By:

Maryam Hami MD,

Associate Prof. of Nephrology
Mashhad University of Medical sciences(MUMS)
 Pain:
1. Kidney pain
2. Ureteral pain
3. Bladder pain
4. Dysuria
 Other symptoms other than pain may
accompany voiding:
1. Urgency
2. Frequency
3. Hesitency
4. Incontinence
 Kidney pain is produced by sudden distention
of the renal capsule and is typically dull, and
steady

 Ureteral pain is a severe colicky pain that often

originates in the CVA and radiates around the
trunk
 Bladder disorders
may cause suprapubic
pain
 refers to painful urination
 Difficult urination is also sometimes described
as dysuria
 It is one of a constellation of irritative bladder
symptoms, which includes urinary frequency
and haematuria
 This is typically described to be a burning or
stinging sensation. It is most often a result of
1. urinary tract infection
2. STD
3. bladder stones
4. bladder tumours
5. prostate disorders
6. anticholinergic drugs
 Urgency:
Is an unusually intense and immediate desire to void. It
can be associated with infection, old age
 Frequency:
urination at short intervals without increase in daily
volume or urinary output, due to reduced bladder
capacity. It can be associated with infection, bladder
neck problems
 Hesitency:

difficulty in beginning the flow of urine; associated

with BPH in men and narrowing of the urethral
opening and may be caused by emotional stress
 Incontinence:
is any involuntary leakage of urine.
Common etiology are:
1. Polyuria

2. Prostate disorders (BPH and cancers)

3. Caffeine and Cola

4. Brain disorders (MS, spinal cord injuries,

Parkinson disease, stroke)
 Stress incontinence,
is due essentially to insufficient strength of the
pelvic floor muscles.
 Urge incontinence

is involuntary loss of urine occurring for no

apparent reason while suddenly feeling the
need to urinate.
 Overflow incontinence:

Sometimes people find that they cannot stop their

bladders from constantly dribbling, or
continuing to dribble for some time after they
have passed urine.
 Oliguria:
is the low output of urine, It is clinically classified
as an output below 400 ml/day
 The decreased output of urine may be a sign of

dehydration, renal failure, hypovolemic shock,

multiple organ dysfunction syndrome, or
urinary obstruction/urinary retention.
 Anuria:
absence of urine, clinically classified as below
100ml/day
 Anuria can be caused by

1. total urinary tract obstruction

2. total renal artery or vein occlusion

3. Shock

4. Cortical necrosis

5. severe ATN

6. Rapidly progressive glomerulonephritis

 Polyuria:
 urine>3 L/d
 Polyuria results from two potential mechanisms:
1. nonabsorbable solutes diuresis
2. water diuresis (DI)
 If the urine volume is >3 L/d and urine
osmolality is >300 mosmol/L, then a solute
diuresis is clearly present and a search for the
responsible solute(s) is mandatory
WE PREPARE URINE SAMPLE
BY CENTRIFUGATION

 Urine supernatant:

 Urine Sediment:
 Urine Dipstick Glucose
Bilirubin
Ketones
Specific Gravity
Blood

pH
Protein
Urobilinogen
Nitrite
Leukocyte Esterase
 Glucosuria Negative
Negative

Trace
Trace (100
(100 mg/dL)
mg/dL)

))mg/dL
mg/dL 250+ (

)mg/dL
mg/dL 500
500++ (

))mg/dL
mg/dL 1000+++
+++ ((

)mg/dL+ 2000
2000++++ (
 Bilirrubinuria Negative
Negative

))weak++ (

))moderate
moderate++
++ ((

)strong+++ (
 Urobilinogenuria mg/dL
mg/dL 0.2

mg/dL
mg/dL 11

mg/dL 2

mg/dL
mg/dL 4

mg/dL 8
 Normal red blood cell excretion in the urine is
up to 2 million RBCs per day.
 Hematuria is defined as two to five RBCs per
high-power field (HPF) and can be detected by
dipstick.
 Common causes of isolated hematuria include:
1. Stones
2. Neoplasms
3. Tuberculosis
4. Trauma
5. Prostatitis
 A single urinalysis with hematuria is common
and can result from menstruation, viral
illness, allergy, exercise, mild trauma
 persistent or significant hematuria:

1. three RBCs/HPF on three urinalyses

2. single urinalysis with >100 RBCs

3. gross hematuria

identified significant renal or urologic lesions in

9.1%
 Hematuria with dysmorphic RBCs, RBC casts,
and protein excretion >500 mg/d is virtually
diagnostic of glomerulonephritis.
 RBC casts form as RBCs that enter the tubule
fluid become trapped in a cylindrical mold of
gelled Tamm-Horsfall protein
 Pyuria
 refers to urine which
contains pus. Defined
as the presence of 4 or
more neutrophils per
high power field
 a cast formed from gelled protein precipitated
in the renal tubules and molded to the tubular
lumen; pieces of these casts break off and are
washed out with the urine.

 Types named for their constituent material

include epithelial, granular, hyaline, cellular
and waxy casts.
1. Infection
2. tubulointerstitial
processes such
as interstitial
nephritis,
systemic lupus
erythematosus,
and transplant
rejection.
 Crystalluria indicates that the urine is
supersaturated with the compounds that
comprise the crystals, e.g. ammonium,
magnesium and phosphate for struvite.
Crystals can be seen in the urine of clinically
healthy animals or in animals with no evidence
of urinary disease (such as obstruction and/or
urolithiasis). 
 means the presence of an excess of serum proteins in
the urine

 The dipstick measurement detects mostly albumin

and gives false-positive results when
1. pH > 7.0
2. urine is very concentrated
3. contaminated with blood.

