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Physical examination
• Physical examination focuses on the
costovertebral angle, abdomen, rectum, groin,
and genitals.
• In women with urinary symptoms, pelvic
examination is usually done.
9/19/2018 Compiled by C Settley 2

• Costovertebral angle
– Pain elicited by blunt striking of the back, flanks,
and angle formed by the 12th rib and lumbar
spine with a fist (costovertebral tenderness) may
indicate pyelonephritis (Inflammation of the kidney due to a
bacterial infection), calculi (A small, hard deposit that forms in the
kidneys and is often painful when passed), or urinary tract
obstruction.

• Costovertebral angle

• Abdomen
– Visual fullness of the upper abdomen is an
extremely rare and nonspecific finding of
hydronephrosis (A condition characterised by excess fluid in a
kidney due to a back-up of urine) or a kidney or abdominal
mass.
– Dullness to percussion in the lower abdomen
suggests bladder distention.
– Bladder palpation can be used to confirm
distention and urinary retention.

• Abdomen
– The kidneys lie rather high under the diaphragm
and lower ribs and are therefore well protected
from injury.
– Because of the position of the liver, the right
kidney is lower than the left.

• Abdomen
– The lower part of the right kidney can sometimes
be felt, particularly in thin patients, but the left
kidney usually cannot be felt unless it is enlarged
or displaced.
– The most successful method of renal palpation is
carried out with the patient lying in the supine
position on a hard surface.

• Abdomen palpation
– Method of palpation of the kidney. The posterior hand lifts the kidney upward. The anterior
hand feels for the kidney. The patient then takes a deep breath; this causes the kidney to
descend. As the patient inhales, the fingers of the anterior hand are plunged inward at the
costal margin. If the kidney is mobile or enlarged, it can be felt between the two hands.

• Abdomen
– On deep inspiration, the kidney moves downward;
the non dominant hand is pushed firmly and
deeply beneath the costal margin in an effort to
trap the kidney.
– When successful, the anterior hand can palpate
the size, shape, and consistency of the organ as it
slips back into its normal position.

• Rectum
– During digital rectal examination, prostatitis may
be detected.
– Less discrete hard areas must be distinguished
from prostate cancer.

• Groin and genitals
– Gross asymmetry, swelling, erythema(superficial reddening
of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood
capillaries), or discoloration of the testes may indicate
infection, torsion (A twisting of the male organ that makes
hormones and sperm), tumour, or other mass.
– Elevation of one testis (normally the left is lower)
may be a sign of testicular torsion.
– The penis is examined with and without retracting
the foreskin.

– Palpation may reveal an inguinal hernia (A bulging of an
organ or tissue through an abnormal opening).
– Cremasteric reflex may be absent with testicular
torsion.
• This reflex is elicited by lightly stroking or poking the superior and
medial (inner) part of the thigh—regardless of the direction of
stroke. The normal response is an immediate contraction of the
cremaster muscle that pulls up the testis

– If swelling is present, the area should be
transilluminated to help determine whether the
swelling is cystic or solid.
• pass strong light through (an organ or part of the body)
in order to detect disease or abnormality.

What are the functions of the
urinary system?
• Regulate blood volume and composition
(e.g. sodium, potassium and calcium)
• Regulate blood pressure.
• Regulate pH homeostasis of the blood.
• Contributes to the production of red blood cells by
the kidney.
• Helps synthesize calcitrol the (active form of Vitamin D).
• Stores waste product (mainly urea and uric acid) before it
and other products are removed from the body.

Urine formation
• Average urine production in adult humans is
about 1–2 litres per day, depending on:
– state of hydration,
– activity level,
– environmental factors,
– weight,
– and the individual's health.

Urine formation
• Producing too much or too little urine requires
medical attention.
• Polyuria is a condition of excessive urine
production (> 2.5 L/day).
• Oliguria when < 400 mL (millilitres) are
produced, and
• Anuria one of < 100 mL per day.

Urine formation
• The first step in urine formation is the
filtration of blood in the kidneys.
• The basic structural and functional unit of the
kidney is the nephron.
• Its chief function is to regulate
the concentration of water and soluble
substances like sodium by filtering the blood,
reabsorbing what is needed and excreting the
rest as urine.

Urine formation
• In the first part of the nephron, Bowman's
capsule filters blood from the circulatory
system into the tubules.
• Hydrostatic and osmotic pressure gradients
facilitate filtration across a semipermeable
membrane.
• The filtrate includes water, small molecules,
and ions that easily pass through the filtration
membrane.

