Assessment of the Urological Patient : History and Examination

1 Assessment of the urological patient: History and examination

Assessment of the urological patient involves initial assessment of the patient’s age, built, taking a complete and detailed history, a thor- demeanour, intelligence and socio‐economic ough physical examination and analysis of a group and adapt your consultation style accord- urine sample. As with all history taking the ingly, based on your experience, in an attempt enquiry should include details of the presenting to make the patient feel comfortable. An ice- complaint and its history, the relevant past breaker such as ‘I hope you haven’t been medical history and a family and drug history. waiting too long’ or ‘Did you manage to park Th e examination should include the abdomen, easily?’ can help the patient to relax. Aim to external genitals and a digital rectal examination project a caring, experienced and open but in men and a vaginal examination in women, if professional image that will put the patient at clinically indicated. Th e urinalysis is most readily ease and facilitate communication. performed by dipstick testing; a formal micro- Then begin with, ‘How old is your patient scopic analysis may be required to investigate and what is his/her occupation? How can any abnormality. I help’, or ‘Your GP has written to us saying you have a problem with…please tell me about it’, which are good open questions to start the H istory consultation. Look out for signs that the patient may not be able to describe the problem due to Communication skills anxiety or embarrassment or a language bar- rier. Then listen. Listen until you are clear on It is perhaps even more important with urology the nature of the problem, or the patient has than with other specialities, because of the gone off on a tangent and you feel you have to personal nature of someCOPYRIGHTED of the symptom com- gently MATERIALredirect him/her. Once you are clear on plexes, for the clinician to create a personal the presenting complaint, obtain a history of it rapport and a warm environment to facilitate and ask more specific questions aimed at enquiry into sometimes intimate problems. eliciting the important diagnostic points. The Stand up to greet the patient and welcome him/ following are common complaints initiating a her warmly. Introduce yourself and make an consultation.

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Basic symptoms computerised tomography including a urographic phase and cystoscopy as a minimum. Haematuria Non‐visible haematuria The presence of blood in the urine is termed hae- Non‐visible or microscopic haematuria is maturia. Haematuria has many causes ranging defined by the presence of more than three from the insignificant to life‐threatening cancers erythrocytes per high‐power field on microscopy and is often a result of urinary tract infection or at least 1+ on dipstick of a fresh midstream (UTI). The patient should therefore be asked urine sample. It is usually detected in the com- whether the blood was accompanied by symp- munity on routine urine testing or during the toms of urinary tract inflammation such as dysu- investigation of symptoms. A few erythrocytes in ria, pain, urinary frequency or whether the urine the urine are common and often found after smelled offensive. In all patients with a history of heavy exercise. After exclusion of infection as a haematuria, the urine should be examined by cause, a single episode of non‐visible haematuria dipstick and cultured if this suggests infection accompanied by LUTS or persistent asympto- (see later). The extent of investigation required matic haematuria is clinically significant and for a confirmed infection is guided by patient should be investigated. characteristics; however, all patients with symp- Asymptomatic non‐visible haematuria com- tomatic infections should be treated with appro- monly represents early chronic kidney disease, priate antibiotics and the urine retested for blood and patients under the age of 40 with no other once the infection has resolved. It is important to risk factors for urothelial malignancy should be remember that UTI itself can be the first sign of investigated with urine protein/creatinine ratio serious urinary tract pathology. Uncommonly, and first referred for nephrological rather than urine discolouration that is reported as haematu- urological opinion if evidence of deteriorating ria may be caused by myoglobinuria, beetroot glomerular filtration rate, significant proteinuria intake and drugs such as rifampicin. It is generally or hypertension is present. The patient should advisable to investigate for haematuria anyway. be asked if there has been a recent upper respir- Haematuria may be visible or non‐visible and atory tract infection as this may be associated associated with other LUTS or asymptomatic, and with glomerulonephritis. this is the starting point for subsequent enquiry. Urological investigation with urinary tract ultrasound and cystoscopy of all other patients is Visible haematuria recommended, and in some centres computer- Visible haematuria is arguably the most impor- ised tomography is also performed. The incidence tant symptom in urology as it implies urological of finding a significant urological abnormality in cancer until proven otherwise, and all patients patients with asymptomatic non‐visible haema- including those with demonstrated infection turia is less than 10%. should undergo investigation. The patient may notice the blood at the beginning, throughout or at the end of the urinary stream, and this sign may KEYPOINTS give an indication of its origin and cause. Initial • Haematuria has many causes ranging from haematuria often originates from the prostate or the insignificant to a range of malignancies. urethra and as such is less likely to reflect bladder Infection should always be excluded; or upper urinary tract pathology, whereas haema- however, it may also be the first sign of turia throughout the stream implies the blood serious pathology. emanates from the bladder or above. Terminal • Asymptomatic non‐visible haematuria is haematuria may indicate upper tract bleeding. commonly nephrological, not urological. This differentiation is unreliable, however, and • Visible haematuria is caused by malignancy all patients require the same investigation with until proven otherwise. upper urinary tract cross‐sectional imaging by

