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  2. 2. Introduction • Most diagnosis can be reached by a complete history and a thorough physical examination • History and Examination also help direct the appropriate selection of subsequent diagnostic studies/investigation(s) • Settings: - Patience - Attentiveness - Privacy (but don’t forget a chaperone) - Communication (avoiding medical jargon) - Calm, caring and competent image
  3. 3. History • Components: - Biodata - Presenting complaint(s) (PC) - History of presenting complaint (HPC) - Past Medical and Surgical history - Medication and allergy history - Family and social history - Review of systems
  4. 4. Presenting complaint and HPC • The Presenting Complaint is a constant reminder as to why the patient initially sought care (this must be addressed) • The HPC requires details of the PC in terms of the duration, onset, severity, chronicity, periodicity and degree of disability
  5. 5. Pain • Pain arising from the GU tract may be quite severe (usually associated with urinary tract obstruction or inflammation) • Renal Pain - usually located in the ipsilateral renal angle (the angle between the 12th rib and the edge of the erector spinae muscle) - usually caused by acute distention of the renal capsule (from inflammation or obstruction)
  6. 6. • Renal Pain - may radiate across the flank anteriorly toward the upper abdomen and umbilicus and may be referred to the testis or labium - Pain due to inflammation is usually steady but pain due to obstruction fluctuates in intensity - may be associated with GIT symptoms (because of reflex stimulation of the celiac ganglion and because of the proximity of adjacent organs (liver, pancreas, duodenum, gallbladder, and colon))
  7. 7. • Renal Pain - patients with renal pain usually are more comfortable moving around and holding the flank - may be confused with pain resulting from irritation of the costal nerves, most commonly T10-T12. Such pain has a similar distribution from the costovertebral angle across the flank toward the umbilicus. However, the pain is not colicky in nature and the intensity of radicular pain may be altered by changing position (unlike renal pain)
  8. 8. • Ureteral Pain - usually acute and due to obstruction - pain from midureteric obstruction is referred to the lower quadrant of the abdomen (may simulate appendicitis on the right or diverticulitis on the left) - the pain may also be referred to the scrotum (in male) or (labium in female)
  9. 9. • Ureteral Pain - Lower ureteral obstruction may cause symptoms of vesical irritation: frequency, urgency, and suprapubic discomfort that may radiate along the urethra in men to the tip of the penis - typically colicky in nature and intensifies with ureteral peristalsis - Severity: severe (worst pain ever) and patient is restless - Ureteral pathology (e.g. tumour) that arises slowly or produces only mild obstruction rarely causes pain
  10. 10. • Vesical Pain - overdistention of the bladder (from AUR) produces severe pain in the suprapubic area - Inflammatory conditions of the bladder usually produce intermittent suprapubic discomfort - cystitis sometimes cause sharp, stabbing suprapubic pain at the end of micturition (strangury) - patients with cystitis frequently experience pain referred to the distal urethra and associated with irritative voiding symptoms such as urinary frequency and dysuria
  11. 11. • Prostatic Pain: - usually secondary to inflammation with secondary edema and distention of the prostatic capsule - poorly localized, and the patient may complain of lower abdominal, inguinal, perineal, lumbosacral, penile, and/or rectal pain - Prostatic pain is frequently associated with irritative urinary symptoms such as frequency and dysuria, and, in severe cases, marked prostatic edema may produce acute urinary retention
  12. 12. • Penile Pain: - pain in the flaccid penis: is usually due to inflammation in the bladder or urethra with referred pain at the urethral meatus; may also be due to paraphimosis - pain in the erect penis is usually due to Peyronie disease or priapism
  13. 13. • Scrotal Pain: - pain arising within the scrotum is usually due to acute epididymo-orchitis or torsion of the testis or testicular appendices - pain arising in the kidneys or retroperitoneum may be referred to the testes - scrotal pain may result from inflammation of the scrotal wall itself e.g. Fourniers gangrene - chronic scrotal pain is usually related to noninflammatory conditions e.g hydrocele or a varicocele and the pain is generally characterized as a dull, heavy sensation that does not radiate
  14. 14. Haematuria • Hematuria is the presence of blood in the urine • Significant haematuria is RBC > 3 RBCs per HPF • Hematuria of any degree should never be ignored • haematuria may be gross or microscopic • the chances of identifying significant pathology increase with the degree of hematuria • hematuria, particularly in the adult, should be regarded as a symptom of malignancy until proved otherwise • Requires immediate urologic evaluation
  15. 15. Haematuria • It is important to ascertain the following: - Duration - Timing: (beginning or end of stream or during entire stream)? - Is the hematuria associated with pain? - Is the patient passing clots? (If the patient is passing clots, do the clots have a specific shape?)
