Download Lecture 1 - Home - KSU Faculty Member websites

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


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

Pain

Can be severe



Inflammation of the GU tract is most severe when it
involves the parenchyma of a GU organ




urinary tract obstruction
inflammation
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


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

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
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



usually arises from the urethra
least common
usually secondary to inflammation.
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
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