STUDY OF UGIT (P-14)

 SYMPTOMS FOF RENAL DISEASE

Renal disease is often revealed only by the incidental findings of hypertension, proteinuria or a raised blood urea concentration. In some cases the underlying disease has been truly symptomatic; in other the significance of apparently trivial symptoms has been ignored.

The symptoms which most often bring patient to a doctor is pain. Pain due to acute bladder or a urethral inflammation is called dysuria; this is a burning or tingling sensation felt as the urethral measures or in the suprpubic area during after micturition. Dysuria frequent and urgent micturition constitutes the syndrome of cystitis; in severe cases there may be blood in the urine (haematuria). Cystitis is extremely common in young women, in whom it is usually related to sexual activity, and in such patients investigation for a serous underlying cause is rarely required. In older women and men and underlying conditions, especially urinary obstruction, must be excluded in men, perineal or rectal or rectal pain suggests infection of the prostate gland (prostatitis). Cystitis should be suspected in young children who cry on micturition infection of the urine children may be due to deformity of the urinary tract and this requires further investigation. Although symptoms of cystitis in women are often due to bacterial infection, this can be proved in only about half the cases.

Pain due to disease of kidney is usually felt in the flank hypochondrium or iliac fossa. Acute obstruction of kidney causes severe, often colicky pain relating to the groin and, in the male patient to the testis, chronic obstruction causes less severe discomfort, often none. The pain of acute pyelonephritis and of renal or peri-renal abscess is also severe, but constant, and is associated with prexial symptoms. If peri-renal pus has tracked upwards under the diaphragm the patient may complain of pain in the chest or shoulder; if it has tracked retroperitoneally over the psoas muscle he may be unable to extend the hips and may have be hold it in flexion. Kidneys which are enlarged (e,g polycystic kidneys) or grossly scarred may cause a dull, nagging flank pain. Acute glomerulonephritis nay produce a full sensation in the flank, but chronic glomerulonephritis is typically painless. It must be emphasized that severe and progressive damage to the kidneys often occurs without their being any discomfort or other symptoms.                        

                                                          Haematuria

Red urine is usually due to haematuria rather than haemoglobinuria. Haematuria may originate in any part of the urinary tract. Its unwise to attribute it to a urinary infection, except in sexually active young women with cystitis. Other causes include glomerulonephritis, excretion of the kidney or urothelium, renal stone disease, necrosis of the renal papilla, begin enlargement of the prostate and (rare and difficult to prove) haemangiomatous malformations involving the outflow tracts of the kidneys.  It is particularly important not to forget the possibility of an underlying carcinoma and it is often necessary to impact the bladder with a cystoscope to ensure that a carcinoma is not to missed. Occasionally an attack of renal colic with haematuria culminates in the passage of a stone or of crumbly material “gravel”. This should be saved for chemical analysis; microscopy may show whether renal papiilary tissue is present.

Frequency of micturition often goes unnoticed during the day, because day time voiding is determined as much by habit and social factors as by necessity.  To be called regularly from sleep in order to micturate is much more easily recognized as abnormal, and this may be due to loss of renal concentrating capacity, urinary infection bladder, obstruction or neurological disease affecting the bladder. Nocturnal micturition (nocturia) is frequently the first symptom of chronic renal disease. If patient complains of frequency try to discover whether large or small quantities of urine or being passed, because there are several important causes of the production of too much urine.

In acute glomerulonephritis the volume of urine produced may be very small (oliguria), and haematuria often occurs. Unless fluid intake is restricted the patient will develop evidence of salt and water accumulation, such as breathlessness, swelling of face and ankle and hypertension. Acute glomerulonephritis rarely causes complete cessation of urine production (anuria); of this occurs obstruction of both kidneys, or of a solitary functioning kidney, or obstruction at the bladder outlet suspected.

The nephrotic syndrome consists of heavy proteinuria, lowering of the plasma concentration of albumin and oedema. The oedema is due to transfer of fluid from vascular to extra-vascular compartments, and to a retention of fluid which is not usually so dramatic as to be noticed by the patient, but which is obvious as an imbalance between measured fluid intake and urine output, or from serial weighing of the patient. The proteinuria may cause notice-able frothing of the urine on micturition, and this may antedate other manifestation of the syndrome by several months.

Just as frequency and dysuria are the most common urinary symptoms in young women, so disturbed micturition due to enlargement of the prostate is the most common urinary abnormality in men past middle age. Characteristically, the stream of urine produced on voiding in poor and the patient complains of difficulty in initiating micturition (hesitancy) and in stopping it (terminal dribbling). Recurrent haematuria may occur and acute retention of urine (an agonizing condition) may supervene. Occasionally a patient presents with uraemia and no attendant symptoms. All these features may be caused by benign enlargement of the prostate, or by carcinoma of this gland.

Urethral discharge is only recognized by men and requires further investigation. It is often unaccompanied by pain, but there may be dysuria and frequency.