How can kidney stones cause testicular pain

History: symptoms and complaints in urology

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History of current complaints

The medical consultation often begins with the question of current symptoms or problems that prompted the doctor's visit. With specific questions, the mentioned complaints are concretized with regard to the localization, the time of occurrence, the severity and known triggers.



Whenever possible, the complaints should be quantified: e.g. B. visual analog scale for pain, IPSS for urination problems or IIEF for erectile dysfunction.

Knowledge of the various causes of key symptoms is the basis for initiating further examinations in a targeted manner and for quickly finding the correct diagnosis. The diagnosis remains a differential diagnosis due to the probability of error, but it is the basis for initiating therapy. In the further course, the diagnosis must be questioned as long as the healing process lasts.

Pain in urology

Pain emanating from the genitourinary tract can be very severe and is usually triggered by sudden urinary flow disorders or inflammation. Gradual urinary flow disorders without inflammation often do not cause pain.

Kidney pain:

arise from the acute expansion of the renal capsule and are perceived in the costovertebral angle lateral to the erector spinae muscle. Continuous pain indicates an infection, an undulating course of pain (colic) indicates a (variable) obstruction of the urine flow (e.g. due to kidney stones or ureter stones).

Kidney pain can be associated with gastrointestinal symptoms due to autonomic reflexes, making diagnosis difficult. Other abdominal organs can also trigger pain in the costovertebral angle. Clinical indications for diseases of the abdominal cavity are immune tension, shoulder pain and patients who avoid any kind of movement in order to prevent the pain from worsening. See also Differential Diagnosis of Acute Abdominal Pain.

Kidney pain can be confused with irritation of the spine or costal nerves. Movement-dependent pain and the absence of colic are typical of acute lumbago.

Ureter pain:

are triggered by a sudden obstruction of the ureteral lumen and are wavy in character (colic). The pain is caused by the stretching and hyperperistalsis of the ureter. An obstruction of the proximal ureter is felt like kidney pain (see Sect. O.). Pain triggered by the middle ureter projecting into the lower abdomen and into the scrotum / labia. The obstruction of the distal ureter also creates pollakiuria and dysuria.

Urinary bladder pain:

are caused by urinary retention (constant pain) or inflammation of the urinary bladder (pain associated with urination). The pain is localized suprapubic in the lower abdomen with radiation to the penis.

Constant suprapubic pain with normal painless micturition speaks against urological disease.



Prostate pain:

are triggered by a prostate capsule expansion, but can be difficult to localize. The patient reports perineal pain, pelvic pain, or rectal discomfort. Furthermore, there may be dysuria, pollakiuria or urinary retention. The most common causes of prostate pain are prostate infections.

Testicular pain:

acute testicular pain is triggered by trauma, infection, or torsion. In addition to the direct scrotal localization, the pain is also projected into the lower abdomen. Chronic testicular pain is caused by non-inflammatory diseases such as hydrocele, varicocele, spermatocele or tumors.

The embryonic origin of the testes from the retroperitoneum is the cause of the pain radiation into the scrotum in ureter pain.

Penis pain:

Flaccid penile pain is caused by trauma, paraphimosis, urethral pain, or bladder pain projection. Pain in the erect penis is caused by induratio penis plastica or priapism.

Micturition disorders

The English acronym LUTS stands for lower urinary tract symptoms and is a collective term for irritative or obstructive micturition problems regardless of the cause. Micturition disorders are subjectively perceived very differently. With the help of a micturition diary, the complaints regarding time and intensity can be documented and help with the assessment of the clinical picture. In principle, the amount of drinking and urine is documented in tabular form for each hour of the day, the volumes are best measured with a measuring cup and not just estimated. Furthermore, complaints such as incontinence, urge or pain are also noted for the corresponding hour of the day.

Irritant symptoms:

Irritant symptoms are pollakiuria (frequent urination), urge symptoms, dysuria (painful urination) and nocturia (nocturnal urination).

Pollakiuria:

Pollakiuria is frequent urination with generally normal urine production. Pollakiuria is differentiated from polyuria (urine volumes over 3 l / day). A normal rate of urination in adults is considered to be less than 8 micturitions per day.

Urge discomfort:

Urge is a sudden occurrence of a strong urge to urinate that is difficult to control. The maximum form of complaint is urge incontinence.

Dysuria:

Dysuria is painful urination, often described as a burning sensation or a stinging sensation. The pain can radiate into the urethra or penis. Pain at the beginning of micturition suggests urethral pathology, dysuria at the end of micturition suggests bladder disease. Dysuria is often triggered by infections of the urinary bladder, urethra or prostate.

Differential diagnosis of pollakiuria, urge symptoms or dysuria:
  • Infections: cystitis, prostatitis, urethritis.
  • Anatomically reduced bladder capacity are: radiogenic cystitis, interstitial cystitis, after bladder surgery, advanced bladder carcinoma or prostate carcinoma, compression of the urinary bladder by lower abdominal tumors or pregnancy.
  • Functionally reduced urinary capacity: residual urine due to subvesical obstruction or neurogenic bladder disorders, overactive urinary bladder, detrusor hyperreflexia, urinary bladder stones, distal ureteral stone, foreign bodies in the urinary bladder, vaginal estrogen deficiency
  • Subvesical obstruction: BPH, prostatitis, prostate cancer, urethral stricture, pelvic floor insufficiency, foreign bodies in the urethra.
  • Medication: diuretics, beta blockers, theophylline, or caffeine.
  • Psychological causes such as stress, nervousness, anxiety disorders or after sexual violence.
Nocturia:

In addition to the causes of pollakiuria (see o.) leads to an isolated nocturnal polyuria (> 50 % of the daily amount) to nocturia.