 A very dilute urine may obscure significant

proteinuria on dipstick examination
 proteinuria that is not predominantly albumin will be
missed.
Protein % of Total Daily Maximum
Albumin 30% 30 mg
Tamm-Horsfall 50% 40 mg
Immunoglobulins 12% 14 mg
Secretory IgA 3% 6 mg
Other 5% 10 mg
TOTAL 100% 150 mg
 Common Causes of Benign Proteinuria
Dehydration
Emotional stress
Fever
Heat injury
Inflammatory process Intense activity
Most acute illnesses
Orthostatic (postural) disorder
 Cause Daily protein excretion

Mild glomerulopathies 0.15 to 2.0 g

Tubular proteinuria
Overflow proteinuria
Usually glomerular 2.0 to 4.0 g

Always glomerular >4.0 g

 Nephrotic syndrome classically presents with
heavy proteinuria (>3.5 g/d), minimal
hematuria, hypoalbuminemia,
hypercholesterolemia, edema, lipiduria and
hypertension
 Acute nephritic syndromes classically present
with hypertension, hematuria, red blood cell
casts, pyuria, and mild to moderate (1-2 g/d)
proteinuria, a fall in GFR .
 If glomerular inflammation develops slowly,
the serum creatinine will rise gradually over
many weeks, is sometimes called rapidly
progressive glomerulonephritis (RPGN);
 The histopathologic term crescentic
glomerulonephritis is the pathologic equivalent
of the clinical presentation of RPGN.
 Azotemia is a medical condition
characterized by abnormally high levels of
nitrogen-containing compounds, such as
urea, creatinine, various body waste
compounds, and other nitrogen-rich
compounds in the blood.
 It is largely related to insufficient filtering of
blood by the kidneys
 Uremia
 is a term used to loosely describe the
symptoms accompanying kidney failure.
 Early symptoms include anorexia and lethargy,
and late symptoms can include decreased
mental acuity and coma. Other symptoms
include fatigue, nausea, vomiting, bone pain,
itch, shortness of breath, and seizures.
1. Size of the kidneys
2. Past history of azotemia
3. Broad cast on U/A
4. Peripheral neuropathy
5. Renal Osteodysthrophy
 Upper UTI:
1) Pyelonephritis
2) Perinephric abcess
3) Prostitis
 Lower UTI:
1) Cystitis
2) urethritis
 the presence of bacteria in the urinary tract,
usually accompanied by white blood cells and
inflammatory cytokines in the urine.

 However, ABU occurs in the absence of

symptoms in the urinary tract and does not
usually require treatment.
 SBP-mmHg DBP-mmHg

Normal <120 And <80

Prehypertens 120-139 Or 80-89
ion
Stage 1 140-159 Or 90-99
Stage 2 ≥160 ≥100
Isolated ≥140 And <90
systolic HTN
 Renal stone: A hard mass that is formed in
urinary tract.
 Nephrocalcinosis: The persence of calcium
deposits in the kidneys.
 Risk factors: hypercalciuria, hyperuricosuria,
hypocitraturia, hyperoxaluria
Kidney stone (calculi)
 Plain film imaging (Radiography)
 Plain film of the abdomen (KUB)
 Urography
 Ultrasonography
 Computed tomography
 Magnetic resonance imaging
 Radionuclide imaging
 The kidneys-ureters-bladder (KUB) is often the
first imaging study performed to visualize the
abdomen and urinary tract
 The film is taken with the patient supine and should
include the entire abdomen from the base of the
sternum to the pubic symphisis
 Can show bony abnormalities, calcification and large
soft tissue masses

. Potts, J. (2004). Essential Urology: A Guide to Clinical Practice. Humana Press Inc
 IVU/ intravenous pyelogram is the classic
modality of imaging the entire urethelial tract
from pyelocalyceal system trhough the ureters
and bladder
 Excellent for indentifying small urethelial lesions as
well as the severity of obstruction from calculi
 Provides anatomical and qualitative functional
information about the kidneys

. Potts, J. (2004). Essential Urology: A Guide to Clinical Practice. Humana Press Inc
 Can be used to evaluate for abnormal anatomy
and function of the lower urinary tract in both
children and adults
 Similar to the cystogram, instillation of contrast
media into the bladder through a urethral cahteter is
also employed
 After full distention of the bladder, the patient is
instructed to void either after removing the catheter
or around the catheter

. Potts, J. (2004). Essential Urology: A Guide to Clinical Practice. Humana Press Inc
 In T1-weighted images (emphasizing the difference in
T1 relaxation times between different tissues), water-
containing structures are dark. T1-weighted images
do not show good contrast between normal and
abnormal tissues. However, they do demonstrate
excellent anatomic detail.
 T2-weighted images emphasize the difference in T2
relaxation times between different tissues. Because
water is bright in these images, T2-weighted images
provide excellent contrast between normal and
abnormal tissues, although with less anatomic detail
than T1-weighted images
 Study of choice for the general imaging of the
kidney and ureter
 used to create cross-sectional images of structures
in the body. In this procedure, x-rays are taken
from many different angles and processed through
a computer to produce a three-dimensional (3-D)
image
 Uptake of contrast by renal parenchyma during
nephrogram phase provides rough estimate of
kidney function
 Useful when renal or ureteral malginancy is
suspected
 uses the radiation released by radionuclides
(called nuclear decay) to produce images
 A radionuclide, usually technetium-99m, is
combined with different stable, metabolically
active compounds to form a radiopharmaceutical
that localizes to a particular anatomic or diseased
structure (target tissue).
 tracer goes to the target organ and can then be
imaged with a gamma camera, which takes
pictures of the radiation photons emitted by the
radioactive tracer