History and Physical exam for the urologic patient Mohammad Al Omar, MD, FRCS (Canada) Assistant professor Consultant Urologist Endourologist, Laparoscopic and Robotic Urologist KKUH, KSU

Introduction Most diagnosis can be reached by a complete history, and a thorough physical examination Challenges in History Communication (anxiety, language, educational background ) Make the patient feel comfortable calm, caring, and competent image Family member

Introduction Time Listen carefully sufficient to express their problems and the reasons for seeking your care Listen carefully without distractions in order to obtain and interpret the clinical information provided by the patient

History Major components Chief complaint History of the present illness Past medical history Family history Review of systems Medications Allergies Social History

Chief Complaint and Present Illness The chief complaint is a constant reminder as to why the patient initially sought care. This issue must be addressed even if subsequent evaluation reveals a more serious or significant condition that requires Duration Severity Chronicity Periodicity Degree of disability Example

Pain Can be severe urinary tract obstruction inflammation Inflammation of the GU tract is most severe when it involves the parenchyma of a GU organ Pyelonephritis Prostatitis Epididymitis Inflammation of the mucosa of a hollow viscus usually produces discomfort Cystitis Urethritis

Pain Tumors: No pain unless obstruction extend beyond the primary organ to involve adjacent nerves

Pain Renal Pain Acute distention of the renal capsule Site: ipsilateral costovertebral angle just lateral to the sacrospinalis muscle and beneath the 12th rib Acute distention of the renal capsule

Pain Associated symptoms Gastrointestinal symptoms Nausea Vomiting Ileus because of reflex stimulation of the celiac ganglion and because of the proximity of adjacent organs

Pain Renal pain may also be confused with pain resulting from irritation of the costal nerves, most commonly T10–T12 which is: not colicky in nature. Severity of radicular pain may be altered by changing position

Ureteral pain Usually acute and secondary to obstruction Midureter ( Rt side): referred to the right lower quadrant (McBurney's point) and simulate appendicitis Midureter (Lt side) :referred over the left lower quadrant and resembles diverticulitis. Scrotum in the male or the labium in the female. Lower ureteral obstruction frequently produces symptoms of bladder irritability( frequency, urgency, and suprapubic discomfort)

Vesical Pain Vesical pain is due Overdistention inflammation

Prostatic Pain Inflammation with secondary edema and distention of the prostatic capsule poorly localized lower abdominal Inguinal Perineal Lumbosacral rectal pain. irritative urinary symptoms ( frequency and dysuria) acute urinary retention.

Penile Pain Pain in the erect penis is usually due to Peyronie's disease or priapism Pain in the flaccid penis usually secondary to inflammation in the bladder or urethra referred pain that is maximally at the urethral meatus paraphimosis

Testicular Pain Acute pain Chronic scrotal pain epididymitis torsion of the testicle Chronic scrotal pain hydrocele varicocele, dull, heavy sensation that does not radiate Referred pain: kidneys or retroperitoneum

Hematuria Hematuria : the presence of blood in the urine In adults, should be regarded as a symptom of urologic malignancy until proved otherwise Is the hematuria gross or microscopic? Timing: (beginning or end of stream or during entire stream)? Is it associated with pain? Is the patient passing clots? If the patient is passing clots, do the clots have a specific shape?

Hematuria Initial hematuria: Total hematuria Terminal hematuria usually arises from the urethra least common usually secondary to inflammation. Total hematuria most common bladder or upper urinary tracts. Terminal hematuria the end of micturition secondary to inflammation bladder neck or prostatic urethra.

Lower Urinary Tract Symptoms Irritative Symptoms Urinary frequency Nocturia Frequency Dysuria: painful urination Incontinence Stress Urge

Obstructive Symptoms Decreased force of urination Urinary hesitancy Intermittency Post void dribbling Straining

Enuresis Urinary incontinence that occurs during sleep Mostly in children up to 5 years

Urethral Discharge Urethral discharge is the most common symptom of venereal infection.

Fever and Chills Usually in Pyelonephritis Prostatitis Epididymitis

Past Medical History Systemic diseases that may affect the GU system diabetes mellitus. multiple sclerosis TB Schistosomiasis

Family History prostate cancer Stones( cystine) Renal tumors (some types)

Previous Surgical Procedures it is worthwhile obtaining as much information as possible before any intended surgery, because most surprises that occur in the operating room are unhappy ones.

Smoking and Alcohol Use Cigarette smoking urothelial carcinoma, mostly bladder cancer Erectile dysfunction. Chronic alcoholism impaired urinary function Sexual dysfunction. testicular atrophy, and decreased libido.

PHYSICAL EXAMINATION General Observations visual inspection of the patient Cachexia Malignancy, TB Jaundice or pallor Gynecomastia endocrinologic disease alcoholism hormonal therapy for prostate cancer

Kidneys Palpation of the kidneys supine position The kidney is lifted from behind with one hand in the costovertebral angle In neonates, palpating of the flank between the thumb anteriorly and the fingers over the costovertebral angle posteriorly

Kidneys Auscultation : epigastrium for bruit renal artery stenosis aneurysm. renal arteriovenous fistula.

Abnormal Physical Examination Findings—Kidneys The most common abnormality detected on examination of the kidneys is a mass In neonates and younger children, the transillumination helps to distinction between cystic and solid

Bladder at least 150 ml of urine in it to be felt. Percussion is better than palpation A bimanual examination, best done under anesthesia, is very valuable to asses bladder tumor extension

Bladder

Penis The position of the urethral meatus Priapism: sickle cell disease

Hypospadias

Scrotum and Contents Painful Painless Torsion Epididymitis firm or hard area within the testis should be considered a malignant tumor until proved otherwise Painless Spermatocele Hydrocele Varicocele Transillumination : Cystic vs. solid Painless solid testicular mass is tumor until proven otherwise

Rectal and Prostate Examination in the Male Digital rectal examination (DRE) : every male after age 40 years Men of any age who present for urologic evaluation

Prostate Examination Acute Prostatitis Benign Prostatic Hyperplasia Carcinoma of the Prostate