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The Urological Examination in Family m a The Urological Examination In Family Practice C. T. WOLAN, MD SUMMARY This article outlines the various procedures available to the family physician who wishes to perform a complete urological examination on a patient. Techniques for specimen collection, etc., are described. Those procedures which would not be performed by the family physician are noted, showing when they might be ordered as an aid in diagnosis. Dr. Wolan is clinical associate professor of surgery at the University of Saskatchewan and head of the Department of Urology at the University Hospital. THE FAMILY physician is confronted with problems of The same is true of a patient with chronic bladder outlet the genitourinary tract more frequently than might be obstruction - he fills until the bladder is painful, then expected. It has been estimated by various observers that dribbles out a few ml with much effort and experiences between three and eight percent of patients coming to a relief, only to void again in 15 minutes because the bladder family physician's office have a primary or secondary is again full. Some people have become so used to this urological complaint. The family physician should be able frequency or are so reticent to admit a urinary problem in to carry out much of the preliminary investigation at least case it means an operation that they say "I don't have any to make a preliminary diagnosis, deciding from this if and trouble at all. I urinate every hour during the day and get when to refer the patient to a urologist or nephrologist for up and pass water several times at night". Frequency with further investigation and/or treatment. no urological findinigs should alert one to the possibility of diabetes. History 1. Frequency 2. Nocturia Frequency of urination is a symptom indicating a This is similar to frequency, but because it is more urinary problem, usually inflammation or irritation of the troublesome to get up at niglht to void, the patient is more bladder, prostate, or urethra. An inflamed bladder has likely to seek help sooner. limited distention and needs more frequent emptying to keep it empty and less painful. Prostatitis gives the urge to 3. Dysuria void more frequently, as does urethritis. A stone or other Pain on urinating is usually a burning type of 'scalding' foreign body is especially irritating to the bladder when it discomfort, usually due to inflammation of the urethra or produces a mechanical inflammation of the trigone. bladder. Terminal dysuria (discomfort at the end of voiding Also, a bladder which does not empty completely or after voiding) is usually due to a trigonitis or prostatitis, requires only half its usual time to reach full distention since this is the part of the urinary tract which contracts at again and needs emptying more frequently. It takes only a the end of urination to get the last bit of urine out. few ml let out of a bladder to give a feeling of relief from urgency; for example, a patient with a painful bladder 4. Pyuria distended well above his pubis may experience relief after Patients often complain of cloudy urine, which is not only a few ml have been drawn off by catheter, even necessarily pyuria. Older men, particularly, keep a jar at the though he still has about 1000 ml of urine in his bladder. bedside to save themselves a trip to the toilet. They pass 30 CANADIAN FAMILY PHYSICIAN/DECEMBER, 1975 family physician for some other complaint, but because he was thorough and did a proper urinalysis instead of the 'sink test', lie sent them for investigation, which uncovered an early bladder tumor, with subsequent complete cure. A word about hematuria in patients who are anti- coagulated: some physicians are inclined to attribute this to anticoagulation and leave it at that. In my experience the anticoagulation is often 'the straw that broke the camel's back' and incites a pre-existing lesion to bleed. These people need urological investigation, or at least, a urological consultation. 6. Urgency This has the same causes as frequency but much more acutely. Sometimes urgency results in urgency incon- tinence; this more than anything else brings the patient to the physician for relief. They can put up with a little frequency but are less tolerant of urgency and almost totally intolerant of urgency incontinence. 