Urologic symptoms and examination


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Urologic symptoms and examination

  1. 1. Urological symptoms Urology Department Undergraduate courses
  2. 2. History Taking <ul><li>The medical history is the cornerstone of the evaluation of the urologic patient. </li></ul><ul><li>A complete history can be divided into: </li></ul><ul><li>The chief complaint </li></ul><ul><li>History of the present illness </li></ul><ul><li>The patient's past medical and surgical history </li></ul><ul><li>Family history. </li></ul>Magdy Fath-Alla, 2009
  3. 3. Complaint <ul><li>Urological complaint(s) can be categorized into one or more of: </li></ul><ul><li>Pain </li></ul><ul><li>Changes in the act of micturition </li></ul><ul><li>Changes in gross appearance of urine </li></ul><ul><li>Changes in function and/or appearance of male genitalia. </li></ul><ul><li>Systemic symptoms </li></ul>Magdy Fath-Alla, 2009
  4. 4. Pain <ul><li>Pain arising from the GU tract may be quite severe and is usually associated with </li></ul><ul><li>Obstruction: </li></ul><ul><li>Ureteric stone. </li></ul><ul><li>Urinary retention. </li></ul><ul><li>Inflammation </li></ul><ul><li>parenchymatous organs inflamm. produces severe pain (pyelonephritis, prostatitis, and epididymitis) </li></ul><ul><li>Inflammation of the mucosa of a hollow viscus such as the bladder or urethra usually produces discomfort. </li></ul><ul><li>Tumors of GU tract usually do not cause pain unless they produce obstruction or extend to adjacent nerves. </li></ul>Magdy Fath-Alla, 2009
  5. 5. Renal Pain <ul><li>Site: ipsilateral costovertebral angle just lateral to the sacrospinalis muscle and beneath the 12th rib. </li></ul><ul><li>Pain due to inflammation is usually steady ( dull ache ) due to acute distention of the renal capsule, </li></ul><ul><li>Pain due to obstruction fluctuates in intensity ( colicky) . </li></ul><ul><li>may be associated with gastrointestinal symptoms because of reflex stimulation of the celiac ganglion. </li></ul><ul><li>Radiation: across the flank anteriorly toward the upper abdomen and umbilicus and may be to the testis or labium. </li></ul>Magdy Fath-Alla, 2009
  6. 6. Differential Diagnosis of Renal Pain <ul><li>1) Pain of intraperitoneal origin (perforated duodenal ulcer or pancreatitis) has the following characters: </li></ul><ul><li>Radiates into the back, but the site of greatest pain and tenderness is in the epigastrium. </li></ul><ul><li>Radiates into the shoulder because of irritation of the diaphragm and phrenic nerve. </li></ul><ul><li>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. </li></ul>Magdy Fath-Alla, 2009
  7. 7. Ureteral Pain <ul><li>usually acute and secondary to obstruction. </li></ul><ul><li>Distribution of the pain according to site: </li></ul><ul><ul><li>In upper ureteral obstruction, the pain may be referred to the scrotum in the male or the labium in the female. </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>Lower ureteral obstruction causes bladder irritability (frequency, urgency, and suprapubic discomfort). </li></ul></ul>Magdy Fath-Alla, 2009
  8. 8. Vesical and Prostatic pain <ul><li>Vesical pain </li></ul><ul><li>due to retention or inflammation. </li></ul><ul><li>Constant suprapubic pain that is unrelated to urinary retention is seldom of urologic origin. </li></ul><ul><li>Inflammatory conditions of the bladder usually produce intermittent suprapubic discomfort. </li></ul><ul><li>Prostatic pain </li></ul><ul><li>due to inflammation with secondary edema and distention of the prostatic capsule. </li></ul><ul><li>poorly localized to lower abdominal, inguinal, perineal, lumbosacral, and/or rectal pain. </li></ul>Magdy Fath-Alla, 2009
  9. 9. Penile and Testicular Pain <ul><li>Penile pain </li></ul><ul><li>Pain in the flaccid penis is referred pain from bladder or urethra and maximally at the urethral meatus. </li></ul><ul><li>Pain in the erect penis is usually due to Peyronie's disease or priapism. </li></ul><ul><li>Scrotal pain </li></ul><ul><li>Primary pain arises from within the scrotum: </li></ul><ul><ul><li>Acute epididymitis or torsion of the testis. </li></ul></ul><ul><ul><li>Chronic scrotal pain (dull, heavy) due to hydrocele or varicocele. </li></ul></ul><ul><li>Referred: </li></ul><ul><ul><li>from kidneys or retroperitoneum or from inguinal hernia. </li></ul></ul>Magdy Fath-Alla, 2009
  10. 10. Irritative Symptoms <ul><li>Frequency </li></ul><ul><li>The normal adult voids five or six times per day, with a volume of approximately 300 mL with each void. </li></ul><ul><li>Urinary frequency is due either to increased urinary output (polyuria), detrusor instability or to decreased bladder capacity. </li></ul>Magdy Fath-Alla, 2009
