5.2 Genitourinary Diseases

Why Genitourinary Disease Matters on Part II

The kidneys rest retroperitoneally against the posterior abdominal wall, so renal and ureteral pathology frequently masquerades as low back or flank pain — the bread and butter of chiropractic practice. NBCE Part II exploits this overlap: a vignette describes "low back pain" but quietly adds fever, urinary symptoms, colicky radiation to the groin, or hematuria. The correct clinical impression is genitourinary, not lumbar facet dysfunction. Mastering the distinguishing history qualifiers and urinalysis patterns is essential.

Urinary Tract Infection: Cystitis Versus Pyelonephritis

Uncomplicated cystitis (lower UTI) presents with dysuria, frequency, urgency, and suprapubic discomfort in a non-pregnant woman without systemic signs. Urinalysis shows positive nitrites (gram-negative bacteria such as E. coli reduce nitrate), positive leukocyte esterase, and pyuria. Treatment is outpatient antibiotics; this is not a chiropractic case unless you are recognizing it for referral.

Pyelonephritis (upper UTI) adds fever, chills, flank pain, and costovertebral angle (CVA) tenderness. Urinalysis may show WBC casts — formed only in renal tubules, confirming renal parenchymal involvement. Complicated pyelonephritis (diabetes, pregnancy, obstruction, male patient, recurrent infections) may require hospitalization and imaging to exclude abscess or obstruction.

Proteus mirabilis produces urease, alkalinizes urine, and predisposes to struvite (staghorn) calculi — a classic board association.

Nephrolithiasis and Obstructive Uropathy

Renal colic from nephrolithiasis causes sudden, severe flank pain that waxes and wanes (colicky), radiates to the groin or testicle/labia, and is accompanied by nausea and microscopic or gross hematuria. Unlike mechanical back pain, it does not improve with rest, position change, or spinal manipulation. Pain severity often drives the patient to pace rather than lie still.

Stone composition matters for prevention: calcium oxalate (most common), uric acid (acidic urine, gout), struvite (infection-related, alkaline urine), and cystine (hexagonal crystals, hereditary). Non-contrast CT is the gold standard for detection; ultrasound is preferred in pregnancy.

Hydronephrosis from obstruction (stone, BPH, tumor) causes flank pain and declining renal function. Bilateral obstruction or anuria is an emergency.

Glomerular Disease: Nephritic Versus Nephrotic Syndrome

Nephritic syndrome reflects glomerular inflammation with a leaky but not massively porous filter:

• Hematuria with RBC casts and dysmorphic red cells
• Mild-to-moderate proteinuria (<3.5 g/day)
• Hypertension and periorbital edema
• Decreased GFR

Prototype: post-streptococcal glomerulonephritis — child or young adult with tea-colored urine, periorbital edema, and hypertension 1–3 weeks after pharyngitis or impetigo; low complement C3.

Nephrotic syndrome reflects heavy protein loss:

• Proteinuria >3.5 g/day
• Hypoalbuminemia and generalized pitting edema
• Hyperlipidemia and lipiduria (oval fat bodies, fatty casts)

Prototype in adults: diabetic nephropathy or membranous nephropathy.

Prostate Disease and Male GU Emergencies

Benign prostatic hyperplasia (BPH) in older men causes obstructive symptoms (hesitancy, weak stream, dribbling, incomplete emptying) and irritative symptoms (frequency, nocturia, urgency). Digital rectal exam reveals a smooth, enlarged prostate. PSA may be mildly elevated; significant elevation or a hard, nodular gland raises concern for prostate cancer — refer for urologic evaluation and biopsy.

Prostatitis (acute bacterial) presents with fever, perineal/suprapubic pain, dysuria, and a tender, boggy prostate on DRE. Do not perform vigorous prostate massage in acute bacterial prostatitis — it risks bacteremia.

Testicular torsion is a surgical emergency (6-hour window to salvage the testis): sudden severe unilateral scrotal pain, nausea, a high-riding testis, absent cremasteric reflex, and negative Prehn sign (no pain relief with elevation). Doppler ultrasound shows absent blood flow. Epididymitis (more common in sexually active men) causes gradual onset, positive Prehn sign, and increased flow on Doppler.

Female GU Considerations

Pyelonephritis and nephrolithiasis present similarly in women. Ectopic pregnancy must be excluded in any woman of childbearing age with abdominal or flank pain — missed diagnosis is catastrophic. Pelvic inflammatory disease (PID) causes lower abdominal pain, fever, cervical motion tenderness, and mucopurulent discharge.

Interstitial cystitis (bladder pain syndrome) causes chronic suprapubic pain relieved by voiding, frequency, and urgency with negative cultures — a diagnosis of exclusion.

Laboratory and Imaging Support

Key labs for GU clinical impressions:

• Urinalysis: cells, casts, crystals, nitrites, protein, glucose
• Urine culture: confirms organism and sensitivities in complicated or recurrent UTI
• BUN/creatinine: renal function; rising creatinine with obstruction is urgent
• PSA: prostate screening and cancer monitoring (interpret with age and prostate size)
• Complement C3: low in post-streptococcal GN

Imaging: renal ultrasound (hydronephrosis, stones, mass), CT without contrast (stones), Doppler scrotal ultrasound (torsion vs epididymitis).

Referral Red Flags

Refer immediately or send to the emergency department for:

• Testicular torsion suspicion (sudden scrotal pain in a young male)
• Anuria or bilateral renal obstruction
• Fever with CVA tenderness and systemic toxicity (pyelonephritis, sepsis)
• Gross hematuria with clots or hemodynamic instability
• Suspected ectopic pregnancy (abdominal pain + missed period + positive pregnancy test)
• Rapidly rising creatinine or acute kidney injury
• Palpable renal mass or unexplained weight loss with hematuria (malignancy)

A chiropractor who recognizes CVA tenderness and fever has already changed the clinical pathway — the impression is renal, not lumbar.

Exam Tip

When flank or "low back" pain is described, scan the stem for urinary symptoms, fever, colicky radiation, hematuria, or scrotal findings. If any are present, the GU diagnosis outranks the musculoskeletal one on Part II.