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Lower urinary tract symptoms Dysuria – This is a painful micturition and is generally felt both suprapubically and over the LUTS are a common reason for someone to urethral meatus. It is usually a sign of inflam- seek a urological opinion with over a half of mation in the urinary tract. the population likely to experience them at some point in their lifetime; the incidence, as might be While often attributed to bladder outfl ow expected, increases with age. LUTS occur in both obstruction and functional bladder problems, sexes, reminding us that these symptoms are not LUTS are not disease or organ specifi c. Storage specifi c to the enlarged prostate and are currently symptoms in particular may refl ect a wide range classifi ed as either voiding or storage symptoms. of pathologies from impaired fl uid and solute handling problems to non‐specifi c infl ammation Voiding symptoms of the urinary tract and can also be a sign of under- Hesitancy – This is a delay in the start of lying malignant processes. Identical storage and micturition. Normally it takes a second or so to voiding symptoms may be caused by either start passing urine. bladder muscle dysfunction or outfl ow tract Intermittency – This is a stop/start pattern that obstruction due to benign or malignant prostatic happens involuntarily during micturition and is enlargement. It is therefore important to deter- generally due to prostatic obstruction. mine the presence of individual voiding and stor- Poor flow – This is a decreased flow of urine and age symptoms, to quantify their severity and to can be due to prostatic obstruction or urethral elucidate other symptoms and signs that may stricture. This happens over a long period of indicate their origin. time. Straining – This is due to the use of abdominal Polyuria muscles to empty the bladder. Polyuria is the excessive production of urine, Terminal dribble – This is passing drops of urine usually defi ned as over 2.5 L/24 h in an adult. at the end of micturition and is generally an It should not be forgotten that someone who early sign of obstruction secondary to prostatic drinks large volumes of anything, particularly enlargement. diuretics such as caff eine‐containing drinks and Feelings of incomplete bladder emptying – alcohol, is likely to need to void more often due to This is the feeling of needing to void again increased urine production. In addition to the soon after voiding. fl uid load, caff eine increases bladder smooth muscle excitability directly and can precipitate Storage symptoms urinary storage symptoms. A history of fl uid Frequency – A normal adult will pass urine 3–7 intake is therefore valuable. It is also important to times during the day with volumes of around remember the impact of non‐urological diseases 200–400 mL per void. Urinary frequency is either on urinary symptoms, specifi cally those infl u- due to increased urinary output (polyuria) or encing renal fl uid and solute handling such as decreased bladder capacity. diabetes mellitus, which causes glycosuria and Nocturia – This is getting up at night more than an osmotic diuresis, and less commonly diabetes once. It can be due to either increased urine insipidus. Random serum glucose and electro- production or decreased bladder capacity. lytes should therefore be analysed. Frequency without nocturia is usually psychological. On the other hand, nocturia without Nocturia frequency can be related to heart failure or dia- Nocturia is the need to wake from sleep to pass betes insipidus. urine at night. In normal health, nocturnal urine Urgency – The International Continence Society output is reduced to less than the bladder capacity defines urgency as ‘a complaint of a sudden so that we don’t need to get up to void. Nocturia compelling desire to pass urine, which is diffi- may be caused by either the functional bladder cult to defer’. reservoir volume being reduced, such as occurring

