Rare urination and other symptoms: pain, temperature, swelling

Among the disorders associated with urinary function, urologists pay attention to such a symptom as a rare urination - a decrease in the volume of urine produced by the kidneys (diuresis) and, accordingly, a decrease in its excretion from the bladder.

This deviation is called oliguria (Greek oligos - a few + uron - urine), denoted by the code R34 for ICD-10.

It is difficult to accurately determine the rate of excreted urine, because there is a dependence of this biochemical process on fluid intake, physical activity and many other factors. Nevertheless, the average daily urine output in a healthy adult is 1.4-1.7 liters, and the number of urination produced during the day can range from five to seven. And the first signs of oliguria - a reduction in these indicators by a third.

[1], [2], [3], [4]

Epidemiology

According to experts, Centers for Disease Control and Prevention (USA), oliguria affects people of all ages, but is more often detected in newborns and in early childhood due to comorbid conditions and high morbidity leading to dehydration. At 11.5% are more often diagnosed in male patients.

According to the frequency, the diagnosis "anuria and oliguria" occupies the seventh position in the list of symptoms associated with urinary problems, and is on the second place among the most dangerous signs of nephrologic and urological diseases.

According to data published in the International Society of Nephrology, the frequency of oliguria and the reduction of urine excretion vary widely depending on the clinical situation. In North America, this symptom is recorded in approximately 1% of adult patients of urologists and up to 5% in hospitalizations.

Acute renal failure in oliguria is defined in almost 10% of patients in the neonatal intensive care unit, and after cardiac surgery reaches 15-30%. At the same time, more than two thirds of patients with a rare urination in the history did not meet the criteria for serum creatinine level. And only a decrease in urine output, which is noted in more than half of patients in critical condition, predetermined a significantly higher risk of death.

According to official statistics, in 2015 two patients died from acute oliguria in the United States, and a fatal outcome for 683 patients with severe clinical course of diseases became inevitable due to deterioration due to a decrease in the volume and frequency of urine output.

[5]

Causes of the rare urination

Just note that the pathology does not relate to a rare urination in the heat: it is simple at too high a temperature of the air, the body is protected from overheating by increased sweating, and in order to prevent dehydration and disturbance of water-salt homeostasis, the autonomic nervous system gives the kidneys a "command" excretion of water and strengthen its reverse absorption in the tubules.

With extrarenal oliguria, these causes of rare urination are associated, such as obstruction of the urinary tract - if they are partially blocked by a tumor in the bladder or kidney stones. Although, in the first place, to the number of diseases and pathological conditions in which symptoms of rare urination appear, urologists refer to:

• dehydration of the body  (dehydration) with loss of fluid due to prolonged vomiting or diarrhea, as well as hyperhidrosis with fever and infectious intoxication;
• decrease in glomerular filtration rate in acute form of renal failure (hepatorenal syndrome) and chronic renal failure;
• acute tubulointerstitial nephritis;
• pyelonephritis;
• glomerulonephritis  (inflammation of the renal glomeruli);
• hereditary polycystic kidney disease;
• renal amyloidosis;
• cirrhosis of the liver;
• chronic heart failure, ischemic heart disease, heart attack;
• myocarditis (inflammation of the heart muscle);
• severe arterial hypertension (which can lead to the development of arteriolar nephrosclerosis with partial renal dysfunction). In addition, hypertension usually accompanies acute glomerulonephritis, that is, it may be secondary to changes in vascular tone;
• hypothyroidism or autoimmune thyroiditis;
• autoimmune disorders, for example, systemic lupus or  Goodpasture's syndrome.

Drinking urine sharply decreases in the development of conditions requiring urgent medical action: peritonitis and sepsis; cardiogenic and anaphylactic shock; hemouurmic syndrome; bleeding and hypovolemic (hemorrhagic) shock.

[6]

Risk factors

In addition to all the listed diseases, the risk factors for oliguria consist in increasing the secretion of the pituitary hormone vasopressin (antidiuretic hormone, ADH), a physiological regulator of water excretion by the kidney. Violation of its production can occur due to damage to the hypothalamus and pituitary gland: tumor formation, craniocerebral trauma, infectious inflammation (meningitis or encephalitis), congenital anomalies (hydrocephalus, cerebellar atrophy, etc.), pathologies of the peripheral nervous system.