  11. 11. Irritative Symptoms <ul><li>Nocturia is nocturnal frequency. </li></ul><ul><li>Normally, adults arise no more than twice at night to void (decrease urine concentration with age). </li></ul><ul><li>Nocturia occur in the patient with congestive heart failure and peripheral edema, old aged and drinking fluids at night. </li></ul><ul><li>Dysuria is painful urination commonly referred to the urethral meatus. </li></ul><ul><li>at the start of urination indicate urethral pathology. </li></ul><ul><li>at the end (strangury) indicate bladder origin. </li></ul><ul><li>Dysuria is frequently accompanied by frequency & urgency. </li></ul><ul><li>Urgency the sudden intense desire to void that the patient can not defer. </li></ul>Magdy Fath-Alla, 2009
  12. 12. Obstructive Symptoms <ul><li>Urinary hesitancy delayed start of urination. </li></ul><ul><li>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. </li></ul><ul><li>Straining refers to the use of abdominal musculature to urinate. </li></ul><ul><li>Intermittency means interrupted stream. </li></ul><ul><li>Postvoid dribbling refers to the release of few drops of urine after micturition. </li></ul>Magdy Fath-Alla, 2009
  13. 13. Incontinence <ul><li>Urinary incontinence is the involuntary loss of urine </li></ul><ul><li>Continuous Incontinence most commonly due to: </li></ul><ul><li>urinary tract fistula (as vesico-vaginal fistula usually due to gynecologic surgery, radiation, or obstetric trauma. </li></ul><ul><li>ectopic ureter that opens either at the urethra or the female genital tract. </li></ul><ul><li>Stress Incontinence is sudden leakage of urine with coughing, sneezing, exercise (increase intra-abdominal pressure). </li></ul><ul><li>most common in women after childbearing or menopause and men after prostatic surgery and injury to the external urethral sphincter. </li></ul><ul><li>  </li></ul>Magdy Fath-Alla, 2009
  14. 14. Incontinence <ul><li>Urge Incontinence </li></ul><ul><li>loss of urine preceded by a strong urge t o void. </li></ul><ul><li>Due to: cystitis, neurogenic bladder. </li></ul><ul><li>Overflow Urinary Incontinence </li></ul><ul><li>Due to advanced urinary retention and high residual urine volumes. </li></ul><ul><li>Urine dribble due to bladder overflow. </li></ul><ul><li>Enuresis </li></ul><ul><li>micturition that occurs during sleep. </li></ul><ul><li>It occurs normally in children up to 3 years old. </li></ul>Magdy Fath-Alla, 2009
  15. 15. Changes in the gross appearance of urine <ul><li>Hematuria </li></ul><ul><li>the presence of blood in the urine > 3 RBCs per high-power microscopic field (HPF). </li></ul><ul><li>painless hematuria in adults, should be regarded as a symptom of urologic malignancy until proved otherwise. </li></ul><ul><li>In evaluating hematuria: </li></ul><ul><li>gross or microscopic. </li></ul><ul><li>Initial, terminal or allthrough. </li></ul><ul><li>Painful or not. </li></ul><ul><li>Associated with clots or not and shape of clots. </li></ul><ul><li>  </li></ul>Magdy Fath-Alla, 2009
  16. 16. Changes in the gross appearance of urine <ul><li>Cloudy Urine </li></ul><ul><li>Pyuria </li></ul><ul><li>Pyuria is a urinary tract infection in which large quantities of white blood cells cause urine to have a cloudy appearance. </li></ul><ul><li>Microscopic examination of the urine will demonstrate pus cells. </li></ul><ul><li>Phosphaturia </li></ul><ul><li>due to precipitation of phosphates in alkaline urine. </li></ul><ul><li>Acidification of urine with acetic acid at the time of urine analysis causes clearing of the specimen. </li></ul>Magdy Fath-Alla, 2009
  17. 17. Abnormal appearance and/or function of the male external genitalia <ul><li>Male sexual dysfunction and impotence </li></ul><ul><li>impotence is the inability to achieve and maintain an erection adequate for intercourse. </li></ul><ul><li>Other male sexual disorders, including loss of libido, absence of emission, absence of orgasm & premature ejaculation. </li></ul><ul><li>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. </li></ul>Magdy Fath-Alla, 2009
  18. 18. Abnormal appearance and/or function of the male external genitalia <ul><li>Penile complaints </li></ul><ul><li>Cutaneous lesions. </li></ul><ul><li>Penile curvature. </li></ul><ul><li>Urethral discharge most common symptom of venereal infection. </li></ul><ul><ul><li>purulent thick, profuse, and yellow to gray discharge is typical of gonococcal urethritis. </li></ul></ul><ul><ul><li>scanty and watery discharge is due to nonspecific urethritis. </li></ul></ul><ul><ul><li>bloody discharge suggests carcinoma of the urethra. </li></ul></ul><ul><li>Scrotal complaints </li></ul><ul><li>Cutaneous lesions. </li></ul><ul><li>Absent or retractile testis. </li></ul><ul><li>Scrotal swellings or masses. </li></ul>Magdy Fath-Alla, 2009
