Smiths General Urology, Seventeenth Edition (LANGE Clinical Medicine)
Authors: Macfarlane, Michael T.
Title: Urology, 4th Edition
Copyright 2006 Lippincott Williams & Wilkins
> Table of Contents > Part One - Chief Presentations > Chapter 7 - Genitourinary Pain
Chapter 7
Genitourinary Pain
The process of diagnosing the etiology of a patient's pain is still one of the most difficult aspects of clinical medicine. Here, probably more than anywhere else, clinical experience and judgment are vital elements. I recommend Cope's Early Diagnosis of the Acute Abdomen by William Silen (New York: Oxford University Press, 2005). It is an unequaled crash course in clinical experience and judgment.
Kidney Pain
Pain associated with the kidney is the result of sudden distention of the renal capsule, as occurs with acute ureteral obstruction. It is referred to as flank pain and is usually colicky in nature (i.e., intermittent or in waves). Patients are often restless and cannot find a comfortable position. Reflex nausea and vomiting may be noted because of the common autonomic and sensory innervation of the gastrointestinal and urologic systems.
A dull, constant ache in the costovertebral angle also can characterize renal pain. This is less likely to be associated with acute obstruction but rather is secondary to renal parenchymal enlargement from pyelonephritis or a tumor. Renal pain must not be confused with flank or back pain of musculoskeletal origin or radiculitis, which can be aggravated or relieved by postural changes. Finally, remember that many renal diseases are painless, despite massive degrees of obstruction or kidney enlargement by tumors, because of the slow, gradual progression of the disease.
Ureteral Pain
Ureteral pain also is colicky and is intimately related to renal pain. Acute ureteral obstruction, as with a stone, will cause hyperperistalsis and spasm of the ureteral smooth muscle as it attempts to overcome the obstruction. Flank pain from renal capsular distention also will be noted, and the pain will radiate from the flank
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down the ipsilateral lower quadrant into the scrotum and testicle in male patients or the vulva in female patients. The level of ureteral obstruction can often be inferred by how far into the groin the pain radiates. Always be careful not to overlook other common intraabdominal pathology, such as appendicitis and diverticulitis, which can often be confused with ureteral pain.
Bladder Pain
Overdistention of the bladder as with acute urinary retention can produce severe suprapubic pain. However, most bladder pathology manifests with lower urinary tract symptoms (see Chapter 2), such as frequency, urgency, and dysuria, rather than suprapubic pain. Diseases of the uterus, such as fibroids and endometriosis, or of the colon, such as inflammation or fecal impaction, also may first be seen with suprapubic pain.
Prostatic Pain
Inflammatory conditions of the prostate can appear with a vague discomfort or fullness in the perineal or rectal area; however, lower urinary tract symptoms are usually the primary complaint. Prostate cancer will rarely cause pain in the perineal area until an advanced stage.
Testicular Pain
Testicular pain, as will occur with torsion, epididymo-orchitis, or trauma, is primarily felt locally in the area of the testicle and epididymis and may radiate to the ipsilateral lower abdomen (see Chapter 10). Testis cancer is typically painless.
Back and Leg Pain
Patients with prostate cancer may occasionally first be seen with complaints of low back pain radiating down one or both legs, secondary to bony metastases. Any evidence of lower-extremity weakness or difficulty walking should alert one to the possibility of cord or nerve root compression and must be treated as a medical emergency (see Chapter 22). Lower urinary tract symptoms are often associated with low back pain.