Dr. Ahaghotu - Urology Physical Examination

8/12/2019 Dr. Ahaghotu - Urology Physical Examination

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Introduction to Patient CareEvaluation of the Genitourinary

System

C. A. Ahaghotu, M.D., F.A.C.S.Associate Professor and Chief of

UrologyHoward University Hospital


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What is Urology?


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Definition: the study of the

male and female urinarytract and the male

genitalia


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Introduction

Training Requirements

1-2 years of general surgery3-4 years of general urology

1-3 years of fellowship (optional)


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Urology Subspecialties

Urologic Oncology

Erectile Dysfunction

InfertilityEndourology/Urolithiasis

Voiding Dysfunction (incontinence)

Pediatric UrologyReconstructive urology/ trauma


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History takingPain Location-flank, suprapubic, inguino-scrotal,

perineal, labial

Radiating pattern*

T10-L2 & S2-4,-groin, flank, meatus

Quality-colicky, sharp, dull, squeezing, burning

Severity index-1-10

Timing-intermittent vs.. consistent Precipitating/palliating factors*

Very few palliating factors

Aggravating factors include micturation

Often associated with GI symptoms (nausea,vomiting, diarrhea)

Evaluation of the genitourinarysystem


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History taking

Lower urinary tract symptoms(prostatism)

Obstructive: hesitancy, slow stream,intermittency, post void dribbling, incompleteemptying

Irritative: frequency, urgency, dysuria, nocturia

Causes include

bladder outlet obstruction-prostate, stones, strictures,tumors

inflammation-infection, stones, tumors, radiation, drugs

neurovesical dysfunction-CNS disease, trauma, aging



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History taking

Upper urinary tract

Pain, fever, chills, nausea, vomiting,hypertension

Causes include:

Ureteral obstruction-stones, tumor, clot,stricture

Inflammation-infection, radiation, trauma

Ischemia-vascular injury



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History taking

Incontinence-involuntary leakage ofurineUrge-related

Preceded by urgency

Associated with irritative symptoms

Irritative and obstructive causes

Stress-relatedPrecipitated by increased intra-abdominalpressure (Valsava maneuver)

Causes include pelvic floor weakness,urethral sphincter deficiency

Evaluation of thegenitourinary system


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History taking

Incontinence

Overflow-related

Associated with obstructive symptoms

Causes include obstructive vs. detrusorinsufficiency

Total incontinence

Bypassing the continence mechanism (vesico-vaginal, rectovesical, vesico-cutaneous fistulae)

Mixed picture



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Urgency


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Stress


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Overflow

E l ti f th it i t


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History taking

Urinary retention Acute

Suprapubic pain, urgency, tender suprapubic mass

Precipitated by ETOH intake, medications (e.g.. -

agonists)Associated with causes of lower urinary tractsymptoms

ChronicIncomplete emptying, overflow incontinence,

suprapubic massCauses may be obstructive vs. detrusor insufficiency

Complications include UTI, sepsis, renalinsufficiency

Evaluation of the genitourinary system

E l ti f th it i


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History taking

Hematuria (gross) Timing

Initial-anterior urethraTerminal-prostatic urethra, bladder neckTotal-bladder, upper urinary tract

ClotsVermiform-ureterAmorphous-bladderClot retention

Associated symptomsIrritative-suggests inflammatoryPainless-malignancyObstructive-prostatic varicesCo-morbid causes for coagulopathy



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Initial

hematuria

Terminalhematuria

Totalhematuria


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History taking

Erectile dysfunction Inability to achieve and/or maintain an

erection adequate for satisfactory intercourse Medical history is important

Causes include vascular disease, neurologicaldisease, drugs, trauma

Infertility Inability to conceive despite 12 months of

consistent effort

Primary vs.. secondary Causes include hypogonadism, ductal

obstruction, drugs, varicocele, unusual sexualpractices


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History taking

Past medical historyMedications (diuretic, adrenergic agents)

Prior surgery, radiation, trauma

Family/social historyFamilial diseases (e.g.. prostate cancer,

urolithiasis, vesico-ureteral reflux)

