Differentials
Common
Menstruation
History
identified by obtaining a menstrual history
Exam
typically no exam findings
1st investigation
- none:
diagnosis is based on typical history
Other investigations
Cystitis (urinary tract infection)
History
typically presents with dysuria, frequency, or urgency
Exam
suprapubic tenderness may be present; otherwise exam is often normal
1st investigation
- urinalysis:
positive for leukocyte esterase and/or nitrites
- urine culture:
≥10² colony-forming units
More
Other investigations
Pyelonephritis
History
fever, chills, flank pain, rigors, nausea and vomiting, dysuria, urinary frequency, urgency
Exam
costovertebral angle tenderness
1st investigation
- urinalysis:
pyuria with WBC casts and bacteriuria
- urine culture:
≥10² colony-forming units
Other investigations
- ultrasound:
may suggest inflammation or obstruction
- helical CT of urinary tract with intravenous contrast:
may suggest inflammation or obstruction
Nephrolithiasis
History
flank or groin pain, history of nephrolithiasis
Exam
nonspecific or may find flank tenderness
1st investigation
- helical CT of urinary tract without contrast:
visible stone present[45]
Acute prostatitis
History
fever, dysuria, and frequency occur and are often associated with suprapubic, perineal, or sacral pain; obstructive symptoms may occur in severe cases
Exam
fever may be present and digital rectal exam demonstrates a tender "boggy" prostate; exam often diagnostic
1st investigation
- urine microscopy:
positive for leukocytes and/or bacteria
- urine culture:
positive
More
Other investigations
- culture of prostate secretions:
positive growth of bacteria
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Benign prostatic hyperplasia (BPH)
History
urine outflow obstruction symptoms (difficulty voiding, changes in urine volume, lower abdominal discomfort or bladder fullness, and nocturia) occur
Exam
enlarged firm prostate on digital rectal exam; suprapubic tenderness may be present due to bladder fullness if severe obstruction; exam is often diagnostic
1st investigation
- post void residual volume:
high post void residual volume suggests bladder outlet obstruction
- prostate-specific antigen:
elevated greater than age guideline
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Other investigations
- transrectal ultrasound:
enlarged prostate
More
Trauma (sexual activity, exercise, contusion)
History
recent sexual activity, strenuous exercise, or injury to the back (costovertebral angle area) or genitalia
Exam
may reveal signs of trauma (mucosal tears, ecchymoses) of the external genitalia; typically no exam findings
1st investigation
- none:
diagnosis is based on typical history and exam
Other investigations
Uncommon
Bladder stone
History
dysuria or frequency may occur
Exam
no specific exam findings
1st investigation
- ultrasound:
presence of shadowing that moves with patient repositioning
Other investigations
- helical CT of urinary tract with intravenous contrast:
visible stone that moves with patient repositioning
- virtual cystoscopy:
visible stone
Renal cell carcinoma
History
risk factors include male sex, smoking, ages >55 years, residence in developed country, black or American Indians, obesity, hypertension, dialysis, acquired cystic renal disease; family history of renal cell carcinoma; flank pain; may be asymptomatic (over 50% of cases detected incidentally)
Exam
exam normal or a renal mass may be palpable; evidence of anemia can occur, as well as paraneoplastic syndromes
1st investigation
- helical CT of urinary tract with intravenous contrast:
solid renal mass with contrast enhancement
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Urothelial cancer (upper tract)
History
non-visible or visible hematuria (in 70% to 95%), pain (in 8% to 40%), bladder irritation (in 5% to 10%), or constitutional symptoms (in <5%)
Exam
generally normal, rarely a flank mass is palpable
1st investigation
- helical CT of urinary tract with intravenous contrast:
filling defect or visualized noncystic mass with contrast enhancement
Simple renal cyst
History
usually found incidentally; flank pain may be the presenting symptom
Exam
generally normal; rarely a flank mass is palpable
1st investigation
- renal ultrasound:
fluid-filled (cystic) mass
Polycystic kidney disease
History
most common presenting symptoms abdominal pain and hematuria; positive family history may be present
Exam
hypertension, palpable kidney or liver, and/or a cardiac murmur may be present
1st investigation
- renal ultrasound:
3 or more cysts, unilateral or bilateral (if ages 15-39 years); 2 or more cysts each kidney (if ages 40-59 years); 4 cysts each kidney (if ages ≥60 years)
Medullary sponge kidney
History
most patients are asymptomatic and go undiagnosed; risk is increased for calculus and infection renal colic; dysuria or hematuria may be presenting symptoms
Exam
generally negative
1st investigation
- helical CT of urinary tract with intravenous contrast:
