KURSK STATE MEDICAL UNIVERCITY

DEPARTMENT OF PROPEDEUTICS OF INTERNAL DISEASES

Subjective and objective

(inspection, palpation,
percussion, auscultation)
examination of the
urinary system.

Lecturer: Ph. D.,

assistant professor Serikova L.N.

KURSK 2021
 Urinary system anatomy
The main functions of
the urinary system are
• elimination waste
from the body,
• regulation blood
volume and blood
pressure,
• control levels of
electrolytes and
metabolites,
• to regulate blood pH.
 Subjective examination of the urinary system

Complains
System review
Anamnesis
morbi

Anamnesis
vitae
 Complains (main)
• Pain (lumbar pain, suprapubic pain,
pain during urination)
• Disorders of quantity of urine (polyuria,
oliguria, anuria)
• Disorders of quality of urine (color,
smell, transparency)
• Disorders of act of urination
(pollakiuria, ishuria, nocturia,
involuntary urination, stranguria)
• edema
 Secondary complains
- Disorders of appetite (loss of appetite, anorexia)
- Dryness and unpleasant taste in the mouth
- Nausea, vomiting, diarrhea
- Fatigue, weakness
- Irritability
- Headache, Dizziness, Loss of memory
- Heart's pain
- Dyspnea
- Arthralgia
- Impaired vision
- Hemorrhagic manifestations
- Loss of weight
- Disturbed sleep (nocturnal insomnia, sleepiness during
the day)
- Unpleasant odor from the mouth
- Itching
- Fever
 Pain

• Pain in diseases of urinary organs, depending on the

causes causing them, has qualitative differences:
• spasms of the urinary tract;
• inflammatory edema of the mucosa and / or
stretching of the renal pelvis;
• stretching the renal capsule.
 Renal colic

• Renal colic - attack-like, extremely

intense pain in the lumbar area.
• The cause of such pain is the blockage
of the ureter with a stone, which leads
to a violation of the outflow of urine,
overflow and stretching of the pelvis,
irritation of the nerve endings.
• Renal colic occurs suddenly, more
often during or after : physical stress,
walking, shaking, drinking abundant
fluid, sometimes alone, at night.
 Pain characteristic
• unilateral,
• localized in the lumbar area or lower in the
course of the ureter,
• irradiates down (in the perineum, genitals, inner
thighs).
• increased, then weakened, i.e. have the
character of colic.
• lasts from a few minutes to a day or more.
• Pain is accompanied by fever and chills, nausea
and vomiting.
• Blood in the urine can be seen (hematuria)
• Relieved by hot application, antispasmodics,
analgetics
Area of possible renal colic pain

During passage of
ureteral stone leads
to smooth muscle
spasm.

With acute
obstruction ureter
joins the renal
pelvis dilation.

patients.uroweb.org
 Pain
Dull aching pain in the lumbar region is
observed in glomerulonephritis (on both
sides), pyelonephritis (on one or two sides)
and others
• is associated with gradual stretching of the
kidney capsule due to swelling of the kidney
tissue
• is accompanied by a disorder of the passage
of urine and renal pelvis dilation.

Dull pains in the suprapubic region,

sometimes in the sacrum appear in diseases
of the bladder.
 Parenchymal renal diseases
(renal amyloidosis, glomerulonephritis, pyelonephritis,
etc.)
and right ventricular failure

inflammatory swelling
and stagnant kidney tissue

the gradual stretching of the renal capsule

- pain in the lumbar region (not intensive,

dull,aching, constants, long-lasting)
 Renal infarction
the rapid stretching of the renal capsule

- pain in the lumbar region (intensive, begin

acutely, long-lasting)

The stones in the renal pelvis (in the absence of

significant defeat of the passage of urine and stretching
the renal pelvis).
Mechanism: stimulation of receptors in the lining of the
pelvis.
Characteristics of pain:
• dull;
• low-intensity;
• occur when changing the position of the body.
 Diuresis – is secretion of urine during of
certain period of time. Diuresis can be
positive (the amount of urine excreted
exceed the volume of liquid taken) or
negative (the reverse ratio).
Dysuria – is deranged excretion of urine.