Also, a greater likelihood of this disorder of the urinary function exists in cancer diseases that affect the lungs, the thyroid gland, the organs of the genitourinary system of men and women, the gastrointestinal tract and the pancreas; with Ewing's sarcoma and leukemia in children and adolescents.

Diuresis may decrease during the administration of medications such as anticholinergic and antihypertensive agents, loop diuretics, antibiotics of the aminoglycoside group and quinolones, nitrofuran derivatives, antitumor drugs (Methotrexate, Cisplatin, Alvocidib, etc.).

Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit the renal synthesis of vasodilating prostaglandins, and their use in children with fever and intercurrent dehydration is the cause of acute oliguria.

[7], [8], [9], [10]

Pathogenesis

With excessive secretion of ADH and, accordingly, a significant increase in its concentration in the blood plasma, diuresis in adults can be reduced to 0.4-0.5 liters per day, which in many cases explains the pathogenesis of a decrease in the number of urination.

Thus, excessive production of ADH is observed when the body is dehydrated - when the volume of intercellular fluid decreases dramatically and the number of urination decreases - in acute conditions and severe forms of diseases. The same happens with a sharp decrease in the volume of circulating blood (hypovolemia) - in cases of bleeding.

The synthesis of this hormone is elevated in hypertension - in response to an increase in the levels of aldosterone (adrenal cortex hormone) and kidney produced angiotensin II. Entering a system that supports the water-salt balance (renin-angiotensin-aldosterone), both these neurohormones cause a water retention in the body, strengthening the antidiuretic effect of vasopressin.

In chronic heart failure and liver cirrhosis, the release of ADH can be the result of a so-called osmotic trigger, when the lack of intravascular volume of the blood, the neurotransmitters react like hypovolemia.

Deficiency of thyroid hormones, caused by hypothyroidism or autoimmune thyroiditis, systemically depresses metabolism and causes a rare urination.

And with glomerulonephritis and the initial stage of acute renal failure, the filtration of blood plasma slows down the glomeruli of nephrons, which leads to a decrease in diuresis and a decrease in the number of urination.

In the presence of oncology, the pathogenesis of oliguria development is associated with the lysis of tumor cells and the release of increased amounts of potassium, phosphate and nitrogenous bases into the blood. And further their cleavage with uric acid leads to hyperuricemia and hyperphosphataemia, as a result of which high concentrations of uric acid and calcium phosphate in the renal tubules potentiate the risk of acute damage to the kidneys and a decrease in urine production.

[11], [12], [13], [14]

Symptoms of the rare urination

Among other symptoms, a rare urination with edema occurs with chronic heart failure and cirrhosis of the liver, with glomerulonephritis and kidney inflammation in children. Puffiness in combination with oliguria, as well as increased thirst and with a plentiful drink a rare urination may be present in the clinical symptomatology of the third degree of hypertension.

Edema of the kidney parenchyma - with a reduction in the number of deurinations, proteinuria and hematuria - are noted in cases of their amyloid dystrophy with regular hemodialysis.

In patients who underwent an acute impairment of cerebral circulation, a rare urination after a stroke (hemorrhagic or ischemic) is part of a neurological disorder. And this can be another confirmation of extensive damage to the structures of the brain (hypothalamus, temporal and frontal zones) due to its short-term hypoxia.

Rare urination with pain of any localization is explained by a reflex decrease in diuresis: the sympathetic nervous system reacts to the pain syndrome by ejection of adrenaline and norepinephrine, which increases the level of vasopressin affecting the formation of urine in the kidneys.

And on rare urination and back pain, patients with glomerulonephritis, arteriolar nephrosclerosis and polycystic kidney disease complain. Violation of the outflow of urine from the kidneys - congenital hydronephrosis in children, as well as the development of edema of the kidneys and ureter in pregnant women cause a decrease in urination accompanied by pain in the back, side or abdominal cavity, and nausea and vomiting. Headaches and pain in the abdominal region are noted in the  acetone syndrome.

