EVALUATION OF THE UROLOGIC PATIENT Dennis G.

Lusaya, MD SCOPE OF UROLOGY Urology Surgical specialty Devoted study & Tx of disorders of GU tract Surgical correction of acquired/congenital abnormalities Dx & tx of many medical disorders of GU tract Importance to other branches in medicine - 15% of px will have urologic c/o or abnormality - wide overlap w/ other specialties - awareness of specific dx & Tx measures that are available w/in this specialty
Urologists have a unique and interesting position in medicine. Their patients encompass all age groups, including prenatal, pediatric, adolescent, adult, and geriatric. Because there is no medical subspecialist with similar interests, the urologist has the ability to make the initial evaluation and diagnosis and to provide medical and surgical therapy for all diseases of the genitourinary (GU) system. Historically, the diagnostic armamentarium has included urinalysis, endoscopy, and intravenous pyelography. Recent advances in ultrasonography, CT, MRI, and endourology have expanded our diagnostic capabilities. Despite these advances, however, the basic approach to the patient is still dependent on taking a complete history, executing a thorough physical examination, and performing a urinalysis. These basics dictate and guide the subsequent diagnostic evaluation.

GENITOURINARY PAIN Organ Sensory Innervation Local pain Kidney T10-12 L1

Etiology

Site of pain

Bladder Testicle

T6-L5 S1-4 S1-4

Inflammation Obstruction Ischemia Trauma Obstruction Inflammation Trauma Torsion Inflammation Trauma Torsion

Ipsilateral CVA th Flank below 12 rib

Suprapubic region Ipsilateral testicle

Penis

S2-4

Glans, foreskin or erect shaft or penis

Referred pain Ureter Upper T11-12 Middle Lower Bladder Prostate Testicle T12-L1 T6-L5 S1-4 T6-L5 S1-4 S2-4 S1-4

Obstruction Obstruction Obstruction Cystitis Prostatitis Inflammation Trauma Torsion

Evaluation of a Urologic patient History (cornerstone) chief complaint history of the present illness Past medical/family hx Physical Examination Urinalysis

Ipsilateral testicle Inguinal canal Bladder Suprapubic region Ipsilateral testicle or labia Distal urethra Tip of the penis Perineum, rectum, lower groin, back Ipsilateral groin lower abdomen CVA

The basic approach to the patient is still dependent on taking a complete history, executing a thorough physical examination, and performing a urinalysis. Complete History chief complaint (why the patient initially sought care ) history of the present illness (duration, severity, chronicity, periodicity, and degree of disability) past medical history family history basic evaluation of the urologic patient, which should include a careful history, physical examination, and urinalysis. These three basic components form the cornerstone of the urologic evaluation and should precede any subsequent diagnostic procedures. Following completion of the history, physical examination, and urinalysis, the urologist should be able to establish at least a differential, if not specific, diagnosis that will allow the subsequent diagnostic evaluation and treatment to be carried out in a direct and efficient manner.

RENAL COLIC Pain Distribution Reflects the somatic sensory distribution of the spinal level of innervation (T10-L1) Most probable hypothesis: Afferents from the skin and viscera converge on the same neuron on the spinal cord, and share the same ascending neuron Etiology of Pain Caused by obstruction Pressure rise above the stone Tension rise probably the pain evoking factor (Kiil 1957) Tension = k x Pressure x Radius (Laplace) Radius and therefore tension greatest in the renal pelvis GENITOURINARY PAIN (same as above) VOIDING SYMPTOMS Irritative Definition/ Symptoms Symptoms Frequency Voiding at 2 hour interval

History of Present Illness A. Symptoms (departure from normalappearance/function/sensation) - chief complaint-why the patient initially sought care - character,duration, severity, chronicity, periodicity, and degree of disability B. Urologic symptom - pain & discomfort - alteration of micturition - changes in the gross appearance urine - abn. appearance &/or function of the external genitalia History of Present Illness Pain severe associated - urinary tract obstruction or inflammation Inflammation -most severe when it involves the parenchyma of a GU organ Tumors -usually do not cause pain unless they produce obstruction or extend beyond the primary organ to involve adjacent nerves

Etiology Decreased bladder capacity or compliance

Possible Causes BOO (BPH, CA, US), RUV, neurogenic bladder, inflammation, extrinsic compression Stress/anxiety Drugs/diuretics Polydipsia, DM, DI BOO (BPH, CA, US), RUV, neurogenic bladder, inflammation, extrinsic compression Postural diuresis (PE, CHF), night time fluid intake

