urologic symptoms and examination

Urological symptoms Urological symptoms

Urology DepartmentUrology Department

Undergraduate coursesUndergraduate courses

History Taking

• The medical history is the cornerstone of the evaluation of the urologic patient.

• A complete history can be divided into:

o The chief complaint

o History of the present illness

o The patient's past medical and surgical history

o Family history.

Magdy Fath-Alla, 2009

Complaint

Urological complaint(s) can be categorized into one or more of:

Pain Changes in the act of micturition Changes in gross appearance of urine Changes in function and/or appearance of

male genitalia. Systemic symptoms


Pain

Pain arising from the GU tract may be quite severe and is usually associated with

Obstruction:• Ureteric stone. • Urinary retention. Inflammation parenchymatous organs inflamm. produces severe

pain (pyelonephritis, prostatitis, and epididymitis) Inflammation of the mucosa of a hollow viscus such as

the bladder or urethra usually produces discomfort. Tumors of GU tract usually do not cause pain unless

they produce obstruction or extend to adjacent nerves.


Renal Pain • Site: ipsilateral costovertebral angle just lateral to

the sacrospinalis muscle and beneath the 12th rib. • Pain due to inflammation is usually steady (dull

ache) due to acute distention of the renal capsule, • Pain due to obstruction fluctuates in intensity

(colicky). • may be associated with gastrointestinal

symptoms because of reflex stimulation of the celiac ganglion.

• Radiation: across the flank anteriorly toward the upper abdomen and umbilicus and may be to the testis or labium.


Differential Diagnosis of Renal Pain

1) Pain of intraperitoneal origin (perforated duodenal ulcer or pancreatitis) has the following characters:

• Radiates into the back, but the site of greatest pain and tenderness is in the epigastrium.

• Radiates into the shoulder because of irritation of the diaphragm and phrenic nerve.

2) Renal pain may also be confused with pain resulting from irritation of the costal nerves (radicular pain), most commonly T10-T12. However, the pain is not colicky in nature.


Ureteral Pain

• usually acute and secondary to obstruction.

• Distribution of the pain according to site:

o In upper ureteral obstruction, the pain may be referred to the scrotum in the male or the labium in the female.

o Midureter obstruction: on the right side is referred to the right lower quadrant (McBurney's point) and simulate appendicitis; on the left side to left lower quadrant.

o Lower ureteral obstruction causes bladder irritability (frequency, urgency, and suprapubic discomfort).


Vesical and Prostatic pain

Vesical pain•due to retention or inflammation.

•Constant suprapubic pain that is unrelated to urinary retention is seldom of urologic origin. •Inflammatory conditions of the bladder usually produce intermittent suprapubic discomfort.

Prostatic pain •due to inflammation with secondary edema and distention of the prostatic capsule. •poorly localized to lower abdominal, inguinal, perineal, lumbosacral, and/or rectal pain.


Penile and Testicular Pain Penile pain•Pain in the flaccid penis is referred pain from bladder or urethra and maximally at the urethral meatus. •Pain in the erect penis is usually due to Peyronie's disease or priapism.

Scrotal pain •Primary pain arises from within the scrotum:

o Acute epididymitis or torsion of the testis. o Chronic scrotal pain (dull, heavy) due to hydrocele or

varicocele.

•Referred:o from kidneys or retroperitoneum or from inguinal hernia.


Irritative Symptoms

Frequency

• The normal adult voids five or six times per day, with a volume of approximately 300 mL with each void.

• Urinary frequency is due either to increased urinary output (polyuria), detrusor instability or to decreased bladder capacity.


Irritative Symptoms Nocturia is nocturnal frequency. • Normally, adults arise no more than twice at night to void

(decrease urine concentration with age). • Nocturia occur in the patient with congestive heart failure and

peripheral edema, old aged and drinking fluids at night.

Dysuria is painful urination commonly referred to the urethral meatus.

• at the start of urination indicate urethral pathology.• at the end (strangury) indicate bladder origin.• Dysuria is frequently accompanied by frequency & urgency.

Urgency the sudden intense desire to void that the patient can not defer.


Obstructive Symptoms

Urinary hesitancy delayed start of urination.

Decreased force and caliber of urinary stream is due to bladder outlet obstruction and commonly results from benign prostatic hyperplasia (BPH) or a urethral stricture.

Straining refers to the use of abdominal musculature to urinate.

Intermittency means interrupted stream.

Postvoid dribbling refers to the release of few drops of urine after micturition.


IncontinenceUrinary incontinence is the involuntary loss of urine

Continuous Incontinence most commonly due to:

• urinary tract fistula (as vesico-vaginal fistula usually due to gynecologic surgery, radiation, or obstetric trauma.

• ectopic ureter that opens either at the urethra or the female genital tract.

Stress Incontinence is sudden leakage of urine with coughing, sneezing, exercise (increase intra-abdominal pressure).

• most common in women after childbearing or menopause and men after prostatic surgery and injury to the external urethral sphincter.


Incontinence

Urge Incontinence • loss of urine preceded by a strong urge to void.

• Due to: cystitis, neurogenic bladder.

Overflow Urinary Incontinence • Due to advanced urinary retention and high residual

urine volumes. • Urine dribble due to bladder overflow.

