Physical examination of the genitourinary tract: Introduction

1.

Physical Examination of
the Genitourinary Tract:
Introduction

2.

The history will suggest whether a
complete or partial examination is
indicated.

3. Examination of the Kidneys Inspection

4. Examination of the Kidneys Inspection

The presence and persistence of
indentations in the skin from lying on
wrinkled sheets suggest edema of the skin
secondary to perinephric abscess.

5. Palpation

The kidneys lie rather high under the diaphragm
and lower ribs and are therefore well protected
from injury.

6. Palpation

The
kidney is lifted by one hand in the
costovertebral angle.

7. Palpation

On deep inspiration, the kidney moves
downward; when it is lowest, the other hand
is pushed firmly and deeply beneath the
costal margin in an effort to trap the kidney
below that point. If this is successful, the
anterior hand can palpate the size, shape,
and consistency of the organ as it slips back
into its normal position.

8. Palpation

The kidney sometimes can be palpated best
with the examiner standing behind the
seated patient.

9. Palpation

Anomalies were found in 0.5% of 11,000
newborns.

10. Palpation

An enlarged renal mass suggests compensatory
hypertrophy (if the other kidney is absent or
atrophic), hydronephrosis, tumor, cyst, or
polycystic disease.

11. Palpation

Tumors may have the consistency of normal
tissue; they may also be nodular.

12. Palpation

This may be elicited by palpation or, more
sharply, by percussion over that area.

13. Percussion

At times, a greatly enlarged kidney cannot be felt
on palpation, particularly if it is soft. This can be
true of hydronephrosis.

14. Transillumination

Transillumination may prove quite helpful in
children under age 1 year who present with a
suprapubic or flank mass.

15. Transillumination

The fiberoptic light cord, used to illuminate
various optical instruments, is an excellent
source of cold light.

16. Differentiation of Renal & Radicular Pain

Differentiation of Renal &
Radicular Pain
Radicular pain is commonly felt in the
costovertebral and subcostal areas.

17. Differentiation of Renal & Radicular Pain

Differentiation of Renal &
Radicular Pain
Frequent causes are poor posture (scoliosis,
kyphosis), arthritic changes in the
costovertebral or costotransverse joints,
impingement of a rib spur on a subcostal
nerve, hypertrophy of costovertebral
ligaments pressing on a nerve, and
intervertebral disk disease.

18. Differentiation of Renal & Radicular Pain

Differentiation of Renal &
Radicular Pain
Radicular pain may be noted as an
aftermath of a flank incision wherein a rib
may become dislocated, causing the costal
nerve to impinge on the edge of a ligament.

19. Differentiation of Renal & Radicular Pain

Differentiation of Renal &
Radicular Pain
Radiculitis usually causes hyperesthesia of the
area of skin served by the irritated peripheral
nerve.

20. Auscultation

Bruits over the femoral arteries may be found in
association with Leriche syndrome, which may
be a cause of impotence.

21. Examination of the Bladder

The bladder cannot be felt unless it is
moderately distended. In adults, if it is
percussible, it contains at least 150 mL of urine.

22. Examination of the Bladder

A sliding inguinal hernia containing some
bladder wall can be diagnosed (when the
bladder is full) by compression of the scrotal
mass. The bladder will be found to distend
additionally.

23. Examination of the Bladder

Bimanual (abdominorectal or abdominovaginal)
palpation may reveal the extent of a vesical
tumor.
To be successful, it must be done under
anesthesia.

24.

Examination of the
External Male Genitalia
Penis
Inspection

25.

If the patient has not been circumcised, the
foreskin should be retracted. This may reveal
tumor or balanitis as the cause of a foul
discharge.

26.

The scars of healed syphilis may be an
important clue. An active ulcer requires
bacteriologic or pathologic study (eg,
syphilitic chancre, epithelioma).

27.

Meatal stenosis is a common cause
of bloody spotting in male infants.

28.

The position of the meatus should be noted. It
may be located proximal to the tip of the glans
on either the dorsum (epispadias) or the
ventral surface (hypospadias).

29. Palpation

Palpation of the dorsal surface of the shaft may
reveal a fibrous plaque involving the fascial
covering of the corpora cavernosa.

30. Urethral Discharge

Urethral discharge is the most common
complaint referable to the male sex organ.
Gonococcal pus is usually profuse, thick, and
yellow or gray-brown.