Increased UO

Nocturia

Voiding 2 times at night

Decreased bladder capacity or compliance

Increased UO

HEMATURIA > 3 rbc/hpf significant never be ignored ,be regarded as a symptom of urologic malignancy until proved otherwise Questions needed to be asked in a px Is the hematuria gross or microscopic? At what time during urination does the hematuria occur (beginning or end of stream or during entire stream)? Is the hematuria associated with pain? Is the patient passing clots? If the patient is passing clots, do the clots have a specific shape? Timing of hematuria Initial Total Likely site Urethra Bladder, ureter, kidney Possible causes Urethral stricture, urethritis, meatal stenosis, urethral CA ADPCKD, hydronephrosis, renal cyst, urolithiasis, GN, exercise, hemorrhagic cystitis, trauma, urothelial CA, Bladder calculus, GUTB, SSD BPH, regrowth BPH, bladder neck polyps, tumors

URINARY INCONTINENCE Involuntary loss of urine is a significant social and hygienic issue that is often emotionally and physically debilitating Type of incontinence Total Definition/symptoms Continuous loss of urine unrelated to activity or position Intravesical pressure from distention overcomes sphincter resistance. Episodic dribbling leak. Often nocturnal. Palpable bladder on examination Episodic leakage of urine with increases in intravesical pressure (cough, laugh, exercise) Episodic leakage of urine w/intravesical pressure (cough, laugh, exercise) Urge Episodic leakage of urine preceded by uncontrollable urge to void Causes Urinary-tract fistula (VV, U-V), female ectopic ureter, epispadias Urinary retention, obstruction vs impaired detrusor function, neurogenic bladder

Overflow

Stress

Terminal

Bladder, neck, prostate

URETHRAL DISCHARGE Fluid other than urine emanating from the urethra = uro evaluation Gonorrhoea thick and purulent yellow or gray fluid + urethral pain Nonspecific urethritis watery fluid + with/without pain Urethral cancer painless bloody discharge, stricture, foreign body PNEUMATURIA Passage of air through the urethra Causes - Enterovesical fistula Cancer Diverticulitis Trauma Congenital anomaly - UTI with gas forming organisms - GU instrumentation (recent catherterization/cystoscopy) Should be distinguished from bubbles in the toilet water with urination ERECTILE DYSFUNCTION Inability to achieve and maintain the rigid erection needed for vaginal penetration History Timing Nocturnal penile tumescence Erection in response to visual and tactile sensation Medical risk factor Psychogenic Often acute + + Organic Gradual loss of function over time -

Mixed

Related or unrelated episodes of urge & stress incontinence

Nocturnal Enuresis

Involuntary loss of urine during sleep

Women: loss of support of bladder neck & proximal urethra (menopause, childbirth, pelvic surgery) Men: urethral length & sphincter weakness (postprostatectomy) Congenital, neurological disease. Inflammation (cystitis, UTI, CA in situ bladder, TCC bladder) infravesical obstruction, (BOO), UMN Neurogenic bladder (CVA, MS, Parkinsons Disease) See above Intrinsic sphincteric deficiency can exhibit the same symptoms as urge incontinence Primary: delayed neurological development Secondary: stress/emotional distress, neurological disease obstruction, infection

Performing GU Exam Be sensitive to the patients comfort Ask if patient needs privacy to remove clothing Use a drape to limit exposure Allow patient to cover up when exam is completed Offer tissue for removing jelly after the exam Technical skills for the GU Exam Review anatomy and physiology Practice a focused exam technique - Note any external abnormalities - Screening opportunity for testicular cancer if appropriate - Detection of hernias, swellings, masses Relate findings and discuss results with the patient after exam GU Exam: Review of Anatomy Penis - Foreskin (prepuce) - Glans - Urethral meatus Scrotum - Testis

- or few

cholesterol, DM, pelvic surgery, vascular disease, smoking

- Epididymis - Spermatic cord Inguinal area - Hernias - Lymph nodes Anus Rectum Prostate

Transillumination, a technique in which a light source is applied to the side of a scrotal enlargement, is useful in determining the nature of a scrotal mass. PALPATE Testis -Note tenderness Epididymis Spermatic cord and adjacent area POSSIBLE FINDINGS Orchitis, torsion Lumps (cancer) Swelling or lumps (cysts, tumors, or epididymitis) Varicocele (bag or worms)

Before beginning the GU Exam Patient may be either supine or standing, but check for hernias or varicoceles when patient stands Explain the procedure to the patient - Use models or diagrams to illustrate - Address patients concerns about pain Chaperone in exam room often advisable Always wear gloves PHYSICAL EXAMINATION Performing the GU Exam KIDNEY The best way to palpate the kidneys is with the patient in the supine position. The kidney is lifted from behind with one hand in the costovertebral angle URINARY BLADDER normal bladder in the adult cannot be palpated or percussed until there is at least 150 mL of urine in it Percussion is better than palpation for diagnosing a distended bladder Performing the GU Exam INSPECT Development of penis and surrounding hair Foreskin (retract if present) Glans Urethral meatus -Note any discharge