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in patients with large post‐micturition residual intervention, including catheterisation, or sur- urine volumes, or by producing too much urine gery should be obtained as often a resected pros- at night so that the bladder is unable to store it. tate may regrow and iatrogenic urethral and This may reflect general polyuria, ornocturnal bladder neck strictures are common. The pres- polyuria, a specific entity in which more than a ence of specific additional symptoms suggestive third of 24 h urine production occurs at night. of pathology in addition to bladder outflow Congestive cardiac failure may cause nocturia obstruction should also be determined. These through several mechanisms, as can obstructive include haematuria, nocturnal enuresis (the sleep apnoea. A history of the symptoms and involuntary loss of urine at night), which is signs of heart failure and the presence of snoring strongly suggestive of high‐pressure chronic should therefore be sought. As with polyuria, urinary retention when occurring in adults, or evening intake of pharmacological and non‐ associated sensory disturbances or back pain, medicinal diuretics such as caffeine and alcohol which should initiate investigations to exclude is an obvious but often overlooked cause of disruption of the bladder’s neurological control nocturia. such as spinal cord compression. Furthermore, Nocturia is more common in the elderly, and a symptoms and signs of inflammation of the loss of the circadian secretion of antidiuretic urinary tract may indicate an inflammatory hormone, which normally reduces nocturnal urine cause for urinary storage symptoms or bladder production, may be present. It is therefore impor- outflow obstruction complicated by infection. tant to assess the patient’s fluid intake, urine output In the absence of polyuria and symptoms and voided urine volume to allow identification of suggestive of alternative diagnosis, the most polyuria, reduced functional bladder capacity and likely causes of LUTS are bladder outflow nocturnal polyuria, and this is performed using a obstruction and bladder dysfunction, that is, frequency–volume chart. either overactive or underactive detrusor contraction. The subsequent management of LUTS is strongly influenced by their severity and the impact on the patient – this is quantified using Overactive bladder the International Prostate Symptom Score (IPSS) syndrome patient questionnaire. Functional bladder problems and bladder outflow obstruction can Overactive bladder syndrome is a condition with sometimes only truly be differentiated from each characteristic symptoms of ‘urinary urgency’, other by pressure‐flow urodynamic studies. usually accompanied by frequency and nocturia, with or without urgency incontinence (i.e. stor- Incontinence age LUTS), in the absence of urinary tract infec- Incontinence is the involuntary loss of urine. tion or other obvious pathology’. The condition It is highly prevalent in the community and may be associated with involuntary contractions occurs more commonly in females in an of the bladder, and this is termed detrusor over- activity (see Chapter 12); however, these contractions are not always associated and are present in KEYPOINTS many asymptomatic patients. Investigation of the patient with LUTS is focused on excluding disorders of fluid handling; Evaluation of LUTS detecting a specific infective, inflammatory or malignant urological cause; and quantifying the A detailed history of the speed of onset of LUTS is severity and impact on quality of life of the important: uncomplicated bladder outflow symptoms. This is achieved using the urine obstruction tends to be insidious, whereas the dipstick, the frequency–volume chart and the rapid onset of severe symptoms suggests an alter- IPSS questionnaire. native diagnosis. A history of previous urological

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age‐dependent manner. Incontinence causes Intermittent incontinence considerable morbidity and expense, and when taking the history the urologist should fi rst ● Urge urinary incontinence is the complaint determine whether the incontinence is continu- of involuntary leakage accompanied by or ous or intermittent – the latter category may be immediately preceded by urinary urgency – subclassifi ed into stress, urge, mixed stress and the feeling of the need to pass urine that is urge or overfl ow incontinence. Symptom ques- diffi cult to defer. Urge incontinence may be tionnaires are useful in documenting symp- caused by an overactive bladder, a complex toms, and a voiding diary of fl uid intake and and incompletely defi ned abnormality of urine output compiled over at least 3 days bladder smooth muscle contractility or by should be recorded. Further insight into the bladder infl ammation. It is important to deter- aetiology of incontinence can be gained by care- mine the cause by assessing the presence of ful history taking. accompanying symptoms and abnormalities on urine analysis. Th e presence of suprapubic pain, haematuria, dysuria and voiding urinary International Continence Society symptoms all suggest a cause other than definitions idiopathic overactive bladder. ● Stress urinary incontinence is the complaint ● Stress urinary incontinence : Involuntary of involuntary leakage on eff ort or exertion, or urine leakage on effort or exertion or on on sneezing or coughing. In women this occurs sneezing or coughing. ● Urgency urinary incontinence : Involuntary due to weakening of the pelvic fl oor neuro- urine leakage accompanied by or immediately muscular mechanisms that support the ure- preceded by urgency. thra and bladder and can occur after childbirth ● Mixed urinary incontinence : Involuntary or in association with aging. It is also a sign of urine leakage associated with both urinary sphincter weakness and may occur urgency and exertion, effort, sneezing or after prostatectomy in men. A detailed obstet- coughing. ric history of respiratory disease and smoking, ● Overactive bladder : Urgency that occurs with or without urgency urinary incontinence and pelvic irradiation and pelvic surgery and bowel usually with frequency and nocturia. Whether habit is therefore required to evaluate stress occurring with incontinence (wet) or without incontinence. incontinence (dry). ● Both stress and urge incontinence may occur together for a number of reasons, and management is initially directed according to which Continuous incontinence type of incontinence predominates. Sometimes determining this requires a pressure‐fl ow Continuous incontinence implies complete fail- urodynamic studies. ure of the sphincter mechanism, as occasionally ● Overfl ow incontinence is characterised by occurring after bladder outfl ow tract surgery intermittent dribbling of small amounts of and more commonly after radical prostatectomy, urine and nocturnal enuresis – the involuntary or the presence of an abnormal urinary tract loss of urine occurring during sleep. Th is allowing bladder or ureteric urine to bypass occurs as the normal inhibitory mechanisms the sphincter mechanism. Th is may be a fi stula and voluntary sphincter contraction that occurring after gynaecological surgery or as is occurs during the day in an eff ort to minimise common in third world countries as a result of leakage is suppressed in sleep. Overfl ow incon- tissue necrosis after poorly managed childbirth. tinence occurs in association with a chroni- Rarely congenital abnormalities such as an cally distended bladder that never empties and ectopic ureter may open distal to the urinary is caused by bladder outfl ow obstruction or sphincter causing continuous incontinence neurological disease and may be insidious. from birth. When occurring in association with bladder

