Differential Diagnosis 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

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: 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) 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 Ratio 10:1 – 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 Luckmann and Sorensen’s Medical-Surgical Nursing. 4 th edition, Philadelphia, PA. WB Saunders. In Goodman CC, Snyder TE 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 Screening for Urogenital Disease. In: Differential Diagnosis for Physical Therapists Screening for Referral. 4 th edition. St. Louis, MO: Saunders Elsevier. p Ignatavicius DD, Workman ML, Mishler MA Medical- Surgical Nursing. 2 nd edition. Philadelphia, PA. WB Saunders, Chart 69-3, p2030.