UROLOGICAL DIAGNOSIS IN GENERAL PRACTICE · bladder. Thisobstruction is usually from enlarge-ment of the prostate. In the majority of cases the enlargement is benign, and on rectal

UROLOGICAL DIAGNOSIS IN GENERAL PRACTICE

By

A. W. BADENOCH M.A. M.D., CH.M., F.R.C.S.

Surgeon and Urologist to the Metropolitan Hospital;,Assistant Surgeon to St. Peter's Hospital.Consulting Urologist, Ashford Hospital, Kent.

(Based on a lecture given to demobilised Medical Officers at the Metropolitan Hospital.)

The great increase in medical knowledge of recentyears has tended more and more to produce special-isation. This obviously has its advantages, since,other things being equal, a doctor who confineshimself to one system or segment of the body,should know more about this particular part thanthe man who has to devote his time to generalmedicine. It does, however, throw a greater onuson the general practitioner, and more especially inregard to diagnosis, since one of the drawbacks isthat the specialist tends to confine himself to hisown system and may well overlook some quiteobvious condition if it is outside his own speciality.It is therefore of great importance that a reasonablediagnosis should be made by the doctor before thepatient is sent to the specialist.

Diagnosis in urology is, on the whole, not difficult,and as is so often the case, the history is one of theutmost importance. Indeed, quite often, a diag-nosis can be made from this alone.

There are four cardinal symptoms in urologicaldisorders: pain, frequency of micturition, difficultyof micturition, and haemituria. One of these ora combination of more than one is almost alwayspresent in disease of the urinary tract.

PainThis may be associated w th either the upper or

lower urinary tract. Renal colic is fairly typicaland a severe attack should never be missed. Thepain varies inversely with the size, and directlywith the degree of movement, of the stone. Indeed,a large branched calculus filling the whole of therenal pelvis and calices may give rise to little or nopain at all and attention may only be directed toit as a result of routine investigation followingsome abnormality such as albumen in the urine.(See Fig. i.) Renal Colic usually starts in the loinposteriorly: it passes through to the front, andwhen the stone reaches the ureter it radiates down-wards through the iliac fossa, in the male to reachthe testes, and in the female, the labium major.Occasionally the pain may pass down the thigh,

but this is not common. Usually nausea, and oftenvomiting, accompanies the pain. When the latteroccurs, it does not relieve the pain and it may comeon at any time during the attack. In contra-distinction to the attitude in peritonitis, thepatient twists and turns and often finds greaterease in a doubled-up position.On examination there is tenderness in the loin

and quite often rigidity of the muscles of the loin.On the right side this may simulate appendicitis,especially occurring in a retrograde appendix, butthe history of colic should usually draw attentionto the renal tract. There is sometimes a littleincreased frequency of micturition and when thestone is at the ureteric orifice or drops into thebladder, this frequency may become quite marked.There is often macroscopic and always microscopicblood in the urine.

Pain in the loin which does not radiate, andbackache, are not necessarily renal in origin.Indeed, more often than not they are unconnectedwith the urinary tract. If, however, they areaccompanied by urinary symptoms, investigationis required. In the early stages of hydronephrosispain is not uncommon, and when an intermittenthydronephrosis becomes completely obstructed, asevere aching pain in the loin is experienced. Thepain of pyelitis is acconmpanied by pyrexia andfrequency of micturition and there is tendernessin the loin. Where there is a large stone in thekidney which has not moved (see Fig. 2), or wherethere is a tuberculous infection of the kidney,there may be an aching pain in the back. Back-ache which has not responded to treatment shouldalways have a urological investigation.

In a lesion of the lower urinary tract, pain maybe quite an important feature. In acute cystitis,severe strangury commonly occurs and is a mostdisturbing symptom. In a vesical calculus,especially where there is no residual urine, pain,referred to the tip of the penis at the end of mic-turition, is again a marked feature.

Pain in the perineum suggests a chronic prosta-titis or vesiculitis.

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POST-GRADUATE MEDICAL JOURNAL

Frequency of MicturitionThe number of times a person passes water is

dependent upon several factors: (a) the amount offluid intake; (b) the speed of intake; (c) fluid lostfrom the body in other ways, e.g. in sweatingand diarrhoea; and (d) the external temperature.

Naturally, a person who habitually drinks copiousquantities of fluid will either pass urine more fre-quently or will pass it in larger quantities than onewho only takes a small amount.

