CHAPTER 32 Urinary problems in females and children

Common adult female urinary concerns include changes in usual urination patterns (frequency, urgency, nocturia, incontinence), changes in urine appearance (color, cloudiness), and pain (dysuria, flank pain, or suprapubic pain).

Urinary problems in adult females can be caused by infection, inflammation, calculi (stones), congenital malformation, or trauma. The majority of urinary tract infections (UTIs) are caused by gram-negative bacteria, predominantly Escherichia coli. The sexually transmitted pathogens Chlamydia trachomatis, Neisseria gonorrhoeae, and herpes simplex are common causes of urethritis. Vaginitis can also cause urinary symptoms in women. Urinary stones can occur anywhere in the urinary tract and are common causes of pain, bleeding, obstruction, and secondary infection.

In children, UTI is the second most common clinical disease of childhood, following respiratory tract disorders. The symptoms of urinary tract disorder may be vague or absent, making the diagnosis easily overlooked. Infection may be present without symptoms, with symptoms that are obviously related to the urinary system, or with symptoms that may divert attention to another organ system problem. Abdominal masses in the newborn are most frequently caused by renal enlargement, specifically dysplastic kidney and/or congenital hydronephrosis. Vesicoureteral reflux (VUR) is the major structural abnormality associated with UTI and renal damage.

Trauma to the urinary tract may be caused by penetrating, blunt, or crushing injuries, or by surgery or instrumentation. Hematuria, oliguria, and pain are the most common symptoms.

Diagnostic reasoning: focused history

Are there systemic or upper urinary tract symptoms present?

Key questions

Have you had a fever or chills?

Have you had nausea or vomiting?

Have you had acute pain in the abdomen or back?

Are you positive for HIV infection? Are you receiving chemotherapy?

In an infant: Has the infant been irritable or had anorexia or lethargy?

Fever and chills

The presence of fever and chills suggests a systemic inflammatory response and indicates an acute condition that should be treated aggressively. Suspect pyelonephritis or lithiasis of the upper urinary system. UTI is the most common bacterial infection in febrile infants and children who present without an obvious source of infection.

Nausea and vomiting

Nausea and vomiting often accompany upper UTI, pyelonephritis, or lithiasis. Like fever and chills, these symptoms suggest a systemic inflammatory response and indicate that the patient may be acutely ill. In newborns and infants, nonspecific symptoms, such as vomiting, diarrhea, and feeding difficulties, may indicate UTI.

Acute pain

Acute pain in the back or abdomen suggests upper UTI and pyelonephritis. Flank pain occurs with stretching of the renal capsule associated with parenchymal swelling, and may indicate infection, obstruction, or primary renal disease.

Urinary tract stones may produce localized back pain or excruciating pain that often radiates to the thigh.

Immunocompromised patients

Immunocompromised patients are susceptible to overwhelming infections by both common and atypical organisms, and aggressive investigation is warranted.

Irritable infant

UTI in neonates and infants is manifested in subtle ways, such as irritability, anorexia, and weight loss. Some infants with UTI present with bacteremia.

Is there hematuria?

Key questions

Have you had blood in your urine? When in the stream does it occur?

Do you have pain with urination?

Do you have bleeding without urination?

Have you done any strenuous exercise recently?

Hematuria

Red-to-brown discoloration is commonly caused by infection, trauma, or urinary tract stones. It can also be caused by parenchymal renal disease, systemic disease, medications, or coagulopathies.

Pyelonephritis or urinary tract stones are common causes of gross (macroscopic) hematuria. Neoplasm, trauma, and some medications can also produce gross hematuria. Gross hematuria occurs in 60% to 90% of bladder tumors. Both bladder and renal neoplasms are less common in women than in men. Hematuria can be produced by local irritation in cystitis. Platelet disorders and hemophilia can cause both gross and microscopic bleeding. Urinary frequency or urgency, dysuria, or suprapubic pain suggests that the origin of hematuria is confined to the lower urinary tract.

Initial hematuria (at the beginning of urination) suggests the urethra is the source, whereas terminal hematuria (at the end of urination) suggests posterior urethra or bladder base involvement. Total hematuria means red blood cells are dispersed throughout the urinary stream, characterizing origination in the kidney, ureter, or bladder.

Pain

Hematuria without pain is usually caused by renal disease or tumor of the bladder or kidney. Other causes of painless hematuria include stones, polycystic kidney disease, renal cysts, sickle cell disease, and hydronephrosis. When discomfort, such as renal colic, accompanies hematuria, suspect a ureteral stone. Hematuria with dysuria suggests bladder infection or lithiasis.

Bleeding without urination

Bladder lesions may produce bleeding independent of micturition.

Strenuous exercise

Transient hematuria is frequent after strenuous exercise, and the amount of bleeding is proportional to the amount of exercise and the trauma sustained by the urinary tract. Exercise-related hematuria is caused by direct trauma to the kidneys and bladder, as well as by ischemic injury. It is caused by the shifting of blood flow from the renal circulation to the heart, lungs, and skeletal muscles during periods of high oxygen demand.

