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URINE EXAMINATION

Indications of Urine Examination

1. Urinary tract symptoms - dysuria, frequency, urgency, hesitancy, nocturia
2. Haematuria (gross or microscopic)
3. Suspected urinary tract infection (UTI)
4. Renal diseases - acute/chronic kidney disease, glomerulonephritis, nephrotic syndrome
5. Hypertension and diabetes mellitus (monitoring for proteinuria)
6. Renal colic / urolithiasis
7. Pre-operative workup
8. Fever of unknown origin
9. Screening for metabolic disorders (diabetes - glycosuria; PKU - phenylketonuria)
10. Monitoring treatment response in renal or urological disease
11. Suspected malignancy of urothelium (cytology)
12. Post-partum or antenatal surveillance

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URINE EXAMINATION - TYPES

A. Macroscopic (Physical/Gross) Examination

• Phosphaturia (benign; clears with acetic acid - alkaline urine)
• Pyuria (leukocyturia with characteristic pungent odour)
• Chyluria (lymph-urine fistula), lipiduria, hyperoxaluria

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B. Microscopic Examination

• 0-5 RBCs/hpf
• 0-5 WBCs/hpf
• Occasional epithelial cells
• No casts, bacteria, or significant crystals

• Casts form in the distal nephron/collecting duct - they take the shape of the tubule
• The matrix is Tamm-Horsfall mucoprotein
• Presence of cellular elements within casts indicates active renal pathology

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C. Biochemical (Chemical) Examination

• Microalbuminuria: 30-300 mg/day - early diabetic nephropathy marker
• Macroproteinuria: >300 mg/day - established glomerular disease
• Nephrotic range: >3.5 g/day

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D. Cytological Examination

• High-grade transitional cell carcinoma (TCC)/urothelial carcinoma - most useful
• Carcinoma in situ (CIS) - urine cytology is especially valuable as CIS may not be visible on cystoscopy
• Viral inclusions (CMV, BK virus in transplant patients)
• Atypical/suspicious cells warranting further investigation

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E. Bacteriological (Microbiological) Examination

• E. coli (70-80% community UTIs)
• Klebsiella, Proteus mirabilis, Enterococcus, Pseudomonas aeruginosa (hospital-acquired)
• Staphylococcus saprophyticus (young women)

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Clinical Significance of Abnormal Urine Findings

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RENAL FUNCTION TESTS

Creatinine and Blood Urea Nitrogen (BUN)

Blood Urea Nitrogen (BUN)

• Reference range: 7-18 mg/dL
• BUN is a product of protein (amino acid) catabolism via the urea cycle in the liver
• Urea is freely filtered at the glomerulus and approximately 40-50% is passively reabsorbed in the proximal tubule

• Prerenal: Dehydration, hypovolaemia, heart failure, GI bleeding (digestion of blood adds to urea load), high protein diet, hypercatabolic states (sepsis, corticosteroids)
• Renal: Acute/chronic kidney disease (intrinsic renal failure)
• Postrenal: Urinary tract obstruction

Serum Creatinine

• Reference range: Males 0.7-1.2 mg/dL; Females 0.5-1.0 mg/dL
• Creatinine is a product of muscle creatine phosphate metabolism - it is produced at a constant rate proportional to muscle mass
• Almost entirely excreted by glomerular filtration (5-10% tubular secretion at normal GFR; as GFR falls, tubular secretion contributes more)
• Creatinine is NOT reabsorbed by the tubules

• A reliable marker of GFR - serum creatinine rises as GFR falls
• A parabolic (inverse, non-linear) relationship exists: a doubling of creatinine indicates ~50% loss of GFR
• Important limitation: Creatinine may remain in normal range despite significant GFR loss (the "creatinine-blind zone") because of compensatory hyperfiltration by remaining nephrons
• Factors falsely raising creatinine: drugs (cimetidine, trimethoprim, fenofibrate), rhabdomyolysis (muscle breakdown), high meat intake
• Factors falsely lowering creatinine: low muscle mass (elderly, malnutrition, amputation), advanced liver disease

BUN : Creatinine Ratio

• Normal ratio: 10:1 to 15:1 (in mg/dL units); 40:1-60:1 in mmol/L
• Ratio >20:1 (prerenal or postrenal): Hypovolaemia, GI bleeding, high protein intake, hypercatabolism, obstructive uropathy. In prerenal states, elevated ADH causes increased proximal tubular water and urea reabsorption, disproportionately raising BUN.
• Ratio 10:1 (intrinsic renal disease): Acute tubular necrosis, glomerulonephritis - BUN and creatinine rise proportionately

• Comprehensive Clinical Nephrology 7th Ed., Textbook of Family Medicine 9th Ed.