In people who habitually have a cup of tea orsome other type of drink before going to bed, itmay be usual for them to get up at night once toempty the bladder. Frequency of micturitiontherefore varies from patient to patient, and it isonly when it has begun to occur without any changein the habit of the patient that it may be of patho-logical significance, and moreover, tunless it occursat night as well as during the day, it may well befunctional.When a patient complains of frequency it is

important, therefore, to find out when it started,whether or not he has altered his habits with regardto fluid intake, or if he has just returned from over-seas, since there is no doubt that a common symp-tom in a person returning from the tropics to thiscooler climate, is frequency of micturition.The cause of the frequencv may vary consider-

ably with the age and sex of the patient. In theyoung of both sexes the most common cause isinfection. Bacillus coli will give rise to an acutecystitis or an acute pyelitis, and frequency is amarked feature. The urine will contain pus,often blood and organisms, and on culture theseorganisms can be identified. The onset of a bacilluscoli infection in the first instance is always acute.Other infections such as from gonococcus andistaphylococcus are less common. A tuberculousinfection of the urinary tract is almost alwavs amore chronic condition. The patient may noticeover a period of months that there has been anincreasing urge to pass water.

In really acute inflammation of the bladder, thefrequency becomes verv marked indeed--evervten minutes or even every five minutes-very smallamounts of water being passed. There is a con-stant desire to micturate and the bladder neverfeels empty. The urine is often streaked withblood and there may be a frank haematuria. Asimilar state of affairs exists where there is a vesicalcalculus and no residual urine to cushion the stone.

There is a type of frequency of micturitionoccurring where there is pus in the urine, but noorganisms are found after repeated examinations,so called abacterial pyuria. In the male this isfrequently accompanied by a non-specific urethritis.

In the older male patient, frequency of micturi-

tion occurs without infection, and then is almostalwavs due to obstruction at the neck of thebladder. This obstruction is usually from enlarge-ment of the prostate. In the majority of casesthe enlargement is benign, and on rectal examina-tion, the gland feels smooth, bilobed, elastic and ismobile. In some cases where the prostate ishard and irregular, the obstruction is due to acarcinoma of the gland.

Frequiency of micturition may occur withoutinfection and without prostatic obstruction. Itmay be due to hyperpiesis, or be accompanied byhyperpiesis.

Difficulty in MicturitionThis occurs in two groups of cases:

i. Where there is mechanical obstruction.2. Wlhere there is a neuro-muscular incoordin-

ation.Obstruction in the female is almost always due

to pressure on the urethra by a tumour arising inthe pelvis.

In the male it largely depends on the age group.In the infant the most common cause is a stenosis

of the external meatus. This may be congenital,but it is often due to inflammation and a meatalulcer brought about by acid napkins. The con-dition is easily recognised, but care should be takenthat the infant does not suddenly micturate in theexaminer's face while he is gazing intently at thestenosed meatus.

Phimosis may rarely cause difficulty in micturi-tion in an infant.

In the youth, difficulty is due to either an acuteurethritis or to the passage of a small stone alongthe urethra. The history and examination shouldmake the diagnosis of each of these conditions easv.

In the middle-aged male the commonest causeis stricture. Up to the time when the treatmentof gonococcal infections became scientific andspecific, the incidence of post inflammatory stric-ture was quite high. It must now be a rapidlydisappearing cause. Especially in view of theincreased exposure to trauma from high-speedtravel and frequent wars, the traumatic stricturemay become actually and relatively more common.The diagnosis of stricture must be confirmed byurethoscopy or instrumentation.

In the older male patient, difficulty in micturi-tion is almost always due to prostatic obstruction.It is estimated that at least one-third of men overthe age of 50 have prostatic symptomis of such adegree that they require medical advice. Accordingto Young, H. H. (J. Urology I945,53. I88), carcinomaof the prostate occurs in I4 per cent of all men pastthe age of 44 years, and is three times as common

October, I946292

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UROLOGICAL DIAGNOSIS IN GENERAL PRACTICE A. W. BADENOCH, M.A., M.D., CH.M., F.R.C.S.

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FIG. I.-Bilateral renal calculi discovered on X-ray of a patient, who was found tohave albuminuria on routine examination.

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NO..FIG. 2(a).-Multiple right renal calculi.

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UROLOGICAL DIAGNOSIS IN GENERAL PRACTICE A. W. BADENOCH, M.A., M.D., CH.M., F.R.C.S-

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FIG. 2(b).-Specimen from same case. This pa.tient was investigated for back-ache, andthe urine was found to contain cystin crystals. The stones were composed of cystin.

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FIG. 3.-Diverticulum on the left side of the bladder shown on excretion urography.