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The pain associated with renal inflammation KEYPOINTS is generally constant and severe and may be associated with systemic signs of sepsis. It may When evaluating incontinence, the history also be associated with gastrointestinal symp- should focus on determining whether it is toms due to the close proximity of the perito- continuous or intermittent. Intermittent incontinence is characterised by stress, urge, neum and intra‐abdominal organs, and a careful mixed stress and urge or overflow incontinence. history and examination may be required to The pathophysiology of the incontinence can determine the true origin. Occasionally, loin subsequently be ascertained with minimal pain may be caused by small calculi in the renal additional investigation. collecting system, particularly if they are still adherent and blocking a papilla.

outflow obstruction, nocturnal enuresis may Ureteric colic be a sign of upper urinary tract obstruction and renal impairment termed high‐pressure Ureteric or renal colic refers to the pain that chronic urinary retention. results from acute obstruction of the ureter associated with the passage of a urinary stone. It is Urological pain historically compared in severity to the pain of childbirth, and in the age of modern obstetric General analgesia, renal colic can reasonably be considered the most severe pain one might be likely to Pain originating from the urological tract is suffer other than through trauma. Renal pain is generally caused by either distension of a viscus intermittent and intensifies with ureteric peri- due to obstruction of the flow of urine, for example, stalsis, which, in the presence of obstruction, a ureteric stone, or inflammation. The pain caused causes the intrarenal pressure to rise and charac- by inflammation is more severe when the paren- teristically causes the patient to writhe and chyma of an organ is involved, for example, testis unable to get into a comfortable position. This or kidney, as this causes the capsule to be stretched. feature differentiates it from other, generally As with all types of pain, a careful history of its site, more morbid, causes of acute abdominal pain duration, type (dull, sharp or burning), radiation, that are generally minimised by lying still. exacerbating and relieving factors and other asso- It is sometimes possible to clinically determine ciated symptoms should be obtained. the site of ureteric obstruction from the location of the pain. Pain originating from the upper two‐ Loin pain thirds of the ureter (that above the pelvic brim) may be referred to the iliac fossa on either side The term loin refers to the area between the lower and must be differentiated from surgical causes. ribs and the pelvis and is used to describe both A stone in the lower third of the ureter near the human and animal anatomy. There are many bladder may cause LUTS and strangury: this is causes of pain in this area and many of these are an unpleasant sensation of a constant need to non‐urological. Loin pain truly originating from void that is not relieved by voiding and suprapu- the kidney is more accurately referred to as renal bic and urethral pain at the end of voiding. Pain angle pain; this is the area between the lateral may also be referred to the tip of the penis or borders of the erector spinae muscles, the 12th labia. rib and the iliac crest. Renal angle pain results Pain caused by chronic insidious obstruction either from distension of the renal pelvis, which of the ureter, for instance, by a slow‐growing ure- occurs with ureteric obstruction, or from disten- teric tumour or gradual extrinsic compression, is sion of the renal capsule, which occurs with acute considerably less severe than acute ureteric colic inflammation of the renal parenchyma in asso- and may be a chronic dull ache or not clinically ciation with pyelonephritis. significant. Non‐urological causes of loin pain