Can the symptoms be localized to the lower urinary tract?

Key questions

What are your primary symptoms (e.g., pain, frequency, urgency, small amounts of urine, nausea, nocturia, itching)?

Have you had any suprapubic pain?

Do you have involuntary urination?

Primary symptoms

Dysuria suggests inflammation of the bladder neck or urethra, usually caused by bacterial infection or irritation that injures the bladder mucosa, leading to inflammatory changes, infiltration, and edema. These changes, from mild stretching of the bladder to a loss of bladder elasticity, can result in urgency and frequency.

Dysuria is the cardinal symptom of uncomplicated lower urinary tract infection (acute bacterial cystitis). In children, it may also be the first indication of an anatomical lesion such as obstruction of the urinary tract or VUR. Other common symptoms include frequency, mild nausea, nocturia, urgency, and voiding small amounts. Fever is notably absent. Infants may have strong-smelling urine and continuously damp diapers.

Dysuria also suggests urethritis, especially if accompanied by vaginal discharge. External dysuria, a burning sensation as the urine passes the inflamed labia, suggests vulvovaginitis. Patients with vulvovaginitis may also report discharge, odor, or itching. Women who have active herpes lesions may also experience external dysuria. Young children with pinworms (Enterobius vermicularis) may have dysuria and vaginitis because of the abrasions that result from periurethral and perivaginal itching and scratching.

Interstitial cystitis produces diminished bladder capacity along with symptoms of frequent painful urination. Hematuria may be present. Increased frequency can also occur as a result of stones or a tumor.

Suprapubic discomfort and urinary incontinence

Discomfort in the suprapubic area is indicative of bladder involvement and urinary incontinence and is characteristic of bladder neck irritability caused by inflammation. Local causes of incontinence can also include pelvic relaxation and impaired bladder muscle activity. Preschool-age children with UTIs frequently have enuresis (see Chapter 31).

Could this be the result of trauma?

Key questions

Have you had any recent injury?

Have you been hit recently?

If a child: Have you noticed the child putting foreign objects in his or her genitourinary tract?

Recent injury

Injury or a blow to the flank area can produce hematuria, originating from the kidney. Straddle injury may result in abrasions and local inflammation, causing pain on urination. About 5% of childhood trauma involves the kidney, making it a relatively uncommon event. About 10% of the injured kidneys have underlying abnormalities, such as hydronephrosis or a horseshoe shape, making them more vulnerable to injury.

Trauma

A victim of domestic violence may present with blood in the urine secondary to trauma. Trauma may or may not be associated with pain. Active children may not remember trauma to the area.

Foreign objects

Children have a propensity to put foreign objects in any orifice. Placing foreign objects in the vagina can cause dysuria and pyuria.

Could this be genitourinary in origin?

Key questions

Are you sexually active? How frequently do you engage in sexual activity?

Have you had a new sexual partner recently?

How many sexual partners do you have?

Does your sexual partner have any symptoms?

Do you use a diaphragm?

Do you have any vaginal discharge?

If a postmenopausal woman: Are you on hormone replacement therapy?

Sexual activity

Factors that contribute to the development of acute bacterial cystitis include frequent sexual intercourse, use of a diaphragm, and use of spermicidal gel for contraception. Urethritis is associated with a history of a new sexual partner, a partner with urethritis, and multiple sexual partners. Masturbation may also cause dysuria in girls, as a result of either local irritation or the introduction of organisms that produce a lower UTI.

Organisms from sexually transmitted infections can cause urethritis when they are present in large numbers in the urethra. A local inflammatory response results. C. trachomatis is the most common pathogen, although N. gonorrhoeae, Trichomonas vaginalis, and herpes simplex can also cause urethritis. Active herpes lesions can also produce dysuria as the urine passes across the inflamed external mucosa.

Diaphragm use

Some women who use a diaphragm experience mechanical compression of the urethra, with subsequent urine retention that predisposes them to the development of cystitis.

Vaginal discharge and hormone therapy

Vaginal infections are a common cause of dysuria, particularly in college-age women. Atrophic vaginitis can also cause dysuria. Postmenopausal women who are not on hormone therapy are more likely to have atrophic vaginitis.

Are there any specific risk factors to point me in the right direction?

Key questions

Have you had this or similar problems before? If yes, when and how many times?

Have you had recent catheterization or urinary tract procedures performed?

Is there a family history of kidney or urinary problems?

Do you have diabetes?

How much spicy food, caffeinated beverages/food, carbonated beverages, or alcohol do you consume?

How much water do you drink?

Do you suppress the urge to urinate (postpone urination)?

Do you use bubble baths, shampoos, feminine hygiene products, powders, and soaps?

Do you have constipation?

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