Deranged of urination (urinary syndrome)

I. Change in the amount of urine;

II. Change in the act of urination;

III. Changes in the quality of urine.

Changing the volume of urine

In healthy adults the urine output

will approximate to the fluid
intake minus the insensible fluid
losses through the skin and
respiratory tract and with feces
(500-800 ml/day). It is equal 70-80
% of water intake.
The daily amount of urine is
normally 800 ml - 2 liters.
 Polyuria
The excessive passage of urine (over
2 l per day for an adult) resulting in
profuse urination and urinary
frequency.

extrarenal renal reasons

reasons
 Extrarenal reasons of polyuria:

- classic sign of diabetes mellitus that is

under poor control or is not yet under
treatment (deranged resorption of water
in renal tubules because of increased
osmotic pressure of the urine (glycosuria);
- resolution of oedema;
- diabetes insipidus (insufficient supply of
antidiuretic hormone, amount of urine
15-20 l);
- excessive fluid intake
- Drugs: diuretics
 Renal reasons of polyuria:

- Nephrogenic
diabetes insipidus
(tubular dysfunction)
- pyelonephritis
(infection of kidneys)
- chronic renal failure
- polycystic kidney
disease (genetic
disease);
 Oliguria

• is decreased production of urine.

• It can be defined as a urine output
that is less than 500 mL/day in adults.
• It is important and requires
investigation because it can be one of
the earliest signs of acute renal
failure;
• however in most cases it can be
reversed.
 Oliguria
Impairment of renal
function
reduction of urinary
excretion of osmotically
active substances and
reduce the specific
gravity of urine

No changes in renal
function
normal or increased
urine density
 Renal and extrarenal reasons of oliguria:

- limited intake of liquid;

- large hemorrhage;
- loss of water through perspiration (as in during hot
weather) or of an unusual loss of water from the
digestive organs (as when a person suffers from a
prolonged case of diarrhea or vomiting);
- kidney inflammation or damage (acute dystrophy of the
kidneys in poisoning (corrosive sublimate, lead,
bismuth, arsenic, mercury, ethylene glycol, methyl
alcohol, etc.), glomerulonephritis, uremia, congestive
kidney, acute renal failure, etc.);
- fluid accumulates in the body's tissues or in the
abdominal cavity, leading to edema in kidney disease
or cardiovascular pathology.
Anuria is complete suppression of
urine formation by the kidney.
Types of anuria
secretory excretory
- pre-renal - postrenal
- renal

reflex anuria
(proceeds of a nervous reflex from the
affected to a healthy kidney or after
bougienage urethral catheterization, etc.).
 Anuria

•prolonged crushing syndrome

•transfusion of incompatible blood groups.
 Postrenal anuria
mechanical obstruction
in the upper urinary
tract (usually pelvis and
ureter stones)

- ureteral obstruction
(salts, blood clots, sulfa
crystals);
- compression or
proliferation of the
tumors;
- inflammatory edema of
the mucosa.
II. Change in the act of urination
Ischuria – the urine is retained in the bladder and the patient
is unable to evacuate it.

Reasons:
• cancer or adenoma of the prostate;
• compression or spinal cord injury;
• strictures of the urethra or stones;
• tumors of genital organs,
• pregnancy;
• phimosis;
• acute cystitis;
• acute prostatitis;
• post-operative period.
Nocturia is defined by the American Urological
Association as "the need to urinate at least twice
during the night." The amount of urine excreted during
night often exceeds the amount of daily urine.

Nocturnal polyuria is an important

cause of nocturia in which there is an
overproduction of urine at night. It is
defined to be nighttime urine volume
that is greater than 20-30% of the
total 24 hour urine volume and is an
age dependent observation.

Global polyuria is
another major cause of
nocturia that consists of
both day and nighttime
urine overproduction.
Women generally
experience nocturia as a
result of the consequences
from childbirth,
menopause, and pelvic
organ prolapse.

