3 Phimosis Means narrowing of the external urethral orifice. a. Congenital: a condition where, in men, the foreskin cannot be fully retracted over the glans penis.b. Acquired: secondary to inflammatory lesions.
14 Diagnosis of renal calculi I. Clinical picture. II. Investigations.
15 I. Clinical PictureAsymptomatic if the stone do not cause any obstruction.Severe flank pain: colicky in nature (comes and goes in spasmodic waves). Pain in the back occurs when calculi produce an obstruction in the kidney or pain caused by peristaltic contractions of the ureter as it attempts to expel the stoneFlank pain referred to genitaliaNausea, vomiting may misleadMicrohematuria if stone have rough surface.The picture of acute renal colic is well described in textbooks of physical diagnosis. The mechanism for pain production is through the sudden obstruction of the kidney with stretching of the collecting system and renal capsule. It is the stretching of these structures that causes the pain. The pain is not the result of a foreign body on the mucosa of the ureter. In most cases sudden renal obstruction produces flank pain. It is not possible from the pain to predict what level the stone is at. The only time one can predict the stone’s location is when the patient begins to complain of symptoms of bladder irritation. When this occurs the stone is in the most distal portion of the ureter (intra-mural ureter) which produces some inflammation of the bladder neck and hence the bladder irritative symptoms.The associated gi symptoms of nausea and vomiting may be pronounced and mislead you into thinking that the patient has a gi problem. Look for hematuria, most patients passing a stone will have at least microscopic hematuria.Chronic stone disease may have little associated pain. Although there may be renal and ureteral obstruction present often this has been long standing and no longer produces the dramatic pain of acute obstruction. Often there will be chronic infection which resist attempts at cure.
16 II. Investigations1. Urine analysis: hematuria, infection, type of crystals.2. X - Ray: most of renal stones are radiopaque due to calcification except uric acid stones are radiolucent so not seen.3. Ultrasounography: can show stones and hydronephrosis.4. Intravenous pyelogram (IVP): will show delayed function, hydronephrosis and hydroureter.The physical examination is very important and renal colic needs to be distinguished from non-renal causes of abdominal pain. Expect to see cva tenderness and the absence of signs of peritoneal irritation (i.e... rebound tenderness)The Urine sediment will often have at least microscopic hematuria. The UA is very important to 1- firm up the diagnosis of renal stone 2- detect possible uti.The KUB is helpful since only 5% of stones are radiolucent. Remember that stones may be obscured if they are overlying bone such as the sacrum. The IVU confirms the diagnosis and will show delayed function on the involved side with hydronephrosis and ureteral obstruction eventually reaching the point of the obstructing stone.