The kidney

The nephron
On average, a normal human kidney contains
800,000 to 1.5 million nephrons

Filtration, reabsorption & secretion
in the nephron

Urine formation
• Larger molecules such as proteins and blood
cells are prevented from passing through the
filtration membrane.
• The urinary system is regulated by
the endocrine system by hormones such
as antidiuretic hormone, aldosterone,
and parathyroid hormone

Antidiuretic hormone
• It's a hormone made by the hypothalamus in the brain and
stored in the posterior pituitary gland.
• It tells the kidneys how much water to conserve.
• ADH constantly regulates and balances the amount of
water in your blood.

Aldosterone
• Aldosterone, the main mineralocorticoid hormone, is a
steroid hormone produced by the zona glomerulosa of the
adrenal cortex in the adrenal gland.
• It is essential for sodium conservation in the kidney, salivary
glands, sweat glands and colon.

Parathyroid hormone
• When the blood calcium level is too low, PTH is released to
bring the calcium level back up to normal.
• When the calcium level is normal or gets a little too high,
normal parathyroid will stop releasing PTH.

Urological symptoms
• Haematuria
– the presence of blood in urine.

Urological symptoms
• Retention of urine
– Urinary retention is an inability to completely
empty the bladder.
– Causes include blockage of the urethra, nerve
problems (S2, S3 and S4), certain medications (e.g.
anti inflammatory drugs and chemotherapy), and
weak bladder muscles.
– Blockage can be caused by benign prostatic
hyperplasia, urethral strictures, bladder stones, a
cystocele (A bulge of the bladder into the vagina),
constipation, or tumors.

Urological symptoms
• Incontinence of urine
– Urinary incontinence — the loss of bladder control
is a common and often embarrassing problem.
– The severity ranges from occasionally leaking
urine when coughing or sneezing to having an
urge to urinate that's so sudden and strong you
don't get to a toilet in time.

Urological symptoms
• Polyuria
– Polyuria is excessive or an abnormally large
production of urine.
– Frequent urination is usually an accompanying
symptom.
– Increased production and passage of urine may
also be termed diuresis.
– The most common cause of polyuria in both adults and children is uncontrolled diabetes
mellitus, which causes osmotic diuresis, when glucose levels are so high that glucose is
excreted in the urine. Water follows the glucose concentration passively, leading to
abnormally high urine output.

Urological symptoms
• Dysuria
– painful or difficult urination.
– Stones in the urinary tract, Irritation of the urethra from sexual activity
– Vaginal changes related to menopause.
– Activities such as horseback riding or riding a bicycle.

Cystitis- pg.472
• Inflammation and infection of the urinary
bladder.

Risk factors- pg. 473
• Incomplete emptying of the bladder experienced in
prostatic obstruction, urethral strictures, stenosis of
the external meatus of the urethra, pregnancy,
injuries and/or diseases of the spinal cord
• Bladder calculi, foreign body and neoplasm
• Vesico-retral reflux(a condition in which urine flows retrograde, or backward, from
the bladder into the ureters/kidneys) and recurrent pyelonephritis
• Presence of fistula (A fistula is an abnormal hole in the bowel or the bladder. This
hole leads to leakage of urine into the rectum and faeces travelling into the bladder)

Cystitis: Pathophysiology-pg. 473
• Organism gains entry through the urethra
• Or infection could be due to instrumentation with a scope
or catheter
• In women it could be due to an abnormal connection
between the bladder and vagina that occurs during
childbirth
• Urinary stasis (incomplete bladder emptying) may result in
cystitis
• Conducive breeding place while it erodes (gradually wears
away) bladder mucosa

Assessment and common findings-
pg. 473
• This condition usually presents with lower
abdominal pain, frequency of micturition,
and/or dysuria.
• There are no features of sepsis, e.g. fever.
• Urine dipstick testing usually shows nitrites,
with/without leukocytes; protein and/or blood
may also be detected.

Nursing management- pg. 473
• Encourage patient to drink plenty of fluids to
flush the toxins out
• Intake and output so that kidney function is
monitored
• Antibiotics as prescribed following culture and
sensitivity tests
• Burning on micturition is usually relieved by
making the urine alkaline by giving the patient
agents such as Citro Soda

Pharmacological management
• Empiric treatment (nitrites positive OR
leukocytes positive on dipstick):
– Amoxicillin/clavulanic acid 875/125 mg, oral, 12
hourly for 5 days.
• Severe penicillin allergy:
– Fosfomycin 3 g, oral, as a single dose.
• Refer when the is no response to treatment,
or resistant organism on culture.