Smoking history-quantity and durationDrug abuse

STD exposure-dates, treatments


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History taking

Obstetric/gynecologic history

Parity

Nature of deliveries

Vaginal vs.. caesarian

Forceps delivery

Prolonged/obstructed labor

Episiotomies vs. vaginal injuryMenstrual status

STD exposure

Evaluation of the genitourinary


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Physical examination

General assessment Hygiene Cognitive status Gait

Nutritional status Vital signs

Neurological exam Spasticity vs.. flaccidity

Lateralizing signs Sacral arc integrity (S2-4)

Perineal/introital sensationAnal sphincter toneBulbo-cavernosus reflex



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Evaluation of the genitourinary


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Physical examination

Abdominal exam Inspection-incisional scars, ostomies Palpation

Masses-location, size, consistency, expansile,

tenderness, intra-abdominal vs.. pelvic originBimanual examination of the flank-tenderness,palpable masses

Percussionto elicit renal tendernessTo determine consistency of a masses (e.g..

distended bladder) Auscultation

mid-clavicular line, below 10th ribRenal vascular stenosis, aneurysms, A-Vmalformations



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???


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Bimanual examination of the kidney


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External genital exam

(male)

Inspection (supine & standing) Penis-prepuce, glans, shaft, external urethral

meatus

Scrotum-rugations, symmetry

Perineum-warts, excoriation

Palpation Retraction of prepuce

Testicular exam-position, volume, consistency,symmetry, adnexal structures

Hernia examination

Cremasteric reflex


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Inguinal hernia exam


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(male)

Transillumination

Distinguishes fluid vs.. solid intra-scrotalmasses

Hydroceles ++++

Spermatoceles ++

Hematoceles

Hernias -/+Testes tumors -

E l i l


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(male)

Digital rectal exam Be gentle

Assess anal sphincter tone

Palpate prostateSize

Consistency

Tenderness

Symmetry

Prostatic message when indicated Palpate rectal walls

Stool sample for occult blood


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Digital rectal examination

E t l it l


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(female)

Inspection (dorsal lithotomy)

Pubic hair distribution

Introital tissues

Atrophic changes, ulcers, erosions,discharge, lesions, masses

Tactile sensation

Urethral meatusMucosal status

Stress incontinence

E t l it l


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(female)

Palpation Urethral mobility & consistency

Pelvic floor support

Reducible masses (e.g.. cystocele)

Speculum exam Examine vaginal walls for support, mucosal

integrity

Bimanual exam Assess bladder, uterus, and adnexa tenderness


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Female bimanual exam


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Laboratory studies

Urinalysis (midstreamclean catch

specimen) pH

Specific gravity 1.003-1.040

Protein

Blood

Leukocyte esterase

Nitrite (Griesse test) Glucose

Ketones

Bilirubin

Urine microscopy 10cc fresh urine

Centrifuge at 2000 RPMfor 3-5 mins.

Discard supernatant

Micro-analysis-cells,casts, crystals, bacteria

Micro-hematuria > 2RBCs / hpf

Pyuria > 5 WBCs / hpf

Bacteruria 5/hpf

(100, 000/cc)


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Urine microscopy


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Laboratory studies

Serum Chemistry

Na, Cl, HCO3, BUN, creatinineCreatinine clearance = Ucr(mg/dl) x V(ml)

Pcr(mg/dl)


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Laboratory studies

Prostate Specific Antigen

Prostate enzyme measured in serumNormal range 0-4 ng/ml

Elevated in prostatitis, BPH and prostatecancer


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Imaging Studies

Ultrasonography Scrotum kidney

IVP

CT scanMRIRenal arteriogramRadionuclide studiesCystogramRetrograde urethrogram


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Renal ultra-sonography


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Scrotal ultra-sonography


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Intravenous pyelogram


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CT Kidneys


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MRI Kidneys


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Renal arteriogram


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Renal scan

C


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Cystogram

normal ?????


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Retrograde urethrogram


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Endoscopic evaluation

Cystoscopy

Urethroscopy

Ureteroscopy

nephroscopy


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Cysto-urethroscopy

Direct visualizationof the lower

urinary tractIdentify bladderoutlet obstruction,strictures,neoplasm, fistulae


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Vesico-vaginal fistula

fistula

trigoneRt U.O. Lt U.O


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Dr. Ahaghotu - Urology Physical Examination

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