  16. 16. Haematuria • Initial hematuria: usually arises from the urethra • Total hematuria: - is most common - bleeding is most likely coming from the bladder or upper urinary tracts • Terminal hematuria: - occurs at the end of micturition - usually secondary to inflammation in the area of the bladder neck or prostatic urethra • Association with Pain: pain in association with hematuria usually results from upper urinary tract hematuria with obstruction of the ureters with clots
  17. 17. Haematuria • Presence of Clots: usually indicates a more significant degree of hematuria • Shape of Clots: the presence of vermiform (wormlike) clots, identifies the hematuria as coming from the upper urinary tract • The most common cause of gross hematuria in a patient older than age 50 years is bladder cancer
  18. 18. Lower Urinary Tract Symptoms • Storage (Irritative) Symptoms: - Urinary Frequency: due to either increased urinary output (polyuria) or decreased bladder capacity (from BOO with decreased compliance, increased residual urine, and/or decreased functional capacity due to irritation, neurogenic bladder with increased sensitivity and decreased compliance, pressure from extrinsic sources) or anxiety - Urinary urgency: the complaint of a sudden compelling desire to pass urine, which is difficult to defer - Nocturia: Complaint of interruption of sleep one or more times because of the need to micturate. may be attributed to nocturnal polyuria and/or diminished nocturnal bladder capacity
  19. 19. Lower Urinary Tract Symptoms • Voiding (Obstructive) Symptoms - Decreased force of urination - Urinary hesitancy: a delay in the start of micturition - Straining: involves the use of muscular effort (by abdominal straining, Valsalva or suprapubic pressure) to either initiate, maintain or improve the urinary stream - Intermittency: refers to involuntary start-stopping of the urinary stream. It most commonly results from prostatic obstruction with intermittent occlusion of the urinary stream by the lateral prostatic lobes - Splitting or spraying of urine stream - Terminal dribble • Post-micturition LUTS - Feeling of incomplete emptying - Post-micturition dribble: terminal release of drops of urine at the end of micturition
  20. 20. Incontinence • Urinary incontinence is the involuntary loss of urine • Types of urinary incontinence: 1. Continuous Incontinence: • Causes: - most commonly due to a urinary tract fistula that bypasses the urethral sphincter e.g. vesicovaginal fistula - an ectopic ureter that enters either the urethra or the female genital tract (ectopic ureters never produce urinary incontinence in males because they always enter the bladder neck or prostatic urethra proximal to the external urethral sphincter)
  21. 21. Incontinence 2. Stress Incontinence: • refers to the sudden leakage of urine with coughing, sneezing, exercise, or other activities that increase intra-abdominal pressure • most common in women after childbearing or menopause (due to loss of anterior vaginal support and weakening of pelvic tissues) • also observed in men after radical prostatectomy (if there is injury to the external urethral sphincter)
  22. 22. Incontinence 3. Urgency Incontinence: • Urgency incontinence is the precipitous loss of urine preceded by a strong urge to void 4. Overflow Urinary Incontinence: • secondary to advanced urinary retention and high residual urine volumes • Overflow incontinence has been termed paradoxical incontinence because it can often be cured by relief of bladder outlet obstruction
  23. 23. Enuresis • refers to urinary incontinence that occurs during sleep • It is physiologic in children up to 3 years of age but persists in about 15% of children at age 5 and about 1% of children at age 15 • All children older than age 6 years with enuresis require a urologic evaluation • May be functional or present as a symptom of organic disease (e.g. infection, distal urethral stenosis in girls, posterior urethral valve in males, neurogenic bladder)
  24. 24. Sexual Dysfunction • Loss of Libido - may indicate androgen deficiency (pituitary or testicular dysfunction) - depression and medical illnesses that affect general health and well- being • Erectile dysfunction(ED)/Impotence - impotence refers to the inability to achieve and maintain an erection sufficient for satisfactory intercourse - a careful history will often determine whether it is psychogenic or organic - patients who are able to achieve adequate erections in some situations but not others have primarily psychogenic rather than organic
