2.6 Examination of Urological System Ref: Talley Ch18, Red book Ch9 Aim: not routinely performed but as a ‘general examination’ to detect cause, signs and complications of chronic kidney disease Approach: □ General: → General: consciousness, fluid status → Skin: colour, nodules, bruises, pigmentation, scratch marks, uraemic frost, vasculitis → Breath: hyperventilation, hiccupping, uraemic fetor → Abnormal movements: twitching, tetany, epileptic seizures □ Face: → Skin: rash, skin tethering, hearing aids → Eyes: pallor, jaundice, band keratopathy, fundoscopy → Mouth: mucosal ulcers, gingival hyperplasia, uraemic fetor □ Upper limb: → Hands: palmar crease pallor, asterixis, nails → Arms: scars, AV fistula, peripheral neuropathy, carpal tunnel syndrome □ Neck: JVP, carotid bruit, previous jugular v. puncture, parathyroidectomy scar □ Chest: → Heart: signs of HTN, signs of congestive heart failure, pericardial rub, cardiac tamponade → Lungs: pulmonary oedema, pulmonary infection □ Legs: → Oedema → Skin changes: purpura, livedo reticularis, pigmentation, scratch marks → Others: peripheral vascular disease, peripheral neuropathy and myopathy, gout □ Abdomen: → Inspection: - Scars/devices: Tenckhoff catheter and scars, nephrectomy scars, renal transplant scars - Distension: local mass, ascites → Palpation: - Mass: renal masses, hepatomegaly, transplanted kidney, bladder - Others: AAA, renal/loin tenderness → Percussion: shifting dullness, auscultatory percussion for bladder → Auscultation: renal bruit → Rectal/pelvic examination: prostatomegaly, frozen pelvis □ Back: → Tenderness: bony tenderness, renal tenderness → Sacral oedema □ Male genitalia: → Penis: mucosal ulceration, urethral discharge, other lesions → Scrotum: - Inspection: position, skin lesions, oedema - Palpation: testis, epididymis, vas deferens, spermatic cord - Page 109 of 360 - A. General Examination 1. General Inspection General status: □ Consciousness state: → Uraemic encephalopathy in terminal kidney failure (Reason: nitrogen and toxin retention) → Seizures + coma if overvigorous correction of acidosis (eg. by bicarbonate infusions) □ Fluid status: should be assess in ALL renal patients → Supine/erect BP: - Hypertension: can be both cause and complication of renal disease - Postural hypotension: may indicate hypovolemia → JVP (may ↑ in Rt HF without fluid retention) → Daily weight and fluid balance charts → Oedema: ankle, sacral, pulmonary → Implications: - Volume overload can precipitate AKI or decompensation of CKD - Hypovolemia can precipitate pre-renal AKI Skin: □ Colour: → Café au lait complexion (uraemic tinge): a dirty brown skin tinge (due to impaired excretion of urochromes plus anaemia) → Slate grey to bronze (due to iron deposition in dialysis patients receiving multiple blood transfusion) - Less common with use of exogenous erythropoietin nowadays □ Skin nodules due to calcium phosphate deposition □ Bruises: (due to nitrogen retention → ↓prothrombin consumption, defect in platelet factor III, abnormal platelet aggregation) □ Pigmentation: due to failure to excrete uraemic pigments □ Scratch marks: due to uraemic pruritus → Often a/w hyperphosphataemia, very common □ Uraemic frost: fine white powder on skin due to precipitation of highly concentrated urea out of sweat Breath: □ Kussmaul breathing due to metabolic acidosis □ Hiccupping: ominous sign of advanced uraemia □ Uraemic fetor: ammoniacal fish breath associated with kidney failure Abnormal movements: □ Twitching (myoclonic jerk), tetany, epileptic seizures occurs late in renal failure → Mechanism: neuromuscular irritability or hypocalcemia □ Seizures can be precipitated by overvigorous correction of acidosis - Page 110 of 360 - 2. Face Rash or skin tethering may indicate underlying connective tissue disease (eg. SLE, scleroderma) Hearing aids may be due to Alport syndrome76 Eyes: □ Pallor indicating anaemia77 □ Jaundice due to haemolytic anaemia occurring rarely due to retention of nitrogenous wastes □ Band keratopathy: calcium deposition beneath corneal epithelium parallel to interpalpebral fissure → Caused by 2o/3o hyperparathyroidism or excessive calcium replacement in CKD patients □ Fundoscopy for hypertensive or diabetic changes Mouth: □ Mucosal ulcers due to ↓salivary flow and ↑predisposition to infection78 □ Gingival hyperplasia: thickening of gum → Frequently found in transplant patients on calcineurin inhibitors (cyclosporin and tacrolimus) □ Uraemic fetor 3. Upper Limb Hands: □ Palmar crease pallor indicating anaemia □ Asterixis indicating renal encephalopathy □ Nails: look for leukonychia (whitish discolouration of nails) → Meurcke’s nails: paired white transverse lines near end of nails - Indicates hypoalbuminaemia (eg. nephrotic syndrome) → Mee’s lines: single transverse white band - Indicates arsenic poisoning and CKD → Terry’s half-and-half nails: distal nail brown/red + proximal nail pink and white □ Finger prick scars indicating diabetes Arms: □ Scars: → Implantation/removal of AV shunt (forearm) → Carpal tunnel syndrome surgery (wrist) □ AV fistula: longitudinal swelling with continuous thrills upon palpation → Use: arterialization of veins → easy access for haemodialysis □ Carpal tunnel syndrome79: → Tinel’s sign: tingling sensation in median n. territory upon tapping on palmar side of wrist → Phalen’s sign: flexion of wrist for 30s → tingling sensation → 2-point discrimination test (only when severe CTS is suspected) 76 Alport syndrome is a hereditary nephritis often associated with sensorineural hearing loss and retinal/corneal diseases. 77 Anaemia in CKD patients is multifactorial, including poor nutrition (esp folate deficiency), blood loss, erythropoietin deficiency, haemolysis, bone marrow depression and chronic disease state. 78 Uraemic patients have decreased acute inflammatory responses as a result of nitrogen retention. 79 In CKD, there is decreased clearance of β2-microglobulin (even with modern dialysis). This may accumulate as amyloid deposits in the carpal tunnel, leading to compression of median nerve and carpal tunnel syndrome. - Page 111 of 360 - 4. Neck Jugular venous pressure to assess intravascular volume status Carotid bruits reflect generalized atherosclerosis □ May cause RAS or complicate CKD) Previous jugular vein puncture for vascular access insertion for haemodialysis Parathyroidectomy scars for management of 3o hyperparathyroidism 5. Chest Heart: □ Signs of HTN: heaving apex due to pressure overload □ Signs of congestive heart failure: displaced apex, S3 □ Pericardial rub/cardiac tamponade: can be due to fibrinous/haemorrhagic pericarditis resulting from metabolic toxin retention (uraemic pericarditis) Lungs: □ Pulmonary oedema: can be due to → Uraemic lung disease: non-cardiogenic pulmonary oedema a/w typical bat-wing appearance → Volume overload → Uraemic cardiomyopathy □ Lung infection due to immunosuppression (from CKD itself or its treatment) □ Pleural effusion due to fluid retention □ Pleural rub suggesting uraemic pleuritis 6. Legs Oedema Skin changes: □ Purpura as sign of vasculitis or uraemic bleeding tendency □ Livedo reticularis: red-blue reticular pattern from vasculitis or atheroembolic disease □ Pigmentation due to uraemic pigments □ Scratch marks due to uraemic pruritus Signs of peripheral vascular diseases may suggest underlying diabetes mellitus Signs of peripheral neuropathy and myopathy □ May suggest underlying diabetes mellitus □ May be due to uraemic neuropathy if long-standing failure or under-dialyzed patients Gout: commonly found at 1st MTP □ May be a (rare) cause of renal failure □ Note that 2o uric acid retention is common with CKD but rarely causes clinical gout - Page 112 of 360 - B. Abdominal Examination Carried out as per the usual manner Take note of the following points in a patient with kidney disease 1. Inspection Scars and devices: □ Tenckhoff catheter or scars for peritoneal dialysis → Usually on lower abdomen at or near midline □ Nephrectomy scar: oblique scar in loin region → May need to roll patient over □ Renal transplant scar: right or left iliac fossa → Transplanted kidney may be visible as bulge under the scar as it’s placed in a relatively superficial plane Distension: □ Polycystic kidney □ Ascites due to nephrotic syndrome or peritoneal dialysis 2. Palpation Renal masses: □ Ballotement: (Fr. ‘shake about’) → One hand under renal angle and flick fingers upwards → The other hand placed on LUQ/RUQ feel the kidney moving upwards and then float down again □ Note that: → Enlarged kidneys bulges forwards → Perinephric abscesses/collections bulges backwards Hepatomegaly: polycystic liver may be associated with polycystic kidney disease Transplanted kidney in iliac fossae □ Tenderness may indicate rejection D/dx of palpable kidneys Bladder in hypogastric region Unilateral palpable kidney: Abdominal aortic aneurysm: rupture may precipitate pre-renal failure - Normal – Rt kidney, compensatory hypertrophy of single kidney Renal and loin tenderness indicative of renal colic in a pt - Vascular – acute renal vein thrombosis with abdominal pain - Infection – pyelonephritis, renal abscess, pyonephrosis - Neoplasm – RCC - Congenital – polycystic kidney (with asymmetrical enlargement) - Hydronephrosis Bilateral palpable kidney: - Unilateral causes occurring bilaterally - Endocrine – diabetic nephropathy (common), acromegaly80 - Infiltrative – amyloid, lymphoma 80 Diabetes results in impaired vasodilation, leading to hyperfiltration and enlarged kidneys in early stages. - Page 113 of