dilated collecting tubules; stones may be present within the collecting tubules
Other investigations
Atrophic kidney
History
often no specific history suggests atrophic kidney, although occurs with some congenital abnormalities; history of chronic pyelonephritis, renal artery stenosis, or obstructive uropathy
Exam
typically normal but there may be findings of congenital abnormality; in older people hypertension or an abdominal bruit may exist suggesting renal artery stenosis
1st investigation
- helical CT of urinary tract with or without intravenous contrast:
atrophic kidney
More
Other investigations
Calyceal diverticulum
History
no presenting symptoms, generally an incidental finding
Exam
nonspecific
1st investigation
- CT urography:
visible diverticulum
Other investigations
Renal infarction
History
patient may have no symptoms; if occlusion is acute, then aching flank or abdominal pain, nausea, vomiting, fever, hematuria, and rarely new-onset hypertension may occur; may be history of acute myocardial infarction, atrial fibrillation, endocarditis, trauma, surgery, or angiography as a precipitating event
Exam
exam is nondiagnostic
1st investigation
- CT angiography:
renal artery occlusion
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Renal vein thrombosis
History
symptoms of renal failure, nausea/vomiting, hematuria, and decreased urine output; flank or abdominal pain may be present; history of systemic hypercoagulability
Exam
exam is nondiagnostic
1st investigation
- CT with intravenous contrast:
renal vein occlusion
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Arteriovenous malformations
History
most commonly associated with previous trauma (e.g., needle biopsy, surgery) or may be congenital
Exam
auscultation for abdominal bruits may help support the diagnosis
1st investigation
- renal angiography:
visible arteriovenous malformation
Other investigations
Papillary necrosis
History
occurs with prolonged and excessive use of analgesics, especially nonsteroidal anti-inflammatory drugs (NSAIDs); patients may present with complaint of pain resembling ureteric colic
Exam
generally nonspecific
1st investigation
- CT without contrast:
decreased renal volume, bumpy renal contours, and papillary calcifications
Other investigations
Sickle cell disease
History
presenting symptoms of renal colic or flank pain and hematuria may occur; history of sickle disease with prior episodes of a pain crisis; more common among black people
Exam
exam is nonspecific with possible costovertebral angle tenderness
1st investigation
- CBC with peripheral smear:
sickle-shaped red blood cells
Other investigations
- hemoglobin electrophoresis:
presence of hemoglobin S
- CT angiography:
papillary necrosis
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Hydronephrosis
History
flank pain especially if acute and concurrent to nephrolithiasis; history of urinary obstructive disease with voiding difficulties (lower urinary tract obstruction); bladder pain may occur if lower tract obstruction
Exam
generally nonspecific; rarely a flank mass is palpable; costovertebral angle tenderness may occur, and abdominal exam may identify palpable tender bladder with lower tract obstruction
1st investigation
- helical CT of urinary tract with intravenous contrast:
dilated kidney with dilated collecting system (calyces, ureter)
Other investigations
- renal ultrasound:
may suggest obstruction
Ureteropelvic junction obstruction
History
abrupt onset of flank pain particularly after consuming large quantities of fluids
Exam
generally nonspecific but with possible costovertebral tenderness
1st investigation
- nuclear renal scan:
obstruction with hydronephrosis
Other investigations
- CT urography:
obstruction with hydronephrosis
Vesicoureteral reflux
History
usually presents with history of recurrent urinary tract infection or pyelonephritis and more commonly in children; rarely renal pain with voiding occurs; voiding difficulties (e.g., adult men with benign prostatic hyperplasia)
Exam
nonspecific
1st investigation
- voiding cystourethrogram:
urine reflux from the bladder into the upper urinary tract
More
Other investigations
IgA nephropathy
History
often recurrent painless macroscopic hematuria; Henoch-Schonlein purpura; more common in people from the Mediterranean and Pacific Rim, less common in North Americans; more common in men
Exam
ranges from normal (asymptomatic hematuria) to hypertension or edema in patients with nephrotic syndrome and progressed disease, but no specific exam finding confirms the diagnosis
1st investigation
- urinalysis:
proteinuria
More
Other investigations
- renal biopsy:
IgA deposition in the mesangium with mesangial proliferation as the disease progresses
Thin glomerular basement membrane disease
History
often positive family history without family history of renal failure
Exam
a lack of exam findings helps distinguish this from other glomerular disorders
1st investigation
- urine microscopy:
