Physical Examination

of the Urinary
Wenny Trisnaningtyas, S.Kep.,Ns.,M.Kep
Physical examination focuses:
• Physical examination focuses on the costovertebral
angle, abdomen, rectum, groin, and genitals.
• In women with urinary symptoms, pelvic examination
is usually done.
Regio of costovertebral angle
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, calculi, or
urinary tract obstruction.
Abdomen
• Visual fullness of the upper abdomen is an extremely
rare and nonspecific finding of a kidney or abdominal
mass. Dullness to percussion in the lower abdomen
suggests bladder distention; normally, even a full
bladder cannot be percussed above the symphysis
pubis. Bladder palpation can be used to confirm
distention and urinary retention.
Rectum
• During digital rectal examination, prostatitis may be detected as a
boggy, tender prostate. Focal nodules and less discrete hard areas
must be distinguished from prostate cancer. The prostate may be
symmetrically enlarged, rubbery, and nontender with
benign prostatic hyperplasia.
Groin and genitals
• Inguinal and genital examination should be done with patients standing. Inguinal hernia or
adenopathy may explain scrotal or groin pain. Gross asymmetry, swelling, erythema, or
discoloration of the testes may indicate infection, torsion, tumor, or other mass. Horizontal
testicular lie (bell-clapper deformity) indicates increased risk of testicular torsion. 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. Inspection of the penis can detect
• Hypospadias or epispadias in young boys
• Peyronie disease in men
• Priapism, ulcers, and discharge in either group
• Palpation may reveal an inguinal hernia. Cremasteric reflex may be absent with testicular
torsion. Location of masses in relation to the testis and the degree and location of tenderness
may help differentiate among testicular masses (eg, spermatoceles, epididymitis, hydroceles,
tumors). If swelling is present, the area can be transilluminated to help determine whether the
swelling is cystic or solid. Fibrous plaques felt in the penile shaft are signs of Peyronie disease.
Rectal examination
• A rectal
examination is
where a doctor or
nurse checks
inside your bottom
(anus and rectum)
with their finger.
It's done to help
find out why you're
having certain
symptoms.
You may need a rectal examination
to:
• help find out why you're having symptoms such as
bleeding from your bottom, pain, constipation or
problems with peeing
• check for conditions that affect your bottom such as
piles (haemorrhoids)
• check for lumps or swelling in your anus or rectum that
could be a sign of certain conditions, such as cancer
• check the health of your prostate (a small gland below
the bladder in men)
What happens during a rectal
examination
• A rectal examination can be done at a GP surgery,
hospital or clinic.
• It only takes a few minutes. It may be uncomfortable
but it's not usually painful.
• You can ask for a male or female doctor or nurse, if
one's available. You can have a friend, family member
or other member of staff in the room with you if you
want.
The main steps are:
1.You'll be asked to undress from the waist down, behind a screen.
2.You'll usually be asked to lie on your left side, with your knees
pulled up towards your chest. Sometimes the doctor or nurse
will ask you to use another position that's comfortable for you.
3.The doctor or nurse will part your buttocks and check the
outside of your anus.
4.They'll gently put 1 finger inside your anus. They'll be wearing
gloves and they'll put a lubricating gel on their finger.
5.They might ask you to squeeze the muscle around your anus to
check how well it's working.
6.They'll carefully feel around the inside of your anus and rectum.
• Costovertebral angle (CVA)
tenderness is pain that results
from touching the region inside
of the costovertebral angle. The
CVA is formed by the 12th rib and
the spine. Assessing for CVA
tenderness is part of the
abdominal exam, and CVA
tenderness often indicates
inflammatory kidney
pathology & evaluating
potential kidney stones
CVA Indicate
• Pain in this flank area may indicate a kidney
infection, a back problem, another kind of
internal problem or some form of dysuria – whether
painful urination, difficulty going, or even hematuria.
• To check for CVA tenderness – place one hand over the
costovertebral angle on the back, and percuss with your
other fist.
• You don’t want to be too forceful because if they do have a kidney
stone – this can be very painful.
• However, you also want to ensure you are not percussing too
lightly. Percuss a few times on each side.