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are common and can be diffi cult to diagnose. Acute scrotal pain in adults may also be due to Musculoskeletal back pain is common and is torsion but is more common in this age group typically associated with movement or particular caused by infections and trauma. A history of positions; however, it can be diffi cult to identify. LUTS and those suggestive of infection, as well Other less common causes include pain origi- as a recent change in sexual partners, is therefore nating from the pleura, gastrointestinal tract, important to elicit. Trauma is usually evident; spleen and liver. however, a history of trauma does not exclude other causes of the pain such as torsion and Suprapubic pain tumour. It is not unheard of for an adult to present with testicular pain not resolving after Acute distension of the bladder associated with seemingly minor trauma and found to have a acute urinary retention causes intense pain that torted ischaemia testis requiring removal. is relieved by catheterisation. Chronic bladder Scrotal pain may also originate from infl am- distension, however, is painless, and the bladder matory conditions aff ecting the scrotal wall; may contain litres of urine with no discomfort. these include cutaneous abscess, cellulitis and Constant suprapubic pain unrelated to voiding is Fournier’s scrotal gangrene. Chronic scrotal unlikely to be urological and may originate from pain may be caused by chronic epididymitis or other pelvic organs or distal bowel; intermittent non‐infl ammatory conditions such as hydrocele pain associated with bladder fi lling relates to or epididymal cyst. Varicocele is an abnormally infl ammation most commonly caused by bacte- dilated collection of veins draining the testis and rial cystitis. Severe infl ammation of the bladder characteristically causes a chronic dull ache may cause peritoneal involvement and signs of worse during standing for long periods and localised peritonitis. relieved by lying. Chronic scrotal pain may also Scrotal pain be referred from the retroperitoneum, refl ecting the embryological origin of the testis, or an Scrotal pain may be acute or chronic. Acute scro- inguinal hernia. tal pain in a child is caused by torsion of the testis or testicular appendage (hydatid of Morgagni) Urethral pain and the resulting ischaemia unless proven other- Pain felt in the urethra is usually caused by wise, and urgent surgical exploration of the infl ammation. Dysuria refers to urethral pain scrotum generally indicated. Pain due to torsion that occurs during voiding and is felt at the is generally of sudden onset and may awake the external urethral meatus. It is commonly caused patient. Th ere may be associated vomiting and by lower UTI or infl ammation. Urethritis is previous episodes of intermittent pain. Th e clini- accompanied by urinary frequency and urgency. cal presentation of testicular torsion is varied, however, and pain may be transient and have Prostatic pain resolved at the time of examination. Testicular torsion may present with non‐ Pain originating from prostatic pathology may be specifi c discomfort in the lower abdomen or have diffi cult to describe and be poorly localised. Pain clinical features of appendicitis; it is therefore is often localised to the perineum, between the imperative to examine the scrotum in any patient anus and the scrotum, and may be referred to the presenting with abdominal pain. Urinary symp- testis, suprapubic area or back. Pain on ejacula- toms are sometimes present with testicular tor- tion is strongly suggestive of prostatic pathology, sion and cannot, therefore, be taken as indicating and there are often associated both storage (due urinary infection, which is far less common than to infl ammation) and voiding (due to obstruction) torsion in children. No surgeon ever regretted LUTS. Prostatic pain is generally caused by operating on an acutely painful scrotum, and infl ammation; locally advanced prostate cancer surgical exploration should be regarded as an can cause a similar pain when it invades peripro- investigation rather than a treatment. static tissues.

