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Urinary Problems

The major complaints possible are:

1. PAIN OR BURNING SENSATION

-Pain or burning sensation while passing urine-thesignifies urinary tract infection. Increased frequency of passing urine may also be there.

-It is desirable to confirm the diagnosis withmicroscopic examination of urine. In urine infectionpus cells will be present.

Treatment of urinary tract infection

-If this is not associated with fever likely to be lower urinary tract infection treat with Amoxicillin or co-trimoxazole or ciprofloxacin for 5 to 7 days.

-If this is associated with fever (which means that infectionmay have spread to kidneys) then treatment iswith Amoxicillin or trimoxazole should go on for 14days. Ciprofloxacin is another good choice for UTI givefor 14 days.

-Always advise to drink plenty of water so that there isa high output of urine.

When to refer

-In males after a single episode & in females withrecurrent UTI refer to the CHC for ultrasound to ruleout urinary stones.

-If fever does not subside within three days

2. EXCESSIVE URINE FLOW

-The commonest cause is drinking lots of water. Thisis normal.

-The next common cause is DM. A urine sugar test would confirm this. If it is positive refer it to a doctor inthe community health care center to confirm thediagnosis, to check for complications and to start thedrugs. Subsequently it can be followed up at theprimary health care centre.

-Rarely there are other causes of excessive urine flow like diabetes insipidus and some types of kidney disorders for which person would need to go to atertiary care hospital.

3.DECREASED URINE FLOW

-The commonest cause is lack of drinking water and hot weather. Correct by drinking lot of water.

-If it is not corrected by drinking water occurs alongwith swelling of the feet and/or face then consider oliguria (

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Action required: start an antibiotic-amoxicillin 500mg 8 hourly may add metronidazole. If open ulcers arepresent. Inj procaine penicillin is an alternative.

2.CP: unilateral or bilateral, painful, non-pitting

LD: deep vein thrombosis

AR: Inj heparin 5000 units subcutaneously to berepeated every 6 hours with clotting time to be kept within 2 to 2.5 times the normal.

3.CP: usually unilateral or asymmetrical, does not pit on pressure, long standing

LD: late filariasis, elephantiasis

4.CP: bilateral, pitting, with generalized swelling face,abdomen.

LD: differentiate between these four conditions:kidney/heart/liver disease, severe anaemias

5.CP: bilateral pedal oedema associated withpregnancy often normal but to rule out pre-eclampsiaby checking blood pressure and urine for abdomen.

LD: normal, secondary to anaemia, pre-eclampsia

RENAL DISEASE

1.ACUTE NEPHRITIS

This is clinical syndrome due to glomerular diseasewhich may be a primary disease or secondary to asystemic process. Note that sickle cell disease canalso present as nephropathy.

Diagnosis: - Clinical presentation: oliguria,haematuria,facial puffiness, occasionally pedal oedema

-On examination: patient has hypertension, urineexamination which shows proteinuria and RBCs

Investigation : the presence of RBC casts in urine isdiagnostic- however one can diagnose acute nephritiseven in its absence.

Treatment :

GENERAL GUIDELINES

-bed rest at home

-adequate fluids taking care that excess is not givenwhich would increase oedema but not enough is givento ensure at least 400ml of urine per day. If one canestimate the previous days urine volume a water intake of that plus about 800 to 1000ml would beadequate

-salt restriction- especially if oedemas present

DRUG TREATMENT

-a tablet of furosemide may be tried if there is water logging and hypertension. Not to be given if there is noobvious evidence of fluid excess

-other antihypertensive is required

-treatment of infections. Especially if there is impetigoa course of penilcillin is indicated.

REFER to district hospital if urine flow decreasesfurther or if hypertension is not controlled.

2.NEPHROTIC SYNDROME

This too is due to glomerular disease that can beprimary or secondary. The type of lesion that is most common in children and most responsive to treatment in both adults and children is called minimal testingdisease.

DIAGNOSIS

-proteinuria more than 3.5mg in 24 hours

-hypo-albuminaemia, hyperlipidaemia

-oedema

TREATMENT

-in all adults a renal biopsy is indicated. If this is not available one would have to treat this presumptively aswe treat minimal change disease. But as most cases inadults are not steroids becomes a problem in theabsence of a biopsy report.

-in young children since minimal change disease ismore common one could treat presumptively for thesame and biopsy only if there is no response.

-Treatment for minimal change disease is withprednisolone 1mg/kg/day. To be given till proteinurianormalizes and then tapered over three months.Failure to response usually indicates that it is not minimal lesion. If after tapering steroids there isrelapse then restart prednisolone. If steroid dependence develops refer to tertiary centre for cytotoxic drugs. If there is non-response develops alsorefer to tertiary care centre.