  19. 19. Systemic symptoms <ul><li>Fever and chills occur with infection anywhere in the GU tract but most common with pyelonephritis, prostatitis, or epididymitis. </li></ul><ul><li>Fever, weight loss, and malaise are nonspecific systemic manifestations of: acute and chronic inflammation, renal failure, and genito-urinary malignancy with or without metastases. </li></ul>Magdy Fath-Alla, 2009
  20. 20. Genito-Urinary Examination Urology Department Undergraduate courses
  21. 21. General Examination <ul><li>Apperance: distressed due to pain or does appear unwell suggesting systemic illness and possibly renal failure. </li></ul><ul><li>Complexion: Pallor is evidence of anemia (due to hematuria). </li></ul><ul><li>Vital data: blood pressure. </li></ul><ul><li>Signs of dehydration: dry mouth and tongue may indicate renal failure or polyuria of diabetes. </li></ul><ul><li>Cervical lymph nodes enlargment due to metastatic spread from any urological cancer. </li></ul>Magdy Fath-Alla, 2009
  22. 22. Abdominal Examination <ul><li>Inspection </li></ul><ul><li>scars (specially round umbilicus for laparoscopy scars) </li></ul><ul><li>Distension, prominent veins, local swelling and hernia, pulsation, visible peristalsis, skin lesions. </li></ul><ul><li>Exclude lesions of abdominal wall: Patient raises head, patient does straight leg-raising, &quot;blowing test&quot; or Valsalva. </li></ul><ul><li>Check for inguinal node enlargement. </li></ul>Magdy Fath-Alla, 2009
  23. 23. Abdominal Examination <ul><li>General Palpation </li></ul><ul><li>Use warm hands. </li></ul><ul><li>Examine the tender areas last. </li></ul><ul><li>Light palpation then deep. </li></ul><ul><li>Check for guarding, rigidly and rebound tenderness. </li></ul><ul><li>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. </li></ul><ul><li>Differential diagnosis of abdominal masses. </li></ul>Magdy Fath-Alla, 2009
  24. 24. Abdominal Examination <ul><li>Specific Palpation: </li></ul><ul><li>Kidney bimanual examination ( for renal enlargement or masses) by with a hand posteriorly lifting up the kidney towards the examining abdominally placed hand. </li></ul><ul><li>An enlarged kidney usually </li></ul><ul><li>bulges forwards. </li></ul>Magdy Fath-Alla, 2009
  25. 25. Abdominal Examination <ul><li>Tenderness over the kidney should be tested by gentle pressure over the renal angle. </li></ul><ul><li>Bladder palpation: felt in retention (acute or chronic. </li></ul><ul><li>Percussion for ascites (shifting dullness) or enlarged bladder. </li></ul><ul><li>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). </li></ul>Magdy Fath-Alla, 2009
  26. 26. Scrotum and Genitalia examination <ul><li>Penis examination : inspection and palpation of: </li></ul><ul><li>Prepuce to exclude phimosis and hypospadias. </li></ul><ul><li>Glans. </li></ul><ul><li>Skin (looking for ulcers, rashes) and Urethral discharge. </li></ul><ul><li>Examine the scrotum : </li></ul><ul><li>Inspect scrotal skin </li></ul><ul><li>Palpate testes, epididymis and vas </li></ul><ul><li>Identify scrotal swellings: scrotal or inguinoscrotal. </li></ul>Magdy Fath-Alla, 2009
  27. 27. <ul><ul><li>Is it possible to get above the swelling? </li></ul></ul><ul><ul><li>Is the swelling solid or cystic? </li></ul></ul><ul><ul><li>Is there a hydrocele, varicocele or epididymal cyst? </li></ul></ul><ul><ul><li>Testing for translucency with a torch will determine whether the mass is cystic or a solid mass. </li></ul></ul>Magdy Fath-Alla, 2009 Scrotum and Genitalia examination
  28. 28. <ul><li>Differential diagnosis (common swellings) </li></ul><ul><li>A) Attached to the testis : </li></ul><ul><li>Solid (non-translucent): testicular tumor. </li></ul><ul><li>Cystic (translucent): hydrocele. </li></ul><ul><li>B) Separate from the testis : </li></ul><ul><li>Solid (non-translucent): chronic epididymitis. </li></ul><ul><li>Cystic (translucent): epididymal cyst. </li></ul>Scrotum and Genitalia examination Magdy Fath-Alla, 2009
  29. 29. Rectal Examination <ul><li>Rectal examination is performed to palpate the prostate gland and anal canal to assess : </li></ul><ul><li>prostate Size. </li></ul><ul><li>prostate Consistency. </li></ul><ul><li>prostate medial sulcus. </li></ul><ul><li>prostate tenderness. </li></ul><ul><li>Bladder base </li></ul><ul><li>Anal tone. </li></ul><ul><li>Anal pathology. </li></ul><ul><li>A hard area in either or both lobes suggests a cancer and a biopsy is needed to obtain histological diagnosis. </li></ul>Magdy Fath-Alla, 2009
  30. 30. Bimanual examination of the bladder for masses in the male in the female
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