Critical thinking and diagnostic reasoning when assessing problems with the genitourinary system

With the prevalence of urological symptoms increasing within the ageing population and people self-managing symptoms until they become bothersome, nurses play a pivotal role in ensuring that patients follow the most appropriate pathway of care. To demonstrate excellence in patient safety, the advanced clinical practitioner must have a clear understanding of common conditions affecting the lower urinary tract, in order to undertake a comprehensive assessment of the presenting symptoms and associated comorbidities, interpret examinations and diagnostic investigations relevant to urological disorders, identify the relationships and provide a differential diagnosis based on the information gathered. Table 1 shows the differential diagnoses for a patient presenting with symptoms suggesting a urinary tract infection (UTI).

Common presenting symptoms and differential diagnosis

Lower urinary tract symptoms in men are classed as follows:

• Voiding: weak or intermittent flow, straining, hesitancy, incomplete emptying
• Storage: frequency, urgency with/without leakage, nocturia.
• Post-micturition: terminable dribble. Lower urinary tract symptoms in women are:
• Storage: increased daytime frequency, nocturia, urgency, incontinence, enuresis, continuous urinary leakage, bladder pain syndrome
• Voiding symptoms: retention, poor flow, hesitancy, intermittent stream, straining, terminal dribble
• Post-micturition symptoms: dribble, feeling of incomplete emptying
• Symptoms associated with sexual intercourse: dyspareunia, vaginal dryness, incontinence
• Symptoms associated with genitourinary prolapse: a feeling of ‘something coming down’, heaviness, dragging sensation, low backache.

Renal colic

The incidence of kidney stone disease (urolithiasis) is rising, with a lifetime risk of 10–15%, and a recurrence rate of 50% within 10 years (Wilcox et al, 2020). Renal colic is more prevalent in males (ratio 3:1 female) between the ages of 20 and 40 years. It is more common in industrialised countries that have high dietary sodium and protein levels. Medications such as diuretics, antacids, steroids, antivirals and vitamins C and D can promote the formation of calcium stones when taken at levels above the daily recommendation. Those at risk of stone formation are younger people with ureteric reflux, older females with history of recurrent UTI (struvite calculi) or people with neuropathic bladder dysfunction. Struvite (staghorn) calculi account for 10-15% of all urinary calculi (Flannigan et al, 2014).

Renal colic presents with a sudden onset of colicky pain radiating from the renal area to the loin or groin. The pain is caused by obstruction of flow in the ureter, leading to increased wall tension in the urinary tract. Prostaglandin synthesis is increased, and vasodilatation causes a diuresis, which further increases pressure. Prostaglandins may also cause smooth muscle spasm in the ureter. The episodes of pain can be intermittent, but it should not be assumed that cessation of pain means the stone has been passed. Imaging is essential for diagnosis and to discount other pathologies such as appendicitis, pancreatitis, or pelvic inflammatory disease. The complications associated with renal colic are UTI, urosepsis or chronic kidney disease.

Urinary retention

Retention is defined as the inability to void voluntarily at a bladder volume of 600 ml, a volume at which there is usually a strong desire to do so. This inability to void leads to over-distension of the bladder. Urinary retention is common in adult males secondary to an outflow obstruction caused by benign prostate enlargement (benign prostatic hyperplasia/BPH), malignancy, urethral stricture or urinary stones.

According to Dougherty and Aeddula (2021), acute retention is most common in men aged 60-80 years, with 10% of men in their seventies and 30% in their eighties experiencing an episode of acute urinary retention. In addition to age, it is associated with race, obesity, diabetes, high alcohol intake and physical inactivity. Risk factors are linked to benign prostatic hyperplasia (BPH). It is inevitable that immediate management of acute retention will be indwelling catheterisation and potential surgical intervention, both of which pose risk of complications. However, transurethral resection of the prostate (TURP) reduces acute retention by 85-90% (Lin et al, 2018).

