History Physical exam and Specialized methods of urological diagnosis

History , Physical exam and Specialized methods of urological diagnosis

( Lecture # 1 )

History

Pain : Location (CVA, genitals, suprapubic ) Onset, Quality ( colicky, burning ) Severity, Radiation . Associated symptoms : Fever, Chills, Weight loss, Nausea, Vomiting . Irritative symptoms : Frequency, Nocturia, Dysuria, Urgency . Obstructive Symptoms : Hesitancy, Straining, Intermittency, decreased force or caliber of stream, Prolonged voiding, post-void dribble, Incomplete emptying .

History

Incontinence : Stress incontinence, Urge inco., Overflow inco., history of neurological problems, past pregnancies and method of delivery, past abdominal-pelvic operations . Urine : Hematuria, Pneumaturia, foul smell, Colour (cloudy, white, orange) . Urethral discharge : ( colour, amount, smell ), Sexual history, UTIs, external skin lesions, lymphadenopathy . Others : Renal calculi, Infertility, Erectile dysfunction, Congenital disorders, family history of urological disease.

Physical Exam

Inspection Abdomen : masses, Scars from previous operations, Suprapubic distention, hair distribution . Penis : Circumcision, Phymosis/Paraphymosis, Epispadias, Hypospadias, Urethral discharge, Superficial ulcers or vesicles, Venereal warts, Meatal stenosis, Balanitis . Scrotum : Testicular atrophy, Testicular asymmetry, Dilated veins (varicocele ) on Standing, Scrotal erythema/edema/cysts/hemangiomas .

Physical Exam

Palpation Kidneys, Bladder, Penis, Testes, Vas deference, Epididymis, Prostate .Abdomen : Masses, CVA tenderness, Suprapubic distention/ tenderness (examine for dullness on percussion), lymphadenopathy.Penis : Peyronie’s plaques, Penile masses, Penile tenderness .Scrotum : Scrotal tenderness/masses (size, consistency, location, mobility, shape), hernia, hydrocele, spermatocele.

Physical Exam

Palpation continue Spermatic cord : ( varicocele, fusiform enlargement, thickening of the cord ), absence of vas deference . Epididymal : size/induration/tenderness . Prostate : on DRE ( Digital Rectal Exam ) Size, Consistency ( rubbery, hard, boggy, indurated ), Nodularity ( size, location ), Tenderness, Warmth .

SPECIALISED METHODS OF UROLOGICAL DIAGNOSIS

Clinical examination Fig. bimanual palpation of the kidney

Laboratory investigation

Urine analysis This is best performed on a mid-stream specimen of urine. After cleansing the external urethral meatus, the first 20 ml or so of urine (containing bacteria and cells from urethra) are discharged before collecting the next part of the voided urine in a sterile container.

Laboratory investigation cont. … Chemical tests "Dipstick" = a strip coated with chemicals for measuring the urine pH and for detecting the presence of glucose, protein or blood; bilirubin, urobilinogen, ketones and nitrites can also be detected. The urine pH Varies between 4.5 and 8.0 Persistently alkaline urine (pH > 8.0) suggest infection with urea-splitting organism such as Proteus mirabilis

Laboratory investigation cont. … Protein The amount of protein in the urine is normally less than 100 mg/24 h. Dipstick will only detect levels greater than 300 mg/l Transient proteinuria (e.g. UTI) or persistent (glomerulopathia) Glycosuria Usually diabetes mellitus, rarely renal glycosuria

Laboratory investigation cont. … Microscopy Microscopical examination of urine directly of the urinary sediment studied after centrifugation Red blood cells White blood cells Epithelial cells Casts - from glomerular disorders (hyaline or cellular)


Laboratory investigation cont. … Crystals - related to stone disease Bacteria - Gram stain should be performed; if tuberculosis is suspected, the urinary sediment should be stained using the Ziehl-Nielsen methods Ova schistosomiasis

Laboratory investigation cont. … Culture The specimen should be plated out promptly or refrigerated until processing to prevent multiplication of bacteria after voiding. Significant infection is present if there are more than 100 000 (= 10 5 ) organism/ml , whilst counts less than 10 000 (=10 3 )/ml suggest contamination.

