Differential Diagnosis – “U”

• Acute cholecystitis, acute cholelithiasis.
• Acute appendicitis.
• Pelvic inflammatory disease.
• Diverticulosis and/or diverticulitis.
• Intestinal obstruction.
• Leaking abdominal aortic aneurysm.
• Musculoskeletal sprains.
• Herniated disk.
• Hepes zoster (shingles).
• Gastrointestinal dysfunction with ileus and/or toxic colonic dilatation

• Primary  megaureter.
• Ureterocele (ectopic and orthotopic).
• Ureteric valve.
• Distal ureteric stenosis.
• Ureteric atresia.
• Circumcaval ureter and variants.

• Urethritis (gonococcal, chlamydial, trichomonal).
• Cystitis.
• Prostatitis.
• Vaginitis (candidiasis, chemical).
• Meatal stenosis.
• Interstitial cystitis.
• Trauma (foreign body, masturbation, horseback or bike riding).

Intrinsic Lesions

• Valve (posterior, anterior, saccular diverticulum).
• Stenosis, atresia.
• …
• Inflammatory stricture.
• Traumatic stricture:
  • External trauma (saddle injury, and so on).
  • Iatrogenic trauma (catheter, cystoscopy, surgery).
• Urethral “tumors”:
  • Girls: leiomyoma.
  • Boys: polyp, rhabdomyosarcoma. Miscellaneous (epidermolysis bullosa).

Extrinsic Lesions

Presacral mass dissecting inferiorly (tumor, cyst).

Fecal impaction (Hirschsprung’s, postrepair anal atresia, habitual constipation, neuropathy).

Mass originating in genital organs:

• Boys: utricle cyst, prostate rhabdomyosarcoma, seminal vesicle cyst, Cowper’s duct cyst.
• Girls: hydrometrocolpos, hydrocolpos, fused labia

• Hyperuricemia.
• Excessive dietary purine.
• Medications (salicylates, allopurinol, probenecid).
• Urine pH <5.5 (e.g., diarrhea, high animal protein diet).
• Decreased urine output (dehydration, malabsorption, diarrhea, inadequate fluid intake).
• Tumor lysis.
• Hemolytic anemia.
• Myeloproliferative disorders

Obstructive Cause

• Urethral stricture.
• Enlarged  prostate.
• Lower genitourinary tract malignancy. Pelvic malignancy.
• Bladder stones.
• Foreign body.
• Blood clot.
• Posterior urethral valves.
• Ureterocele.

Primary Detrusor Insufficiency

• Detrusor areflexia.
• Multiple sclerosis.
• Iatrogenic injury during abdominal or back surgery.
• Spinal cord injury.
• Myelomeningocele

• Mechanical obstruction: urethral stone, foreign body, urethral stricture, BPH, prostate carcinoma, prostatitis, trauma with hematoma formation.
• Neurogenic bladder.
• Neurologic disease (MS, parkinsonism, tabes dorsalis, CVA).
• Spinal cord injury.
• CNS neoplasm (primary or metastatic).
• Spinal anesthesia.
• Lower urinary tract instrumentation
• Medications (antihistamines, antidepressants, narcotics, anticholinergics).
• Abdominal or pelvic surgery.
• Alcohol toxicity.
• Pregnancy.
• Anxiety.
• Encephalitis.
• Postoperative pain.
• Spina bifida occulta

INTRARENAL

Uric acid nephropathy. Sulfonamide precipitates. Acyclovir, indinavir precipitates. Multiple myeloma.

URETERAL

Intrinsic

• Intraluminal.
  • Nephrolithiasis.
  • Papillary necrosis.
  • Blood clots.
  • Fungus balls.
• Intramural.
  • Ureteropelvic junction dysfunction.
  • Ureterovesical junction dysfunction.
  • Ureteral valve, polyp, or tumor.
  • Ureteral stricture. Schistosomiasis. Tuberculosis. Scarring from instrumentation. Drugs (e.g., nonsteroidal anti-inflammatory agents [NSAIDs]).

Extrinsic

Vascular system.

• Aneurysm: abdominal aorta or iliac vessels.
• Aberrant vessels: ureteropelvic junction.
• Venous: retrocaval ureter.

Gastrointestinal tract.

• Crohn’s disease.
• Diverticulitis.
• Appendiceal abscess.
• Colon cancer.
• Pancreatic tumor, abscess, or cyst.

Reproductive  system.

• Uterus: pregnancy, prolapse, tumor, endometriosis.
• Ovary: abscess, tumor, ovarian remnants.
• Gartner’s duct cyst, tuboovarian abscess.

Retroperitoneal  disease.

• Retroperitoneal fibrosis: radiation, drugs, idiopathic.
• Inflammatory: tuberculosis, sarcoidosis.
• Hematoma.
• Primary tumor (e.g., lymphoma, sarcoma).
• Metastatic tumor (e.g., cervix, ovarian, bladder, colon).
• Lymphocele.
• Pelvic lipomatosis.

BLADDER

Neurogenic bladder.

