 EXAMINATION OF A UROLOGIC PATIENT

 Dr. Je Sean S. Ciocson, FPUA, FPCS

 Symptoms of Disorders of the GU Tract
 In the workup of any patient, the history is of paramount importance
 It is necessary to discuss here only those urologic symptoms that are apt to be brought
to the physician’s attention by the patient
 It is important to know not only whether the disease is acute or chronic but also
whether it is recurrent
 Obtaining the history is an art that depends on the skill and methods used to elicit
information
 SYSTEMIC MANIFESTATIONS
 Symptoms of fever and weight loss should be sought
 The presence of fever associated with other symptoms of urinary tract infection
may be helpful in evaluating the site of the infection
 Renal carcinoma sometimes causes fever that may reach 39°C (102.2°F) or more
 Weight loss is to be expected in the advanced stages of cancer
 In children who have “failure to thrive” (low weight and less than average height
for age), chronic obstruction, urinary tract infection, or both should be suspected
 General malaise may be noted with tumors, chronic pyelonephritis, or renal failure
 LOCAL PAIN
 Local pain is felt in or near the involved organ
 The pain from a diseased kidney (T10–12, L1) is felt in the costovertebral angle and in
the flank in the region of and below the 12th rib
 Pain from an inflamed testicle is felt in the gonad itself
 REFERRED PAIN
 Originates in a diseased organ but is felt at some distance from that organ
 The ureteral colic caused by a stone in the upper ureter may be associated with severe
pain in the ipsilateral testicle
 A stone in the lower ureter may cause pain referred to the scrotal wall
 The burning pain with voiding that accompanies acute cystitis is felt in the distal urethra
in females and in the glandular urethra in males
 Abnormalities of a urologic organ can also cause pain in any other organ
 Kidney Pain
 Typical renal pain is felt as a dull and constant ache in the costovertebral angle just
lateral to the sacrospinalis muscle and just below the 12th rib
 This pain often spreads along the subcostal area toward the umbilicus or lower
abdominal quadrant
 Many urologic renal diseases are painless because their progression is so slow that
sudden capsular distention does not occur
 Ureteral Pain
 Typically stimulated by acute obstruction (passage of a stone or a blood clot)
 There is back pain from renal capsular distention combined with severe colicky pain
(due to renal pelvic and ureteral muscle spasm)
 Radiates from the costovertebral angle down toward the lower anterior abdominal
quadrant
 In men, it may also be felt in the bladder, scrotum, or testicle
 In women, it may radiate into the vulva
 Ureteral Pain
 With stones in the midportion of the ureter on the right side, the pain is referred to
McBurney’s point and may therefore simulate appendicitis
 For distal stones symptoms of vesical irritability such as urinary frequency and urgency
may occur
 Vesical Pain
 The overdistended bladder of the patient in acute urinary retention causes agonizing
pain in the suprapubic area
 Constant suprapubic pain not related to the act of urination is usually not of urologic
origin
 Chronic urinary retention due to bladder neck obstruction or neurogenic bladder may
experience little or no suprapubic discomfort even though the bladder reaches the level
of the umbilicus
 Terminal dysuria may be a major complaint in severe cystitis
 Prostatic Pain
 When the prostate is acutely inflamed, the patient may feel a vague discomfort or
fullness in the perineal or rectal area
 Lumbosacral backache is occasionally experienced as referred pain from the prostate
 Inflammation of the gland may cause dysuria, frequency, and urgency
 Testicular Pain
 May be due to trauma, infection, or torsion of the spermatic cord is very severe and is
felt locally, although there may be some radiation of the discomfort along the spermatic
cord into the lower abdomen
 Uninfected hydrocele, spermatocele, and tumor of the testis do not commonly cause
pain
 Varicocele may cause a dull ache in the testicle that is increased after heavy exercise
 Epididymal Pain
 Acute infection of the epididymis is the only painful disease of this organ and is quite
common
 The pain begins in the scrotum, and some degree of neighborhood inflammatory
reaction involves the adjacent testis
 In the early stages of epididymitis, pain may first be felt in the groin or lower abdominal
quadrant.