Urinary tract infection in women
• Urinary tract infections are more common in women. They
usually occur in the bladder or urethra, but more serious
infections involve the kidney.
• A bladder infection may cause pelvic pain, increased urge
to urinate, pain with urination and blood in the urine. A
kidney infection may cause back pain, nausea, vomiting and
fever.

Causes
• sexual intercourse, especially if
more frequent, intense, and
with multiple or new partners
• diabetes
• poor personal hygiene
• problems emptying the
bladder completely
• having a urinary catheter
• bowel incontinence
• blocked flow of urine
• kidney stones
• some forms of contraception
• pregnancy
• menopause
• procedures involving the
urinary tract
• suppressed immune system
• immobility for a long period
• use of tampons
• heavy use of antibiotics, which
can disrupt the natural flora of
the bowel and urinary tract

Assessment and common findings
• Flank pain/tenderness
• Temperature ≥38ºc or higher
• Other features of sepsis, i.e. tachypnoea, tachycardia,
confusion and hypotension
• Vomiting
• In complicated, recurrent or upper UTIs, mid-stream urine
should be sent for microscopy, culture and sensitivity.
– What is a mid-stream urine test?

Nursing management
• Women with recurrent UTIs should be advised
to:
– void bladder after intercourse and before retiring at
night
– not postpone voiding when urge to urinate occurs
– change from use of diaphragm to an alternative type of
contraception

Pharmacological management
• Uncomplicated community acquired cystitis Ciprofloxacin, oral, 500
mg 12 hourly for 3 days.
• Complicated community acquired cystitis Ciprofloxacin, oral, 500
mg 12 hourly for 7 days.
• For pregnant women: Amoxicillin/clavulanic acid, oral, 875/125 mg
12 hourly for 7 days.
• Severe penicillin allergy in 1st trimester: Fosfomycin, oral, 3 g as a
single dose dissolved in a glass of water.
• Severe penicillin allergy in 2nd and 3rd trimester: Nitrofurantoin,
oral, 100 mg 6 hourly for 7 days. Avoid near term (38 to 42 weeks)
and consider fosfomycin in these cases.
• Adjust antibiotics according to urine microscopy, culture and
sensitivity results in complicated, recurrent or upper UTIs.

UTI in children
• Childhood urinary tract infections are fairly
common and are generally caused by bacteria.

Clinical features
• Common symptoms and signs of UTIs in
children include pain and urgency with
urination, blood in the urine,
abdominal/pelvic pain, fever, flank pain, and
vomiting.

Urine specimen
• It is not necessary to send a culture for
everyone because the majority of UTIs are
caused by the same bacteria.
• The single most important lab test is
urinalysis.
• A urine sample will be tested for signs of
infection, such as the presence of white blood
cells and bacteria.

Urinalysis
• A dipstick — a thin, plastic stick with strips of
chemicals on it — is placed in the urine to
detect abnormalities.
• The chemical strips change colour if certain
substances are present or if their levels are
above normal.

Urinalysis• Acidity (pH).
– The pH level indicates the amount of acid in urine. Abnormal pH
levels may indicate a kidney or urinary tract disorder.
• Concentration.
– A measure of concentration, or specific gravity, shows how
concentrated particles are in your urine. A higher than normal
concentration often is a result of not drinking enough fluids.
• Protein.
– Low levels of protein in urine are normal. Small increases in protein
in urine usually aren't a cause for concern, but larger amounts may
indicate a kidney problem.
• Sugar.
– Normally the amount of sugar (glucose) in urine is too low to be
detected. Any detection of sugar on this test usually calls for
follow-up testing for diabetes.

Urinalysis• Ketones.
– As with sugar, any amount of ketones detected in your urine could
be a sign of diabetes and requires follow-up testing.
• Bilirubin.
– Bilirubin is a product of red blood cell breakdown. Normally,
bilirubin is carried in the blood and passes into your liver, where it's
removed and becomes part of bile. Bilirubin in your urine may
indicate liver damage or disease.
• Evidence of infection.
– If either nitrites or leukocyte esterase — a product of white blood
cells — is detected in your urine, it may be a sign of a urinary tract
infection.
• Blood.
– Blood in your urine requires additional testing — it may be a sign of kidney
damage, infection, kidney or bladder stones, kidney or bladder cancer, or blood
disorders.

Urinalysis

Urinalysis
• Microscopic exam
– White blood cells (leukocytes) may be a sign of an
infection.
– Red blood cells (erythrocytes) may be a sign of kidney
disease, a blood disorder or another underlying medical
condition, such as bladder cancer.
– Bacteria or yeasts may indicate an infection.
– Crystals that form from chemicals in urine may be a sign
of kidney stones.