7. Incontinence Urgency incontinence has already been mentioned. In older males, incontinence may be overflow due to a distended bladder. In a middle-aged or older female, it may be due to relaxation of the pelvic floor with a cystourethro- cele and loss of vesicle-urethral angle. This can be surgically corrected with good results. Another incontinence in older women is often due to what I like to call a 'lead pipe' urethra. The urethra is chronically inflamed, fibrotic, and strictured as a result of repeated urethritis and periurethritis. The sphincter action is ineffective in these patients, who are almost miraculously cured by urethral dilatation. It is very hard to convince some gynecologists that this syndrome exists; instead, they keep on doing repeated Marshall-Marchette types of opera- tion, etc., without success when one urethral dilatation cures them, even though it may have to be repeated periodically. Neurogenic incontinence from a nerve lesion, spinal warm urine which cools by morning, making the sediment trauma, etc., requires urological and neurological investiga- precipitate out and become visible. Also, if they do have tion and various treatments, often with appliances such as some infection the change in pH from urea splitting catheters and collection devices. bacteria which have been growing in the urine for several The aged in their second childhood have bladder control hours precipitates out the solute normally held in solution similar to that found in young children. They just do not and makes a cloudy sediment. A few drops of dilute HC1 or cerebrate well enough. acetic acid will dissolve the sediment and the urine will become clear, whereas real pyuria will remain cloudy. 8. Incomplete Emptying Pus in the urine indicates urinary tract infection which This may be neurological or obstructive, both of which needs further investigation, except for pyuria following require further investigation. The older man who must prostatectomy or urinary tract surgery. These urines usually urinate two or three times while shaving in the morning culture negatively; the pyuria after prostatectomy might almost certainly has prostatism and does not empty his last for two to three months and is a normal finding. bladder completely the first time. The 'busy little girl' who runs into the toilet, squirts a 5. Hematuria little and runs out to play again in a hurry, is one who Hematuria, whether microscopic or gross, is always needs training, because this eventually leads to more serious important. Asymptomatic hematuria without frequency or urinary problems. dysuria and in the absence of trauma is much more important than that with symptoms. The hematuria of 9. 'Organ Music' prostatism is almost always due to infection rather than to This is a term originated by one of my colleagues. It carcinoma of the prostate. Prostatic carcinoma does not refers to vague groin, suprapubic, and testicular discomfort. bleed by itself, but when it produces retention and It is quite often a 'fixation syndrome' and may indicate low infection, there may be hematuria. grade urinary or prostatic infection producing vasitis, but How much blood is important? Persistent microscopic more often these people are overly apprehensive to very hematuria requires an explanation. I have seen several cases little real discomfort, which may be aggravated by cre- of microscopic hematuria found in patients visiting their masteric spasm. Sometimes, it is due to some vague CANADIAN FAMILY PHYSICIAN/DECEMBER, 1975 31 intrascrotal pathology which may not be obvious at the 12. Colic time but may show up with re-examination. For this Colic is usually ureteral in origin, not due so much to reason, these people should be properly followed and spasms of the ureter fighting an obstruction, but almost re-examined until one is quite sure that it is nothing more always to increased intraluminal pressure, which may be than 'organ music'. due to a spasm but also to the continuing production of urine by the kidney over-distending the uret-er with 10. Suprapubic Discomfort pressure. It is usually due to a stone but we must not forget A very common complaint often due to cystitis, spastic that it can be due to the passage of a blood clot originating bladder or distended poorly emptying bladder. in renal bleeding, or it may be due to ureteral pathology. Colic should be investigated until a diagnosis of the etiology 11. Testicular or Vulva Pain is made. It is sometimes difficult to find the cause for this Ordinary muscle antispasmodics have little effect on condition. There may be local pathology, but there may relaxing ureteral muscle except in large, almost toxic doses. also be a lower ureteral problem such as a stone. Dr. Donald In my experience, pain relief with analgesics is much more Smith, professor of urology at the University of California effective. School of Medicine in San Francisco, has recently presented a collection of cases of nerve compression by paravertebral 13. Injury ligaments, proven by exploration. Until now these cases had Injury may produce pain and blood. One should always been completely misdiagnosed. I am sure there will be investigate all urological complaints in injury. reports in the literature of this cause as we start looking for Here I would like to put in my personal plea for not it. overlooking a pre-existing testicular lesion just because we TABLE.
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