Nocturia in men can be

directly attributed to benign
prostatic hyperplasia, also
known as enlarged prostate.
 Multiple factors that could cause
nocturia (both men and women):

• diuretic medications;
• caffeine;
• alcohol;
• overactive bladder treatment;
• excessive fluids before bedtime;
• chronic renal failure
Multiple factors that could cause nocturia (both men and women):

• chronic glomerulonephritis;
• chronic pyelitis;
• diabetes mellitus;
• diabetes insipidus;
• high blood pressure;
• heart disease;
• congestive heart failure;
• vascular disease (vascular
nephrosclerosis);
• sleep disorders;
 Isuria
The patient urinates at about equal intervals
with evacuation of about equal portion of urine.
Reasons: chronic renal insufficiency.
Isosthenuria
In the presence of isuria and nocturia of renal
origin, which arise due to the loss by the
kidneys of their concentrating ability, the
gravity of the urine is monotonous.
Hyposthenuria
The gravity of the urine is decreased.
Reasons: nephrosclerosis, renal arteriosclerosis,
chronic renal diseases in the terminal stage.
 CLINICAL EVALUATION
OF RENAL DISORDERS
Normally, adults void about 4 to 6 times/day,
mostly in the daytime
• Pollakyuria – frequent micturition (more than 6
times per day)
Causes:
• Inflamation of the bladder( cystitis),
• Stress
• Overcooling
• Pregnancy
• Benign tumor of prostate gland (adenoma)
Pollakiuria+polyuria
Pollakiuria+nocturia
 ENURESIS

• Enuresis is the involuntary passage

of urine.
• It is common in childhood and does
not necessarily indicate either
physical or psychological
abnormality.
• Reasons: emotional disturbance and
persist into adult life, may indicate
underlying disease of the kidneys
or urinary tract (rarely).
Urinary incontinence is the uncontrolled leakage of
urine from the bladder.

dilipraja.com
 Urge incontinence
The most common cause of urge incontinence is
inappropriate and involuntary bladder
contractions.

Causes:
• urinary tract infections;
• cancer;
• Parkinson's disease;
• Alzheimer's disease;
• certain drugs such as hypnotics or narcotics;
• injury (such as those occurring during surgery);
• benign prostatic hyperplasia (BPH).
 Stress incontinence
Certain muscles, known as the "pelvic floor
muscles" support the bladder. If these
muscles weaken, the bladder can move
downward, pushing slightly out of the
bottom of the pelvis toward the vagina.
• Pregnancy
• Childbirth
• menopause
• if the muscles that do the squeezing weaken.
• as a result of drugs,
• surgical trauma or radiation damage.
 Overflow bladder

• Week bladder muscles caused by nerve

damage from diabetes or other diseases
(e.g., tumours, radiation, surgery)
• Obstructed urinary outflow, such as
those caused by prostate enlargement
and urinary stones
• Under active bladder contractions
caused by certain medications. These
medications lead to urinary retention
with bladder distension.
 Stranguria
• Stranguria is a bladder condition
wherein the patient experiences painful,
slow urination. Strangury often
combined with pollakiuria.

• Cystitis pain occurs at the end of

urination, with a maximum reduction of
the urinary bladder.

• If urethritis pain occurs during urination

and may persist after urination.
 III. Changes in the quality of urine
In a normal urine light yellow to yellow, depending on the
concentration of the urohrome and other pigments as well
as its specific gravity.
Causes of haematuria and their relationship to pain
Painless Painful May be either
- glomerulonephritis, - urinary tract - reflux
- tumor of the kidney, infection, nephropathy
ureter, bladder or prostate, - renal calculi and renal
- schistosomiasis, with obstruction, scarring,
- hypertensive - adult
nephrosclerosis, polycystic
- interstitial nephritis, kidney disease
- acute tubular necrosis, - renal stones
- renal ischaemia without
(renovascular disease) obstruction
- distance running or other
severy exercise,
- coagulation disorder,
- anticoagulant therapy
Color of urine Possible causes
Colorless Diabetes mellitus, diabetes insipidus,
chronic renal failure
Intensely Fevers, hyperthyroidism, tumors
colored
Orange-brown Conjugated bilirubin,
Senna, rhubarb
Concentrated normal urine (very low fluid
intake)
Red-brown Blood, myoglobin, free hemoglobin,
porphyrins
Drugs – rifampicin, metronidazole, warfarin
Beetroot, blackberries
Brown-black Conjugated bilirubin
Drugs – L-dopa
Homogenetisic acid (in alkaptonuria or
ochronosis)
Milky-white Chyluria and lipuria
Dark blue Methylene blue
 Color of urine sediment Possible causes
yellow sand high content of uric acid
brick-red large number of urate
white, solid phosphate
(amorphous phosphates)
greenish pus
(creamy character)