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IMAGING OF THE URINARY TRACT

Plain X-Ray KUB (Kidney, Ureter, Bladder)

Definition and Purpose

Indications

1. Suspected renal/ureteric calculi (first-line screening)
2. Flank pain / acute renal colic
3. Follow-up of known radio-opaque urinary calculi (post-ESWL or post-ureteroscopy)
4. Assessment of stone burden before surgical planning (PCNL, ESWL)
5. Abdominal pain - assess bowel gas pattern, organomegaly
6. Pre-IVU scout film (baseline for contrast study)
7. Monitoring for catheter or stent position
8. Screening for calcification (adrenal, lymph node, AAA calcification)

Technique

Normal Findings on Plain KUB

• Kidneys: Visible as soft-tissue shadows ("renal outline") alongside the psoas shadow. Right kidney slightly lower than left. Size: 11-14 cm (3.5 vertebral body lengths). Smooth outlines.
• Psoas shadow: Symmetric, well-defined lateral margin of the psoas major muscle bilaterally.
• Ureters: Not visible on plain KUB.
• Bladder: May be seen as a soft-tissue density in the pelvis if full.
• Bowel gas: Scattered gas in non-dilated small and large bowel.
• Bony structures: Lumbar vertebrae, sacrum, pelvis, lower ribs - no lytic/sclerotic lesions.

Abnormal Findings

• Renal calculi: A radiopaque shadow in the line of the ureter (L1-L5, then along the bony pelvic brim, into pelvis) suggests ureteric calculus. Pain is colicky with radiation to groin/testicle.
• Urinary tract obstruction: Plain KUB may show dilated bowel (paralytic ileus from ureteric colic), or loss of psoas shadow from inflammatory mass.

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Intravenous Urography (IVU) / Intravenous Pyelography (IVP)

Definition

Indications

1. Haematuria (investigating source - upper vs. lower tract)
2. Renal/ureteric calculi - to assess obstruction, anatomy, and collect system
3. Suspected urinary tract obstruction (hydronephrosis / hydroureter)
4. Renal anomalies (horseshoe kidney, duplex system, ectopic kidney)
5. Recurrent UTI (structural abnormalities, reflux)
6. Suspected urothelial tumour of the upper tract
7. Flank pain / loin pain
8. Pre-surgical planning
9. Suspected PUJ (pelviureteric junction) obstruction
10. Bladder mass assessment

Procedure / Technique

1. Pre-procedure: Check serum creatinine (contraindicated if significantly elevated), allergy history, hydration status, metformin (hold 48 hours pre-procedure), thyroid function if history of thyroid disease.
2. Scout film (KUB): Plain AP radiograph of the entire urinary tract.
3. Contrast injection: 1-2 mL/kg of non-ionic iodinated contrast (e.g., iohexol, iomeprol) injected IV as a bolus.
4. Timed films:
   • 1-3 min (nephrogram phase): Renal parenchyma opacifies homogenously - assesses renal size, outline, and perfusion.
   • 5 min: Pelviocalyceal system fills - PCS anatomy, calyces, pelvis.
   • 10-15 min: Ureters fill - course, calibre, filling defects, obstruction.
   • 20-25 min: Full length ureters + bladder.
   • Post-micturition film: Residual urine, bladder emptying, lower ureteric detail.
5. Compression: A compression band may be applied over the ureters to enhance pelvicalyceal filling.
6. Oblique views for ureteric calculi or bladder lesions.