Urinalysis

Recurrent UTI’s
• Bacteria can enter the urinary tract from the outside to cause a UTI to
come back, or a recurrent infection can be caused by bacteria that remain
in the urinary tract after a previous infection. Symptoms of recurrent UTI
in men and women include the frequent urge to urinate, burning pain or
pressure, cloudy or discoloured urine, and chills and fever. Children with
UTIs are more likely to have fever without the other symptoms. Common
conditions that can lead to recurrent UTIs include:
• Being in a nursing home or hospital
• Diabetes
• Kidney or bladder stones
• Having a catheter
• Previous urinary tract surgery
• Sexual activity
• Having an infected or enlarged prostate
• Being born with an abnormality of the urinary tract

Penile disorders- pg. 544
• Phimosis
– When the penile foreskin is constricted over the
glans, making retraction difficult or impossible

Phimosis: Aetiology- pg. 544
• Occurs in uncircumcised males
• But can be congenital or acquired
• As a result of inflammation, infection or local
trauma
• Prolonged phimosis caused by chronic
inflammation and irritation predisposes the
individual to penile cancer

• Paraphimosis
– Paraphimosis is a urologic emergency in which the
retracted foreskin of an uncircumcised male
cannot be returned to its normal anatomic
position.
– It is important for clinicians to recognize this
condition promptly, as it can result in gangrene
and amputation of the glans penis.

• Paraphimosis

What is the difference between
phimosis and paraphimosis?
• Phimosis defines an inability to retract the
foreskin after it was previously retractible or
after puberty, usually secondary to distal
scarring of the foreskin.
• Paraphimosis is the entrapment of a
retracted foreskin behind the coronal sulcus
and is a disease of uncircumcised or partially
circumcised males.

What is the difference between
phimosis and paraphimosis?

• Circumcision
– Male circumcision is the removal of the foreskin
from the human penis.
– In the most common procedure, the foreskin is
opened, adhesions are removed, and the foreskin
is separated from the glans.

Circumcision

Circumcision:
autonomy & informed consent
• South African law has been drawn up with the
protection of South Africans in mind and
demands very high standards for informed
consent.
• The National Health Act (2003) states:

Circumcision:
Autonomy & Informed consent
1. Every health care provider must inform a user of-
• a. the user’s health status except in circumstances where there is
substantial evidence that the disclosure of the user’s health status would
be contrary to the best interests of the user;
• b. the range of diagnostic procedures and treatment options generally
available to the user;
• c. the benefits, risks, costs and consequences generally associated with
each option; and
• d. the user’s right to refuse health services and explain the implications,
risks, obligations of such refusal.
2. The health care provider concerned must, where possible, inform the user
as contemplated in subsection in a language that the user understands and in
a manner which takes into account the user’s level of literacy.

Circumcision:
Ethical & legal issues
• Consent
• South Africa
• Cultural ritual
• Western culture
• SA government negotiate with custodians of
traditional circumcision to regulate practices due
to high mortality & morbidity rates

Circumcision:
Essential health information
• Genital hygiene
• Prevention of penile disorders
• STI’s/HIV, AIDS- reduces risk by 60%
• Post circumcision, men should be encouraged to
eat protein rich foods and drink water to enhance
healing
• Wound infection

• Circumcision: Ethical and legal issues
– Informed consent
– Cultural/initiation
– High mortality and morbidity in traditional
practices

• Circumcision: Essential health information
– Effective genital hygiene to prevent penile
disorders
– After circumcision, men should be encouraged to
eat protein rich foods and drink water to enhance
healing.
– Personal hygiene for wound prevention

• Epispadias
– An epispadias is a rare type of malformation of the
penis in which the urethra ends in an opening on
the upper aspect of the penis.
– It can also develop in females when the urethra
develops too far anteriorly.

• Hypospadias
– A condition in which the opening of the penis is
on the underside (ventral) rather than the tip.

Reference list
• https://accessmedicine.mhmedical.com/content.aspx?bookid=508&sectio
nid=41088081
• https://www.epainassist.com/pelvic-pain/urethral-stricture
• https://www.slideshare.net/blackempress/urinary-outflow-obstruction-
presentation
• https://www.mayoclinic.org/tests-procedures/urinalysis/about/pac-
20384907
• https://slideplayer.com/slide/4381644/
• http://www.mammothmemory.net/biology/organs-and-systems/kidneys-
the-renal-system/what-a-nephron-looks-like-up-close.html

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