gelatinous mucus

Transparency
Healthy human urine is clear and slightly foaming. It
can to turn cloudy on standing in air.
Transparency depends on the presence urine: the
amount of salts, of cellular elements, bacteria, mucus,
fat.
Fever is the symptom of infectious
inflammatory affections of the
kidneys, the urinary ducts and
perirenal cellular tissue.

Fever, accompanied by chills, often

seen in patients with acute
pyelonephritis.
Long-term subfebrile temperature
occurs in tuberculosis of the kidneys,
cancer.
 Oedema

Causes of development:
• renin-angiotensine-aldosteron system
hyperactivation (retention of Na and H2O in body)
(arterial hypertension, glomerular diseases, etc.);
• decrease of the oncotic plasma pressure (nephrotic
syndrome, glomerulonephritis, amiloidosis,
diabetes melitus, etc.);
• decrease of the filtration kidneys function
(glomerulonephritis, renal insufficiency, etc);
• increase of the vascular permeability
(glomerulonephritis, vasculitis, etc.).
Edema
 Oedema of cardiac origin Oedema of renal origin
begin with the legs and lower earliest localized on the face
abdomen, in bedridden
patients - with lower back and
sacrum, located symmetrically

arise in the evening arise in the morning

cardiac edema develop slowly, renal edema occur very
gradually, over weeks, months quickly, for one night or a few
days
swelling tight, leaving a hole soft
under pressure
cyanotic pale
progress upward progress downward
 Objective examination
(typical symptoms the defeat the urinary system)
General inspection
1. The general condition of the patient may differ
(from satisfactory, grave to extreme grave).
2. Patient looks younger (renal infantilism).
3. Consciousness. May be different (Examples: a clear
conscience - the initial stage of the disease, uremic
coma).
4. Body position:
- more active;
- paranephritis - with lower limb flexed at the knee and
hip joint on the affected side( reduced muscle tone on the
affected side);
- spastic reflex contraction of the smooth muscle
(renal colic) of the patient feels intense paroxysmal
pain and can not find the position is improved
condition.
5. Facies nephritica
(Bright's face) – pale,
edematous, especially in
the upper and lower
eyelids. In advanced
cases: the increase in the
intensity of edema
paraorbital region,
marked dryness and
yellowish of the skin,
powdered by the crystals
of the of uric acid, hair intranet.tdmu.edu.ua
may fall out.
6. Constitution - is not typical.
7. Skin with chronic renal failure pale, dry, powdered,
scratching. Oedema.
 Typical symptoms of other systems
Kussmaul’s respiration
is hyperventilation, gasping and labored respiration,
usually seen in states of respiratory acidosis.

Pleural friction rub (uremia - uric acids crystals

deposition).
Apex beat is diffuse, high amplitude, intensified.
Tachycardia, S2 accentuation at the point of
aortic valve, pericardial rub. Increased blood
pressure.
Unpleasant odor (ammonia smell) from the mouth.
 Inspection of region of the kidneys
Zone of direct kidneys
projection. Located on the
back right and left to the
spine, at the level of the
T11 to L3 vertebrae. The
area of one kidney projection
corresponds to the area of
one patient's palm.