• Positive CVA tenderness is when the patient reports pain with
percussion. From my own experience – this is often very painful for
those with acute kidney stones.
• However, I have also had plenty of patients with negative CVA
tenderness who had acute renal pathology including kidney stones.
Physical examination of
the abdomen
• Physical examination of the abdomen includes inspection,
auscultation, palpation, and percussion.
• Note that the order of physical assessment differs for the abdominal
system compared to other systems.
• Palpation should occur after the auscultation of bowel sounds so that
accurate, undisturbed bowel sounds can be assessed. The abdomen is
roughly divided into four quadrants: right upper, right lower, left
upper, and left lower.
• When assessing the abdomen, consider the organs located in the
quadrant you are examining.
Inspection
• The abdomen is inspected by positioning the patient supine on an examining table or bed. The head and
knees should be supported with small pillows or folded sheets for comfort and to relax the abdominal wall
musculature. The patient’s arms should be at their side and not folded behind the head, as this tenses the
abdominal wall. Ensure the patient is covered adequately to maintain privacy, while still exposing the
abdomen as needed for a thorough assessment. Visually examine the abdomen for overall shape, masses,
skin abnormalities, and any abnormal movements.
• Observe the general contour and symmetry of the entire abdominal wall. The contour of the abdomen is
often described as flat, rounded, scaphoid (sunken), or protuberant (convex or bulging).
• Assess for distention. Generalized distention of the abdomen can be caused by obesity, bowel distention
from gas or liquid, or fluid buildup.
• Assess for masses or bulges, which may indicate structural deformities like hernias or related to disorders in
abdominal organs.
• Assess the patient’s skin for uniformity of color, integrity, scarring, or striae. Striae are white or silvery
elongated marks that occur when the skin stretches, especially during pregnancy or excessive weight gain.
• Note the shape of the umbilicus; it should be inverted and midline.
• Carefully note any scars, and correlate these scars with the patient’s recollection of previous surgeries or
injury.
• Document any abnormal movement or pulsations. Visible intestinal peristalsis can be caused by intestinal
obstruction. Pulsations may be seen in the epigastric area in patients who are especially thin, but otherwise
should not be observed.
Auscultation
• Auscultation, or the listening, of the abdomen, follows inspection for more accurate
assessment of bowel sounds. Use a warmed stethoscope to assess the frequency and
characteristics of the patient’s bowel sounds, which are also referred to as peristaltic murmurs.
• Begin your assessment by gently placing the diaphragm of your stethoscope on the skin in the
right lower quadrant (RLQ), as bowel sounds are consistently heard in that area. Bowel
sounds are generally high-pitched, gurgling sounds that are heard irregularly. Move your
stethoscope to the next quadrant in a clockwise motion around the abdominal wall.
• It is not recommended to count abdominal sounds because the activity of normal bowel
sounds may cycle with peak-to-peak periods as long as 50 to 60 minutes.[9] The majority of
peristaltic murmurs are produced by the stomach, with the remainder from the large intestine
and a small contribution from the small intestine. Because the conduction of peristaltic
murmur is heard throughout all parts of the abdomen, the source of peristaltic murmur is not
always at the site where it is heard. If the conduction of peristaltic sounds is good,
auscultation at a single location is considered adequate.
• Hyperactive bowel sounds may indicate bowel obstruction or
gastroenteritis. Sometimes you may be able to hear a patient’s bowel
sounds without a stethoscope, often described as “stomach growling”
or borborygmus. This is a common example of hyperactive sounds.
• Hypoactive bowel sounds may be present with constipation, after
abdominal surgery, peritonitis, or paralytic ileus. As you auscultate the
abdomen, you should not hear vascular sounds. If heard, this finding
should be reported to the health care provide
Palpation
• Palpation, or touching, of the abdomen involves using the flat of the
hand and fingers (not the fingertips) to detect palpable organs,
abnormal masses, or tenderness
• When palpating the abdomen of a patient reporting abdominal pain,
the nurse should palpate that area last. Light palpation is primarily
used by bedside nurses to assess for musculature, abnormal masses,
and tenderness. Deep palpation is a technique used by advanced
practice clinicians to assess for enlarged organs. Lightly palpate the
abdomen by pressing into the skin about 1 centimeter beginning in the
RLQ. Continue to move around the abdomen in a clockwise manner.