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FIG. 4.-X-rays of a case of polycystic kidney disease in a patient investigatedfor bilatera] renal swelling.

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UROLOGICAL DIAGNOSIS IN GENERAL PRACTICE A. W. BADENOCH, M.A., MILD, CH.M., F.R.C.S.

FIG. 5(a).-Enormous dilatation of left ureter in patient who was found to have albumenand a trace of pus in the urine.

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I'IG. 5(b).-Specimen from same case showing dilatation of ureter with the kidney relatively normal in size.

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UROLOGICAL DIAGNOSIS IN GENERAL PRACTICE A. WV. BADENOCH, M.A., I.D., CH.M., F.R.C.S.

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FIG. 6(a).-Stone in the right ureter.

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FIG. 6(b).-Bilateral hydro-ureter in a patient investigated for recurrent attacks ofurinary infection.

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SFIG. 7(a).-Retrograde pyelogram showing a large left hydronephrosis, mainlyextra-renal in type, with appearance suggestive of obstruction at the pelvo-ureteric juniction.

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FIG. 7(b).-Specimen removed showing the obstruction due to aberrant renal vessels.

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FIG. 8(a).-Small stone in region of the right ureter.

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UROLOGICAL DIAGNOSIS IN GENERAL PRACTICEas cancer of any other internal organ in males.Prince, C. L. and Vest, A. S. (South Med. J. I943,36. 680), state that I7 to 2o per cent of men overthe age of 50 years have carcinoma of the prostate.These figures are not in accordance with experiencein this country. In all cases of prostatic obstruc-tion it is wise to do an excretion urography. Thefunction of the kidneys will be shown, and whetheror not there has been any dilatation resulting fromback pressure. A diverticulum of the bladder isoften shown by this investigation. (See Fig. 3.)

Neuro-muscular IncoordinationDisturbance of micturition occurs in many

lesions of the nervous system. In complete trans-verse lesions of the spinal cord or of the caudaequina micturition is always affected. In othersthis is not constant. The most important of theseare syphilis of the nervous svstem and disseminatedsclerosis, in both of which difficulty of micturitionfrequently occurs.

HaematuriaFortunately, most patients are alarmed at the

appearance of blood in the urine. As a smallamount appears to be much more when dilutedwith water, it is not often that blood is passed withthe patient unaware of its occurrence. It is alwaysa sign of the utmost importance. Frank haema-turia in the absence of casts portends a surgicallesion. Associated with pain it is usually due to amoving stone. Indeed, before the advent ofX-rays, an important test for stone in the kidneywas to make the patient jump to the floor from akitchen table and if shortly afterwards bloodappeared in the urine, the diagnosis was said tohave been established. Associated with frequency,and especially if blood appears at the end ofmicturition, one must always suspect either anacute inflammation at the base of the bladder or avesical calculus. Injury, of course, followed byhaematuria, indicates that the urinary tract hasbeen involved in the trauma. If renal, the bloodis well mixed, and there may be fine clots-uretericcasts-which may give rise to colic. There maybe a well-mixed haematuria in a slight injury of thebladder, but if this is at all severe, extravasationwill have occurred, and neither urine nor blood willbe passed. In an injury of the urethra, bloodescapes from the external meatus independent ofmicturition.The most common cause of painless haematuria

is a growth in the urinary tract, and the mostcommon growth is a villus papilloma of the bladder.With painless haematuria and a swelling in the

loin, a neoplasm of the kidney may be confidentlydiagnosed. Not infrequently, haematuria may bethe chief symptom of an enlarged prostate, althoughit is very rarely the only one. In such cases it iscommon to find blood at the external meatusimmediately after a rectal examination has beendone.Jn the absence of injury, blood from the urethra

independent of micturition is usually associatedwith vesiculitis, when there is also a blood-stainedemission. Very rarely it is due to a urethralpapilloma.Having taken an adequate history, the patient

must be examined. His general condition shouldbe assessed: a dry tongue with thirst may indicatefailure of the kidneys: a moist, clean tongue, withoutthirst, means the kidney function is adequate.It is not common for abdominal examination toreveal anything abnormal. In thin people thelower pole of each kidney can usually be felt, butin the well-rounded or obese, this is not possible.It is usual to palpate both kidneys from the rightside of the patient, the left hand being passed underthe back to tlhe left loin. If the kidney feelsenlarged it may be due to a neoplasm, to hydron-ephrosis or to cystic disease. A hydronephrosis issmooth and cystic. A neoplasm may be smooth,but is usually irregular, is much harder, and feelssolid. A cystic condition may be smooth, whenthere is a single cyst, or irregular and hard wherethere is polycystic disease. (See Fig. 4.)A distended bladder can usually be felt supra-