  25. 25. Sexual Dysfunction • Failure to ejaculate: - may result from several causes: androgen deficiency, sympathetic denervation, pharmacologic agents, and bladder neck and prostatic surgery - A careful history will usually determine the cause of this problem - Patients who complain of absence of ejaculation should be questioned regarding loss of libido or other symptoms of androgen deficiency, present medications, diabetes, and previous surgery - Anorgasmia is usually psychogenic or caused by certain medications used to treat psychiatric diseases
  26. 26. Sexual Dysfunction • Premature Ejaculation - inability to delay ejaculation for more than one minute after penetration - Bothersome and distressing to the patient - it is almost always psychogenic - with counseling and appropriate modifications in sexual technique, this problem can usually be overcome - Alternatively, treatment with serotonin reuptake inhibitors such as sertraline and fluoxetine has been demonstrated to be helpful in men with premature ejaculation
  27. 27. Haematospermia • Refers to the presence of blood in the seminal fluid • It almost always results from nonspecific inflammation of the prostate and/or seminal vesicles and resolves spontaneously, usually within several weeks • frequently occurs after a prolonged period of sexual abstinence, • hematospermia that persists beyond several weeks requires further urologic evaluation for an underlying etiology: - exclude the presence of tuberculosis - a PSA and a DRE done to exclude prostatic carcinoma and - a urinary cytology done to exclude the possibility of TCC of the prostate
  28. 28. Pneumaturia • passage of gas in the urine • almost always due to a fistula between the intestine and the bladder • common causes include diverticulitis, carcinoma of the sigmoid colon, and Crohn disease • rarely patients with DM may have gas-forming infections (with CO2 formation) Urethral Discharge • most common symptom of venereal infection • a purulent discharge that is thick, profuse, and yellow to gray is typical of gonococcal urethritis • the discharge in patients with nonspecific urethritis is usually scant and watery • a bloody discharge suggest carcinoma of the urethra, foreign body or stricture Fever and Chills: pyelonephritis, prostatitis, epididymitis
  29. 29. Past Medical and Surgical History • Several Medical Illnesses have urologic Sequelae e.g. - DM frequently develop autonomic dysfunction that may result in impaired urinary and sexual function - hypertension increases the risk of sexual dysfunction (due to PVD and antihypertensives induced ED) - Patients with neurologic diseases such as multiple sclerosis are also more likely to develop urinary and sexual dysfunction • Previous Surgical Procedures especially in the urinary tract may be relevant e.g. a recurrence of a previously treated urethral stricture • patients with sickle cell anemia are prone papillary necrosis, Priapism and ED
  30. 30. Medication History • Review all patient’s medications • most antihypertensive medications cause ED, and changing antihypertensive medications can sometimes improve sexual function Family History • Examples of genetic diseases include adult polycystic kidney disease, tuberous sclerosis, von Hippel-Lindau disease, renal tubular acidosis, and cystinuria • 8-10% of prostate Ca is familial
  31. 31. Social History • Cigarette smoking: - increased risk of urothelial carcinoma (bladder cancer) - increased risk of peripheral vascular disease and erectile dysfunction • Chronic alcoholism: may cause - autonomic and peripheral neuropathy with resultant impaired urinary and sexual function - impaired hepatic metabolism of estrogens, resulting in decreased serum testosterone, testicular atrophy, and decreased libido
  32. 32. Physical Examination • General Observations: note - demeanour (e.g. in pain, anxious, depressed) - whether they appear to be in good general health or frail • Inspection for signs of underlying disease such as pallor, jaundice, clubbing and oedema • Heart rate, blood pressure, temperature, respiratory rate, oxygen saturations are essential in the acute situation