Note: brown urine and rare urination is a signal of fluid deficiency in the body, as evidenced by the excess urinary content in the urine (a substance containing bile pigments).

Rare urination in the baby

The normal frequency of urination in children varies widely and depends on age. So, most children by the age of three or four years urinate about ten times a day, and adolescents - as much as adults.

But children can also suffer from oliguria. True, physiologically caused by a rare urination in a child in the first two to three days after birth is a consequence of the adjustment of lactation in the mother and extrauterine digestion in the baby. But in the future, cases of decreased urination and a more saturated color of urine should not go unnoticed: this symptom can be a warning for the development of dehydration, which young children suffer extremely hard.

Moreover, in infants, oliguria with palpable kidneys involves  renal vein thrombosis, polycystic kidney disease, multi-cystic dysplasia, or hydronephrosis.

Practice shows that the causes of rare urination in children are basically the same as in adults, but in all infections and hyperthermia the symptom of diuresis in children is more pronounced.

According to pediatricians, this symptom often appears in infectious diseases (including respiratory viral diseases) and in  acute kidney failure in children.

Rare urination in women

In addition to the above common causes of rare urination in women, there are specific reasons - in the restructuring of the body associated with menopause and the period of pregnancy.

Rare urination during pregnancy is most often observed with early toxicosis (due to frequent vomiting) and gestosis (with increased blood pressure). In addition, during the period of gestation, the activity of the antidiuretic hormone (ADH) increases, which is promoted by the increase in the level of the neurohormone angiotensinogen in the blood - in response to the natural increase in the content of the female sex hormones (estrogen and estradiol) in the blood, the receptors of which are present in the organs of the urinary system.

With menopause, oliguria provokes functional disorders of the autonomic nervous system, partially regulated by neurohormones of the pituitary and hypothalamus, as well as changes in the endocrine system and overall metabolism.

Rare urination in men

Typically, a rare urination in men is observed with kidney failure, urolithiasis, inflammatory processes in the organs of the genital area, tumors in the genitourinary system, heart problems, elevated blood pressure, diseases of the brain or spinal cord.

For example, a rare urination with pain, cuts and spasms in the abdomen can provoke a narrowing of the urethra, hyperplasia, adenoma or malignant tumor of the prostate. However, most often in these cases is diagnosed ishuria - urinary retention due to the inability to completely empty the bladder.

Indirect factors that violate the normal process of urination can be alcoholism (causing cirrhosis of the liver), abuse of diuretics, intense antibiotic therapy, nervous overexertion, etc.

Forms

As you can see, the pathological reduction in the number of urination can be due to many causes, and depending on the etiology, oliguria - as a symptom of a violation of urinary function - is divided into the types: renal primary, renal secondary and extranal.

Primary renal oliguria (renal) is associated directly with damage to the structure of the kidneys or ischemia of its vessels. These include congenital abnormalities and renal dysfunction, inflammatory processes, acute tubular necrosis, primary glomerular diseases and vascular lesions (eg, arteriolar nephrosclerosis).

Secondary renal oliguria (prerenalnaya) is a functional reaction of structurally normal kidneys to insufficient blood circulation (hypoperfusion) with bleeding, sepsis, shock conditions, dehydration (caused by vomiting, diarrhea, extensive burns), strokes, cardiovascular diseases, etc. To normalize the intravascular volume - by mobilizing the renin-angiotensin-aldosterone system and activating the sympathetic nervous system - the glomerular filtration rate decreases, the reverse absorption of electrolytes and water increases, and the yield of urine decreases. She accounts for two thirds of all diagnosed cases of reduced urination in acute renal failure.

And to the extrarenal oliguria (postrenal) is a rare urination with mechanical or functional obstruction of the flow of urine in the ureter, bladder or urethra.

[15], [16], [17], [18]

Complications and consequences

In general, long-term reduction of urination and acute renal failure may have serious short-term and long-term consequences and complications. Everything depends on the etiology, age and condition of other body systems.