pubicaly, rising out of the pelvis, but even if notpalpable there is dullness on percussion. On rectalexamination the prostate and vesicles can be felt.Normally the gland is smooth, flat and firm. Whenbenign enlargement takes place it becomes moreelastic, but remains smooth and the lobes on eitherside bulge into the rectum and are differentiatedby a mid-line groove. If the enlargement is mainlyintra-vesical, there may not be much projectioninto the rectum, but it may be felt bimanually. Ifone or both lobes of the prostate are hard andirregular, then carcinoma of the gland should besuspected. An infiltrating carcinoma of the bladdermay be felt per rectum, more especially bi-manually, and if this is so, it usually means thatthe prognosis is grave.

Urine ExaminationThe urine must always be examined for sugar

and albumen. If either of these is present, furtherinvestigation is required. If the urine remainscloudy after heating and adding acetic acid, it isalmost certain that there is an infection or a haema-turia present. In this case a centrifuged depositshould be examined microscopically and a bacterio-

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306 POST-GRADUATE MI

logical culture of a sterile specimen should be made.If tuberculosis is suspected, at least three specimensfrom the early morning urine, passed on threeconsecutive days, should be examined for tuberclebacilli. If still negative, a culture should be madeor a guinea pig injected with a specimen of theurine. A chronic infection of the urinary tract inthe absence of tuberculosis, is usually due to someobstructive lesion or the presence of calculus, andif the chronic infection fails to clear up undercourse of chemotherapy a further investigationshould be undertaken. A considerable lesion of theurinary tract may be present with little or nothingin the way of signs or symptoms. (See Figs. 5 and6.)

X-ray InvestigationsAll patients with a suspected surgical lesion of

the upper urinary tract should be X-rayed. In

-DICAL JOURNAL October, I946the large majority of cases this examination shouldtake the form of an intravenous pyelogram. Thefunction of both kidneys will be revealed and thepresence of an hydronephrosis, except when thereis little or no function, will be shown. If no shadowappears on excretion urography, then a retrogradepyelogram may be indicated, when a large hydrone-phrosis may be demonstrated. (See Fig. 7.) Theposition of a renal calculus will be given and anyobstruction from a ureteric calculus will be revealed.(See Fig. 8.) It may show a filling defect from aneoplasm of the kidney, but as a general rule thegreater capacity of the retrograde pyelogram isrequired for this.With the history, physical examination, examina-

tion of the urine and X-ray, a diagnosis will havebeen established in many cases, and all thatremains is to refer the patient to a specialist for-confirmation of diagnosis and for advice as to thenecessity and scope of treatment.

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FIG. 8(b).-Dilatation of ureter and pelvis indicating,that operation was necessary.

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INTRAVENOUS ANAESTHESIA --- *sosi-* r,;n RONALD JARMAN, D.S.C., M.R.C.S., D.A.

A less obvious mistake, wherethe needle has transfused thevein and the solution is in-vading the tissues deep tothe vein. This is only noticedwhen the patient complainsof pain, or when the swellingitself becomes obvious.Removal of the needle,

massage and immediate treat-ment with anti-phlogistinefor at least twenty-four hoursis necessary.

An obvious mistake.a. The needle partly pierces

the vein, blood withdrawninto the syringe and atthe same time the needlecomes out of the vein.

b. The solution injected intothe surrounding tissues,producing a weal.The needle should be taken

out completely. The site ofpuncturemassagedandtreatedwithhot anti-phlogistine packs

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INTRAVENOUS ANAESTHESIA RONALD JARMAN, D.S.C., M R.C.S., D.A.

Correct method for injection.

r A..

.:'E

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The approved method ofintravenous injection.a. A record syringe io c.c.'S

eccentric nozzle.b. A seeker tube, a needle,

size 14, short bevel.c. The injection in three

movements:i. Piercing the skin.2. Traversing the inter-

vening tissues.3. Piercing the vein.

The bevel of the needlemay be up or down. It ispurely a matter of choice.

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INTRAVENOUS ANAESTHESIA RONALD JARMAN, D.S.C., M.R.C.S., D.A.

..4..

Injecting a vein on the back of the wrist-other moresuitable veins are not to be found.

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UROLOGICAL DIAGNOSIS IN GENERAL PRACTICE · bladder. Thisobstruction is usually from enlarge-ment of the prostate. In the majority of cases the enlargement is benign, and on rectal