Urologic Manifestations of Diseases Dr Adel Al Hunayan

UROLOGIC MANIFESTATIONS OF DISEASES Dr. Adel Al-Hunayan Surgery UROLOGIC MANIFESTATIONS OF DISEASES 1. History 2. Physical Examination HISTORY SYMPTOMS 1. 2. 3. 4. Pain or discomfort. Alteration of micturition. Changes in the gross appearance of the urine. Abnormal appearance or function of the external genitalia. 1. PAIN OR DISCOMFORT RENAL PAIN  Kidney innervated by sensory fibers to T10-L1 segments of the S.C.  Pain is secondary to capsular distention, inflammation, infarction or collecting system distention.  Dull, aching in the costovertebral angle URETERAL PAIN  Upper ureter is innervated by T10-L1  Lower ureter innervation is similar to the pelvic organs  Pain is felt in the suprapubic area, bladder, penis or urethra. BLADDER PAIN  Bladder distention  Suprapubic pain  Bladder inflammation  Burning pain in the tip of the urethra 1. PAIN OR DISCOMFORT PROSTATIC PAIN  Innervation : Sacral S.C.  Felt in the lower back, rectum or perineum. PENILE PAIN  Urethra and penile pain is directly related to a site of inflammation. SCROTAL PAIN  Secondary to DX in testis or epididymis • Acute: Trauma, torsion or acute inflammation. • Chronic: Varicocele, Hydrocele, Testis Tumour. 2. ALTERATION OF MICTURITION Change in urine volume ANURIA Urine output < 100 cc/Day OLIGURIA: Urine Output < 400 cc/Day POLYURIA Increase in the volume of urine excretion on a daily basis e.g. increase fluid intake, diuretic etc. 2. ALTERATION OF MICTURITION IRRITATIVE SYMPTOMS DYSURIA: Burning sensation in the distal urethral in males and the entire urethra in females.Seen in bladder, prostatic or urethral inflammation STRANGURY: Intense discomfort accompanying frequent voiding or small amounts or urine. URGENCY: Sudden severe urge to void that may or may not be controllable. FREQUENCY: Increased number of times one feels the need to urinateDue to:True decrease in bladder capacity (non-compliant bladder or bladder wall edema).Decrease in the effective bladder capacity in cases of high post void residual. NOCTURIA:Night time equivalent of urinary frequency. Due to decrease in the effective bladder capacity that forces the patient to arise at night to urinate. 2. ALTERATION OF MICTURITION OBSTRUCTION SYMPTOMS HESITANCY: Prolonged interval necessary to voluntarily initiate the urinary stream. STRAINING: The need to increase the intra-abdominal pressure in order to initiate voiding. TERMINAL DRIBBLING: Prolonged dribbling of urine from the meatus after the completion of micturition. SENSE OF RESIDUAL URINE: Sense of incomplete bladder evacuation. RETENTION OF URINE Acute  Painful Chronic  Painless INTERRUPTION POOR FORCE OF THE URINARY STREAM BIFURCATION: Double stream secondary to urethral stricture. 2. ALTERATION OF MICTURITION URINARY INCONTINENCE TOTAL INCONTINENCE: constant dribbling of urine from the bladder OVERFLOW INCONTINENCE:constant dribbling through the bladder outlet in the presence of distended bladder URGENCY INCONTINENCE: Severe urge sensation resulting in involuntary bladder evacuation. 2. ALTERATION OF MICTURITION URINARY INCONTINENCE STRESS INCONTINENCE:  Involuntary loss of urine due to sudden increase in the intra-abdominal pressure.  Is the result of loss of the normal anatomic relationship between the bladder and the urethra. ENURESIS Involuntary urination and bed wetting occurring during sleep. 3. CHANGES IN THE GROSS APPEARANCE OF THE URINE CLOUDY URINE Phosphaturia Pyuria Chyluria PEUMATURIA  Passage of gas along with urine while voiding  Seen in fistula between the GIT and the GU system.  