However, the development of acute kidney failure occurs in almost two thirds of cases, and in children under one year severe acute renal damage requiring replacement renal therapy has a very high level of mortality (up to 30%).

As a result of the retention of fluid, sodium and potassium in the body, water-electrolyte homeostasis and acid-base balance are disturbed, which leads to the development of  metabolic acidosis; complications from the cardiovascular system (including arterial hypertension, heart failure with arrhythmia and pulmonary edema); hematological and neurological disorders.

[19], [20], [21], [22], [23]

Diagnostics of the rare urination

To reveal such a symptom as a rare urination is not difficult: oliguria is determined if the urine output is less than 1 ml per kilogram of body weight per hour in children and less than 0.5 ml in adults. This is one of the clinical signs of renal failure associated with a decrease in diuresis.

The efforts of doctors are aimed at determining the causes of this symptom, for which a survey is necessary. Blood tests are done: general, biochemical, on the level of creatinine, renin, ADH, for the presence of nephrogenic antibodies and immunoreactivity; in men - for the presence of a prostatic antigen.

In acute oliguria, hemodynamics with a volume of circulating blood is determined.

Urine tests are performed: general (clinical), diurnal, bacteriological, sodium level, specific gravity and osmolality. If necessary, other laboratory tests are also prescribed - to clarify the diagnosis.

Instrumental diagnosis involves visualization of the relevant organs, for which the ultrasound examination of the kidneys and bladder is used, the urethra of the urethra (urethrography). Specific features of the functioning of the bladder (filling, emptying and its speed), for which uroflowmetry and cystometry are carried out. In rare cases, a magnetic resonance imaging with a contrast agent is required.

[24], [25], [26], [27], [28], [29], [30]

Differential diagnosis

Given the spectrum of diseases with this symptom, differential diagnosis by physicians of various specializations (with additional examination) can be carried out. But all of the above is reduced to blood and urine tests for emergency conditions.

[31], [32], [33], [34], [35], [36]

Treatment of the rare urination

It is a mistake to think that the treatment of rare urination can only be symptomatic - with the help of diuretics; or will help treatment by alternative means (which in this case is unacceptable, since most of the herbs used have diuretic properties).

Urologists warn that with the help of diuretics, secondary renal oliguria is treated (ie due to hypertension, heart failure or cirrhosis of the liver) - when the excretory function of the kidneys is not compromised, and in response to the drug, they can provide plasma filtration and urine production in a normal volume.

So the method of oliguria treatment and the medications used is the etiology of this symptom and the condition of the kidneys, and the goal of therapy is the normalization of the urinary function. And in most patients, the acute condition is amenable to intensive therapy without the development of severe renal failure.

To increase the diuresis in cases of secondary (pre-renal) oliguria, it is customary to inject (dropwise into the vein) the loop diuretics Mannitol (Mannit, Diosmol, Renitol) or Furosemide; the dosage is calculated by body weight. The use of these drugs requires monitoring the level of sodium and potassium in the serum.

And to improve the internal circulation of the blood (if the patient does not have severe dehydration), Dopamine is also administered intravenously.

To restore the fluid and increase diuresis, the children are parenterally injected with sodium chloride in the form of an isotonic solution, as well as Ringer's solution.

To increase the volume of urine with a rare urination with edema associated with chronic cardiac and adrenal insufficiency, hypertension or hypothyroidism, Tolvaptan (an antidiuretic hormone inhibitor) can be used to increase the level of sodium in the blood.

Prevention

The average adult daily releases about 75-80% of the fluid consumed in the urine, so the main method of preventing rare urination is the optimal drinking regime and control of the volume of water entering the body.

Doctors are strongly advised to stop using alcoholic beverages, treat existing diseases and take medicines only in accordance with medical recommendations.

[37], [38], [39], [40], [41], [42]

Forecast

To emphasize the real danger of a sharp decrease in the frequency of urination and a critical for the body to reduce the production of urine by the kidneys, it is enough to note a very high percentage of deaths - in the absence of timely urgent (often resuscitative) medical care. If you leave a rare urination without attention, the development of this symptom can lead to a terminal state.

[43], [44], [45], [46]