Enuresis • micturition that occurs during sleep. • It occurs normally in children up to 3 years old.


Changes in the gross appearance of urine

Hematuria •the presence of blood in the urine > 3 RBCs per high-power microscopic field (HPF).

•painless hematuria in adults, should be regarded as a symptom of urologic malignancy until proved otherwise.

•In evaluating hematuria:gross or microscopic. Initial, terminal or allthrough.Painful or not.Associated with clots or not and shape of clots.


Changes in the gross appearance of urine

Cloudy UrinePyuria • Pyuria is a urinary tract infection in which large quantities

of white blood cells cause urine to have a cloudy appearance.

• Microscopic examination of the urine will demonstrate pus cells.

Phosphaturia • due to precipitation of phosphates in alkaline urine. • Acidification of urine with acetic acid at the time of urine

analysis causes clearing of the specimen.Magdy Fath-Alla, 2009

Abnormal appearance and/or function of the male external genitalia

Male sexual dysfunction and impotence•impotence is the inability to achieve and maintain an erection adequate for intercourse. •Other male sexual disorders, including loss of libido, absence of emission, absence of orgasm & premature ejaculation. •Bloody ejaculate (Hematospermia) refers to the presence of blood in the seminal fluid. It almost always results from nonspecific inflammation of the prostate and/or seminal vesicles.


Abnormal appearance and/or function of the male external genitalia

Penile complaints•Cutaneous lesions.•Penile curvature.•Urethral discharge most common symptom of venereal infection.

o purulent thick, profuse, and yellow to gray discharge is typical of gonococcal urethritis.

o scanty and watery discharge is due to nonspecific urethritis.o bloody discharge suggests carcinoma of the urethra.

Scrotal complaints•Cutaneous lesions.•Absent or retractile testis.•Scrotal swellings or masses.


Systemic symptoms

• Fever and chills occur with infection anywhere in the GU tract but most common with pyelonephritis, prostatitis, or epididymitis.

• Fever, weight loss, and malaise are nonspecific systemic manifestations of: acute and chronic inflammation, renal failure, and genito-urinary malignancy with or without metastases.


Genito-Urinary ExaminationGenito-Urinary Examination

Urology DepartmentUrology Department

Undergraduate coursesUndergraduate courses

General Examination

• Apperance: distressed due to pain or does appear unwell suggesting systemic illness and possibly renal failure.

• Complexion: Pallor is evidence of anemia (due to hematuria).

• Vital data: blood pressure.• Signs of dehydration: dry mouth and tongue

may indicate renal failure or polyuria of diabetes.

• Cervical lymph nodes enlargment due to metastatic spread from any urological cancer.


Abdominal Examination

Inspection • scars (specially round umbilicus for laparoscopy

scars)• Distension, prominent veins, local swelling and

hernia, pulsation, visible peristalsis, skin lesions.• Exclude lesions of abdominal wall: Patient raises

head, patient does straight leg-raising, "blowing test" or Valsalva.

• Check for inguinal node enlargement.



General Palpation• Use warm hands.• Examine the tender areas last. • Light palpation then deep. • Check for guarding, rigidly and rebound

tenderness. • Determine for any mass: site, tenderness, size

and shape, surface (irregular or smooth), edge (regular or irregular), consistency (soft or hard), mobility, whether pulsatile or ballotable.

• Differential diagnosis of abdominal masses.



Specific Palpation:

• Kidney bimanual examination (for renal enlargement or masses) by with a hand posteriorly lifting up the kidney towards the examining abdominally placed hand.

• An enlarged kidney usually

bulges forwards.



• Tenderness over the kidney should be tested by gentle pressure over the renal angle.

• Bladder palpation: felt in retention (acute or chronic.

Percussion for ascites (shifting dullness) or enlarged bladder.

Auscultation for a renal bruit in renal artery stenosis (above umbilicus, 2cm to left or right of the midline and also in both flanks with the patient sitting up).


Scrotum and Genitalia examination

Penis examination: inspection and palpation of:

Prepuce to exclude phimosis and hypospadias.

Glans.

Skin (looking for ulcers, rashes) and Urethral discharge.

Examine the scrotum:Inspect scrotal skin Palpate testes, epididymis and vas Identify scrotal swellings: scrotal or inguinoscrotal.


– Is it possible to get above the swelling?

– Is the swelling solid or cystic?

– Is there a hydrocele, varicocele or epididymal cyst?

– Testing for translucency with a torch will determine whether the mass is cystic or a solid mass.



Differential diagnosis (common swellings)

A) Attached to the testis:

• Solid (non-translucent): testicular tumor.

• Cystic (translucent): hydrocele.

B) Separate from the testis:

• Solid (non-translucent): chronic epididymitis.

• Cystic (translucent): epididymal cyst.



Rectal Examination

Rectal examination is performed to palpate the prostate gland and anal canal to assess :

• prostate Size.

• prostate Consistency.

• prostate medial sulcus.

• prostate tenderness.

• Bladder base

• Anal tone.

• Anal pathology.

A hard area in either or both lobes suggests a cancer and a biopsy is needed to obtain histological diagnosis.


Bimanual examination of the bladder for masses

in the male in the female

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urologic symptoms and examination

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