IN THE NAME OF GOD

HISTORY AND PHYSICAL EXAMINATION IN UROLOGY

HISTORY C.C & P.I Past medical history Family history

PAIN

PAIN  Sever pain : distention of hollow viscus e.g ureteral obstruction, urinary retention  Tumor : usually do not pain unless produce:  Obstruction  Extend beyond the primary organ Pain in urogenital cancer is late presentation Pain in urogenital cancer is late presentation

RENAL PAIN  Location (CVA)  Radiation  Associated symptoms  Inflamatory pain (steady)  Obstructive pain (colic)

URETERAL PAIN  Acute Obstruction  acute ureteral dilatation  Ureteral spasm and hyperperistaltism  pain

URETERAL PAIN  Radiation:  1/3 upper: testis  1/3 middle: scrotom – labia  1/3 lower: penis –meatus-irritative. bladder symptoms  Chronic ureteral pathology no pain

Bladder pain  Acute pain: acute urinary retention  Intermittent suprapubic pain: inflammation(cystitis- IC)  Continious suprapubic pain: non urologic

Aute urinary retention

PROSTATE PAIN  Secondary to inflammation Edema –distention of the prostatic capsule  Localized in perineoum  Refer to lombosacral- inguinal –lower extremity

PENILE PAIN  Flaccid:  STD  paraphimosis  Erection:  priapism—  peyronie disease

TESTIS PAIN  Primary :  Acute :  torsion  Hematoma(trauma)  orchiepididimitis  Chronic :  hydrocele  varicocele  spermatocele  Referral :  kidney  retroperitoneoum  indirect inguinal hernia

HEMATURIA  Definition : macroscopic– microscopic  RBC> 2 hpf  Initial : Urethra  total : bladder and upper tract  terminal : bladder neck & prostatic urethra

HEMATURIA  Painless hematuria :  malignancy( bladder- kidney)  Hematuria+ flank pain :  stone  Hematuria+ irritative symptoms :  cystitis( bacterial- hemorragic)

LOWER URINARY TRACT SYMPTOMS(LUTS)

IRRITATIVE SYMPTOMS  Frequency :  Polyuria (DM-DI-excessive fluid intake)  Decreased bladder compliance :  Bladder outlet obstruction & residual urine  Decreased functional capacity  External pressure  Anxiety

IRRITATIVE SYMPTOMS  Urgency : strong,sudden impulse to void  Causes:  Inflammation: e.g Acute cystitis  Hyperreflexive neurogenic bladder  Advanced urinary outlet obstruction  Anxiety

IRRITATIVE SYMPTOMS  Dysuria : painful urination  Usually by inflammation  Initial : urethral pathology  Terminal(strangury) : bladder

IRRITATIVE SYMPTOMS  Nocturia : nocturnal frequency  Frequency without nocturia : psychogenic  Nocturia without frequency : CHF  Normal nocturia :  old age  Excessive fluid drink in night : caffeinated & alcoholic beverages

OBSTRUCTIVE SYMPTOMS  Hesitency  Intermittency  Decreased force & caliber  Post void dribbling  Straining  Incomplete emptying

OBSTRUCTIVE SYMPTOMS  Common cause :  BPH  Urethral stricture  Neurogenic bladder  Uncommon cause :  Prostate cancer  Urethral cancer  Foreign body

URINARY INCONTINENCY  True(continous) :involuntay loss of urine at all times & all position  Common cause:  Fistula(VVF-UVF)  Sphincter destruction  Ectopic ureter

URINARY INCONTINENCY  Stress urinary incontinency(SUI):  Sudden leakage of urine with coughing, sneezing, and exercise that increased intravesical pressure  Cause:  multipar women  after menopause  men after prostate surgery

URINARY INCONTINENCY  Urge incontinence (UI):  Loss of urine preceded by a strong urge to void  Cause:  cystitis  Neurogenic bladder  Advanced bladder outlet obstruction

URINARY INCONTINENCY  Overflow incontinency (paradoxical inc):  Secondary to advanced urinary retention and high residual urine volume

