1. DIAGNOSIS

2. Signs and Symptoms Symptoms Related to Voiding Urinary Incontinence Hematuria

3. Signs and Symptoms: Symptoms Related to Voiding Categories: Specific irritative symptoms include dysuria, frequency, and urgency. – These symptoms generally imply inflammation of the urethra, prostate, or bladder – commonly caused by infection, they can also be caused by malignancy – in patients with symptoms that persist after treatment with appropriate antibiotics, malignant processes such as transitional cell carcinoma must be ruled out Specific obstructive voiding symptoms include a weak urinary stream, urgency, frequency, hesitancy, intermittency, nocturia, and sense of incomplete emptying. – Hesitancy refers to a delay in initiating a urinary stream – Intermittency refers to repeated starting and stopping of the urine stream during voiding – The most common cause in men: benign prostatic hyperplasia – Urethral strictures may also obstruct the bladder outlet and are often secondary to trauma, urethritis or previous instrumentation of the bladder Schwartz’s Principles of Surgery 8 th ed.

4. Signs and Symptoms: Urinary Incontinence

5. Schwartz’s Principles of Surgery 8 th ed.

6. Signs and Symptoms: Urinary Incontinence Schwartz’s Principles of Surgery 8 th ed.

7. Signs and Symptoms: Hematuria Patients with gross or microscopic hematuria, in the absence of obvious evidence of a urinary tract infection, need to be evaluated with upper and lower tract studies. Significant microscopic hematuria : >5 rbc/hpf in spun urine; >2rbc/hpf in unspun urine is. Patients with gross painless hematuria should be considered to have a urinary tract malignancy until proven otherwise. Schwartz’s Principles of Surgery 8 th ed.

8. Signs and Symptoms: Hematuria Timing of hematuria Likely sitePossible Causes InitialUrethraUrethral stricture TotalBladder, ureter, kidney Hydronephrosis, renal cyst, urolithiasis, urothelial CA, cystitis trauma TerminalBladder Neck, prostate BPH, bladder neck polyps, tumors

9. Physical Examination Kidney Urinary Bladder Female Genitalia – Bimanual examination Examination of the Penis, Scrotum, and Testis Digital Rectal Exam Schwartz’s Principles of Surgery 8 th ed.

10. Physical Examination KIDNEY Patient in supine Palpate just below and parallel to the 12th rib, just reaching the costovertebral angle. “capture” the kidney between your two hands on patient’s deep inspiration Ask the patient to breathe out and then to stop breathing briefly. Slowly release the pressure of your left hand, feeling at the same time for the kidney to slide back into its expiratory position. If the kidney is palpable, describe its size, contour, and any tenderness. Bate’s Guide to Physical Examination and History Taking

11. Physical Examination Urinary Bladder Can be palpated when there is at least 150mL of urine in it Percussion is better than palpation for diagnosing a distended bladder. A careful bimanual examination, best done with the patient under anesthesia, is invaluable in assessing the regional extent of a bladder tumor or other pelvic mass, induration and mobility. Tenderness over the suprapubic area may indicate cystitis.

12. Physical Examination Female Genitalia External Inspection – The labia minora, clitoris, urethral meatus, vaginal opening, or introitus – Note any inflammation, ulceration, discharge, swelling, or nodules. – If there are any lesions, palpate them. Bate’s Guide to Physical Examination and History Taking

13. Physical Examination Female Genitalia Bimanual Examination Note any nodularity or tenderness in the vaginal wall, including the region of the urethra and the bladder anteriorly. Palpate the cervix, the uterus, each ovary Assess the Strength of the Pelvic Muscles and bladder mobility May reveal a variety of abnormalities including benign/malignant masses, unflammatory lesions, pelvic prolapse Bate’s Guide to Physical Examination and History Taking

14. Physical Examination Examination of the Penis, Scrotum, and Testis The physical examination of a male patient should be performed with the patient standing and the physician seated on a stool. Inspect: the skin of the penis, scrotum, and the surrounding inguinal region Palpate: – testicles for masses or tenderness and the size of the testicles should be noted. Normally, have a firm, rubbery consistency with a smooth surface – The epididymis can be palpated on the posterolateral surface of the testicles – The vas deferens can be felt by gently compressing the scrotum above the testicles. – The penis should be gently massaged to express any urethral discharge. – The penile shaft and urethra should be palpated along the length of the penis. Any nodules or fibrotic plaques on the corporal bodies should be noted. Hydroceles – a buildup of fluid between the two layers of the tunica vaginalis – can be confirmed by transilluminating the sac with a penlight. Varicoceles – may be palpable in the scrotum and represent dilated veins Schwartz’s Principles of Surgery 8 th ed.

15. Physical Examination Digital Rectal Examination (DRE) Should be performed in every male after age 40yrs the patient leaning over an examination bench and resting on his elbows or the patient can be lying in a lateral decubitus position begins by separating the buttocks and inspecting the anus for pathology, usually hemorrhoids Estimation of anal sphincter tone is of great importance

16. Physical Examination Digital Rectal Examination (DRE) Palpation: – Using lubrication, the index finger is gently inserted into the rectum. – The prostate is palpated, and any nodules, indurations or asymmetry should be noted. – Valsalva will often bring the prostate closer to the anus and facilitate the exam. Normally, the prostate is about the size of a chestnut and has a consistency similar to that of the contracted thenar eminence of the thumb (with the thumb opposed against the little finger). Bate’s Guide to Physical Examination and History Taking

17. Laboratory Examination -clean midstream catch is usually adequate -in children,urine can be collected by placing a urine collection bag over the urethral meatus Examination of urine urinary pH specific gravity protein glucose ketones bilirubin urobilinogen hemoglobin, leukocytes, and nitrites relies on color changes produced by chemical reactions with substances in the urine

18. Examination of Urine pH - will reflect the pH of the serum Specific gravity – reflects the hydration status of the patient and the concentrating ability of the kidney Proteinuria – indicate intrinsic renal pathology or the presence of excess protein in the serum. Glucose and Ketones – screening for diabetes – greater than 180 mg/dL

19. Examination of Urine Bilirubin and high levels of Urobilinogen – liver disease or hemolysis. Hemoglobin, myoglobin, and red blood cells – can produce a positive result on dipstick tests for blood. Leukocytes and nitrites – inflammation, which is most commonly caused by a bacterial infection. Leukocyte esterase, – an enzyme found in neutrophils

20. Urine Culture Greater than 10 5 organisms/mL – UTI 100 organisms/mL of a known urinary pathogen – bacterial infection Antibiotic sensitiviy testing

21. Tests for Kidney Function Specific gravity – with a progressive decrease in renal function, the specific gravity does not decrease below approximately 1.015. Creatinine clearance – volume of plasma from which creatinine is completely removed per unit of time and is a clinical approximation of the glomerular filtration rate (GFR) and renal function – Clearance=UV/P – N: 90 to 110 mL/min

22. Tests for Kidney Function Gold standard for measuring GFR – Inulin is an ideal substance for measuring GFR because it is completely filtered by the kidney without being secreted or reabsorbed by the tubules. – Vs.Creatinine Secreted in small amounts by the proximal tubule. Therefore, creatinine clearance will slightly overestimate GFR at all levels of kidney function. This effect is most pronounced when kidney function is severely compromised, where creatinine clearance can overestimate GFR by as much as 1.5- to twofold.