Presenting symptoms of an obstruction may include hesitancy, frequency, poor stream and increased abdominal pressure. Non-obstruction retention caused by inappropriate detrusor muscle innervation can occur following a stroke, anaesthesia, acquired brain injury, spinal cord injury or diabetic neuropathy. Neurogenic causes are more prevalent in younger males and females (Dougherty and Aeddula, 2021). Drugs reported to induce retention are anti-muscarinics, anticholinergics, alpha-adrenergic agonists, anti-psychotics, opiates, and tricyclic antidepressants. Older people are at a higher risk of experiencing drug-induced retention due to existing comorbidities and associated medication (Verhamme et al, 2008).

Benign prostatic hyperplasia (BPH)

BPH causes bladder outlet obstruction with or without symptoms and is one of the most common problems seen in older males (in 40% of men aged over 50 years and 75% of men over 70 years). Symptoms vary according to the degree of enlargement and can include urinary urgency, frequency, nocturia and voiding difficulties. The International Prostate Symptom Score (IPSS) (Medscape, 2021) is the gold standard for assessing the severity of lower urinary tract symptoms (LUTS) by measuring the impact of symptoms on quality of life (Praveen, 2013). The tool involves symptom profiling: incomplete emptying, frequency, intermittency, urgency, weak stream, straining, nocturia, and the impact on quality of life due to urinary symptoms. This can involve physical, emotional, psychological, sexual and social issues. IPSS is not regarded as a reliable diagnostic tool for LUTS suggestive of BPH but it can be used to measure the severity of LUTS after diagnosis (Lee and Weiss, 2021).

Fowler's syndrome (females)

Although the true prevalence of Fowler's syndrome is unknown, it is a common cause of urinary retention in females aged 20-30 years. Retention develops when the urethral sphincter fails to relax and it can occur following surgery, childbirth, opiate use, UTI or other illness. The female may present with a history of infrequent voiding with an interrupted flow and chronic urinary retention. Symptoms may be accompanied by high levels of comorbidity with 50% of sufferers having neurological pain, 31% psychological symptoms and 24% functional neurological disorder (Hoeritzauer et al, 2015).

Bladder cancer

Bladder cancer affects more than 10 000 people a year and is the seventh most common cancer in the UK, predominantly affecting people aged 50-70 years with a ratio of 2:1 male to female. Early detection, diagnosis and containment (the cancer does not spread beyond the bladder) (Figure 1) are key to survival because only 46% of those diagnosed survive for 10 years or more, however the survival rate has increased over the past 40 years (Cancer Research UK, 2021).

Several risk factors have been highlighted:

• Kidney or bladder stones, some genetic conditions and family history
• A history of occupational exposure to chemical carcinogens such as 2-naphthylamine or benzidine in the chemical or rubber industries may induce bladder cancer in later life (International Agency for Research on Cancer (IARC), 2010)
• A history of occupational exposure as a hairdresser with a 30-35% higher risk than the general population. Some carcinogenic chemicals were banned from hair dyes in the 1970s and the risk is not linked to personal use of hair dyes (Harling et al, 2010)
• A high concentration (10 μg/litre) of arsenic in drinking water (Gibb et al, 2011; IARC, 2014; Saint-Jacques et al, 2014; Tsuji et al, 2014)
• It is estimated that 45% of bladder cancer cases in the UK are caused by smoking (Brown et al, 2018).

Presenting symptoms include a UTI not responding to antibiotics, haematuria, lower back pain, urinary frequency, incontinence, tiredness, abdominal pain or weight loss.

Prostate cancer

Prostate cancer is the most common cancer diagnosed in men in the UK (1:8), with a higher prevalence in African Caribbean men (1:4) and a risk that increases with age. Worldwide, the incidence of prostate cancer has increased in all groups between the ages of 15 and 40 years, with evidence suggesting links to underdiagnosis, substance exposure, environmental carcinogens and obesity (Bleyer et al, 2020). In most cases prostate cancer is slow growing and many men are asymptomatic, but in younger males the cancer can be more aggressive, leading to lower rates of survival. Treatment may cause devastating side effects of erectile dysfunction, infertility and incontinence. There is a 5-10% inherited risk (links to the BRCA1/2 genes). Currently there is not a reliable enough approach to testing for prostate cancer—a prostate-specific antigen (PSA) result alone can be an unreliable indicator (Cancer Research UK, 2019).

