EVALUATION OF

UROLOGIC PATIENTS

IRFAN
FIRMANSYAH
Pembimbing: dr. Kuncoro Adi, SpU(K)
 INTRODUCTION

UROLOGIS
T The patients encompass all age groups

No medical subspecialist with similar

UNIQUE interest

The urologist has the ability to make the initial evaluation and
diagnosis and to provide medical and surgical therapy for all
diseases of the GU systems
 HISTORY TAKING
Chief Complaint and present illness

Pain is an unpleasant
sensory and emotional
experience associated
with actual or potential
tissue damage, or
described in terms of
such damage
 HISTORY TAKING
Chief Complaint and present illness

Obstructi
on

Pain in
GU tract
 HISTORY TAKING
Chief Complaint and present illness

Renal Ureteral Vesical

pain pain pain
Acute Overdistention
Acute distention Distention of Due to acute urinary
of renal capsule ureter retention

Secondary to Inflammation
Inflammation Obstruction Produce intermittent
suprapubic discomfort
Hyperperistalsis
and spasm of
smooth muscle

Obstruction

May be
associated with
GI symptoms
 HISTORY TAKING
Chief Complaint and present illness

Prostatic Penile Testicular

pain pain pain
Secondary to Flaccid Primary
inflammation Secondary to Secondary to
Edema and inflammation in acute epididymitis
distention of bladder or or testicular
prostatic urethra torsion
capsule
Referred
Erect From the kidneys
Poorly localized Due to or retroperitoneum
Peyronie
disease or
priapism Chronic
Noninflammatory
conditions such as
a hydrocele or a
varicocele
 HISTORY TAKING
Chief Complaint and present illness

>3
RBC/HPF
Gross
Types
Microscopic

Initial Urethra

Bladder or upper
Timing Total
urinary tract
Hematuria
Bladder neck or
Terminal
prostatic urethra

Upper GU tract hematuria

Severe,
Pain with obstruction of the
colicky pain
ureters with clots

Vermiform
Clots
(wormlike) clots
 HISTORY TAKING
Chief Complaint and present illness

Frequency

Irritative Nocturia

Dysuria
Lower urinary
Weakstream
tract symptoms
Hesitancy

Obstructive Intermittency
Postvoid
dribbling
Straining
 HISTORY TAKING
Chief Complaint and present illness

Incontinence

Continuous Stress Urgency Overflow

 HISTORY TAKING
Chief Complaint and present illness

Loss of libido Androgen deficiency

Psychogenic
Impotence
Organic

Androgen deficiency
Sexual dysfunction

Sympathetic denervation
Failure to ejaculate
Pharmacologic agents

Bladder neck and prostatic surgery

Psychogenic
Anorgasmia
Medications

Premature ejaculation Psychogenic

 HISTORY TAKING
Chief Complaint and present illness

Due to nonspecific inflammation of prostate and/or

Hematospermia seminal vesicles
Resolves spontaneously, within several weeks

Due to a fistula between intestine and bladder

Pneumaturia Common causes: diverticulitis, carcinoma of sigmoid
colon, and regional enteritis (Crohn disease)

Urethral The most common symptom of venereal infection

discharge
May occur with infection in GU tract
Fever and chills with urinary obstruction septicemia
Fever and chills need emergency treatment
HISTORY TAKING
PAST MEDICal history

Diabetes Mellitus

May impair urinary and sexual function

Tuberculosis

Patient with impaired renal function, ureteral obstruction, or chronic,

unexplained UTIs

Hypertension

Increased risk of sexual dysfunction

Neurologic disease

Multiple sclerosis may develop urinary and sexual dysfunction

Surgical treatment of bladder outlet obstruction in the presence of
detrusor hyperreflexia increased urinary incontinence postoperatively

Sickle cell anemia

Papillary necrosis and erectile dysfunction secondary to recurrent priapism

 HISTORY TAKING
Others

Family history Medications and Previous Smoking and

Prostate cancer Allergies surgical alcohol use
Adult polycystic kidney Many drugs interfere procedures Cigarette smoking
disease, tuberous with urinary and sexual Previous operations risk of urothelial
sclerosis, von Hippel- function carcinoma, peripheral
may make subsequent
Lindau disease, renal All medicinal allergies vascular disease,
ones more difficult
tubular acidosis, and should be asked erectile dysfunction
cystinuria Chronic alcoholism
neuropathy with
resultant impaired
urinary and sexual
function
PHYSICAL EXAMINATION
General observations