Rarely seen in UTI secondary to Gas forming bacteria 3. CHANGES IN THE GROSS APPEARANCE OF THE URINE HEMATURIA PASSAGE OF RED URINE Painful: urothelial inflammation Painless: is a sign of cancer until proven otherwise. Initial: the source often is the anterior urethra. Terminal: the source often is the posterior urethra. Total: bleeding from the bladder or above. 4. ABNORMAL APPEARANCE OR FUNCTION OF THE MALE EXT. GENITALIA.  SEXUAL DYSFUNCTION INFERTILITY  PENILE PROBLEMS  SCROTAL PROBLEM 4. ABNORMAL APPEARANCE OR FUNCTION OF THE MALE EXT. GENITALIA. PENILE PROBLEMS  Cutaneous lesions  Penile curvature: results from scarring or fibrosis of the tunica Albuginea  Urethral discharge  Bloody ejaculate: results from inflammation or congestion of the seminal vesicles 4. ABNORMAL APPEARANCE OR FUNCTION OF THE MALE EXT. GENITALIA. SCROTAL PROBLEMS  Cutaneous lesions  Scrotal swelling 4. ABNORMAL APPEARANCE OR FUNCTION OF THE MALE EXT. GENITALIA. Scrotal swelling Scrotal Wall Testis Haematima;urinary extravasation; edema. Carcinoma; torsion of testes; appendix testis. Epididymis Spermatic cord Epididymitis; tumour. Hydrocele; hematocele; hernia; varicocele; lipoma. PHYSICAL EXAMINATION KIDNEY AND FLANKS INSPECTION  Sitting or standing position.  Scoliosis, flank bulge or edema can be seen. PALPATION Supine position.  One hand beneath the flank in question and the other beneath the ipsilateral costal margin anteriorly 3. PERCUSSION  Sitting position  Mainly to costo-vertebral angle to elicit tenderness 4. AUSCULTATION  Bruit is heard at the costo-vertebral angle secondary to renal art. Stenosis, and aneurysm or A-V malformation. BLADDER AND ABDOMEN NSPECTION  Supine position.  Full or distended bladder is often visible. PALPATION AND PERCUSSION  Supine position.  The bladder is often percussable above symphysispubis if it contains more than 150 cc.  The kid’s bladder is usually percussable at much smaller volumes. PENIS INSPECTION  Skin lesions, Circumcised ? Phymosis ? Paraphymosis?  Position of Ext. urethral meatus:Hypospadias, epispadias.  Bend: Torque: Lateral deviation Chordea : Ventral or Dorsal deviation. PALPATION  Areas of fibrosis as in Peyronie’s Dis.  Area of induration along the urethra as in urethral stricture  Milking the urethral to express and urethral discharge in cases suspected to have STD. SCROTUM AND SCROTAL CONTENTS POSITION: Initially standing; later Supine. INSPECTION  Skin lesions  Presence or absence of testis  Hypoplasia of hemiscrotal skin in cryptorchidism  Varicocele  Swelling: Hematocele, hydrocele, hernia or tumour SCROTUM AND SCROTAL CONTENTS PALPATION TESTIS  Note size and orientation.  Long axis >4 cm.  Tenderness or masses. EPIDIDYMIS  Normally lies posterolateral aspect of the testis.  Areas of tenderness, induration. SCROTUM AND SCROTAL CONTENTS PALPATION Cord  Vas.  Lipomas.  Varicocele: Bag of warms. EXT. INGUINAL RING  To R/O hernias PROSTATE- PR POSITION • Lying: Left lateral decubitus with flexed legs at hips and knees with the upper leg pulled higher than the lower leg. • Standing: The patient bend over the exam table. PROSTATE- PR Only the posterior aspect of the prostate is palpable: R/O Prostate ca.  Normal Prostate: Small, flat, median furrow, 2 lateral sulci, heart shaped, rubbery consistency.  Abnormal prostate: Indurated (ca or granulomatous prostatitis), tender (inflammation), fluctuation (abscess).  Prostatic Message: To collect prostatic secretions for Gram stain and culture