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Issue

What is UrologyUROLOGYDone by:

Abdullah Abdul-Hai

Alawi AlkhadrawiLoai Alkhalaf

rology is a part of medical science that deals withgenitourinary tractdiseases or disorders ofmale and only

urinary tractdisorders offemale.

If you had a patient in any de-partment, you should follow

this system in order to reach a

diagnosis:

1.Taking history.

2.Doing physical examination.

3.Ordering investigations (if

needed).

Taking History

In the history you should know:Patient identification: i.e.

name, age, gender and loca-

tion.

Chief complain (in patients

words): e.g. if he said Passing

blood in the urine, dont say

hematuria.

History of present illness: e.g.

onset, severity, medical inter-

vention ..etc

Past medical and surgical.

Social history.Family history.

Allergic history.

Review of systems.

Physical Examination

General appearance.

Vital signs.

More specific examination to

know what is going on

(discussed in the lab).

Investigations

You may need to do some in-

vestigations to exclude differ-

ential diagnosis and reach the

final diagnosis.

U

Designed by:

Ali Zaki

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Pain

Pain is very common (not commonest) symptom in

urology. You should ask the patient about the onset,severity, aggregating & relieving factors.

Renal pain usually sustained, long acting, ipsilateral

pain in the back or costovertebral angel usually lateral

to sacrospinalis muscle & usually below the 12th rib.

Sometime, patients due to the severity of the pain they

have associated GI symptoms because of stimulation

celiac ganglion (wiki). It can refer to the distribution of

L1 and L2 to lower part of the abdomen and even to

the scrotum or -in females- to the labia.

Urethral pain is usually due to distension of the urethra

due to obstruction by a stone or clot. It can refer to the

tip of the penis or scrotum. With chronic obstruction

(months-years) the pain subside.

The location of the pain can give you a hint where the

obstruction is (but not always accurate) and can give

you associated symptom. For example if the obstruc-

tion in upper or middle part of the ureter, usually thepain in the upper part of the abdomen or sometimes in

McBurney's point (it is 2 fingers above the inguinal liga-

ment) making it confusing with appendicitis. If the ob-

struction in lower part of ureter the pain is usually

lower, however, patient may present with associated

lower urinary track symptoms in form of frequency and

urgency.

Bladder pain is intermittent pubic discomfort above

symphysis pubis and may refer to the distal tip of the

urethra.

You may have a patient complains of strangury ( sev

pain at the tip of urethra at the end of micturition -wi

), so you have to ask if has pain somewhere else, th

will give you a hint ( e.g. pain in the supra pubic areabladder pain due to cystitis or stones in the bladder).

Prostatic pain is poorly localized. It might be perine

pain at the end of micturition for prolong time and it

difficult to diagnose and manage.

Penile pain (pain in the penis) depends on the status

the penis, if erected it should direct you to diseases li

priapism (prolong painful erection, it is very common

sickle cell anemia -wiki-) or Peyronies disease (fibro

change in the penis itself -wiki-).

Testicular pain is very dangerous and urgent conditio

If someone ask you to asses 10 years old patient wi

testicular pain, you have to see him immediately b

cause he might have torsion (twisting) of the testis an

may die within few hours (3-6h). Management is us

ally surgical (immediate seek help). However there

differential diagnosis like orchitis, epididymitis or epi

dymo-orchitis, here you may have further investigatioIf you had a 20 years old patient suddenly woke up w

severe pain. You saw him in the ER within 2 hrs w

redness, fever and swelling. This pushes you towa

testicular torsion so you dont need to investigate. B

if the pain started 1 day ago and the patient ignored

you may order ultra-sound for investigation, so if the

is blood inside this suggest inflammation (e.g. epid

dymo-orchitis), if not means torsion.

Renal pain also called colicky pain because the patie

usually is turning over the bed trying to reduce t

pain. (Note that patient with appendicitis will be lyi

flat doesnt want to move because if he moved that w

increase the pain.)