Men may present with any or a combination of the following symptoms:

• Frequency and/or nocturia
• Retention
• Poor flow or hesitancy
• Pain or a burning sensation on voiding
• Impotence
• Pain during ejaculation
• Haematuria
• Pain in the lower back, hips or thighs.

According to Lorenzo et al (2019), most prostate cancer starts in the peripheral zone at the back of the prostate where there is 70% of tissue mass (Figure 2). Lower urinary tract symptoms occur due to BPH positioned in the transition zone on the inside of the prostate gland surrounding the urethra.

PSA is a protein made by the prostate gland and a PSA blood test, although not a specific diagnostic test, is carried out when screening for the presence of cancer in the prostate gland. However, PSA levels can be elevated due to UTI, prostatitis, recent vigorous exercise, recent ejaculation or prostate stimulation, urethral catheterisation or prostate enlargement. Acceptable PSA levels vary according to age (Macmillan Cancer Support, 2021):

• 40-50 years: 1-2 ng/ml
• 50-59 years: 3.0 ng/ml
• 60-69 years: 4.0 ng/ml
• 70 years and over: 5.0 ng/ml

A diagnosis of prostate cancer will be based on the integration of information following a blood test for PSA level, digital rectal examination of the prostate and transrectal ultrasound-guided biopsies. Diagnostic imaging such as MRI may be required to support diagnosis.

Prostatitis (acute and chronic)

Defined as swelling or inflammation of the prostate gland, 2 in 10 000 men experience an acute bacterial infection that is commonly linked with a UTI but not sexually transmitted infection. Acute prostatitis can follow urethral instrumentation, trauma, bladder outflow obstruction or dissemination of infection from elsewhere in the body. It is caused by urinary pathogens, in 50% of cases Escherichia coli. Men diagnosed with chronic prostatitis (also referred to as primary prostate pain syndrome) will present with a minimum of 3 months' history of symptoms or urogenital pain which is linked to inflammation. The risk of chronic prostatitis increases with age (Engeler et al, 2021). The male may present with symptoms of severe pain at the base of the penis and/or anus, painful voiding or difficulty in voiding, painful defecation, lower back pain or penile discharge.

Urethral stricture

This is defined as a narrowing of part or all the urethra due to scar tissue. According to Lazzeri et al (2016) the incidence is unknown but greatly increases in males older than 55 years in western countries. Stricture formation is more prevalent in males than females. Scar tissue can form due to injury, instrumentation (45%) or infection with subsequent inflammation (20%) (Tritschler et al, 2013). In order to manage a stricture effectively, it is important to find the underlying cause. Presenting symptoms may include incomplete emptying of the bladder, UTI, urinary frequency, pain, slow flow or spraying when voiding. On assessment a female may describe urine spraying on her thighs during voiding.

Peyronie's disease

Peyronie's disease is a non-cancerous formation of scar tissue resulting in curvature of the penis. It is characterised by the presence of fibrous, inelastic lesion in the tunica albuginea that is palpable beneath the penile skin. The disease has two distinct phases: active inflammation causing pain followed by plaque formation (flat scar tissue) and progression of the disease.

Experienced by 1 in 20 men in the UK or 3-9% of men worldwide, Peyronie's can have higher prevalence in some subgroups such as people with diabetes (Randhawa and Shukla, 2019). Initially linked in 1828, Peyronie's disease and Dupuytren's disease are often comorbid (25% of cases) and thought to have a similar underlying pathophysiological mechanism (Shindel at al, 2017). Dupuytren's disease is a condition causing thickening and scarring to the fascia under the skin on the palm. Gradually, several fingers may become curled in towards the palm.

The symptoms of Peyronie's include deformity of the penis, curvature that hinders sexual intercourse, painful erections, or erectile dysfunction. Such symptoms can have a significant impact on the psychological wellbeing of the man, affecting self-esteem and quality of life.

