Getachew wondim
April 2013
HISTORY
Medical history is the cornerstone in the evaluation of a
urologic patient, and a well-taken history will frequently
elucidate the probable diagnosis
The urologist must be a detective and lead the patient
through detailed and appropriate questioning to obtain
accurate information.
Time
sufficient to express their problems and the reasons for
seeking care
Listen carefully:
without distractions in order to obtain and interpret the
clinical information provided by the patient
Challenges in history
anxiety, language, educational background, impaired
hearing, mental capacity
Make the patient feel comfortable
calm, caring, and competent image to pt to build a two way
communication
Family member or interpreter
Chief Complaint and Present Illness
C/c must be clearly defined because it provides the initial
information to begin formulating the differential diagnosis.
It is a constant reminder as to why the patient initially sought
care.
This issue must be addressed even if subsequent evaluation
reveals a more serious condition.
In the HPI:
Duration
Severity
Chronicity
Periodicity
Degree of disability of the problem are important considerations.
Pain
Can be local or referred
Can be severe in:
urinary tract obstruction
inflammation
Inflammation of the GU tract is most severe when it
involves the parenchyma of a GU organ
Pyelonephritis
Prostatitis
Epididymitis
Inflammation of the mucosa of a hollow viscus usually
produces discomfort
Cystitis
Urethritis
Pain
Tumors:
No pain unless
obstruction
extend beyond the primary organ to involve adjacent nerves
Pain
Renal Pain:
Site: ipsilateral costovertebral
angle beneath the 12th rib (T10–
12, L1)
Dull aching type
May radiate across the flank
anteriorly toward the lower
abdomen and umbilicus.
May be referred to the testis or
labium.
Associated symptoms
Gastrointestinal symptoms:
Nausea
Vomiting
Ileus
Pain
Renal pain may also be
confused with pain resulting
from irritation of the costal
nerves, most commonly T10–
T12 which is:
not colicky in nature.
Severity of radicular pain
may be altered by changing
position
Ureteral pain
Usually acute and secondary to obstruction
If the obstruction is in the upper ureter, the pain radiates
to the testicle
Midureter ( Rt side): referred to the right lower quadrant
(McBurney's point) and simulate appendicitis
Midureter (Lt side) :referred over the left lower quadrant
and resembles diverticulitis.
May radiate to scrotum in the male or the labium in the
female.
Lower ureteral obstruction produces Sxs of bladder
irritability and suprapubic discomfort that may radiate
along the urethra in men to the tip of the penis.
Ask further questions for stone:
Previous hx of stone disease?
Passage of stones?
Hematuria?
Vesical Pain
Vesical pain is due to:
Overdistention
Improved after urination
Inflammation
Inflammatory conditions of the bladder usually
produce intermittent suprapubic discomfort
The most common cause of bladder pain is
infection;the pain is usually referred to the distal
urethra and is related to the act of urination
Prostatic Pain
Inflammation with secondary edema and
distention of the prostatic capsule
poorly localized
lower abdominal
Inguinal
Perineal
Lumbosacral
rectal pain.
irritative urinary symptoms ( frequency and dysuria)
acute urinary retention.
Penile Pain
Pain in the erect penis is usually due to Peyronie's
disease or priapism
Pain in the flaccid penis
usually secondary to inflammation in the bladder or urethra
referred pain that is maximally at the urethral meatus
Paraphimosis, infected phimosis, penile fracture
Testicular Pain
Acute pain
Epididymitis, orchitis
torsion of the testicle
Chronic scrotal pain
hydrocele
varicocele,
dull, heavy sensation that does not radiate
Referred pain: kidneys or retro peritoneum
Hematuria
Hematuria : the presence of blood in the urine
In adults, should be regarded as a symptom of
urologic malignancy until proved otherwise
Timing: (beginning or end of stream or during entire
stream)?
Amount of bleeding?
Bleeding d/o, bleeding from other sites?
Family hx of hematologic malignancy?
Is it associated with pain?
Is the patient passing clots?
If the patient is passing clots, do the clots have a specific
shape?
Lower Urinary Tract
Symptoms
Irritative Symptoms
Frequency :
is due to either increased urinary output or decreased
bladder capacity.
Polyuria?
hx of DM, DI, or excessive fluid intake should be
asked.
Decrease in bladder capacity?
Irritation, neurogenic bladder, extrinsic
pressure, anxiety
Nocturia:
Is it associated with frequency?
Is he/she a cardiac pt? elderly?
Is he/she alcoholic? Takes caffeinated beverages?
Dysuria:
At the start of urination?
At the end?
Obstructive Symptoms
Decreased force of urination:
Is usually secondary to bladder outlet obstruction and
commonly results from BPH or a urethral stricture
Urinary hesitancy:
Delay in the start of micturition
Intermittency:
B/c of intermittent occlusion of the urinary stream by the
lateral prostatic lobes, vesical calculi
Straining
Post void dribbling
Scoring of LUTS:
AUA symptom index
IPSS
24-Jan-17 23
Incontinence
Stress Incontinence:
involuntary leakage with Increase IAP. Weakening of pelvic
floor, or phincteric damage
Urge Incontinence: cystitis, neurogenic bladder,advanced BOO
leading ti dec bladder comliance.