red blood cell (RBC) casts; no proteinuria
More
Other investigations
- renal biopsy:
extremely thin glomerular basement membrane
More
Acute glomerulonephritis
History
often associated with fever from recent infection (e.g., streptococcal infection); there may be nausea and vomiting, edema, sore throat, rash, arthralgia, and complaints of dark urine or oliguria; a history of hepatitis, endocarditis, or systemic autoimmune disease may suggest a cause
Exam
exam could demonstrate hypertension, skin changes (jaundice, rash, purpura), pericardial rub with uremia, ascites (liver failure), edema, arthritis, or neurologic abnormalities with renal failure
Other investigations
- renal biopsy:
proliferative glomerular changes and/or immunoglobulin deposits (varies with specific disease state)
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Lupus nephritis
History
multisystem disease that may include central nervous system (CNS), heart, or lung complaints; more often presents with arthralgia, rash, or Raynaud phenomenon
Exam
American College of Rheumatology criteria establish the diagnosis; exam findings included among the criteria are malar rash, discoid rash, oral ulcers, arthritis, and serositis;[50] exam may identify abnormalities associated with CNS, heart, or lung involvement
Other investigations
- antinuclear antibody (ANA):
positive with higher titers being more suggestive (1:160 highly suggestive)
More - renal biopsy:
glomerular or tubular deposits of immunoglobulin and complement in a granular pattern
Hereditary nephritis (Alport syndrome)
History
more common in males, and family history may suggest the diagnosis; ocular changes and sensorineural hearing loss also occur
Exam
hearing loss and eye exam findings such as perimacular pigment changes and lenticonus (congenital lens abnormalities) may be identified along with hypertension
1st investigation
- urinalysis:
proteinuria
More
Other investigations
- renal biopsy:
reticulation and thickening of the glomerular basement membrane
Urothelial cancer (bladder)
History
more common in men and associated with risk factors for urinary tract cancer including age >40 years; tobacco use; occupational exposure to dyes, benzenes, and aromatic amines; use of medication such as cyclophosphamide or ifosfamide, and aristolochic acid (in some herbal weight loss preparations)
Exam
nonspecific
1st investigation
- cystoscopy with biopsy:
biopsy demonstrating urothelial cancer
Other investigations
- CT urogram:
bladder tumors, upper urinary tract tumors, and/or obstruction may be seen
More
Cystitis (interstitial)
History
more common in women; symptoms may increase with stress, menses, or sexual intercourse and include urgency, frequency, or pressure and pain in the pelvic and perineal area; pain in men may involve the penis or scrotum
Exam
suprapubic tenderness may be present
1st investigation
- cystoscopy:
visible bladder wall inflammation
Other investigations
- urinary bladder biopsy:
variable
More
Cystitis (radiation-induced)
History
symptoms of urgency or frequency, or pressure or pain in the pelvic and perineal area in a patient with a history of irradiation cancer therapy
Exam
suprapubic tenderness may be present
1st investigation
- cystoscopy:
pale mucosa and telangiectasia
Other investigations
Cystitis (eosinophilic)
History
symptoms of urgency or frequency, or pressure or pain in the pelvic and perineal area
Exam
suprapubic tenderness may be present
1st investigation
- cystoscopy:
biopsy demonstrates eosinophilia
Other investigations
Bladder diverticulum
History
may be associated with obstructive symptoms and recurrent urinary tract infection
Exam
suprapubic tenderness may be present if obstruction occurs
1st investigation
- cystoscopy:
visible diverticulum
Other investigations
- helical CT of urinary tract with intravenous contrast:
visible diverticulum
- CT virtual cystoscopy:
visible diverticulum
Bladder papilloma
History
obstructed urine flow
Exam
suprapubic tenderness if urine flow is obstructed
1st investigation
- cystoscopy:
visible papilloma and pathology from biopsy demonstrating absence of cancer cells
Other investigations
- helical CT of urinary tract with intravenous contrast:
filling defect within bladder
- CT virtual cystoscopy:
filling defect within bladder
Prostate cancer
History
often no symptoms; may be associated with urine outflow obstruction symptoms (difficulty voiding, changes in urine volume, lower abdominal discomfort or bladder fullness, and nocturia)
Exam
palpable nodule or asymmetry may be present on digital rectal exam
1st investigation
- serum prostate-specific antigen (PSA):
typically >4 nanograms/mL
More
Other investigations
- multiparametric MRI:
suspicious focus in prostate; dynamic contrast-enhanced imaging suspicious for malignancy
More - transrectal ultrasound-guided biopsy:
positive for cancer cells
Prostate stone
History
rarely symptomatic or may be associated with chronic prostatitis
Exam