 GASTROINTESTINAL SYMPTOMS OF UROLOGIC DISEASES
 The patient with acute pyelonephritis not only has localized back pain, symptoms of
vesical irritability, chills, and fever but also generalized abdominal pain and distention
 patient who is passing a stone down the ureter has typical renal and ureteral colic and,
usually, hematuria and may experience severe nausea and vomiting as well as
abdominal distention
 Cause of the Mimicry
 RENOINTESTINAL REFLEXES
 Renointestinal reflexes account for most of the confusion
 There is common autonomic and sensory innervations of the two systems
 ORGAN RELATIONSHIPS
 The right kidney is closely related to the hepatic flexure of the colon, the
duodenum, the head of the pancreas, the common bile duct, the liver, and the
gallbladder
 The left kidney lies just behind the splenic flexure of the colon and is closely
related to the stomach, pancreas
 PERITONEAL IRRITATION
 SYMPTOMS RELATED TO THE ACT OF URINATION
 Frequency, Nocturia, & Urgency
 Frequency may be caused by residual urine, which decreases the functional
capacity of the organ
 Nocturia may be a symptom of renal disease related to a decrease in the
functioning renal parenchyma with loss of concentrating power
 Dysuria
 Painful urination is usually related to acute inflammation of the bladder, urethra,
or prostate
 Enuresis
 Bedwetting at night. It is physiologic during the first 2 or 3 years of life
 Symptoms of Bladder Outlet Obstruction
 HESITANCY
 LOSS OF FORCE AND DECREASE OF CALIBER OF THE STREAM
 TERMINAL DRIBBLING
 URGENCY
 ACUTE URINARY RETENTION
 CHRONIC URINARY RETENTION
 INTERRUPTION OF THE URINARY STREAM
 SENSE OF RESIDUAL URINE
 CYSTITIS
 Incontinence
 TRUE INCONTINENCE
 STRESS INCONTINENCE
 URGE INCONTINENCE
 OVERFLOW INCONTINENCE
 Other Symptoms
 Oliguria & Anuria
 caused by acute renal failure (due to shock or dehydration), fluid-ion imbalance,
or bilateral ureteral obstruction
 Pneumaturia
 passage of gas in the urine strongly suggests a fistula between the urinary tract
and the bowel
  Certain bacteria, by the process of fermentation, may liberate gas on rare
occasions
 Cloudy Urine
 most often cloudy merely because it is alkaline; this causes precipitation of
phosphate
 Infection can also cause urine to be cloudy and malodorous
 Other Symptoms
 Chyluria
 The passage of lymphatic fluid or chyle is noted by the patient as passage of
milky white urine
 The cause is obstruction of the renal lymphatics, which results in forniceal
rupture and leakage
 Filariasis, trauma, tuberculosis, and retroperitoneal tumors have caused the
problem
 Bloody Urine
 Carcinoma of the kidney or bladder, calculi, and infection are a few of the
conditions in which hematuria is typically demonstrable at the time of
presentation
 OTHER OBJECTIVE MANIFESTATIONS
 Urethral Discharge
 Skin Lesions of the External Genitalia
 Visible or Palpable Masses
 Edema
 Bloody Ejaculation
 Gynecomastia
 COMPLAINTS RELATED TO SEXUAL PROBLEMS
 Sexual Difficulties in Men
 Sexual Difficulties in Women
 Physical Examination of the GU Tract
 EXAMINATION OF THE KIDNEYS
 EXAMINATION OF THE BLADDER
 EXAMINATION OF THE EXTERNAL MALE GENITALIA
 EXAMINATION OF THE FEMALE GENITALIA
 RECTAL EXAMINATION IN MALES
 LYMPH NODE
 NEUROLOGIC EXAMINATION
Good Afternoon!