Материал: Oxford American Handbook of Urology ( PDFDrive )

FLANK PAIN 17

Acute flank pain—non-stone, urological causes

•Clot or tumor colic: a clot may form from a bleeding source within the kidney (e.g., renal cell carcinoma or transitional cell carcinoma [TCC] of the upper urinary tract). A ureteral TCC may cause ureteric obstruction and acute flank pain. Flank pain and hematuria are often assumed due to a stone, but it is important to approach investigation of patients from the perspective of hematuria and to rule out cancer.

•Ureteropelvic junction obstruction (UPJO), also known as ureteropelvic junction obstruction (UPJO), may present acutely with flank pain severe enough to mimic a ureteric stone. A CT scan will demonstrate hydronephrosis, with a normal-caliber ureter below the PUJ and no stone. MAG3 renography usually confirms the diagnosis, demonstrating delayed emptying.

•Infection: e.g., acute pyelonephritis, pyonephrosis, emphysematous pyelonephritis, xanthogranulomatous pyelonephritis. These patients have a high fever (>38*C), whereas patients with a ureteric stone do not (unless there is associated infection) and are often systemically ill. Imaging studies may or may not show a stone, and there will be radiological evidence of infection within the kidney and perirenal tissues (such as edema or perinephric stranding on CT scan).

•Other less common causes include ptotic kidney, renal infarction or necrosis, renal vein thrombosis, calyceal diverticulum, renal cystic disease (medullary sponge kidney, hemorrhagic cysts), renal bleed (trauma or spontaneous from renal cell carcinoma or angiomyelolipoma), testicular torsion.

Acute flank pain—nonurological causes

Vascular

• Leaking or dissecting abdominal aortic aneurysm

Medical

•Pneumonia/pleurisy

•Myocardial infarction

•Malaria with bilateral flank pain and dark hematuria: “black water fever”

•Herpes zoster

Musculoskeletal

• Muscle spasm, sprain, flank hernia

Gynecological and obstetric

•Ovarian pathology (e.g., twisted ovarian cyst)

•Ectopic pregnancy

•Ovarian vein syndrome

Gastrointestinal

•Acute appendicitis

•Inflammatory bowel disease (Crohn’s, ulcerative colitis)

•Diverticulitis

•Perforated peptic ulcer

•Bowel obstruction

•Pancreatitis

18 CHAPTER 1 Preliminary investigation

Neurological/spinal

•Vertebral or spinal cord/nerve root irritation (bulging or herniated intervertebral disk, sciatica, tumor

•Vertebral body fracture or collapse

Distinguishing urological from nonurological flank pain

History and examination are most important. Patients with ureteric colic often move around the bed in extreme pain and are unable to find a comfortable position. Those with peritonitis lie still. With pancreatitis the patient gets relief with leaning forward.

Palpate the abdomen for signs of peritonitis (abdominal tenderness and/ or guarding) and examine for abdominal masses (pulsatile and bruit suggests aneurysm). In ovarian vein syndrome, pain can worsen on lying down or between ovulation and menstruation.

Examine the patient’s back, chest, and testicles. Costovertebral angle tenderness suggests a renal process or musculoskeletal process. In women, do a pregnancy test.

Urinalysis is critical as it suggests or excludes a urinary tract cause. However, up to 26% of patients with a documented stone on CT do not have hematuria.3,4

Chronic flank pain—urological causes

Renal or ureteric cancer

•Renal cell carcinoma

•Urothelial carcinoma of the renal pelvis or ureter

Renal stones

•Staghorn calculi

•Non-staghorn calculi, calyceal diverticular stone

Renal infection

•TB, fungal, malarial

•Chronic pyelonephritis, renal abscess

•Ureteropelvic junction obstruction

Testicular pathology (referred pain)

•Testicular neoplasms

•Testicular trauma

•Epidimo-orchitis

Ureteric pathology

•Ureteric reflux

•Ureteric stone (may drop into the ureter, causing severe pain which then subsides to a lower level of chronic pain)

3 Bove P, Kaplan D, Dalrymple N, et al. (1999). Reexamining the value of hematuria testing in patients with acute flank pain. J Urol 162:685–687.

4 Jindal G (2007). Acute flank pain secondary to urolithiasis: radiologic evaluation and alternate diagnoses. Radiol Clin North Am 45(3):395–410.

FLANK PAIN 19

Chronic flank pain—nonurological causes

Gastrointestinal

•Bowel neoplasms

•Liver disease

Spinal disease

•Prolapsed intervertebral disc

•Degenerative disease

•Spinal metastases

20 CHAPTER 1 Preliminary investigation

Urinary incontinence in adults

Definitions

Urinary incontinence (UI): involuntary loss of urine that is objectively demonstrable and is of social and/or hygienic concern (international Continence Society definition).