Mixed incontinence:
combination of urge and stress incontinence
most common type of incontinence in women
Overflow Urinary Incontinence:
also called paradoxical incontinence or incomplete emptying.
2ry to advanced retention and high residual urine volume.
Enuresis:
Age after 6 yrs?
Female?
Sexual Dysfunction
Loss of Libido:
may indicate androgen deficiency
Decreased or absent ejaculation?
medical illnesses?
depression?
Impotence:
A careful history will often determine whether the problem
is primarily psychogenic or organic.
Marital stress or change or loss of a sexual partner?
Normal erections with alternative forms of sexual
stimulation?
Nocturnal or early morning erections?
Failure to Ejaculate:
Risks of autonomic denervation of the prostate and
seminal vesicle?
Pharmacologic agents, particularly α-adrenergic
antagonists?
Previous bladder neck or prostatic urethral surgery?
present medications? Diabetes?
Absence of Orgasm:
usually psychogenic or caused by certain medications
used to treat psychiatric diseases
decreased penile sensation owing to impaired pudendal
nerve function?
Premature Ejaculation :
almost always psychogenic
Hematospermia
It almost always results from nonspecific inflammation of
the prostate and/or seminal vesicles.
Resolves spontaneously, usually within several weeks It
frequently
Occurs after a prolonged period of sexual abstinence
Pneumaturia
Fistula between the intestine and the bladder?
Post urinary tract instrumentation or a urethral catheter
placed?
Gas-forming infections?
Urethral Discharge
purulent discharge that is thick, profuse, and yellow to
gray? gonococcal urethritis
scant and watery? Non specific inflammation
Bloody discharge? carcinoma of the urethra.
Fever and Chills
Associated with urinary obstruction? septicemia
Pyelonephritis, pyonephrosis, prostatitis, or epididymitis?
Medical History
Previous Medical Illnesses with Urologic Sequelae:
DM,HTN?
Tuberculosis?
MS or other neurologic diseases?
Sickle cell diseases?
Smoking and Alcohol Use
Cigarette smoking
urothelial carcinoma, mostly bladder cancer
Erectile dysfunction.
Chronic alcoholism
impaired urinary function
Sexual dysfunction.
testicular atrophy, and decreased libido.
Family History
Previous Surgical Procedures
Allergies
PHYSICAL EXAMINATION
A complete and thorough physical examination is an
essential component of the evaluation of patients who
present with urologic disease.
It allows the urologist to select the most appropriate
diagnostic studies.
Along with the history, the physical examination
remains a key component of the diagnostic evaluation
and should be performed meticulously.
General Observations
visual inspection of the patient
Cachexia
Malignancy, TB
Jaundice or pallor
LAP
Gynecomastia
endocrinologic disease
alcoholism
hormonal therapy for prostate cancer
Kidney Examination
Inspection: mass, fullness at CVA
Palpation:
Supine
lying on one side
Percusion: to outline mass, swelling hematoma
Auscultation: bruit
Bladder
at least 150 ml of urine in it to be felt.
A bimanual examination, best done under anesthesia, is
very valuable to asses bladder tumor extension
Bimanual Examination
Insert a lubricated gloved finger into the rectum( males) or
gloved fingers into the vagina
Apply fingers of the anterior hand on the suprapubic area
Attempt to palpate the bladder between 2 hands
Is the bladder palpable? Is it mobile or fixed?
Gives clinical information regarding local invasion and extent
of the tumor
Bladder
Penis
Inspection:
meatal opening, shape, lesions,…
Palpation:
fibrotic plaques, tenderness
Hypospadias and epispadias
Scrotum and Contents
Symmetry
Change following increase in IAP
Consistency
Transillumination
Cord approximable
Testis? Location, Symmetry, consistency, lie pain?
Rectal and Prostate Examination in the Male
Digital rectal examination (DRE) :
For every male after age 40 years
Men of any age who present for urologic evaluation
It should be performed at the end of P/E.
Proper positioning is crutial!
Adequat time for the pt until proper position and
relaxed, a few reassuring words.
The examiner’s other hand on the pt’s lower abdomen
for gentle contact and to steady the pt.
A well-lubricated gloved index finger is inserted gently into
the rectum
Have the patient Valsalva or bear down as you are
inserting the gloved finger
estimation of sphincter tone..
Testing perianal sensation
Palpate the prostate in systematic fashion: right,
middle, left; apex to base
Allow the pt adequate time to wash and dress at the end of
the procedure
Prostate Examination
Normal prostate
Normal prostate is size of a chest nut( 4
cm(L) x 4 cm(W) x2cm(D)). Has rubbery
consistency or consistency of contracted
thenar eminence.
Prostate Examination
Enlarged, rubbery, no fixation, no induration, smooth
surface: BPH
Prostate is enlarged, fluctuant, warm, and painful:
prostatitis
One area of the prostate feels irregular, nodular, stony
hard or fixed: Pr ca
If firm area: early ca, prostate calculi, fibrosis,
nodularity from TB,…
References
CAMPBELL-WALSH UROLOGY 10TH EDITION
SMITH’S GENERAL UROLOGY 17TH EDITION
HACHISON’S CLINICAL METHODS
BATE’S GUIDE TO PHYSICAL EXAMINATION
UPTODATE 19.3
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