1. IN THE NAME OF GOD

2. HISTORY AND PHYSICAL EXAMINATION IN UROLOGY

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

4. PAIN

5. 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

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

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

8. 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

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

12. Aute urinary retention

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

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

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

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

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

22. LOWER URINARY TRACT SYMPTOMS(LUTS)

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

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

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

26. 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

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

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

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

32. 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

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

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

35. ENURESIS

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

37. Sexual dysfunction in male

38. Decreased libido  Endocrine  Psychologic

39. ERECTILE DYSFUNCTION  Psychogenic  Neurogenic  Vasculogenic

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

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

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

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

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

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

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

47. PHYSICAL EXAMINATION

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

49. 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

50. 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

51. hypospadiasis

52. Epispadiasis

53. phimosis

54. Paraphimosis

55. Genital herpes

57. Syphlis ulcer

58. Peyronie disease

62. 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

63. 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

64. 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

65. RECTAL EXAMINATION(DRE)

67. COMMON ABNORMAL PHYSICAL FINDING

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

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

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

71. 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

72. spermatocele

73. spermatocele

74. hydrocele

75. hydrocele

76. hydrocele

77. varicocele

78. varicocele

79. Testis torsion(R)

80. Testis torsion

81. Scrotal hematoma

83. Inguinal hernia

85. PROSTATE  Acute bacterial prostatitis  BPH  Prostate cancer

86. THE END