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Urinary tract infections KEYPOINTS UTI is the symptomatic inflammatory response By taking a careful history and examination, of the urothelium to the presence of microorgan- most causes of urological pain can be isms and is usually associated with bacteriuria elucidated without further investigation. (the presence of bacteria in the urine). UTIs are a Distension of a urological viscus and stretching common reason for referral. The presentation of the capsule of an organ due to inflammation may be varied, depending on the organism and are the main mechanisms of urological pain. site of resulting inflammation, and it is important Loin pain has many non‐urological causes. to elicit the precise symptoms resulting from the Scrotal pain in children is an emergency and purported infection. Bacteriuria itself may be usually necessitates surgical exploration to asymptomatic; the urine of most patients with exclude testicular torsion. long‐term catheters contains bacteria and this only requires treatment when associated with symptoms of inflammation. Erectile dysfunction Lower UTIs are those in which the inflamma- Erectile dysfunction is the inability or reduced tion is confined to the urethra and bladder and ability to attain a satisfactory penile erection. typically present with dysuria which is the sen- There are a number of causes, and the history sation of urethral pain on voiding and com- should be aimed at differentiating between them. monly referred to as burning urine or passing It is firstly necessary to confirm the problem as broken glass. Dysuria is usually accompanied by truly erectile dysfunction and not another sexual urinary frequency, urgency and suprapubic pain dysfunction such as failure of or pain on ejacula- relieved by voiding when the bladder is inflamed, tion, anoragsmia or psychological causes in and the urine may be cloudy or smell bad. This nature; the most important point to elicit here is symptom complex is commonly termed cystitis. whether morning erections occur and whether A substantial proportion of lower UTIs present the dysfunction occurs all the time or just in a with visible haematuria and termed haemor- particular situation. A reduced libido is a sign of rhagic cystitis. both psychological causes and testosterone Infections involving the upper urinary tracts deficiency. (ureters and kidneys) present differently, Erectile dysfunction may be caused by trauma although lower tract symptoms may also be both to the penis itself and the pelvis, and this present if secondary to an ascending infection. history is important to elicit as traumatic vascu- Infection of the renal parenchyma promotes a lar damage is the only cause that is, sometimes, systemic inflammatory response, and the correctable by surgery. The next step is to iden- patient is febrile and unwell. The combination tify any reversible causes other than trauma, of loin pain, tenderness and fever with evi- which although rarely resulting in complete dence of bacteriuria or pyuria is termed acute return of erections can often improve the situa- pyelonephritis. tion and are important to identify for other reasons. The most prevalent of these are smoking Pneumaturia and alcohol. It should not be forgotten that erectile dysfunction may be the first symptom of Pneumaturia is the presence of air in the urine. atherosclerotic vascular disease and may It is an uncommon symptom and is almost predate ischaemic heart disease, and a general pathognomonic for the presence of an abnormal assessment of the patients’ cardiovascular risk communication between the bladder and status and lipid profile is indicated. The history bowel – a vesico‐colic fistula. This occurs in the should also determine whether the patient is fit presence of bowel inflammatory disease such as cardiovascularly enough to resume sexual activ- diverticulitis, or malignancy, and is also predis- ity should his erections be artificially improved. posed to by pelvic radiotherapy.

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retention. Traditional signs of an enlarged kidney are a bimanually palpable mass in the loin which Examination moves up and down with respiration, and which Examination of the urological patient should you can get above. A normal kidney is palpable in include a general examination, examination of thin individuals (Figures 1.1 and 1.2 ). the abdomen, the external genitalia and when An enlarged bladder may not be palpable if indicated a digital rectal examination and vaginal the patient is large, and it is often not possible examination. Th e urologist should be gentle and to reliably diff erentiate by palpation between sensitive to the patient, and the intimate nature an enlarged full bladder and a pelvic mass of the examination and verbal permission for each aspect of the examination should be sought. It is wise and mandatory when a male urologist is Bimanually You can ‘get above it’ palpable examining a female patient to have a nurse chap- lump erone present who will record their details in the medical record to document their presence.

Costal General margin

Non‐specifi c signs of anaemia, cachexia, lym- Moves with phadenopathy, hepatomegaly and uraemia respiration may all be urologically related, and the abdomen and external genitalia should fi rst be properly inspected. With the increasing advance- ment of minimally invasive surgical techniques, it is becoming less common to see the large deforming thoraco‐abdominal, ‘roof top’ or extended paramedian scars of the open nephrectomy, and it may be diffi cult to see the small punctures through which laparoscopic Figure 1.1 Physical signs of an enlarged kidney. ports are inserted. Th e combination of two small punctures with a 4–5 cm iliac fossa scar suggests a nephrectomy, whereas three small punctures are created during laparoscopic pyeloplasty or partial nephrectomy. Similarly a Resonant to series of lower abdominal punctures may percussion conceal a major operation such as radical prostatectomy or cystectomy; a cystectomy may not necessarily involve creation of a stoma if an orthotopic bladder reconstruction has been Colon performed. A lower midline or Pfannenstiel scar may indicate any open pelvic operation and is used during both urological and gynaecological procedures, again less commonly.