Urinary tract infection

Symptoms of a UTI are a common reason for consultation and assessment in a primary care setting, with 11% of females having at least one infection and 3% having three or more in the previous year (Butler et al, 2015). The prevalence of infection in females is higher than in men due to several factors: the shorter length of urethra providing easier transit of perineal and faecal flora into the bladder, proximity of the urethra to the anus, pregnancy, lower levels of oestrogen in peri/post-menopausal women and sexual contact. Approximately 1 in 2000 men will experience one infection each year. The high incidence and occurrence of UTI lead to escalating healthcare costs. UTI treatment is the second most common reason for antibiotic prescribing. A patient with an indwelling catheter may be at risk and present with symptoms of a catheter-associated urinary tract infection (CAUTI).

Symptoms of UTI include urgency, frequency, nocturia, dysuria, abdominal pain, haematuria, pyrexia, or hypothermia or sudden incontinence. They are frequently linked with the factors are listed in Table 2:

Diagnosis should be based on LUTS and urine dipstick testing for an uncomplicated UTI. Urine cultures should be considered in the presence of risk factors for complicated UTIs such as acute pyelonephritis, symptoms persisting or recurring in 2-4 weeks after treatment, pregnancy or male with UTI (Tan and Chlebicki, 2016).

It is vital to always maintain patient safety by recognising a deteriorating patient at risk of urosepsis and presenting symptoms of fever, pain, nausea and vomiting, reduced urine output, hyperthermia, hypothermia, tachycardia and tachypnea.

Painful bladder syndrome

Painful bladder syndrome, also known as interstitial cystitis, is a chronic inflammatory condition with unknown origin affecting a million people in the USA and Europe, with a ratio of 5:1 female to male. It is described as symptoms of pain related to the bladder, accompanied by urinary urgency, frequency or nocturia, with a duration of 6 months and in the absence of other identifiable causes. Primary bladder pain syndrome may be associated with negative cognitive, behavioural, sexual or emotional consequences, as well as symptoms suggestive of sexual dysfunction (Engeler et al, 2021).

The most common findings under cystoscopy are ulceration (Hunner's ulcers), inflammation on the bladder wall, oedema, and small vessel bleeding (glomerulations). Cystoscopy may detect no abnormalities; therefore, diagnosis will be based on symptoms. Anecdotally, symptoms are often misdiagnosed as recurrent UTI leading to mismanagement and the risk of antibiotic resistance.

Overactive bladder syndrome

This is defined by the International Continence Society as urinary urgency with frequency and nocturia with or without incontinence (Drake, 2018). Anecdotal evidence suggests 12% of the adult population in the UK experience symptoms of an overactive bladder and prevalence increases with age. In many cases the cause of overactive bladder is undetermined and not linked to neurogenic influences following diagnosis of a stroke, Parkinson's, or multiple sclerosis. People commonly present with a combination of symptoms that may significantly impact on quality of life. Frequent voiding of small volumes and nocturia are bothersome symptoms and completion of a 3-day bladder diary will provide a reliable measure of frequency. Further investigation of symptoms is required to discount UTI or a urinary stone.

Conclusion

Early presentation and subsequent diagnosis of urinary symptoms is vital to achieving the best outcomes. Achieving an accurate diagnosis in a timely manner will lead to better patient safety. To achieve this the specialist nurse or advanced clinical practitioner requires a proficient knowledge of common urology disorders along with advanced clinical skills to interpret results of examination and investigations, utilise knowledge and experience to make a differential diagnosis and make evidence-based management recommendations for managing the person's individual needs.

KEY POINTS

• The prevalence of people having bothersome urological symptoms is increasing
• Urology symptoms have a significant impact on quality of life
• Early diagnosis is key to achieving better outcomes and improves patient safety
• Specialist nurses and advanced clinical practitioners play a pivotal in ensuring patients achieve an accurate, timely clinical diagnosis

CPD reflective questions

• As an advanced clinical practitioner, how do you keep your knowledge and competence up to date?
• Is your understanding of urological disorders comprehensive?
• Do you need to undertake additional learning in order to advance your knowledge?