TESTIS

should be palpated gently between the finger tips of both hands. The testes normally have a firm, rubbery consistency with a smooth surface

INSPECT Inguinal and femoral areas Instruct patient to cough or bear down PALPATE External inguinal ring through scrotal skin Instruct patient to cough or bear down Lymph nodes

POSSIBLE FINDINGS Sudden swelling in scrotum (hernia or mass) Pain during cough or strain should be evaluated POSSIBLE FINDINGS Direct hernia (felt on pad of examining finger) Indirect hernia (auscultate for bowel sounds) Enlarged nodes (infective or malignant disorders)

POSSIBLE FINDINGS Sexual maturation, rashes, scabies Phimosis (cannot be retracted over glans) Ulcers, scars, nodules or inflammation Urethritis

SCROTUM To examine for a hernia, the physician's index finger should be inserted gently into the scrotum and invaginated into the external inguinal ring THE MALE GU EXAM The digital rectal exam Assess the patients strength and mobility before positioning him Common positions for the DRE - Modified lithotomy - Sims position - Left lateral position - Standing, hips flexed Ask the patient if he feels stable and comfortable before proceeding (DRE) should be performed in every male after age 40 years and in men of any age who present for urologic evaluation Performing the DRE Make sure lighting is sufficient Glove both hands and spread the buttocks apart Inspect the sacrococcygeal and perianal areas Palpate any abnormal areas, noting lumps or tenderness Ask the patient about localized feelings of tenderness or pain Lubricate the gloved index finger Warn the patient before inserting the finger Gently press on the sphincters edge and wait for it to relax, then insert your finger into the anal canal

Hypospadias is a congenital abnormality in which the urethral meatus is positioned either along the ventral shaft of the penis or on the scrotum or perineum instead of being located at the tip of the penis. 1 of 300 live male births INSPECT and PALPATE Shaft of the penis -Note any induration or tenderness Fibrous areas (ask if patient has crooked erection) Visible lesions POSSIBLE FINDINGS Urethral stricture or carcinoma

Peyronies disease Syphilis or cancer

Remember to replace the foreskin if retracted INSPECT Skin of scrotum Contour of scrotum POSSIBLE FINDINGS Rashes, inflammation Swelling, or bulges (hernia or hydrocele) Cryptochordism (undescended testis)

Pause and allow patient to adjust to your finger, then continue to insert finger fully Assess sphincter tone by asking the patient to squeeze anal muscles around finger Examining the rectum Examine the posterior and lateral walls of the rectum by gently rotating the finger through 180 degrees To palpate the entire circumference of the rectum, you should turn away from patient and hyperpronate your wrist Sweep your finger across the anterior and anterolateral walls of the rectum Note texture and elasticity of the rectal lining Rectal Exam: possible findings Normal rectal mucosa feels uniformly smooth and pliable Polyps may be attached by a stalk or base Masses or irregularly shaped nodules Areas of unusual hardness Abscesses (perirectal sepsis) may be indicated by extreme tenderness Hemorrhoids (internal and external) Examining the prostate Inform the patient that youre going to examine the prostate gland Sweep your finger over the prostate gland (found anteriorly through rectal wall) Identify the 2 lobes with a longitudinal groove (median sulcus) between them Note the size, nodularity, consistency and tenderness of the prostate Prostate Exam: possible findings Normal prostate About 2.5 cm from side to side Prominent median sulcus Consistency is rubbery and smooth Tenderness not usual, but patients should feel urge to urinate when you palpate Benign prostatic hypertrophy (BPH) Enlargement of gland is symmetrical Marked protrusion into rectal lumen Smooth with no nodularity Median sulcus may be indistinguishable Consistency is rubbery, boggy or slightly elastic Prostate cancer Asymmetric shape Hard consistency Discrete nodule may be palpable Median sulcus often obscured Note: hard areas of prostate are not always cancerous but may indicate conditions such as prostatic stones or chronic inflammation Acute prostatitis Gland is swollen Firm consistency Very tender to touch Examine the gland carefully Pay attention to patients verbal and nonverbal cues Concluding the Exam Inform the patient before withdrawing your finger Note the color of any fecal matter on glove Use fecal material for occult blood testing if this is indicated for CRC screening Offer the patient a tissue

Allow the patient to cover up and rise to sitting position before discussing results