General Symptoms in Urology

http://en.wikipedia.org/wiki/Celiac_gangliahttp://en.wikipedia.org/wiki/Celiac_gangliahttp://en.wikipedia.org/wiki/Stranguryhttp://en.wikipedia.org/wiki/Priapismhttp://en.wikipedia.org/wiki/Priapismhttp://en.wikipedia.org/wiki/Peyronie's_diseasehttp://en.wikipedia.org/wiki/Peyronie's_diseasehttp://en.wikipedia.org/wiki/Peyronie's_diseasehttp://en.wikipedia.org/wiki/Priapismhttp://en.wikipedia.org/wiki/Stranguryhttp://en.wikipedia.org/wiki/Celiac_ganglia

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Hematuria

It means passing blood in the urine. You should put in

mind false hematuria.

Hematuria is defined as presence of more than 3 RBCsin urine sample by high power field under the micro-

scope.

Seeing blood by the eye doesnt need microscope

(gross hematuria), but you may need to confirm that

this is blood not only discoloration of the urine.

You have to ask the patient whether it is painful or

painless. Painless hematuria pushes you toward ma-

lignancy. If it is painful hematuria you should think

about infection, stones, trauma ...etc

Types of hematuria are:

Continuous or total: usually originate from thebladder or upper urinary track.

Initial (rare): usually originated from the urethra

e.g. urethral tumor or urethritis.

End of micturition: originated from the bladder

(common in Egypt due to schistosomiasis).

You should ask the patient if he is passing stones o

clots. Passing clots give you a hint that this is not m

croscopic, there is a lot of bleeding inside caused b

trauma, tumor, stones or infections. Vermifor(wormlike) clot means it comes from upper urina

tract.

General Symptoms in Urology

They are the commonest symptoms in urology. We used to classified them into obstructive and irritative symp-

toms. But now we classified them into storage and voiding symptoms.

Storage symptoms

described by frequency, urgency, nocturia, burning micturition.

Frequency

Usually normal adult person goes to bathroom 4-5 times/ day, depending on taking of fluid, medical condition o

medications. It may rise to 8 and still normal if it is not bothering him. If patient go to the bathroom very often

e.g. every two hours, that means he go to bathroom more than eight times, we call it frequency.

Nocturia

If he wake up from sleep and go to bathroom, this is nocturia. It is during sleep not during the night. If it is one

time and it is not bothering him we do not call it nocturia, if it is one time and it is bothering him we call it noc-turia, two-time or more is defiantly nocturia.

Urgency

It is sudden intense feeling to go to the bathroom, even if he can hold it or go to the bathroom. It has three

grades, mild, moderate and severe.

Mild: he can hold more and more.

Moderate: he can ask you to go to the bathroom.

Severe: he have to run to the bathroom.

Lower Urinary Tract Symptoms (LUTS)

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Voiding symptoms

These patients have difficulty in initiating urination

(Hesitancy), straining, weak intermitted flow and ter-minal dribbling (patient continues to leak urine after

micturition has ceased).

We used to incorporate incomplete emptying with

voiding symptoms. we call it now post voiding symp-

tom, and he need to pass urine again within few min-

utes.

Incontinence (important in exams)

Very important common symptom mostly found in

females. It is five types: Stress incontinence: when they start cough, laugh

or left any heavy object, they start to leak, be-

cause of weakness of pelvic floor.

Urgency incontinence: when patient has sudden

intense feeling to go to the bathroom and start to

leak while he is going to bathroom.

Mixed incontinence (the commonest): have both

of them.

Continuous innocence: (common in females) theyleak all the time. Usually it is due to:

lesion in sphincter.

one ureter is not going to the bladder (going

directly to the urethra).

the commonest is caused by fistula between

bladder and vagina after surgery or labor.

Overflow incontinence (common in males): we

have a 55 year old male patient with enlarge

prostate with difficulty in voiding (i.e. urine is a

cumulating more and more), after he finish, h

want again to go to the bathroom. He has pos

voiding residual and that residual increase witime so no more room for urine inside.

That is why, it is important in examination to fin

if there is residual of urine inside the bladder

not. These patients usually they have full bladd

but they are not aware of that, and when the

start to move or cough they start to leak.

Lower Urinary Tract Symptoms (LUTS)

Sexual dysfunction (in male)

Two types:

libido problems: rare.

Impotence problems: difficulty in erection. We

used to think that it is due to psychological problem

but actually it is more organic.

International prostate symptomscore (IPSS)

It is a questionnaire by which we can monitor

the success of treatment or surgical interven-

tion. It is scaled up-to 35. Mild (0-7), moder-

ate (8-19), severe(20-35).