• Diabetes mellitus.
• Spinal cord defect.
• Trauma.
• Multiple sclerosis.
• Stroke.
• Parkinson’s disease.
• Spinal anesthesia.
• Anticholinergics.

Bladder neck dysfunction.

Bladder calculus.

Bladder cancer.

URETHRA

• Urethral stricture.
• Prostate hypertrophy or cancer.
• Obstruction from instrumentation.

Renal glomerular diseases

• IgA nephropathy (Berger disease)
• Thin basement membrane disease
• Acute glomerulonephritis (e.g., poststreptococcal)
• Lupus nephritis
• Hereditary nephritis (e.g., Alport syndrome)

Renal tubulointerstitial diseases

• Papillary necrosis
• Sickle cell nephropathy
• Analgesic nephropathy
• Polycystic kidney disease
• Medullary sponge kidney

Vasculitis

• Henoch-Schönlein purpura
• Wegener granulomatosis

Infection

• Pyelonephritis
• Xanthogranulomatous pyelonephritis
• Renal tuberculosis
• Fungal infection

Obstruction

• Ureteropelvic junction obstruction
• Ureteral stricture

Nephrolithiasis

Malignancy

• Renal cortical tumors (renal cell carcinoma, benign tumors)
• Upper tract urothelial carcinoma

Fibroepithelial polyp

Vascular diseases

• Renal arteriovenous malformations (congenital, acquired)
• Iliac arterio-ureteral fistula
• Renal artery aneurysm (especially ruptured)
• Renal artery pseudoaneurysm
• Renal artery and/or vein thrombosis
• Hemangioma
• Atheroembolic disease
• Nutcracker syndrome
• Loin-pain hematuria syndrome

Trauma

Blunt

Penetrating

Lateralizing essential hematuria

Ureteropelvic Junction

• Ureteropelvic junction obstruction

Proximal and Middle Ureter

• Ureteral folds
• Ureteral valves
• Strictures
• Benign fibroepithelial polyps
• Retrocaval ureter

Distal Ureter

• Ureterovesical junction obstruction
• Vesicoureteral reflux
• Prune-belly syndrome
• Ureteroceles

Bladder

• Bladder diverticula
• Neurologic conditions (e.g., spina bifida)

Urethra

• Posterior urethral valves
• Urethral diverticula
• Anterior urethral valves
• Urethral atresia
• Labial fusion

• Normal finding.
• Pyelonephritis.
• Chronic renal disease.
• Nephrotic syndrome.
• Acute tubular necrosis.
• Interstitial nephritis.
• Nephritic syndrome.
• Glomerulonephritis.
• Eclampsia.
• Heavy metal ingestion.
• Allograft rejection.
• Hypothyroidism.

Colorless

Disease

• Diabetes mellitus.
• Diabetes insipidus.

Drug

• Ethyl alcohol.
• Diuretics.

Miscellaneous

• Overhydration.

Yellow-orange

Drug

• Tetracycline.
• Flutamide.
• Pyridium.
• Azo Gantrisin (Roche Labs, Nutley, NJ).
• Sulfasalazine.
• Vitamin B.

Miscellaneous

• Dehydration.

Milky White

Disease

• Urinary tract infection/pyuria.

Blue-green

Disease

• Pseudomonas urinary tract infection.

Drug

• Methylene blue.
• Urised (Polymedica Pharmaceuticals, Woburn, MA).
• Indigo carmine.
• Doan’s pills (Novartis Consumer Health, Parsippany, NJ).
• Clorets (Cadbury Adams, Parsippany, NJ).
• Amitriptyline.

Red-brown

Disease

• Hematuria.
• Hemolytic anemia.
• Hemoglobinuria.
• Lead poisoning.
• Mercury poisoning.
• Porphyria.

Drug

• Rifampin.
• Ex-Lax (Novartis Consumer Health, Parsippany, NJ).
• Phenolphthalein.
• Phenothiazines.
• Nitrofurantoin.
• Doxorubicin.

Miscellaneous

• Beets.
• Blackberries.
• Rhubarb.

Brown-black

Disease

• Fecaluria.
• Methemoglobinuria.
• Melaninuria.

Drug

• Metronidazole.
• Methyldopa.
• Methocarbamol.

Miscellaneous

• Fava beans.
• Aloe.

With a Positive Dipstick

• Hematuria.
• Hemoglobinuria: negative urinalysis.
• Myoglobinuria: negative urinalysis.

With a Negative Dipstick

Drugs

• Aminosalicylic acid.
• Deferoxamine mesylate.
• Ibuprofen.
• Phenacetin.
• Phenolphthalein.
• Phensuximide.
• Rifampin.
• Anthraquinone laxatives.
• Doxorubicin.
• Methyldopa.
• Phenazopyridine.
• Phenothiazine.
• Phenytoin.

Dyes

• Azo dyes.
• Eosin.

Foods

• Beets, berries, maize.
• Rhodamine B.

Metabolic

• Porphyrins.
• Serratia marcescens (red diaper syndrome).
• Urate crystalluria.