Abdomen Urological examination of the abdomen is focused on detecting an enlarged kidney, sug- Figure 1.2 There is often a band of resonance in gesting tumour, or bladder, suggesting urinary front of the kidney from gas in the colon.

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Resonant

Resonant Dull

Bladder

Figure 1.3 The bladder is dull to percussion.

Figure 1.4 An enlarged bladder may go to one or other side.

Inferior epigastric vessels

Rectus sheath Anterior superior iliac spine Direct hernia Indirect inguinal hernia Inguinal ligament Pubic tubercle

Femoral artery Femoral hernia

Saphena varix

Long saphenous vein

Figure 1.5 Landmarks for groin hernias.

(Figures 1.3 and 1.4). It is therefore important Examination of the groins is an important part of to re‐examine the patient after catheterisation, the urological investigation. Although inguinal if clinically indicated, as a pelvic mass will still and femoral herniae are dealt with by general be present. An ultrasound will also reliably surgeons, they often account for symptoms that distinguish between solid and cystic swellings. initiate urological referral (Figures 1.5 and 1.6).

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Inferior epigastric artery and vein

Anterior superior iliac spine Indirect hernia Direct hernia

Femoral artery Pubic tubercle Femoral vein

Figure 1.6 Pantaloon hernia.

Inguinal lymph nodes drain the external be strictured and involved with a transitional cell genitalia and lower limb and may be enlarged carcinoma or ectopic. Th e glans penis should in infections or tumours of these regions. also be examined, specifi cally as it may harbour a Examination of the groin for enlarged lymph premalignant skin lesion or overt squamous cell nodes is particularly important when there is a carcinoma. Palpation of the penile shaft will penile cancer. Small, so‐called ‘shotty’ nodes, a identify the hard localised plaques that cause reference to shotgun pellets, are normally palpa- erectile deformity and dysfunction in Peyronie’s ble in thin individuals; tenderness or persistent disease, and severe strictures of the penile ure- enlargement over 1 cm in size is a sign of con- thra may also be palpated ventrally. cern. Groin nodes may also be involved in meta- static spread from pelvic disease but not testis Scrotum cancer unless this has advanced to involve the Examination of the scrotum should take place scrotal wall. with the patient both lying and standing. External genitalia Th e scrotum should at fi rst be inspected with the patient standing, looking for skin lesions and the characteristic bag of worms’ appearance Penis of the varicocele (Figure 1.7 ). With the patient lying, the scrotum should be Th e penis should also be routinely examined. gently palpated looking for abnormal lumps. Th e foreskin may give rise to a number of symp- If one is found, the following questions should toms, and when infl amed or phimotic (tight and be answered. scarred), it can be implicated in the aetiology of UTIs, LUTS, pain and haematuria. Th e foreskin ● Can you ‘get above’ the lump? If you can it should be gently retracted after asking the must be scrotal, and if not it is probably an patients permission or alternatively asking the inguinal hernia (Figure 1.8 ). patients to do this themselves to allow inspection ● Is the swelling solid or cystic? Th is is tested by of the external urethral meatus. Th e meatus may determining the presence of fl uctuance in

Chapter No.: 13 Title Name: Kaisary 0002618351.indd 0002618351.indd 13 12/28/2015 4:53:47 PM Comp. by: Mohamad abdul Rasheeth Date: 28 Dec 2015 Time: 04:53:44 PM Stage: Printer WorkFlow:CSW Page Number: 13 14 Assessment of the urological patient

Cough impulse

Figure 1.9 Lump in the scrotum: check whether it is solid or fluctuant. Determine fluctuation in two planes.

Figure 1.7 Varicocele: enlarged testicular veins. There is a cough impulse and the swelling disappears when the patient lies down.

Cylinder, for example, roll of paper

Pen torch

Figure 1.10 To see if light shines through a swelling, it helps to use a cylinder, for example, one made from rolled‐up paper.