31. Urethral Discharge

Although gonorrhea must be ruled out as the
cause of a urethral discharge, a significant
percentage of such cases are found to be
caused by chlamydiae.

32. Urethral Discharge

Bloody discharge should suggest
the possibility of a foreign body in
the urethra (male or female),
urethral stricture, or tumor.
Urethral discharge must always be
sought before the patient is asked
to void.

33. Scrotum

Angioneurotic edema and infections
and inflammations of the skin of the
scrotum are not common.

34.

Elephantiasis of the scrotum is caused by
obstruction to lymphatic drainage. It is endemic
in the tropics and is due to filariasis.

35. Testis

The testes should be carefully palpated with the
fingers of both hands.

36. Testis

A hydrocele will cause the intrascrotal
mass to glow red.

37. Testis

About 10% of tumors are associated with a
secondary hydrocele that may have to be
aspirated before definitive palpation can be
done.

38. Testis

The atrophic testis (following
postoperative orchiopexy, mumps
orchitis, or torsion of the spermatic
cord) may be flabby and at times
hypersensitive but is usually firm and
hyposensitive.

39. Epididymis

The epididymis is sometimes rather
closely attached to the posterior
surface of the testis, and at other
times it is quite free of it.

40. Epididymis

In the acute stage of epididymitis, the testis
and epididymis are indistinguishable by
palpation; the testicle and epididymis may
be adherent to the scrotum, which is
usually quite red.

41. Epididymis

Chronic painless induration should suggest
tuberculosis or schistosomiasis, although
nonspecific chronic epididymitis is also a
possibility.

42. Spermatic Cord & Vas Deferens

Spermatic Cord & Vas Deferens
A swelling in the spermatic cord may be cystic
(e.g., hydrocele or hernia) or solid (e.g.,
connective tissue tumor).

43. Spermatic Cord & Vas Deferens

Spermatic Cord & Vas Deferens
Careful palpation of the vas deferens
may reveal thickening (e.g., chronic
infection), fusiform enlargements (the
"beading" caused by tuberculosis), or
even absence of the vas.

44. Spermatic Cord & Vas Deferens

Spermatic Cord & Vas Deferens
When a male patient stands, a mass
of dilated veins (varicocele) may be
noted behind and above the testis.

45. Testicular Tunics & Adnexa

Testicular Tunics & Adnexa
Hydroceles are usually cystic but on occasion
are so tense that they simulate solid tumors.
Transillumination makes the differential
diagnosis. They may develop secondary to
nonspecific acute or tuberculous epididymitis,
trauma, or tumor of the testis.
The latter is a distinct possibility if hydrocele
appears spontaneously between the ages of 18
and 35. It should be aspirated to permit careful
palpation of underlying structures.

46. Testicular Tunics & Adnexa

Testicular Tunics & Adnexa
Hydrocele usually surrounds the testis
completely.

47. Examination of the Female Genitalia

Vaginal Examination
Diseases of the female genital tract may involve
the urinary organs secondarily, thereby making a
thorough gynecologic examination essential.

48. Inspection

In newborns and children especially, the
vaginal vestibule should be inspected for a
single opening (common urogenital sinus),
labial fusion, split clitoris and lack of fusion
of the anterior fourchette (epispadias), or
hypertrophied clitoris and scrotalization of
the labia majora (adrenogenital syndrome).

49. Inspection

Biopsy is indicated if a malignant tumor
cannot be ruled out.

50. Inspection

The diagnosis of senile vaginitis (and urethritis)
is established by staining a smear of the vaginal
epithelium with Lugol's solution.

51. Inspection

Multiple painful small ulcers or blisterlike lesions
may be noted; these probably represent herpes
virus type 2 infection, which may have serious
sequels.

52. Inspection

The presence of skenitis and bartholinitis may
reveal the source of persistent urethritis or
cystitis.
The condition of the vaginal wall should be
observed.
Bacteriologic study of the secretions may be
helpful.
Urethrocele and cystocele may cause residual
urine and lead to persistent infection of the
bladder.

53. Inspection

They are often found in association with stress
incontinence.

54. Palpation

A soft mass found in this area could be a
urethral diverticulum.
Pressure on such a lesion may cause pus to
extrude from the urethra.

55. Palpation

A stone in the lower ureter may be
palpable. Evidence of enlargement of the
uterus (e.g., pregnancy, myomas) or
diseases or inflammations of the colon or
adnexa may afford a clue to the cause of
urinary symptoms (e.g., compression of a
ureter by a malignant ovarian tumor,
endometriosis, or diverticulitis of the
sigmoid colon adherent to the bladder).

