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 consultation. Look out for signs that the patient H istory may not be able to describe the problem due to anxiety or embarrassment or a language bar- Communication skills 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. Urology Lecture Notes, Seventh Edition. Amir V. Kaisary, Andrew Ballaro and Katharine Pigott. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd. 0002618351.indd 3 12/28/2015 4:53:44 PM 4 Assessment of the urological patient 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 Chapter No.: 13 Title Name: Kaisary 0002618351.indd 0002618351.indd 4 12/28/2015 4:53:44 PM Comp. by: Mohamad abdul Rasheeth Date: 28 Dec 2015 Time: 04:53:44 PM Stage: Printer WorkFlow:CSW Page Number: 4 Assessment of the urological patient 5 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.