Testicle ●● Is the lump separate from the testis or not? A cystic swelling inseparable from the testis is probably a hydrocele (Figure 1.11). Figure 1.8 Lump in the scrotum: can you get ●● A cystic lump separate from the testis is probably above it? an epididymal cyst (Figure 1.12). In practice it is often difficult to differentiate these two entities; two planes (Figure 1.9). A cystic lesion also this is not clinically important. usually transilluminates, that is, lights up if a ●● If the lump is solid, it is crucially important to torch is pressed against it in a darkened room determine whether it is separate from the testis (Figure 1.10). or not. If it is separate, it is most likely to be an

Chapter No.: 13 Title Name: Kaisary 0002618351.indd 0002618351.indd 14 12/28/2015 4:53:47 PM Comp. by: Mohamad abdul Rasheeth Date: 28 Dec 2015 Time: 04:53:44 PM Stage: Printer WorkFlow:CSW Page Number: 14 Assessment of the urological patient 15

Vas deferens Parietal tunica vaginalis Epididymis Epididymis

Testis Testis

Hydrocele

Figure 1.14 A solid swelling in the testis is a cancer until proven otherwise. Figure 1.11 Hydroceles lie in front of the testis and tend to surround it.

area of infl amed epididymis or sperm granu- loma after vasectomy (Figure 1.13 ). If it is not separate from the testis, it should be considered a testicular tumour until proven otherwise Cysts (Figure 1.14 ), and an urgent ultrasound will of epididymis confi rm. ● Th e vas deferens lies posterior to the spermatic cord. If it is infl amed, it can feel thickened and fi rm. If it has been operated Testis upon, for example, vasectomy, it might show a nodule along its course. If multiple knotty swellings are felt, this would strongly suggest tuberculosis (Figure 1.15 ).

Figure 1.12 Cystic swellings behind the testis are cysts of the epididymis. Vaginal examination Vaginal examination should be performed in women with LUTS or incontinence, haematuria or pelvic pain. Th e external urethral meatus should be inspected for signs of surgery or stenosis and the patient asked to cough both in the Epididymis lying and standing positions to assess urethral hypermobility, the presence of pelvic organ pro- lapse and stress incontinence. Although rare, Testis urethral carcinoma may cause urethral stenosis and fi rst present as LUTS. Uncommonly, a urethral diverticulum may be palpable. Th is presents as a cystic mass in the anterior vaginal wall and is associated with per- Figure 1.13 Solid swellings in the epididymis are sistent dysuria, dyspareunia (painful sexual usually inflammatory. intercourse) and UTI.

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Ureter

Vas deferens Vas

Vesicle

Nodule in prostate Epididymis

Figure 1.15 Multiple knotty swellings in the Figure 1.16 Anatomical landmarks that may be epididymis and a ‘beaded’ are highly suggestive felt per rectum. of tuberculosis.

Digital rectal examination KEYPOINTS Rectal examination although included in the general abdominal examination is arguably not • As with all surgical examinations, a general and organ‐specific examination is required. mandatory for all urological complaints, although generally advisable when dealing with pelvic or • Great sensitivity should be applied when LUTS and haematuria. One may perform a rectal examining intimate organ systems and examination in both sexes in the left lateral posi- specific permission always sought. tion. Inspection of the anal margin is mandatory, • A chaperone is required during the urological for anal carcinoma or external thrombosed piles, examination. and always ask the specific permission of the • Inspection should precede palpation, including patient and exclude the presence of an anal fissure during the rectal and vaginal examination. or painful haemorrhoids first. • Vaginal examination is important in women Introduce the gloved index finger carefully and with recurrent infections and unexplained slowly with plenty of lubrication. Once inside the urinary symptoms. rectum, carefully palpate circumferentially to exclude a low rectal tumour. Then palpate the prostate gland, which is found anteriorly. Palpate for examination under a light general anaesthetic nodules, a discrepancy between the two lateral with the patient in the lithotomy position. In the lobes, and firmness (Figure 1.16). The examination male one finger is placed in the rectum, and in will often be uncomfortable but should not be the female two fingers are placed in the vagina, painful; a tender prostate is a sign of inflammation. and the organs are examined by compressing A more thorough examination of the pelvis in them against the other hand placed on the both sexes may be performed using bimanual anterior abdominal wall suprapubically.

Chapter No.: 13 Title Name: Kaisary 0002618351.indd 0002618351.indd 16 12/28/2015 4:53:48 PM Comp. by: Mohamad abdul Rasheeth Date: 28 Dec 2015 Time: 04:53:44 PM Stage: Printer WorkFlow:CSW Page Number: 16