If you find a patient with severe score and

there is obstruction, we usually do surgical

intervention. But it the patient has mild score,

usually doesnt improve.

The symptoms which included in IPSS are

incomplete emptying, frequency, intermit-tency, urgency, straining, nocturia, and qual-

ity of life due to urinary symptoms. They are

scaled in 5 degrees.

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Allergy

It is more common in west rather than in our re-

gion.

It is very important to ask the patient if he has any

allergy to some drugs or contrasts.

Severe shock may result if we give the patient an

antibiotic or a contrast (for IVP or CT scan) that he

is allergic to.

Family history

Genetic diseases e.g. polycystic kidney, tubu

lar sclerosis.

Any renal problem in the family e.g. rena

stones.

Family history of prostate cancer.

Past Surgical History

Patients may come with postoperative vasoconstriction which may lead to void-

ing symptoms (slow stream, Intermittency, weak flow).

A patient with a history of cystoscopy (instrumentation of urethra and bladder)

may come complaining of stricture.

Patients may come with difficulty to void (incontinence) due neurological dys-

function which is commonly caused by a surgery due to back trauma.

social history

Smoking increases development of bladder

cancer (transitional cell carcinoma).

Alcohol consumption increases the inci

dence of testicular atrophy and decrease in

libido.

Past medical History

Diabetes mellitus may affect autonomic nerve, patient with incontinence and

leakage they may have Diabetic cystopathy, neurogenic bladder or recurrent

UTI because of the poor control of diabetes mellitus.

We have to ask about TB, it is not common, it can cause renal impairment or

even destruction.

Hypertension may cause sexual dysfunction.

Sickle cell anemia may cause papillary necrosis, erectile dysfunction, renalmedullary carcinoma, and priapism.

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1- General appearance

Jaundice and pallor prostate cancer that metastasize to the liver leads

to jaundice.

Bladder tumor that bleeds over the time and

cause anemia leads to pallor.

Chronic diseases (e.g. renal failure) lead to pallor.

Cachexia

Reduction in the weight of the patient.

Obesity

Due to some endocrine abnormality.Gynecomastia

Might be due to hormonal therapy for prostate caner

Edema

Secondary to cardiac failure or renal insufficiency

(patient will present with edema in the scrotum

"hydrocele").

2- Vital signs

Blood pressure.

Pulse rate.

Respiratory rate.

Oxygen saturation.

Temperature: Temp. may indicate infection e.g.

pyelonephritis, cystitis, urethritis which could be a

killer. Obstructed urinary tract + fever pye-

lonephritis urosepsis which may cause death

within hours.(It is important to know the different grades of the

temp either fever or not exam Q)

3- Examination of lymph

nodes

Most important for U. Tract:

Supra clavicular LN (for testicular tumors).

Inguinal LN (for testicular or penile tumors).

4- Examination of kidney

We start by looking for obvious abnormalities e.g

masses, cysts or hydronephrosis.Normally kidneys are not palpable except for children

and thin women. In men kidney is not palpable be

cause they have a very good muscular shape.

Kidney examination (called Bimanual Palpation):

We put one hand "below the edge of costal mar

gin" of the patient while he is in supine position.

We ask the patient the patient to take a deep in

spiration and we palpate the lower pole of th

right kidney. Left kidney is almost impossible to palpate.

If there is a mass we put a source of ligh

"Transillumination" behind the kidney or in th

plan in order to differentiate whether it is cystic o

non-cystic.

We look also for tenderness which may indicat

inflammation or infection.

Physical Examination

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5- Bladder examination

Usually bladder is not palpable unless there is at least150 CC of urine exam Q.

As any examination we start by inspection.

usually full bladder is in the "midline suprapubic"

and as you start to palpate usually it is smooth

and you can go above but you can't go bellow it

and it does not move with respiration.

If you press during palpation the patient will tell

you that he has feeling of urgency.

The most important examination for the bladde

is "percussion". We start above the symphysis p

bis and usually it is dull.

6- Penis examination

Phimosis: uncircumcised penis with difficulty

retracting the foreskin.

Balanitis: infection of the glans penis.

Presence of ulcers or masses indicates mali

nancy.

Presence of vesicles indicates infection with hepes.

7- Examination of the urethra

Opening of the urethra normally is in the tip of th

glans.

Hypospadias: opening of the urethra in the ventr

(lower) part of the penis.