Laboratory investigation cont. … Antibiotic sensitiveness is determined using culture plates with antibiotic discs that inhibit the growth of susceptible organisms. If tuberculosis is suspected, three early morning samples of urine (EMU) are taken and cultured on Lowenstein-Jensen medium .

Laboratory investigation cont. …

Diagnostic imaging
Plain abdominal X-ray (KUB) The KUB (a plain X-ray to include the kidneys, ureters and bladder) is useful to detect: - Radio-opaque urinary calculi (90% of calculi) unless they overlie areas of the bony skeleton - Soft tissue masses in the renal areas and pelvis - Gallstones (10%) - Pelvic phleboliths

Diagnostic imaging cont. … - Calcified lymph nodes - Sclerotic deposits in prostate cancer (osteoplastic metastases - for other tumours are more typical osteolythic metastases)

Fig. plain X-ray of pelvis with cystolithiasis

Fig. plain X-ray with multiple left nephrolithiasis


Diagnostic imaging cont. … Intravenous urography (IVU) - After a plain film, iodine-containing contrast medium is injected intravenously and serial films are taken to follow its excretion by the kidneys - The nephrogram phase - on the initial film 1-3 minutes after injection, contrast medium is in the glomeruli and proximal tubules so that a clear image of the renal outline is obtained

Diagnostic imaging cont. … - The pyelogram phase - subsequent excretion of contrast medium outlines the collecting systems, renal pelvis, ureter and bladder, showing any structural abnormalities or filling defects - The procedure may be complicated by allergic reaction to the contrast medium, ranging in severity from a mild urticarial rash to anaphylactic shock .

Diagnostic imaging cont. … Ultrasound - The most frequently used radiological techniques in urological disorders - Almost all urological out-patient department are able to perform ultrasound immediately after physical examination - Colour-flow Doppler techniques - measuring blood flow

Fig. Ultrasonography of the kidney with a tumour 81 x 73 mm (T2)

Fig. Ultrasonography of the kidney with hydronephrosis

Fig. Transrectal ultrasonography of prostate in two plains (sagittal and transversal)

Fig. Colour-flow Doppler of blood supply of the kidney


Diagnostic imaging cont. … CT scanning (computed tomography) - Multidetector Spiral CT - It enables reconstructions in different planes and biphasic CT angiography PET/CT - Combination of positive emission tomography and CT. - It allows precise localisation of tumours.

Fig. Biphasic CT angiography of the left kidney.

Fig. PET/CT with metastases of kidney cancer to the soft tissue around the right hip joint.

Diagnostic imaging cont. … MRI (magnetic resonance imaging)

Fig. MRI Coronary Plain with Kidneys with bilateral simple renal cyst


Diagnostic imaging cont. … Arteriography - Renal arteriography is used in diagnosis of renal vascular disorders, renal tumours and renal trauma; therapeutic embolisation of the renal artery can be performed at the same time to control bleeding from the kidney.

Diagnostic imaging cont. … - Iliac arteriography is useful for assessing the pelvic tumours or trauma, and therapeutic embolisation of the internal iliac artery is occasionally used for uncontrollable bladder haemorrhage, pelvic trauma, and priapism.

Diagnostic imaging cont. … Other radiological techniques Antegrade pyelogram - contrast medium is injected via a small-bore needle passed into the collecting system under local anaesthetic or via a percutaneous nephrostomy Ascending ureterogram - using a catheter inserted into the ureteric orifice at cystoscopy Urethrography (ascending and descending) - contrast medium is instilled directly into urethra (ascending urethrography), contrast medium is passed out and is performed with micturition



Diagnostic imaging cont. … cystogram (it can demonstrate vesicourethral reflux) and descending urethrography. Urethrography is useful for diagnosis of urethral stricture mainly. Lymphography - following injection of contrast medium into a lymphatic in the foot is used to demonstrate the iliac and para-aortic nodes in pelvic malignancy; nowadays, it has been replaced by CT scanning

Diagnostic imaging cont. … Radionuclide studies Renal scintigraphy It is useful mainly for dynamic diagnosis - upper urinary tract obstruction, assessing of renal function of both kidneys. Bones scintigraphy It is most widely used in the detection of bony metastases from prostatic, bladder and renal carcinoma.