Normal IVU Findings

• Bilateral symmetrical nephrogram within 3 minutes
• Smooth renal outlines; right kidney at L1-L3, left at T12-L2
• PCS: Elegant calyceal pattern with sharp fornices and papillae
• Ureters: Pencil-thin, course along transverse processes, cross the SI joint to the pelvis
• Bladder: Smooth wall, rounded, no filling defects
• Normal post-void: minimal residual

Abnormal IVU Findings

• Severe contrast allergy (relative - premedicate)
• Renal failure (creatinine >200 mmol/L) - contrast nephrotoxicity risk
• Myelomatosis (contrast may precipitate acute renal failure in myeloma kidney)
• Diabetes mellitus with metformin (hold metformin)
• Pregnancy (radiation risk)
• Severe dehydration (increases contrast nephrotoxicity)

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Retrograde Ureteropyelography (Retrograde Urogram)

Definition

Indications

1. Failed or non-diagnostic IVU - when the kidney is not functioning or IVU is inadequate
2. Renal failure (does not rely on GFR; contrast is not absorbed systemically in significant amounts)
3. Contrast allergy to IV contrast
4. Evaluation of ureteral obstruction - defines level, length, and nature of stricture
5. Filling defects in ureter or PCS seen on IVU - differentiates calculus, clot, tumour, extrinsic compression
6. Haematuria workup when other investigations are inconclusive
7. Pre-operative planning - before ureteroscopy, PCN, or ureteroplasty
8. PUJ obstruction - to confirm diagnosis and length of stricture
9. Evaluation of trauma to the ureter
10. Stent placement guidance
11. Upper tract urothelial carcinoma evaluation

• Medscape - Retrograde Pyelography

Technique (Retrograde Ureteropyelography)

1. Anaesthesia: Spinal or general anaesthesia (procedure is done under cystoscopic guidance).
2. Positioning: Lithotomy position.
3. Cystoscopy: Rigid or flexible cystoscope is inserted; both ureteric orifices are identified.
4. Ureteric catheterisation: A 5-6 Fr open-ended ureteric catheter (or Chevassu catheter) is advanced under vision into the ureteric orifice and up the ureter.
5. Contrast injection: Water-soluble iodinated contrast (e.g., urografin 15-25%) is gently injected in controlled amounts (5-10 mL) under fluoroscopic guidance. Avoid over-distension (risk of pyelosinus backflow, bacteraemia, and post-procedure fever).
6. Fluoroscopic images: AP and oblique films are taken to image the ureter, PUJ, and pelviocalyceal system.
7. Retrograde pyelogram vs. retrograde ureterogram: If the catheter is advanced to the renal pelvis, a pyelogram is obtained; if it only fills the ureter, it is a ureterogram.
8. Ureteric catheter placement: A stent or catheter may be left in situ as part of treatment.

Normal Retrograde Urogram Findings

• Ureter smooth, uniform calibre throughout (3-4 mm)
• No filling defects, no strictures
• Smooth, symmetric pelviocalyceal system
• No extravasation of contrast
• Normal PUJ without delay

Abnormal Findings and Clinical Significance

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Ultrasonography (USG) in Urogenital Diseases

Importance and Advantages

• No ionising radiation - safe in children and pregnant women
• Real-time imaging - dynamic assessment of organ vascularity (Doppler)
• Portable and widely available
• Can detect hydronephrosis, renal masses, calculi (with posterior acoustic shadowing), bladder abnormalities
• Guides percutaneous procedures (biopsies, nephrostomy)

Indications in Urogenital Diseases

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HAEMATURIA

Causes of Haematuria

Classification by Origin

1. Glomerulonephritis (IgA nephropathy - most common cause of recurrent haematuria worldwide, post-streptococcal GN, Henoch-Schönlein purpura, MPGN, focal segmental GS)
2. Renal calculi / nephrolithiasis
3. Renal cell carcinoma (painless haematuria - classic triad: haematuria, loin pain, flank mass)
4. Transitional cell carcinoma of the renal pelvis
5. Renal tuberculosis
6. Polycystic kidney disease
7. Medullary sponge kidney
8. Renal trauma / injury
9. Renal vein thrombosis
10. Arteriovenous malformation
11. Sickle cell trait/disease
12. Alport syndrome (hereditary nephritis with deafness and ocular defects)