Renal

• Pyelonephritis
• Blood clot
• Renal infarction
• Tumor (kidney or pelvis)
• Papillary necrosis

Ureteral

• Tumor
• Blood clot
• Stricture

Bladder

• Tumor
• Blood clot
• Urinary retention

Intraabdominal

• Peritonitis
• Appendicitis
• Biliary disease
• Bowel obstruction
• Vascular disorder
• Aortic aneurysm
• Mesenteric insufficiency

Retroperitoneal

• Lymphadenopathy
• Fibrosis
• Tumor

Gynecologic

• Ectopic or tubal pregnancy
• Ovarian torsion, cyst rupture
• Pelvic inflammatory disease
• Cervical cancer
• Endometriosis
• Ovarian vein syndrome

Neuromuscular

• Muscle pain
• Rib fracture
• Radiculitis

Infectious

• Herpes zoster
• Pleuritis, pneumonia
• Fungal bezoar

Intrinsic Causes

Intraluminal

• Intratubular deposition of crystals (uric acid, sulfas).
• Stones.
• Papillary tissue.
• Blood clots.

Intramural

• Functional.
• Ureter (ureteropelvic or ureterovesical dysfunction).
• Bladder (neurogenic): spinal cord defect or trauma, diabetes, multiple sclerosis, Parkinson’s disease, cerebrovascular accidents.
• Bladder neck dysfunction.

Anatomic

• Tumors.
• Infection, granuloma.
• Strictures.

Extrinsic Causes

Originating in the Reproductive System

• Prostate: benign hypertrophy or cancer.
• Uterus: pregnancy, tumors, prolapse, endometriosis.
• Ovary: abscess, tumor, cysts.

Originating in the Vascular System

• Aneurysms (aorta, iliac vessels).
• Aberrant arteries (ureteropelvic junction).
• Venous (ovarian veins, retrocaval ureter).

Originating in the Gastrointestinal Tract

• Crohn’s disease.
• Pancreatitis.
• Appendicitis.
• Tumors.

Originating in the Retroperitoneal Space

• Inflammations.
• Fibrosis.
• Tumor, hematomas.

• Obstructing ureteral stone with pyonephrosis.
• Staghorn calculus with urinary tract infection.
• Ureteral obstruction with proximal urinary tract infection.
• Urinary retention with urinary tract infection.
• Acute prostatitis with prostatic abscess.
• Perinephric abscess or renal carbuncle.
• Urethral stricture with periurethral abscess.
• Fournier gangrene.
• Foreign body within urinary tract (e.g., Foley catheter).

Pregnancy

• Threatened abortion.
• Incomplete abortion.
• Complete abortion.
• Molar pregnancy.
• Ectopic pregnancy.
• Retained products of conception.

Ovulatory

• Vulva: infection, laceration, tumor.
• Vagina: infection, laceration, tumor, foreign body.
• Cervix: polyps, cervical erosion, cervicitis, carcinoma.
• Uterus: fibroids (submucous fibroids most likely to cause abnormal bleeding), polyps, adenomyosis, endometritis, intrauterine device, atrophic endometrium.
• Pregnancy complications: ectopic pregnancy; threatened, incomplete, complete abortion; retained products of conception.
• Abnormality of clotting system.
• Midcycle bleeding.
• Halban’s disease (persistent corpus luteum).
• Menorrhagia.
• Pelvic inflammatory disease.

Anovulatory

• Physiologic causes:
• Puberty.
• Perimenopausal.
• Pathologic causes:
  • Ovarian failure (FSH over 40 IU/ml).
  • Hyperandrogenism.
  • Hyperprolactinemia.
  • Obesity.
  • Hypothalamic dysfunction (polycystic ovaries); LH/FSH ratio greater than 2:1.
  • Hyperplasia.
  • Endometrial carcinoma.
  • Estrogen-producing tumors.
  • Hypothyroidism.

Anterior Uveitis

• Juvenile rheumatoid arthritis (pauciarticular).
• Sarcoidosis.
• Trauma.
• Tuberculosis.
• Kawasaki disease.
• Ulcerative colitis.
• Postinfectious (enteric or genital) with arthritis and rash.
• Spirochetal (syphilis, leptospiral).
• Heterochromic iridocyclitis (Fuchs).
• Viral (herpes simplex, herpes zoster).
• Ankylosing spondylitis.
• Stevens-Johnson syndrome.
• Idiopathic.
• Drugs.

Posterior Uveitis (Choroiditis—may Involve Retina)

• Toxoplasmosis.
• Parasites (toxocariasis).
• Sarcoidosis.
• Tuberculosis.
• Viral (rubella, herpes simplex, HIV, cytomegalovirus).
• Subacute sclerosing panencephalitis.
• Idiopathic.

Anterior and/or Posterior Uveitis

• Sympathetic ophthalmia (trauma to other eye).
• Vogt-Koyanagi-Harada syndrome (uveo-otocutaneous syndrome: poliosis, vitiligo, deafness, tinnitus, uveitis, aseptic meningitis, retinitis).
• Behçet syndrome.
• Lyme disease.