Jaundice
Skin Pallor

Cachexia
Nutritional status Obesity

Edema of genitalia May be associated with cardiac decompensation,

and lower renal failure, nephrotic syndrome, or pelvic and/or
retroperitoneal obstruction
extremities

Supraclavicular GU neoplasm (prostate and testis

Lymphadenopathy cancer
Inguinal Carcinoma of penis or urethra
PHYSICAL EXAMINATION
KIDNEYS

Palpation
Bimanual examination

Transillumination
Children < 1 y.o with a palpable flank
mass
Percussion of CVA
Localizes pain in renal inflammation

Auscultation of upper abdomen

May reveal a bruit

Nerve root examination

Patient with flank pain
PHYSICAL EXAMINATION
BLADDER

Percussion
Better for diagnosing a distended
bladder
Palpation
Bimanual examination
PHYSICAL EXAMINATION
PENIS

Prepuce and glans penis

Uncircumcised men tumor (penile cancers) or balanoposthitis

Urethral meatus
Position hypospadias or epispadias
Inspection neoplastic or inflammatory lesions within fossa
navicularis
Penile skin
Superficial vesicle herpes simplex
Ulcers venereal infection or tumor
Venereal warts (condylomata acuminata)

Shaft
Dorsal: fibrotic plaques or ridges typical of Peyronie disease
Ventral: tenderness periurethritis, urethral stricture
PHYSICAL EXAMINATION
SCROTUM AND CONTENTS

Inspection
Lesions

Palpation
Testes
Epididymis
Hernia
Spermatic cord

Transillumination
Solid tumor
Cystic hydrocele,
spermatocele
PHYSICAL EXAMINATION
RECTAL AND PROSTATE EXAMINATION IN MALE

Digital rectal examination

Indication Procedure

Men of
any age
who
Male > 40 Anal Guaiac
present Prostate Rectum
y.o sphincter test
for
urologic
evaluation
PHYSICAL EXAMINATION
PELVIC EXAMINATION IN FEMALE

External genitalia Atrophic changes, erosions, ulcers,

discharge, or warts dysuria and pelvic
and introitus discomfort

Caruncles, mucosal hyperplasia, cysts, and

Urethral meatus mucosal prolapse

Cystocele
Valsava
Rectocele
maneuver

May precipitate stress urinary incontinence

Cough

Urethra detect induration sign of chronic inflammation

or malignancy
Palpation Urethral diverticulum purulent discharge from urethra
Bimanual examination
PHYSICAL EXAMINATION
NEUROLOGIC EXAMINATION

Sensory Reflexes
examination examination
Sensory deficits Bulbocavernosus
in penis, labia, reflex
scrotum, vagina, Cremasteric
and perianal reflex
area damage
or injury to
sacral roots or
nerves
 URINALYSIS
Specimen collection

Males

Midstream urine sample

Chronic UTIs VB1, VB2, EPS, and VB3

Females

More difficult to obtain midstream specimen

Catheterized urine sample

Neonates and infants

Using a sterile plastic bag with an adhesive collar over the

infants genitalia
 URINALYSIS
PHYSICAL EXAMINATION OF URINE

Foods, medications, metabolic products, and infection may

Color produce abnormal urine color

Phosphaturia, pyuria cloudy

Turbidity Chyluria milky

Specific gravity reflects the state of hydration and renal

Specific Gravity concentrating ability
and Osmolality Osmolality is a measure of the amount of material dissolved in
urine

Urinary pH reflects the pH in the serum

pH pH > 7.5 suspect UTI due to urea-splitting organism (Proteus)
Acidic urine pH uric acid, cystine lithiasis
 URINALYSIS
CHEMICAL EXAMINATION OF URINE

Urine dipsticks

Hematuria

Proteinuria

Glucose and Ketones

Bilirubin and Urobilinogen

Leukocyte Esterase and Nitrite tests

 URINALYSIS
URINARY SEDIMENT

Cells

Erythrocyte
Leukocyte
Epithelial cells: Squamous cells, Transitional cells, Renal tubular cells

Casts

Tamm-Horsfall mucoprotein
RBC casts
WBC casts
Cellular casts
Granular and waxy casts
Fat casts

Crystals

Acidic urine calcium oxalate, uric acid, and cystine

Alkaline urine triple-phosphate (struvite)
 URINALYSIS
URINARY SEDIMENT

Bacteria

5 bacteria/HPF UTI

Yeast

Characteristics : budding and hyphae

Most commonly found: Candida albicans

Parasites

Trichomonas vaginalis
Schistosoma hematobium

Expressed Prostatic Secretions

Oval fat macrophages postinfection prostatic fluid