESS OF LIGHT CHAINS

CAUSES:
MULTIPLE MYELOMA ESSENTIAL MACROGLOBULINEMIA AMYLOIDOSIS LYMPHOMAS

PHYSIOLOGICAL PROTEINURIA

Only ALBUMIN Of transient character CAUSES:

FEVER

CHILLS
EXERCISE EXTENDED ORTHOSTATISM

INTERMITTENT PROTEINURIA
CONGESTIVE HEART FAILURE

GENERAL MANIFESTATIONS

FEVER SKIN and APPENDAGES OF SKIN

RESPIRATORY changes

DYSPNEA, KUSSMAUL BREATHING

CARDIOVASCULAR changes

URAEMIC PERICARDITIS RHYTHM and CONDUCTION abnormalities

MYOCARDIAL CONTRACTION changes

HYPOTENSION

GENERAL MANIFESTATIONS

GASTROINTESTINAL

NAUSEA, VOMITINGS

ALTERED BOWELL HABIT

HALITOSIS

NEUROLOGICAL

SOMNOLENCE, RESTLENESS, COMA SENSORIAL or MOTOR abnormalities PERIPHERAL NEUROPATHY

RENAL SYSTEM PHYSICAL EXAMINATION GENERAL PHYSICAL EXAMINATION

SKIN and SKIN APPENDAGES:

PALLOR, LEMON-YELLOW COMPLEXION, DRY SKIN

ITCHING, SCRATCH MARKS UREMIC FROST

UREMIDES
BROWN LINE PIGMENTATION OF NAILS

RENAL EDEMA

URAEMIC FROST

BROWN LINE PIGMENTATION

LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION

I. INSPECTION

LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION

I. INSPECTION
LOMBAR REGIONS ABNORMAL BULGING/RETRACTION; SKIN CHANGES BULGING + INFLAMMATION: PERINEPHRITIC ABCESS VERTEBRAL MUSCLES CONTRACTURE: renal colic ABDOMEN BULGING OF THE FLANKS UNI or BILATERAL In: KIDNEY CYSTS, TUMORS HYPOGASTRIC BULGING BLADDER DISTENTION GENITALIA THIN patients, CHILDREN

LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION

II. KIDNEY PALPATION
KIDNEYS ARE NOT PALPABLE EXCEPTION RIGHT KIDNEY in THIN, WELL RELAXED WOMEN TEHNIQUES OF EXAMINATION: BOTH HANDS: 2 METHODS ONE HAND (A) GUYON Place your left hand behind the patient's back below the lower ribs. Place your right hand over the upper quadrant anteriorly just lateral to the rectus muscle. Firmly, but gently, push your two hands together as the patient breathes out. Then ask the patient to breathe in deeply. You may feel the lower pole of the kidney moving down between the hands. Balloting = gently push the kidney back and forwards between your two hands
(B)

Same as the previous

Patient is sitting in RIGHT LATERAL DECUBITUS for LEFT KIDNEY

and LEFT LATERAL DECUBITUS for RIGHT KIDNEY PALPATION.

KIDNEYS PALPATION
RIGHT LEFT

LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION

II. KIDNEY PALPATION

(C) ONE HAND

place your left thumb in the right hypocondrium/ right thumb in the left hypocondrium the other four fingers are placed in the costovertebral angle try to catch the kidney between thumb and fingers and palpate it with your thumb in CHILDREN, VERY SLENDER PATIENTS

LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION

II. KIDNEY PALPATION

1. ENLARGED: unilaterally: PTOSIS, COMPENSATORY HYPERTROPHY,
NEOPLASM, CYSTS

bilaterally: POLYCYSTIC KIDNEY ISEASE (PKD) uni or bilateralLY: HYDRONEPHROSIS, PYONEPHROSIS

2. SHAPE: BEAN

changes in: PKD, TUMORS, PYONEPHROSIS

3. MOBILITY:

slightly mobile firm, elastic

pathological: PTOSIS
4. CONSISTENCY:

HARD in TUMORS, SLIGHTLY INCREASED in PKD,

SOFT in PYO and HYDRONEPHROSIS
5.

smooth, regular IRREGULAR: TUMORS, PKD, PYONEPHROSIS

SURFACE: TENDERNESS: NON TENDER on palpation

6.

LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION

II. PALPATION OF POINTS OF MAXIMUM TENDERNESS

POSTERIOR

COSTOVERTEBRAL: < formed by XII rib with the spine correspond to: KIDNEYS, UPPER PORTION OF URETER COSTOLOMBAR: LOWER and OUTER than the previous

ANTERIOR

SUBCOSTAL: anterior extremity of X rib PARAOMBILICAL: intersection of the horizontal line passing through
umbilicus with the vertical line passing through MacBurneys point

MIDDLE URETERAL:
inferior part of the hypogastrium, close to midline using rectal palpation

LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION

III. KIDNEY PERCUSSION

RESONANCE when anterior percussion of the flanks dullness in : CYSTS and LARGE TUMORS DULLNESS in HYPOGASTRIUM: DISTENDED BLADDER

GIORDANO maneuver

Sit the patient forward and palpate firmly but gently with your fingers. If this does not cause the patient discomfort, warn the patient what to expect firmly strike the renal angle once with the ulnar aspect of your closed fist

It is POSITIVE (elicits/aggravates pain in the lombar region) in: KIDNEY DISTENSSIONS, STONES (!), ACUTE PYELONEPHRITIS

IV. AUSCULTATION
FLANKS, LOMABR REGION in UNI/BILATERAL RENAL ARTERY STENOSIS: ARTERIAL BRUIT