1. 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

2. 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

3. 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

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

5. 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

6. 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

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

8. 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

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

10. 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

11. 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)

12. Vesical Pain
Vesical pain is due
Overdistention
inflammation

13. 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.

14. 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

15. 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

16. 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?

17. 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.

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

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

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

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

22. Fever and Chills
Usually in
Pyelonephritis
Prostatitis
Epididymitis

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

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

25. 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.

26. 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.

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

28. 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

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

30. 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

32. 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

33. Bladder

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

35. Hypospadias

36. 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

38. 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

39. Prostate Examination Acute Prostatitis Benign Prostatic Hyperplasia
Carcinoma of the Prostate