56. Palpation

Rectal examination may afford further
information and is the obvious route of
examination in children and virgins.

57. Rectal Examination in Males

Sphincter & Lower Rectum
The estimation of sphincter tone is of great
importance.

58.

The same is true for a spastic anal
sphincter.

59. Prostate

A specimen of urine for routine analysis should
be collected before the rectal examination is
made.

60. Size

The average prostate is about 4 cm in length and
width. It is widest superiorly at the bladder neck.

61. Consistency

Normally, the consistency of the gland is similar
to that of the contracted thenar eminence of the
thumb (with the thumb completely opposed to
the little finger).

62. Consistency

Generally speaking, nodules caused by
infection are raised above the surface of
the gland.

63. Consistency

At their edges, the induration gradually
fades to the normal softness of surrounding
tissue.

64.

The prostate-specific antigen (PSA) level can be
helpful if elevated. Transrectal ultrasound-guided
biopsy can be diagnostic.

65. Mobility

The prostate should be routinely
massaged in adults and its secretion
examined microscopically.

66. Mobility

It should not be massaged, however, in the
presence of an acute urethral discharge, acute
prostatitis, or acute prostatocystitis; in men near
the stage of complete urinary retention (because
it may precipitate complete retention); or in men
suffering from obvious cancer of the gland.
Even without symptoms, massage is necessary,
for prostatitis is commonly asymptomatic.
Diagnosis and treatment of such silent disease
is important in preventing cystitis and
epididymitis.

67. Massage & Prostatic Smear

Massage & Prostatic Smear
Copious amounts of secretion may be obtained
from some prostate glands and little or none
from others.

68. Massage & Prostatic Smear

Massage & Prostatic Smear
Microscopic examination of the secretion is
done under low-power magnification. Normal
secretion contains numerous lecithin bodies,
which are refractile, like red cells, but much
smaller than red cells.

69. Massage & Prostatic Smear

Massage & Prostatic Smear
The presence of large numbers of pus cells is
pathologic and suggests the diagnosis of
prostatitis.

70. Massage & Prostatic Smear

Massage & Prostatic Smear
On occasion, it may be necessary to obtain
cultures of prostatic secretion in order to
demonstrate nonspecific organisms, tubercle
bacilli, gonococci, or chlamydiae.

71. Seminal Vesicles

Palpation of the seminal vesicles should be
attempted. The vesicles are situated under the
base of the bladder and diverge from below
upward.

72. Seminal Vesicles

Stripping of the seminal vesicles should be done
in association with prostatic massage, for the
vesicles are usually infected when prostatitis is
present.

73. Lymph Nodes

It should be remembered that
generalized lymphadenopathy
usually occurs early in human
immunodeficiency syndrome (HIV).

74. Inguinal & Subinguinal Lymph Nodes

Inguinal & Subinguinal Lymph
Nodes
Such diseases include chancroid,
syphilitic chancre, lymphogranuloma
venereum, and, on occasion,
gonorrhea.

75. Inguinal & Subinguinal Lymph Nodes

Inguinal & Subinguinal Lymph
Nodes
Malignant tumors (squamous cell
carcinoma) involving the penis, glans,
scrotal skin, or distal urethra in women
metastasize to the inguinal and
subinguinal nodes.

76. Other Lymph Nodes

Tumors of the testis and prostate may involve
the left supraclavicular nodes. Tumors of the
bladder and prostate typically metastasize to the
internal iliac, external iliac, and preaortic nodes,
although only occasionally are they so large as
to be palpable.

77. Neurologic Examination

A careful neurologic survey may uncover
sensory or motor impairment that will account for
residual urine (neuropathic bladder) or
incontinence.

78. Neurologic Examination

The bulbocavernosus reflex is elicited by
placing a finger in the patient's rectum and
squeezing the glans penis or clitoris or by
jerking on an indwelling Foley catheter.
The normal reflex is contraction of the anal
sphincter and bulbocavernosus muscles in
response to these maneuvers.

79. Neurologic Examination

It is wise, particularly in children, to seek a
dimple over the lumbosacral area.