Stress urinary incontinence (SUI): urine loss associated with increased intra-abdominal pressure such as exertion, coughing, or sneezing. A diagnosis of urodynamic SUI is made during filling cystometry when there is involuntary leakage of urine during a rise in abdominal pressure (induced by coughing), in the absence of a detrusor contraction.

Urge urinary incontinence (UUI): sudden uncontrollable urgency, leading to leakage of urine.

Overactive bladder (OAB): urinary urgency, with or without urge incontinence, usually with frequency and nocturia, in the absence of causative infection or pathological conditions.

Overflow incontinence: increased residual or chronic urinary retention leads to urinary leakage from bladder overdistention.

Total incontinence: the continuous leakage of urine.

Functional incontinence: loss of urine related to deficits of cognition and mobility.

Mixed urinary incontinence (MUI): a combination of SUI and UUI.

•Both UUI/OAB and MUI require a perception of urgency by the patient.

•25% of women aged >20 years have UI, of whom 50% have SUI, 10–20% have pure UUI, and 30–40% have MUI.

•UI impacts psychological health, social functioning, and quality of life.

Significance of SUI and UUI

SUI occurs in women as a result of bladder neck/urethral hypermobility and/or neuromuscular defects causing intrinsic sphincter deficiency (sphincter weakness incontinence). As a consequence, urine leaks whenever urethral resistance is exceeded by an increased abdominal pressure occurring during exercise or coughing, for example.

In women, obesity, childbirth, and cystocele/uterine prolapse are common causes. In men, prostate surgery (radical prostatectomy, TURP) can result in incompetence or weakness of the external sphincter.

UUI may be due to bladder overactivity (formerly known as detrusor instability) or, less commonly, to a pathological process that irritates the bladder (infection [UTI, vaginitis, pelvic inflammatory disease], tumor [urological, gynecological], urolithiasis) or neuropathy (multiple sclerosis, CNS neoplasms, stroke). The correlation between urodynamic evidence of bladder overactivity and the sensation of urgency is poor, particularly in patients with MUI.

Symptoms resulting from involuntary detrusor contractions may be difficult to distinguish from those due to sphincter weakness. Furthermore,

URINARY INCONTINENCE IN ADULTS 21

in some patients, detrusor contractions can be provoked by coughing, thus distinguishing leakage due to SUI from that due to bladder overactivity can be very difficult. For the diagnosis of OAB, no cause can be identified.

Other types of incontinence

While SUI and especially UUI do not specifically allow identification of the underlying cause, some types of incontinence may allow a specific diagnosis to be made.

•Bed wetting in an elderly man suggests high-pressure chronic retention.

•Total incontinence suggests a fistulous communication between the bladder (usually) and vagina (e.g., due to surgical injury at the time of hysterectomy or C-section) or, rarely, the presence of an ectopic ureter draining into the vagina (in which case the urine leak

is usually low in volume, but lifelong). Total disruption of the internal and external sphincter in men and women can also cause total incontinence.

Diagnosis and management of incontinence

A basic history and physical exam along with urinalysis may identify the cause. In women, a pelvic exam must be performed (cystocele, urethral diverticulum).

Residual urine determination and urinary flow rates can be used to diagnose retention or outflow obstruction. Good flow rate with minimal postvoid residual suggests sphincteric incontinence.

•Urodynamic studies are useful where the history does not clearly indicate the cause.

•Cystometrogram measures bladder compliance, sensations, and detrusor responses to filling. It is particularly useful with urgency and urge incontinence. Documentation of detrusor hyperreflexia or detrusor instability has important therapeutic implications.

•Valsalva leak point pressure determines the intra-abdominal pressure at which urine leaks. A low leak point pressure implies intrinsic sphincter deficiency (ISD).

•Videourodynamic studies are advanced testing if basic evaluation not informative.

Further reading

Anger JT. Saigal CS. Stothers L. Thom DH. Rodriguez LV. Litwin MS (2006). Urologic Diseases of America Project. The prevalence of urinary incontinence among community dwelling men: results from the National Health and Nutrition Examination survey. J Urol 176(5):2103–2108.

Atiemo HO, Vasavada SP (2006). Evaluation and management of refractory overactive bladder.

Curr Urol Rep 7:370–375.

Wein AJ, Rackley RR (2006). Overactive bladder: a better understanding of pathophysiology, diagnosis, and management. J Urol 175:S5–S10.