ENURESIS

ENURESIS  PRIMARY  SECONDARY  Everybody with enuresis should be evaluated

Sexual dysfunction in male

Decreased libido  Endocrine  Psychologic

ERECTILE DYSFUNCTION  Psychogenic  Neurogenic  Vasculogenic

ABSENCE OF EMMISSION  Retrograde ejaculation  Sympathetic denervation  Androgen disturbance  Drugs  Bladder neck & prostate surgery

ABSENCE OF ORGASM  Psychogenic  Medications used to treat psychiatric diseases

PREMATURE EJACULATION  Subjective symptom  Orgasm within less than 1 minute after initiation of intercourse  Cause:  Psychogenic  Anxiety

HEMATOSPERMIA  Causes:  Nonspecific inflammation in prostate & s.v  Prostate and s.v cancers  Initial prostate  Terminal s.v  Evaluation: DRE- urine cytology-TRUS- spermogram

PNEUMATURIA  Cause:  Fistula between bladder and intestine  Common cause:  diverticulitis  sigmoid cancer  regional enteritis(croh,n disease)  Uncommon cause:  diabetes & gas forming infection

URETHRAL DISCHARGE  The most common symptom of veneral infection  Gonococal urethritis  Nongonococal urethritis  Bloody discharge: urethral carcinoma

FEVER  Urogenital infection associated with fever:  Acute Prostatitis  Acute pyelonephritis  Acute epididimo-orchitis  Infection+ obstruction+ fever & chills= sepsis

PHYSICAL EXAMINATION

RENAL EXAMINATION  Bimanual kidney palpation  CVA percussion  RUQ or LUQ ascultation : cystolic bruit  transillumination : cystic- solid

BLADDER EXAMINATION BLADDER EXAMINATION  Volume required for percussion or palpation: 150cc  Volume required for vision : 500cc  Bimanual bladder examination during anesthesia: evaluation of regional extension of bladder tumor

PENILE EXAMINATION  Retraction of prepus and exam of glans penis  Meatus position:  hypospadiasis-  epispadiasis  Penile skin:  vesicle genital herpes  Ulcer sexually transmited- tumors  Stiffness : peyronie plaque

hypospadiasis

Epispadiasis

phimosis

Paraphimosis

Genital herpes

Syphlis ulcer

Peyronie disease

SCROTOM EXAMINATION  Testises: bimanual exam  Normal: 4-6 cm in adults  Firm area within the testis : malignancy  Epididym  Vas deference  Scrotal skin  Spermatic chord  Upright exam is mandatory

RECTAL EXAMINATION(DRE)  Indication :  Every male after age 40 who present for urologic evaluation  Importance is for prostate cancer, the most common cancer in male

RECTAL EXAMINATION(DRE)  Patient position knee chest  Inspection : hemorroid – fissure- fistula- polyp- cancer  EAS( external anal sphincter) tonicity  Prostate : size – consistency- median sulcus  Bulbocavernous reflex

RECTAL EXAMINATION(DRE)

COMMON ABNORMAL PHYSICAL FINDING

KIDNEYS  Mass : common abnormal finding in examination  Adults : cyst – tumor  Children :  cyst & benign:  Hydronephrosis-  MCDK-  RPK  Malignant :  Wilm,s tumor-  Neuroblastoma

PENIS  Phimosis  Paraphimosis  Peyronie disease  Priapism  Hypospadiasis  Epispadiasis  Penile carcinoma

SCROTOM & CONTENTS  Mass :  testis masses : commonly malignant  Epididym & spermatic chord mass : commonly benign  Torsion  Hydrocele  Spermatocele  Trauma( hematoma)

SCROTOM & CONTENTS  Varicocele : enlarged, tortuous spermatic vein above the testis, almost always in left side  Grading :  I palpable only with valsalva  II palpable without valsalva  III visible without valsalva

spermatocele

spermatocele

hydrocele

hydrocele

hydrocele

varicocele

varicocele

Testis torsion(R)

Testis torsion

Scrotal hematoma

Inguinal hernia

PROSTATE  Acute bacterial prostatitis  BPH  Prostate cancer

THE END