Explaining the Exam Results Explain your findings to the patient Negotiate a follow-up plan for the patient - Recommend interval for next physical exam - Cancer screening tests sigmoidoscopy or colonoscopy; PSA if appropriate Address patient concerns and understanding Patient education during the GU Exam Young adult males (<35 yrs) - Sexuality, including safe sexual practices - Self-care, including the testicular self-exam Older adult males (40+ yrs) - Prostate and colorectal cancer screening - Sexual function - Lower urinary tracts symptoms that affect quality of life (e.g. incontinence) THE FEMALE GU EXAM Bimanual Examination done under anesthesia, invaluable in assessing regional extent of a bladder tumor / pelvic mass may reveal a variety of abnormalities of the uterus, ovaries, and cervix, including benign / malignant masses / inflammatory lesions/pelvic prolapse, (cystocele, rectocele, enterocele) assess bladder mobility Female Genitalia Masses Atrophic changes Caruncles Cystocoele Rectocoele condylomata, urethral lesions, and other abnormalities URINALYSIS Collection of urinary specimen male patient, a midstream urine female patient should cleanse the vulva, separate the labia, and collect a midstream specimen possible infection in a female, a catheterized urine sample should always be obtained. neonate / infant :place a sterile plastic bag with an adhesive collar over the genitalia. percutaneous suprapubic aspiration of urine (best way of collection)
The basic approach to the patient is still dependent on taking a complete history, executing a thorough physical examination, and performing a urinalysis. Complete History chief complaint (why the patient initially sought care ) history of the present illness (duration, severity, chronicity, periodicity, and degree of disability) past medical history family history

Physical Exam Color Turbidity Specific gravity(1.001-1.035) Osmolality(50-1200mOsm/L)

False (+) w/ WBC, ph>8, hematuria, drugs (pyridium), vaginal secretions, prolonged fever, excessive exercise, contamination w/ antiseptics/detergents Quantitative test (confirm): <200mg/d (normal) Urinary Sediment the first morning urine specimen is the specimen of choice and should be examined within 1 hour

should be examined microscopically for (1) cells, (2) casts, (3) crystals, (4) bacteria, (5) yeast, and (6) parasites

Osmolality - (50-1200mOsm/L) or (>700-1400mOsm/kg) Normal - Reflects ADH effect - 600-700 (minimal impairment in conc. ability) - 400-600 (moderate) - <400 (severe) pH Ave: 5.5 - 6.5 Acidic: 4.5 - 5.5 Basic: 6.5 - 8.0 >8 = infection w/ urea splitting organism False (+) elevation w/ bacteriuria, old specimens (lose CO2 on standing) WBC (leukocytes) >5-8 suggestive of pyuria (+) symptoms Clumping : sever inflammatory response Sterile pyuria: TB, vaginitis, nephritis, IC, chlamydia Eosinophils (eosinophiluria) 90% allergic interstitial nephritis Also seen: prostatitis, cystitis/UTI, pyelonephritis, cholesterol emboli, RPGN False(-) NSAID assoc. AIN Bacteriuria >1/HPF. Gram stain of unspun urine is semiquatitative 5th 1 organism/oil immersion field= 10 CFU Yeast Most likely due to balanitis (uncircumcised) Fungal Seen in px on broad spectrum Abx w/ foley cath See mycelial elements May grow >100K yeasts on Culture Proteinuria Best indicator of underlying renal pathology Transient/trace or (+) : insignificant

Dysmorphic RBC

Left are Oval fat Bodies, on the right are Oval fat bodies seen on polarized microscope Oval fat bodies consist of degenerated tubular cells containing abundant lipid, which appears refractile Under polarized light, oval fat bodies demonstrate the "Maltese cross" appearance.

Left are WBC cast and RBC cast on the right. This white blood cell cast suggests an acute pyelonephritis. The presence of this red blood cell cast in on urine microscopic analysis suggests a glomerular or renal tubular injury Red blood cell casts contain entrapped erythrocytes and are diagnostic of glomerular bleeding, most likely secondary to glomerulonephritis . White blood cell casts are observed in acute glomerulonephritis, acute pyelonephritis, and acute tubulointerstitial nephritis. Casts with other cellular elements, usually sloughed renal tubular epithelial cells, are indicative of nonspecific renal damage

Left is a hyaline cast, on the right is a waxy cast Hyaline casts, which appear very pale and slightly refractile, are common findings in urine

Left renal tubular cast, right is polygonal squamous epithelial cell. This renal tubular cell cast suggests injury to the tubular epithelium. Squamous epithelial cells; Their significance is that they represent possible contamination of the specimen with skin flora.

Left are triple phosphate crystals, on the right are calcium oxalate crystals These "triple phosphate" crystals look like rectangles, or coffin lids if you are feeling depressed . These are oxalate crystals, which look like little envelopes (or tetrahedrons, depending upon your point of view). Oxalate crystals are common

These cystine crystals are shaped like stop signs. Cystine crystals are quite rare