  33. 33. Abdominal Examination • Inspection: - flank swelling may suggest a hydronephrotic kidney, cystic disease, renal tumour or peri-nephric abscess - Check the groins for hernia • Palpation: palpate for - tenderness - enlargement of the kidneys (distinguished by downward movement with respiration & ballotable nature) - enlargement of the paraaortic lymph glands (may arise from tumours e.g. of the testis) - Bladder distension with urine or bladder enlargement with a tumour
  34. 34. Abdominal Examination • Bladder - the bladder is not usually palpable in adults until it contains approximately 300 ml and can be percussed when it contains 150 ml - Percussion is better than palpation for diagnosing a distended bladder - A painful palpable bladder in someone with difficulty voiding suggest an AUR but the absence of pain suggest chronic urinary retention - A bimanual examination (done under anesthesia) is invaluable in assessing the regional extent of a bladder tumor or other pelvic mass (palpated between the abdomen and the vagina in the female or the rectum in the male) - bimanual examination allows assessment of the mobility of the bladder
  35. 35. • Renal angle tenderness suggest an inflamed kidney • Every patient with flank pain should also be examined for possible nerve root irritation Penis: Examine the penis for • abnormal curvatures • check the urethral meatus for abnormal location that may suggest hypospadias or epispadias • induration along the palpable urethra (signify presence of strictures) • note the presence of urethral discharge In the female, check the urethral orifice for prolapse or caruncle
  36. 36. Scrotum • part of abdominal examination • Assess scrotal skin for erythema, edema, or fixation • Examine the testicles and the cord structures: - The normal testis is smooth and of firm consistency - Tenderness (painful: torsion, epididymo-orchitis) - Scrotal masses should be transilluminated (Painless solid testicular mass is tumour until proven otherwise)
  37. 37. Digital Rectal Examination (DRE) • Usually performed in the left lateral position with the buttocks at the edge of the table and the hips and knees flexed. supine and standing positions may also be used • Prostate gland assessment: - size of the gland: it may be normal or enlarged - consistency: this may be soft, firm or hard - surface of the gland: this may be smooth or irregular - Median groove and lateral sulci: these may be preserved or obliterated - Discomfort: the gland may be tender when inflamed
  38. 38. Digital Rectal Examination (DRE) • Seminal vesicles:- the seminal vesicles may be felt if they are enlarged • Assess the rectum for any tumour or other pelvic masses • Note the presence of faecal impaction • Inspect the gloved finger for blood stain at the end of the examination
  39. 39. Focused Neurologic Examination • Applicable when neurogenic lower urinary tract or pelvic floor dysfunction is suspected • Assess for sensory deficits in the penis, labia, scrotum, vagina, and perianal area generally indicate damage or injury to sacral roots or nerves • Bulbocavernosus reflex (BCR): - reflex contraction of the striated muscle of the pelvic floor in response to various stimuli in the perineum or genitalia - it tests the integrity of the spinal cord–mediated reflex arc involving S2-S4 and may be absent in the presence of sacral cord or peripheral nerve abnormalities
  40. 40. Focused Neurologic Examination • The cremasteric reflex: - elicited by lightly stroking the superior and medial thigh in a downward direction - the normal response in males is contraction of the cremasteric muscle that results in immediate elevation of the ipsilateral scrotum and testis - may be a role for testing this reflex when assessing patients with suspected testicular torsion or epididymitis
  41. 41. References 1. Osman NI, Inman RD. Urological diagnosis, history and investigation. Surg (United Kingdom). 2013;31(7):337–45. 2. Fowler CG. Urinary symptoms and investigations. In: Williams NS, Bulstrode CJK, O’Connell PR, editors. Bailey and Love’s Short Practice of Surgery. 25th editi. London: Edward Arnold (Publishers) Ltd; 2008. p. 1273–1284. 3. Gerber GS, Brendler CB. Evaluation of the Urologic Patient: History, physical examination, and urinalysis. In: Wein AJ, Kavoussi LR, Partin AW, Peters CA, editors. Campbell-Walsh Urology. 11th Edition. Elsevier, PA; 2016. pgs. 35-60. 4. Shittu OB. Symptoms, Examination, Investigations and Instruments in Urology. In: Archampong EQ, Naaeder SB, Ugwu BT, editors. BAJA’s Principles and Practice of Surgery including Pathology in the Tropics. 5th Edition. Repro India Ltd, 2015. Pgs. 857-865.