Epispadias: opening of the urethra in the dors(upper) part of the penis.

Peyronie's disease: Fibrosis in the shaft of the penis.

Physical Examination

To differentiates between the bladder and

bowel obstruction or mass:

- Bladder is in the midline above the

symphysis pubis while mass or obstruction is

usually lateral.

- Bladder is smooth oval-shape while mass is

irregular

- When you press over the mass there will be

no felling of urgency while in the bladder

that feeling is usually present.

- Percussion over the bladder is dull while in

the mass or obstruction it's resonant.

- The definite maneuver to differentiate is to

put a catheter and if there is mass it will

move.

- In the O.R. If there is a mass and we want

to know weather this mass is fixed or not we

do a bimanual examination (male onefinger in the rectum and the other hand in the

lower part of the abdomen) (female twofingers in the vagina and the other hand in

the abdomen) (this is the only way to know

and if this mass is fixed then it will be very

difficult to remove it surgically).

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8- Examination of the scro-tum and it's content

Examination of the skin and scrotal content

(epididymis & testis).

look if there is:

A mass in the testis.

A mass from the abdomen as in "inguinal hernia".

Fluid between the "tunica vaginalis" & "tunica al-

buginea" which means hydrocele.

It is important to examine for "varicocele": ask the

patient to stand and take "valsalva"-wiki- and we ex-amine if there is any dilated veins in side which have

vermiform appearance(usually patients come com-

plaining of infertility).

If there is a mass we do "Transillumination" to prove

whether it is cystic or hard mass (hard mass is malig-

nant until proven otherwise).

9- Digital rectal examination

In males only.Aims to examine the prostate.

Usually any patients >40 years and has some urinar

symptoms we examine the prostate for any infectio

enlargement, or prostate cancer.

In females

In the O.R. we examine for atrophic vaginalis o

masses or prolapses (prolapse of the bladder througvagina called cystocele while prolapse of the bow

called rectocele).

Physical Examination

http://en.wikipedia.org/wiki/Valsalva_maneuver#Urogenitalhttp://en.wikipedia.org/wiki/Valsalva_maneuver#Urogenitalhttp://en.wikipedia.org/wiki/Valsalva_maneuver#Urogenital

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In urine analysis we look for microscopic and chemical

features.

In chemical we look for:

Specific gravity

It gives you the hydration condition of the patient.

Normal urine specific gravity is from 1.010 to 1.020

but it might reach 1.030. fixed specific gravity at 1.010

indicates renal insufficiency.

Osmolarity

Specific test that can be done using urine dipsticks.

Normal value is from 50-120.

Urine color

Normal urine color is pale yellow due to presence of

pigments called "urochrome".

Colorless urine: over hydration or good hydration.

Cloudy: it may indicate infection but not all the

time (chyluria can cause turbid urine).

Red urine: it might be hematuria, hemoglobinuria

or due to some medications e.g. rifampicin.

Green blue urine: due to pigment called

"methylene blue". Black urine: due to some medications e.g. methyl-

dopa or some Laxatives.

Orange urine: due to some drugs e.g. Pyridium (for

treatment of severe irritative symptoms).

Urine PH

Normal PH is from 5.5 to 6.5 (acidic range). If it is alka-

litic (6.5 8) it may indicate infection especially with

"urea- splitting organism" which may lead to forma-

tion of crystals or stones.

Simple urine dipstick test will show if there is RBC's,

glucose or proteins.

Urine sediment could be examined under the micro-

scope to see the presence of RBC's, WBC's, epithelium

or casts (proteins):

RBC's casts glomerulonephritis (glomerular

damage or bleeding).

WBC's cast's acute glomerulonephritis, pye-

lonephritis.

Fatty casts nephrotic syndrome.

Urine Crystals

The most common type of stones are calcium ox-

alate stones.

Some uric acid stones are resistance to ESWL

(Extracorporeal shock wave lithotripsy).

Most common urinary tract infections

Candida.

Trichomonas vagainalis.

Schistosoma haematobium.

Any bacteria in the urinary tract of men equal UTI.

Most of the patients show signs of infection in the bladder.

Collection of urine sample

In male mid stream of urine (we ask the patient to clean his genitalia and to void first and then collectthe urine).

In female if we are expecting a cystic infection we need to collect the urine in a very sterile condition using

catheterization.

Analysis...Urine