Abnormalities in micturition

Micturation Abnormalities Microchapters
Overview
Causes
Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

Overview

Micturition is the act of passage of urine which is a normal physiological process. Any abnormality in urine can cause difficulty in passage of urine. Abnormality of micturition usuallly present with symptoms like dysuria, nocturia, incraesed frequency, dribbling, hesitancy and suprapubic tenderness. Various causes include cystitis, pyelonephritis, cervicitis, prostatitis, benign prostatic hyperplasia etc.It is important to differentiate among the different causes which can help guide the treatment.

Classification

• There is no established system for the classification of abnormalities in micturition.

Causes

• The causes of abnormalities in micturition includes causes of dysuria and incontinence:
  • Cystitis
  • Urethritis
  • Pyelonephritis
  • Cervicitis
  • Prostatitis
  • Benign prostatic hyperplasia
  • Atrophic vaginitis
  • Trauma

Abnormalities of Micturition Differential Diagnosis

Differentiating the diseases that can cause abnormality in micturition:

Abbreviations: N= Normal, UTI= Urinary tract infection, CBC= Complete blood count, CT= Computed tomography, IBS= Irritable bowel syndrome, DRE= Digital rectal examination, HSV= Herpes simplex virus, RBCs= red blood cells, STI= Sexually transmitted infection, PCR=Polymerase chain reaction

Diseases			Clinical manifestations									Para-clinical findings				Gold standard	Additional findings
			Symptoms						Physical examination
												Lab Findings		Imaging
			Fever	Urinary symptoms					Supra-pubic tenderness	Skin lesions	Other	CBC	Urinalysis	Ultrasonography	CT scan
				Dysuria	Frequency	Dribbling	Hesitancy	Nocturia
Inflammatory	Dermatological disorders	Lichen sclerosus	–	+	–	–	+	–	–	Lichenified plaques	–	N	often shows UTI in women	N	N	Biopsy	Constipation IBS
		Behcet's syndrome	–	+	+	–	+	+	–	Erythema nodosum Papules Vesicles	Aphthous ulcer in mouth	N	N	N	N	None	Neurogenic bladder Genital Aphthous ulcers Recurrent cystitis Epididymitis Urethritis
	Infectious diseases	Cystitis	+	+	+	+	+	+	+	N	–	Leukopenia	WBC Leukocyte esterase Ntrite	Bladder wall thickening Intraluminal gas in emphysematous cystitis	Hydronephrosis beaded necklace like in emphysematous cystitis	Urine culture to sensitivity	N
		Urethritis	+	+	+	–	+	–	+	Keratoderma blennorrhagica- in disseminated gonococcal infection Vesicles - HSV Painless ulcer- syphilis Warts- Condyloma acuminatum	–	Leukocytosis	N	N	N	Urethral swab for culture, NAAT	N
		Pyelonephritis	+	+	+	–	–	+	±	N	Urgency	Leukocytosis	WBC Leukocyte esterase Ntrite	Hypoechoic when there is edema(swollen kidney) Gas buubles in emphysematous pyelonephritis	Round swollen kidneys Hypodense appearance Abscesses may not be present	Urinalysis and Urine culture
		Diseases	Fever	Dysuria	Frequency	Dribbling	Hesitancy	Nocturia	Suprapubic tenderness	Skin lesions	Other	CBC	Urinalysis	Ultrasonography	CT scan	Gold standard	Additional findings
		Vulvovaginitis	±	+	+	+	+	–	–	Excoriations in vulva Genital ulceration Candida thrush	Thick white discharge	N	N	N	N	Microbiological diagnosis Wet mount PCR
		Cervicitis	+	±	+	±	–	–	+	Erythematous Friable	Thick yellow green pus	Leukocytosis	WBC	N or show PID like feature	N or show PID like feature	Culture of vaginal discharge	NAAT for gonocooccal cervicitis
		Prostatitis	+	+	+	+	+	+	±	–	Tender prostate	Leukocytosis	WBC Leukocyte esterase Ntrite	N	N	Urine culture	Prostate massage for chronic prostatits leads to raised leukocytes in urine
		Epididymoorchitis	±	+	+	+	–	–	–	–	Cremasteric reflexes present Prehn's sign	Leukocytosis	WBC	N	N	Urine culture	Ceftriaxone for STI Levofloxacin for coliform bacteria
Non-inflammatory	Anatomic	Urethral stricture	–	+	±	+	–	–	–	–	–	N	RBCs	Post void residual; volume is high	–	Retrograde urethrogram+cystoscopy(urodynamic studies)
		Benign prostatic hyperplasia (BPH)	–	+	+	+	+	+	–	–	Enlarged and smooth prostate on DRE	N	May have UTI like picture on some occassion	Enlarged prostate	–		TURP is gold standard treatment
		Diseases	Fever	Dysuria	Frequency	Dribbling	Hesitancy	Nocturia	Suprapubic tenderness	Skin lesions	Other	CBC	Urinalysis	Ultrasonography	CT scan	Gold standard	Additional findings
	Gynecological	Atrophic vaginitis	–	+	+	±	±	+	–	Vaginal dryness Vaginal erythema Excoriation marks	Vaginal discharge	N	N	Thinning of endometrium	N	Clinical examination
		Endometriosis	–	+	–	–	–	–	–	–	Dyspareunia Dyschezia	N	N	Cystic masses attached to adnexa	Cysts	Laparoscopy	Dysmenorrhea Dyspareunia Dyschezia
	Malignancy	Bladder cancer	–	+	+	–	–	–	–	–	Hematuria	Anemia	Hematuria	N	Nodal involvement in the pelvis or retroperitoneum, visceral, pulmonary, or osseous metastasis	Cystoscopy and biopsy
		Vulvovaginal cancer	–	±	±	±	–	–	–	Edematous vulva Lesion on the inner edges of vulva	–	N	When infected, WBC Leukocyte esterase Ntrite	N	Contrast enhancement(vascularity) showing the extent of the disease	Biopsy
	Iatrogenic	Genitourinary instrumentation/ pelvic irradiation	–	+	±	–	±	±	±	Erythema	–	MaybeLeukocytosis	When infected, WBC Leukocyte esterase Ntrite	N	N	Culture
		Trauma	±	±	–	–	–	–	±	Laceration/bruise	Hematuria	Anemia Leukocytosis	Hematuria	Blood in pelvic cavity	Blood in pelvic cavity	Laparotomy