• Palpate the bladder for distention. Note the patient response to palpation,
such as pain, guarding, rigidity, or rebound tenderness. Guarding refers to
voluntary contraction of the abdominal wall musculature, usually the
result of fear, anxiety, or the touch of cold hands. Rigidity refers to
involuntary contraction of the abdominal musculature in response to
peritoneal inflammation, a reflex the patient cannot control.
• Rebound tenderness is another sign of peritoneal inflammation or
peritonitis. To elicit rebound tenderness, the clinician maintains pressure
over an area of tenderness and then withdraws the hand abruptly. If the
patient winces with pain upon withdrawal of the hand, the test is positive.
Percussion of the abdomen:
• A proper percussion technique is necessary to gain maximum information regarding abdominal pathology. When
percussing, one should appreciate tympany over air-filled structures such as the stomach and dullness to percussion,
which may be present due to an underlying mass or organomegaly, such as hepatomegaly or splenomegaly. To
detect splenic enlargement, the percussion of the Castell point, the lowest inferior interspace on the left anterior
axillary line, can be useful while the patient takes a deep breath. A percussion note that changes from tympanitic to
dull as the patient takes a deep breath suggests splenomegaly, with 82% sensitivity and 83% specificity
• Splenomegaly occurs in trauma with hematoma formation, portal hypertension, hematologic malignancies,
infections such as HIV and Ebstein-Barr virus, and splenic infarction.
• Percussion is necessary to assess the size of the liver, percussion downward from the lung to the liver, and then the
bowel; the examiner may be able to demonstrate the change in percussion notes from resonant to dull and then
tympanitic. Shifting dullness, present in ascites, should be demonstrated by percussing from the midline to the flank
till the note changes from dull to resonant and then having the patient roll over on their side towards the examiner
and wait for 10 seconds. This maneuver allows any fluid, if present, to move downwards. The percussion should
then be repeated, moving in the same direction. If the percussion note changes to resonant, shifting dullness is
positive.
• With the patient sitting up, the right and left costal-vertebral angles can be percussed to determine renal tenderness,
such as pyelonephritis.
Groin Assesment
• Introduction
• Introduce yourself to the patient
• Wash your hands
• Explain the examination to the patient
• Reassure them that you will stop if it becomes too painful at any
point
• Ensure verbal consent is adequately obtained
• Offer the patient a chaperone if required
• Always work through a structured approach as below unless
instructed otherwise; be prepared to be instructed to move
on quickly to certain sections by any examine
• Observation
• Examine them standing first and ask them to lower their
underwear
• Assess the patient from in front and from the side, on
both sides, checking for:
• Obvious lumps or swellings
• Asymmetry
• Scars or skin changes
• Ask the patient to cough, to accentuate any hernia
• Palpation
• Examination of the Lump
• If there is an obvious lump, examine that side first; remember to tell the patient exactly
what are you doing throughout.
• Important points to note are:
• One lump or multiple lumps
• Multiple lumps may suggest lymph nodes or possibly superficial lesions
• Consistency (hard or soft)
• Cough impulse*
• Reducible
• Pulsatile
• Able to palpate above it
• If able to get above it, likely to be scrotal swelling; if not able to get above it, likely groin swelling
• *Remember that an incarcerated hernia will most likely not have a cough impulse (as by
definition the hernia is trapped and immovable)
• If you suspect a hernia, clarify the relation to the pubic tubercle:
• Above and medial = inguinal hernia
• Below and lateral = femoral hernia*
• Repeat the examination for the other side of the groin (around 20%
of inguinal hernias are bilateral)
• Ask the patient to lie down; look to see if the lump reduces
spontaneously at this point, as this will indicate a likely hernia
• *Look for a small “pea-sized” lump in the groin, indicative of a
femoral hernia. These are difficult to find because they are small,
but have high rates of obstruction thus essential to look carefully
for; they are often incarcerated and so rarely have a cough impulse
• Differentiating Inguinal Hernia
Genetalia Test