80. NONSPECIFIC INFLAMMATORY DISEASES OF GENITOURINARY ORGANS

81. Nonspecific inflammatory diseases of genitourinary organs:

Acute
pyelonephritis
Chronic pyelonephritis

82. Nonspecific inflammatory diseases of genitourinary organs:

Cystitis
Paracystitis
Urethritis

83. Nonspecific inflammatory diseases of genitourinary organs:

Prostatitis
Vesiculitis

84. Pyelonephritis

is nonspecific inflammatory
infectious process, in which the
parenchyma and pelvis of the
kidney simultaneously or
sequentially are affected.

85. Pyelonephritis

Patients with acute pyelonephritis
present with chills, fever, and
costovertebral angle tenderness.
They often have accompanying
lower-tract symptoms such as
dysuria, frequency, and urgency.

86. Pyelonephritis

Sepsis may occur, with 20–30% of all
systemic sepsis resulting from a urine
infection.

87. Pyelonephritis

Bacteria
are cultured from the urine when the
culture is obtained before antibiotic treatment is
instituted.

88. Pyelonephritis

The infection penetrates into the
kidney by two routes:
-
Hematogenous

89. Pyelonephritis

Of the local factors contributing to
origination pyelonephritis most
often is the disturbance of outflow
of urine (reason – different
anomalies of the kidneys and
urinary paths)

90. Factors, which promote development of acute pyelonephritis

Stones
of the kidney
Ureter and urethra

91. The triad of symptoms of acute pyelonephritis

High
body temperature
Pain in the lumbar area

92. Acute Pyelonephritis

Of great value for diagnostics are
the laboratory methods of
investigations

93. Acute Pyelonephritis

Radiological researches in patients
with AP are necessary to exclude
accompanying diseases, which
promote development of infectious
process, and to specify the character
of pathological changes in serious
cases

94. Acute Pyelonephritis

Treatment
of primary AP in most cases is
conservative

95. Acute Pyelonephritis treatment

The management of acute
pyelonephritis depends on the
severity of the infection.

96. Acute Pyelonephritis treatment

Empiric therapy with intravenous
ampicillin and aminoglycosides is
effective against a broad range of
uropathogens, including enterococci
and Pseudomonas species.
Alternatively, amoxicillin with clavulanic
acid or a third-generation
cephalosporin can be used.

97. Acute Pyelonephritis treatment

Fever from acute pyelonephritis may persist
for several days despite appropriate
therapy.

98. Acute Pyelonephritis treatment

In patients who are not severely ill, outpatient
treatment with oral antibiotics is appropriate. For
adults, treatment with fluoroquinolones or TMPSMX is well tolerated and effective.

99. Vesicoureteral Reflux

Approximately 50% of patients
with the infection of urinary paths
have
Vesicoureteral Reflux – is a
backflow of urine from the bladder
to the ureter and kidney

100. Classification of Vesicoureteral Reflux according to its grades:

Grade
I: a contrast drug fills the ureter, but
does not get into the renal pelvis.

101. Classification of Vesicoureteral Reflux according to its grades:

Grade
IV: moderate dilatation and/or
tortuousity of the ureter with moderate
dilatation of the renal pelvis and calyces

102. Treatment of Vesicoureteral Reflux

Antibacterial treatment is directed to
prevention of development infection
of the urinary paths. Routinely
Sulphonamides and Nitrofurans are
prescribed.

103. Treatment of Vesicoureteral Reflux

-
Indications for operative treatment:
Inefficient conservative treatment

104. Secondary Acute Pyelonephritis

Differs from primary in a clinical
picture by its greater expressivness of
sings of local nature that allows faster
and easier to recognize acute
pyelonephritis

105. Cause of Secondary Acute Pyelonephritis

Stones
of the kidney and ureter

106. Chronic Pyelonephritis

The diagnosis is made by radiologic
or pathologic examination rather than
from clinical presentation.

107. Chronic Pyelonephritis

Many individuals with chronic pyelonephritis
have no symptoms, but they may have a
history of frequent UTIs.

108. Chronic Pyelonephritis

Main X-ray signs are:
-
Deformations of the pyelocaliceal system

109. Chronic Pyelonephritis

-
Main X-ray signs are:
Changes of dimensions and contours of
the kidneys

110. Chronic Pyelonephritis

Renal scarring induced by UTIs is rarely seen
in adult kidneys.

111. Chronic Pyelonephritis

In these patients, urinalysis may show
leukocytes or proteinuria but is likely to
be normal.

