Lecture in urology

1. HISTORY AND EXAMINATION OF THE
UROGENITAL SYSTEM
DR M. O. IFEH
CONSULTANT UROLOGIST AND LECTURER
FEDERAL MEDICAL CENTRE YENAGOA/
NIGER DELTA UNIVERSITY, BAYELSA STATE, NIGERIA

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. 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. 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. 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. • 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. • 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. • 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. • 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. • 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. • 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. • 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. • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. • 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. 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. 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. 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. 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. 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. References
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London: Edward Arnold (Publishers) Ltd; 2008. p. 1273–1284.
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examination, and urinalysis. In: Wein AJ, Kavoussi LR, Partin AW, Peters CA, editors.
Campbell-Walsh Urology. 11th Edition. Elsevier, PA; 2016. pgs. 35-60.
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