Zone of urinary bladder

direct projection. Located
above the pubis on an area
corresponding to area of one
patient's palm.
Hydronephrosis, tumor, cystic, inflammatory swelling
of the perirenal tissue

smoothing or bulging of the flanks or lumbar regions

Paranephritis (inflammation of the perirenal fat)

hyperemia, local temperature increase, swelling of the

skin of the lumbar region

Sudden overflow of the bladder, caused by acute or

chronic urinary retention
(adenoma of the prostate, urethral stricture, central
nervous system)

rounded protrusion of the abdomen

 Kidneys
Location: high and deep under the diaphragm; at the
level of the T12 to L3 vertebrae.
Glandular, bean-shaped organ; 10x5x2,5 cm;
posterior organs.
Kidney tenderness best assessed at the CVA.
R kidney lower; lower portion maybe palpated
anteriorly.

Palpation of the kidneys can be performed at a

different position of the patient: on the back
(Obraztsov-Strazhesko), on the side, standing
(S.Botkin), sitting, in the knee-elbow position
(Pasternatsky), etc.
In most cases, kidney palpated in the horizontal (the
strain of the prelum is absent) and vertical position
(better palpable movable kidney) of the patient.
During Obraztsov-Strazhesko palpation of the patient
in the lying position, his legs should be stretched and
the head placed oh a low pillow.

The right hand should be placed on the abdomen, slightly

below the corresponding costal arch, perpendicularly to it
and laterally of the rectus abdominis muscles.

Left hand slightly below the 12th rib so that

the finger tips be near the spinal column.
Right hand should press deeper with each expiration to
reach the posterior abdominal wall, while the left hand
presses the lumbar region to meet the fingers of the right
hand. When the examining hands are as close to each
other as possible, the patient , the patient should be asked
to breathe deeply by «the abdomen».

As the doctor feels passing kidney, he presses it

slightly toward the posterior abdominal wall and
makes his fingers slide over the surface of the kidney
bypassing its lower pole.
Structure of the conclusions:
- shape (bean),
- size (12×6сm),
- surface (smooth),
- terderness (painless, but in some
patients may appear at the time of
palpation uneasy feeling, resembling
nausea),
- mobility,
- consistency (usually a dense, firm,
elastic).
By results of kidney palpation method
S.Botkin (vertical position) may conclude that
the degree of nephroptosis.

I degree - lower pole of kidney can be palpated

II degree – entire of kidney can be palpated
III degree – if the kidney freely moves about all
direction to pass beyond the vertebral column
and to sink downwards.
 Palpation
(painful points associated with ureter defeat)
1– the front-end X rib

2 (superior point) – at the

edge of the rectus
abdominis muscle
at the level of the
umbilicus

3 (inferior point) – at the

intersection of the bi-iliac
line and the vertical line
passing the pubic
tubercle.
 Palpation
(painful points associated with renal disease)

1 – angel between the 12th

rib and spine

2 – angel between the 12th

rib and longissimus
thoracic muscles
 Percussion of the urinary bladder

Percussion from the

umbilicus downward,
along the median line, the
pleximeter-finger is placed
parallel to the pubic bone.

Palpation of the urinary bladder

Can be palpated over the pubic bone as an elastic
fluctuating formation. If the bladder is markedly
distended, its superior border reaches the umbilicus.
 Percussion
Tapping
The physician placed his
left hand on the his loin
and using his right hand
taps with a moderate force
on the right hand overlying
the kidney region on the
loin. If the patient feels
pain, the symptom is
positive.
Reasons: paranephritis,
pyelonephritis,
osteochondrosis, diseases of
the ribs, lumbar muscles,
and sometimes in diseases Pasternatsky‘s symptom
of the abdominal organs described as urine test before
(gall bladder, pancreas, and after the tapping, and
etc.). then compare them to
determine hematuria.
 Place of auscultation of renal vessels

Anterior

1) 2-3 cm above umbilicus

2) 2-3 cm to the right and left from umbilicus
3) Project a horizontal line from xiphoid process, and
again from umbilicus, then form a vertical line along
the rectus abdominis muscle. Divide this region into 2
part. The middle point (both left and right) is the place
of auscultation.
 Place of auscultation of renal vessels
On posterior side, look for Petit triangle
(inferior lumbar triangle)
Posterior
Borders of Petit
triangle
 Latissimus dorsi
muscle
 Iliac crest
 External
abdominal
oblique muscle