1. Urinary tract infection (cystitis, urethritis)
2. Carcinoma of the bladder (transitional cell carcinoma) - most common cause of painless haematuria in adults >40 years
3. Ureteric calculi
4. Bladder calculi
5. Urethral stricture
6. Benign prostatic hyperplasia (BPH)
7. Carcinoma of the prostate
8. Schistosomiasis (Schistosoma haematobium - "Egyptian haematuria")
9. Bladder trauma / cyclophosphamide-induced haemorrhagic cystitis
10. Urethral caruncle / polyp

• Coagulopathy (haemophilia, warfarin, antiplatelet therapy)
• Thrombocytopaenia
• Infective endocarditis
• Malignant hypertension
• Radiation therapy (radiation cystitis)

• Initial haematuria (first glass only): Anterior urethral lesion
• Terminal haematuria (last glass only): Bladder neck, prostate, posterior urethra
• Total haematuria (all three glasses): Kidney, ureter, or posterior bladder

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Homoeopathic Therapeutics for Haematuria

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HORSESHOE KIDNEY

Description

• Low-lying kidneys (isthmus at L4-L5 vertebral level)
• Malrotation - renal pelves face anteriorly (instead of the normal medial position)
• Calyces point medially and posteriorly (instead of laterally)
• High insertion of the ureters on the renal pelvis (aberrant)

Clinical Significance

1. Pelviureteric Junction (PUJ) Obstruction: Due to high ureteral insertion, aberrant vessels crossing the PUJ, and the malrotated position. Leads to recurrent flank pain, hydronephrosis.
2. Urinary Stasis and Calculi: Impaired drainage predisposes to stone formation (prevalence of stones ~20%). Stones often lodge in lower pole calyces.
3. Recurrent UTI: Stasis predisposes to infection.
4. Associated Anomalies:
   • Genital anomalies (hypospadias, cryptorchidism, bicornuate uterus, duplex vagina)
   • Cardiovascular anomalies (VSD, ASD, coarctation of aorta)
   • Vesicoureteric reflux
   • Turner syndrome (~7% of girls with Turner syndrome have horseshoe kidney)
5. Increased incidence of Wilms' tumour (nephroblastoma) - 2x higher than general population
6. Increased incidence of TCC of the renal pelvis (from chronic stasis/infection)
7. Carcinoid tumours of the horseshoe kidney (rare but well-documented association)
8. Abdominal aortic aneurysm surgery hazard - isthmus lies anterior to the aorta and may complicate surgery
9. Trauma - isthmus is vulnerable to compression against the lumbar spine in abdominal trauma

Radiological Modalities and Findings

Plain X-Ray KUB

• Low-lying kidney shadows, medially directed lower poles
• Calculi visible if present (radiopaque)
• Isthmus may cast a soft tissue shadow across the midline anterior to the spine

Intravenous Urography (IVU) - Classic Imaging

• Low-lying kidneys with lower poles directed medially
• Calyces pointing medially and posteriorly (in a "flower vase" or inverted configuration)
• Renal pelves facing anteriorly (as opposed to normal medial orientation)
• Possible dilation of the PCS indicating PUJ obstruction
• "Flower vase sign" - the PCS configuration resembling an inverted flower vase
• Ureters may appear to drape over the isthmus
• Delayed drainage on the affected side if PUJ obstruction is present

Ultrasound

• Isthmus visualised as a band of tissue anterior to the aorta and inferior vena cava
• Low-lying kidneys with medially directed lower poles
• Useful for detecting hydronephrosis, calculi, or renal masses

CT Scan / MRI (Preferred for Preoperative Assessment)

• Modality of choice for full anatomical delineation
• Clearly demonstrates: isthmus, aberrant vessels, collecting system anatomy, relation to great vessels, bowel (risk of retrorenal colon)
• Contrast CT shows: PCS anatomy, corticomedullary differentiation, renal masses, stone burden
• Essential before PCNL, isthmus division, or oncological surgery

Nuclear Medicine (Isotope Renogram - MAG3/DTPA)

• Assesses differential renal function (split function) in each moiety
• Identifies obstruction at the PUJ (drainage curves)
• Useful pre-operatively if surgical division of isthmus or pyeloplasty planned

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