112. Treatment of Chronic Pyelonephritis

Removal
of causes produsing the
disturbance of urine passage of renal
circuation, venous in particular

113. Chronic Pyelonephritis management

The management of chronic pyelonephritis
is somewhat limited because renal
damage incurred by chronic pyelonephritis
is not reversible.

114. Chronic Pyelonephritis management

Long-term use of continuous prophylactic
antibiotic therapy may be required to limit
recurrent UTIs and renal scarring.

115. Chronic Pyelonephritis management

Rarely, removal of the
affected kidney may be
necessary due to
hypertension or having a
large stone burden in a
nonfunctioning kidney.

116. Necrosis of Renal Papillae

117. Bacteriemic Shock

118. Pyonephrosis

means the final stage of specific or
nonspecific purulent-destructive
inflammatory lesion of the kidney. The
pyonephrotic kidney represents the organ,
exposed to purulent destruction, consisting
of separate cavities, filled with pus, urine
and products of nephrolysis.

119. Apostematous Pyelonephritis

represents a purulentinflammatory process with the
formation of numerous, smallsized pustules (apostemas)
predominantly in the renal cortex.

120. Renal Abscesses

Renal abscesses result from a severe
infection that leads to liquefaction of
renal tissue; this area is subsequently
sequestered, forming an abscess.
They can rupture out into the
perinephric space, forming
perinephric abscesses.

121. Renal Abscesses

When the abscesses extend beyond the
Gerota's fascia, paranephric abscesses
develop.

122. Renal Abscesses

With the development of effective
antibiotics and better management of
diseases such as diabetes and renal
failure, renal/perinephric abscesses
due to gram-positive bacteria are less
prevalent; those caused by E coli or
Proteus species are becoming more
common.

123. Renal Abscesses

Abscesses that form in the renal cortex
are likely to arise from hematogenous
spread, whereas those in the
corticomedullary junction are caused
from gram-negative bacteria in
conjunction with some other underlying
urinary tract abnormalities, such as
stones or obstruction.

124. Renal Abscesses management

The appropriate management of renal abscess
first must include appropriate antibiotic therapy.

125. Renal Abscesses management

The drained fluid should be cultured
for the causative organisms.

126. Renal Abscesses management

If the abscess still does not resolve, then open
surgical drainage or nephrectomy may be
necessary.

127. Pyonephrosis

Pyonephrosis refers to bacterial infection of
a hydronephrotic, obstructed kidney, which
leads to suppurative destruction of the renal
parenchyma and potential loss of renal
function. Because of the extent of the
infection and the presence of urinary
obstruction, sepsis may rapidly ensue,
requiring rapid diagnosis and management.

128. Pyonephrosis

Patients with pyonephrosis are usually
very ill, with high fever, chills, and flank
pain.

129. Pyonephrosis management

Management of pyonephrosis includes
immediate institution of antibiotic therapy
and drainage of the infected collecting
system.

130. Pyonephrosis management

Extensive manipulation may rapidly
induce sepsis and toxemia.

131. Pyonephrosis management

In the ill patient, drainage of the collecting
system with a percutaneous nephrostomy
tube is preferable.

132. Acute Cystitis

The most common causative agent of
cystitis is E.Coli, then
Staphylococcus, Enterococcus,
Proteus, Streptococcus, etc.

133. Acute Cystitis

Acute cystitis refers to urinary infection
of the lower urinary tract, principally the
bladder.

134. Acute Cystitis

The diagnosis is made clinically. In
children, the distinction between upper and
lower UTI is important.

135. Acute Cystitis

Patients with acute cystitis present with
irritative voiding symptoms such as dysuria,
frequency, and urgency.

136. Acute Cystitis

Urine culture is required to confirm
the diagnosis and identify the
causative organism.

137. Acute Cystitis

E coli causes most of the acute
cystitis. Other gram-negative
(Klebsiella and Proteus spp.) and
gram-positive (Staphylococcus
saprophyticus and enterococci)
bacteria are uncommon
pathogens.

138. Acute Cystitis Management

Trimethoprim-sulfamethoxazole and
nitrofurantoin are less expensive and thus
are recommended for the treatment of
uncomplicated cystitis

139. Acute Cystitis Management

In adults and children, the duration of
treatment is usually limited to 3–5 days.
Longer therapy is not indicated.

140. Acute Cystitis Management

Resistance to penicillins and
aminopenicillins is high and thus they are
not recommended for treatment.