Obstructive symptoms:

Weak urine stream, delayed start of micturition, straining during micturition, interrupted urine stream, subsequent dripping, sensation of residual urine, urinary retention.

The most common cause of obstructive micturition problems is benign prostatic hyperplasia. The complaints should be quantified using the IPSS questionnaire. The diagnostic challenge is to identify rare causes such as urethral strictures or neurological diseases as the cause of urination problems [Tab. Causes of urinary retention].

Diagnosis:

Every patient with LUTS should have the following basic exams:

  • Physical examination with digital rectal palpation.
  • Micturition diary: helps distinguish between polyuria and reduced bladder capacity.
  • Ultrasound of the urinary bladder and kidneys: residual urine? Urinary Bladder Diseases? Prostate size? Urinary congestion?
  • Urine sediment

In unclear or complicated cases, the following examinations can be helpful:

  • Symptom Score (IPSS)
  • Creatinine in the serum: for urinary obstruction.
  • PSA: if DRE is suspicious or if prostate cancer screening is desired.
  • Urinary stream measurement: in case of anamnestic difficulties regarding the urinary stream strength.
  • Cystoscopy: in the case of hematuria, very weak urine stream, in the absence of drug therapy success, before surgical therapy.
  • Urodynamics: in the case of neurological diseases, unclear situations before planned operations.
  • Internal support: for nocturnal polyuria and simultaneous cardiopulmonary disease.

Urinary incontinence

With the help of a careful medical history and a micturition diary, the cause of the urinary incontinence can be narrowed down.

Hematuria

The microhematuria is defined by at least 5 erythrocytes per field of view with a 400-fold magnification of the urine under the microscope. If blood is visible in the urine, one speaks of (macro) hematuria.

By specifically questioning the patient and assessing the urine sediment, the cause of the hematuria can be narrowed down and rational, further imaging and endoscopic diagnostics can be initiated [see causes of hematuria].

Pneumaturia

The excretion of gases with the urine is almost always a sign of a urinary bladder-intestinal fistula, caused by sigmoid diverticulitis, colon cancer, Crohn's disease or after radiation. Gas-producing bacteria can rarely trigger pneumaturia as part of a urinary tract infection. The anamnestic must be distinguished from (one-off) pneumaturia after cystoscopy or catheterization.

Hematospermia

Blood in semen (hematospermia) can be traced back to harmless causes in the majority of cases [see section Hematospermia: Blood in semen].

Discharge from the urethra

Purulent discharge suggests gonorrhea, glassy discharge suggests non-gonorrheic urethritis. Bloody discharge is caused by autoerotic acts or can be a sign of urethral cancer.

Disorders of sexuality

Patients should be actively asked about sexual disorders. The general anamnesis records risk factors for causes of sexual dysfunction: internal diseases, neurological diseases, mental illnesses, operations, drugs (antihypertensive drugs, sedatives, antiandrogens, ...), alcohol, smoking or drugs.

Libido disorders:

with reduced ejaculate volume are an indication of a hormonal disorder (hypogonadism, Cushing's disease, hyperprolactinemia). Libido disorders with a normal ejaculate volume can be triggered by depression or internal diseases.

Erectile dysfunction:

In addition to a precise sexual history (duration, degree of erection, changes, partner change, psychological stress, libido, nocturnal erections, ...), the extent of erectile dysfunction should be quantified using the IIEF questionnaire.

Ejaculation Disorders:

The exact sexual history must differentiate between ejaculatio praecox, retrograde ejaculation, lack of ejaculation or orgasmic disorders.

Risk factors for retrograde ejaculation are prostate surgery (TURP), alpha-blockers, or retroperitoneal surgery.



History of previous and known diseases

Personal history

Completed or known medical illnesses are of great interest when assessing the current clinical picture. The patient's information should be supplemented or supported by questions about the key symptoms of all organ systems [Tab. important key symptoms].

Questions about key symptoms
GenerallyAppetite? Thirst? Trouble sleeping? Night sweats? Body weight? Fever?
Head and neckEyesight? A headache? Dizziness? Sore throat? Lymph nodes?
thoraxTo cough? Sputum? Shortness of breath? Heartache? irregular pulse? Breast lump?
abdomenDiarrhea? Constipation? Blood in the stool? Vomit? Stomach pain?
Genitourinary tractUrination? Urine color? sexual discomfort? Pain?
Motion
apparatus
Lower back pain? Muscle or joint pain?
miscellaneousSkin rash? Paralysis? Seizure disorders?

External anamnesis:

the information from colleagues (doctor's letter) and relatives supplement and confirm the personal history.

Medication history

The exact recording of the medication intake provides valuable information on known diseases. Furthermore, side effects of medication are often the cause of problems with urination or sexuality. It is also important to record known intolerances or allergies.



Operations

Operations carried out so far and their course should be recorded with the year. Before planned operations in previously operated regions, an operation report of the previous operation is helpful.

Luxury foods

The recording of alcohol and tobacco consumption enables the assessment of numerous clinical risks.

Risks associated with smoking:

Urothelial carcinoma, renal cell carcinoma, penile carcinoma, increased cardiovascular risk (erectile dysfunction, renal artery embolism), increased perioperative complications (wound healing disorders, anastomotic leakage, pulmonary complications).

Risks associated with increased alcohol consumption:

Hypogonadism, peripheral neuropathy with disorders of sexuality or micturition, gynecomastia, increased perioperative complications (hepatic dysfunction, alcohol withdrawal syndrome, wound healing disorders).

Family history

Specific questions were asked about the most common hereditary or familial diseases in the urological specialty:


Social history

Professional history:

Urothelial carcinoma is a recognized occupational disease with appropriate temporal exposure to toxins (chemical industry, rubber processing, steel industry, car mechanic, leather industry, dental technician).







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