usually an incidental radiographic finding but if large could be palpable on digital rectal exam
1st investigation
- transrectal ultrasound:
visible stone within the prostate
Other investigations
- helical CT of urinary tract:
visible stone within the prostate
Bladder neck contracture
History
difficulty voiding, changes in urine volume, lower abdominal discomfort (bladder fullness) with or without history of recurrent urinary tract infection
Exam
palpable bladder fullness and suprapubic tenderness may be present
1st investigation
- post void residual volume:
high post void residual volume suggests bladder outlet obstruction
- cystoscopy:
visible obstruction at bladder neck
Other investigations
- voiding cystourethrogram:
visible obstruction at bladder neck
Urethritis
History
recent sex partner change may suggest STI; presents similar to typical urinary tract infection (UTI) with dysuria, or frequency
Exam
may not be associated with abnormal exam findings; if caused by STI, men may have demonstrable penile discharge and women may have mucopurulent cervicitis
1st investigation
- urine culture:
negative culture (≥10² colony-forming units confirms UTI)
More
Other investigations
- gonorrhea/chlamydia nucleic acid amplification test:
positive for gonorrhea or chlamydia
More
Urethral stricture
History
difficulty voiding, changes in urine volume, lower abdominal discomfort (bladder fullness) with or without history of recurrent urinary tract infection
Exam
palpable bladder fullness and suprapubic tenderness may be present
1st investigation
- post void residual volume:
high post void residual volume suggests bladder outlet obstruction
- cystoscopy:
visible obstruction within the urethra
Other investigations
- voiding cystourethrogram:
visible obstruction within the urethra
Phimosis
History
inability to retract the foreskin with possible foreskin irritation or pain; may be history of urinary tract infection
Exam
inability to retract the foreskin
1st investigation
- none:
diagnosis is clinical based on inability to retract the foreskin
Other investigations
Penile cancer
History
a nonhealing or fungating painless lesion of the penis; most often in uncircumcised men
Exam
exam may demonstrate an erythematous lesion early in the course of disease; later the lesion becomes a nonhealing ulcer or an exophytic fungating growth
1st investigation
- penis biopsy:
squamous cell carcinoma
Other investigations
HIV
History
symptoms from none to those of full-blown immunodeficiency; history of risk factors such as sexual activity and exposure to blood products
Exam
no specific exam findings confirm HIV; findings may be consistent with opportunistic infections suggestive of HIV
1st investigation
- serum HIV test (enzyme-linked immunosorbent assay [ELISA] and Western blot):
positive antibodies on both ELISA and Western blot
- serum p24 antigen:
positive
More
Other investigations
Lymphoma
History
often presents with a complaint of lymphadenopathy; may also have fever, night sweats, and weight loss; symptoms of a mass effect may occur and vary by location of the mass (chest, abdomen, central nervous system, genitourinary)
Exam
the exam often demonstrates lymphadenopathy especially in the neck region; other findings vary based on the organ involved (e.g., pleural effusion in the chest)
1st investigation
- lymph node biopsy:
positive for cancer cells
Other investigations
- helical CT of urinary tract with intravenous contrast:
mass lesions with or without findings of urinary tract obstruction
More
Multiple myeloma
History
bone pain with persistent generalized weakness and fatigue suggests the diagnosis
Exam
no specific exam finding confirms multiple myeloma but pallor is common and hepatosplenomegaly may occur
1st investigation
- serum protein electrophoresis:
M-spike >2g for IgA but needs to be >3.5g for IgG
More
Other investigations
- bone marrow aspirate/biopsy:
plasmacytosis >10%
- bone radiographs (classically the skull):
"punched out" lytic lesions
Urinary tract tuberculosis
History
symptoms like those of urinary tract infection occur: dysuria, frequency, or costovertebral angle pain with kidney involvement; history of previous episodes with sterile pyuria may indicate tuberculosis
Exam
no specific exam findings
1st investigation
- urine dipstick:
leukocyte esterase-positive; positive for red blood cells
- acid-fast bacilli smear and culture of extrapulmonary biopsy specimen:
positive
More - chest x-ray:
consolidation, pulmonary infiltrates, mediastinal or hilar lymphadenopathy, upper zone fibrosis
More - sputum acid-fast bacilli smear and culture:
presence of acid-fast bacilli (Ziehl-Neelsen stain) in specimen
More - nucleic acid amplification tests (NAAT):
positive for M tuberculosis
More
Other investigations
- CT urography (intravenous contrast):
calcifications, cavitations, or signs of obstruction suggest tuberculosis
- lateral flow urine lipoarabinomannan (LF-LAM) assay:
positive
More
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