Differential Diagnosis

Renal and Urologic Disorders

Renal and Urologic Disorders

c/o flank pain, LBP or pelvic pain may be renal or urologic in origin

The urinary tract– Consists of the kidneys, ureters, bladder and

urethra– Disposes the body’s toxic waste products and

unnecessary fluid– Regulates metabolic processes for homeostasis

Renal and Urologic Disorders

Renal and Urologic Disorders

Visceral and cutaneous sensory fibers enter the spinal cord close together. Thus when visceral pain fibers are stimulated, cutaneous fibers are also stimulated

Patient may c/o “skin pain” or hyperesthesia Renal and urethral pain are felt throughout

T10-L1 dermatomes

Renal and Urologic Disorders

Renal/kidney pain is typically felt in the posterior subcostal and costovertebral regions

Ureteral pain is felt in the groin or genital region

With renal or ureteral pain, radiation around the flank into the lower abdominal quadrant

Abdominal muscle spasm with rebound tenderness occurs on the same side

Renal and Urologic Disorders

Renal and/or ureteral pain is not altered by changing body position

Usually described as achy and dull, occasionally severe and boring

Pain may be accompanied by nausea, vomiting and impaired intestinal motility

Pseudorenal Pain

Irritation of costal nerves due to mechanical derangement of costovertebral or costotransverse joints

Most commonly occurs at T10 and T12 Absent early morning, increases with activity Is affected by body position Aggravated by prolonged sitting Test for pain with percussion over the

costovertebral angle (Murphy’s percussion)

Murphy’s Percussion Test

Renal and Urologic Disorders

Active trigger points of the lower internal oblique and lower rectus abdominus can cause irritation of the detrusor and urinary sphincter muscles resulting in urinary frequency, retention of urine and groin pain

Kidney Stones

Nephrolithiasis – Formation of calculi in the kidney

Pain is excruciating, spasmodic and radiating Often accompanied by severe nausea and

vomiting Characteristic symptom is sudden, sharp,

severe pain – Originates deep in the LB and radiates to genitals or thighs

Kidney Stones

Vary in size– Most are the size of a grain of sand– Some will be as large as a pearl– A few will grow to the size of a golf ball

May be smooth or jagged Usually brown or yellow in color

Kidney Stones

Renal Tumors

Classic sign is a flank mass with unexplained weight loss, fever, pain and hematuria

The presence of any amount of blood in the urine requires physician referral – primary symptom of urinary tract neoplasm

Prostate Tumors

Benign prostatic hypertrophy is common in men > 50 years old

Prostate enlargement interferes with normal passage or urine through the bladder

Urination is increasingly difficult and the bladder never feels completely empty

May be accompanied by LB, hip or leg pain

Urinary Incontinence

Four primary types:– Stress– Urge– Mixed– Overflow

Incontinence is not a normal part of the aging process

Urinary Incontinence

Onset of cervical spine pain with any type of incontinence is a red flag!!!

This combination of findings suggests cervical disc protrusion pressing on the spinal cord

Cervical spinal manipulation would be contraindicated

Renal Failure

Urine volume is significantly decreased or absent

Severe edema resulting in heart failure Severe fatigue and intolerance to normal

daily activities Eventual damage to other body systems –

CNS, PNS, eyes, GI tract, integumentary system, endocrine system and cardiopulmonary system

If untreated death

Urine Analysis (Urinalysis)

Creatinine

Males: 0.6-1.2 mg/dl

Females: .5-1/1 mg/dl

Elderly: May be higher

Children: Vary by age and sex

Increase – Indicates renal failure or increase in muscle mass

Decrease – Seen during pregnancy (increased fluid volume

Urine Analysis (Urinalysis)

BUN (Blood urea nitrogen)10-20 mg/dl

Increase – Seen with renal failure, lactic acidosis, DKA, GI bleed, increased protein catabolism, decreased volume and corticosteroid use

Decrease – Due to hepatic damage or decreased protein intake

BUN/Creatinine Ratio10:1 – 20:1

Renal and Urologic Disorders

Few objective PT tests are specific for the renal/urologic systems

– Most information comes from subjective history– PT must ask specific questions

Medical tests usually include:– Urinalysis– Blood studies– Diagnostic US– Radiology

Renal and Urologic Disorders

Questions regarding voiding– Increased frequency at night?– Urinary urgency/incontinence?– Pain or burning with voiding?– Hematuria

Renal and Urologic Disorders

PQRST P = Factors that provoke or palliate pain Q = Quality of pain R = Region and radiation of pain S = Severity T = Timing with other ADLs such as sleeping

or eating

References

Black JM, Matassari-Jacobs E, editors. 1993. Luckmann and Sorensen’s Medical-Surgical Nursing. 4th edition, Philadelphia, PA. WB Saunders. In Goodman CC, Snyder TE. 2000. Overview of Renal and Urologic Signs and Symptoms. In: Differential Diagnosis in Physical Therapy. 3rd edition. St. Louis, MO: Saunders Elsevier. p239.

Goodman CC, Snyder TE. 2007. Screening for Urogenital Disease. In: Differential Diagnosis for Physical Therapists Screening for Referral. 4th edition. St. Louis, MO: Saunders Elsevier. p436-466.

Ignatavicius DD, Workman ML, Mishler MA. 1995. Medical-Surgical Nursing. 2nd edition. Philadelphia, PA. WB Saunders, Chart 69-3, p2030.