Evaluation of the Urologic
Patient
Maryam Taheri, Urologist
Shohada-e Tajrish Hospital
Urology Nephrology Research Center
Shaheed Beheshti University of Medical Sciences
• Urinary System
– Kidneys
– Ureters
– Bladder
– Urethra
kidneys
- Typically each kidney weighs 150 g in the male
and 135 g in the female.
- The kidneys generally measure 10 to 12 cm
vertically, 5 to 7 cm transversely, and 3 cm in the
anteroposterior dimension.
- Because of compression by the liver, the right
kidney tends to be somewhat shorter and wider.
Also the right kidney sits 1 to 2 cm lower than
the left.
- Generally, the right kidney resides in the space
between the top of the first lumbar vertebra to
the bottom of the third lumbar vertebra. The
left kidney occupies a more superior space from
the body of the 12th thoracic vertebral body to
the 3rd lumbar vertebra.
• Internal anatomy of
the Kidneys
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Renal arteries
Renal capsule
Hilum
Cortex
Medulla(Pyramid)
Calyces
Collecting tubules
Ureters
- Urine, which is formed within the
nephrons, flow into the ureter, a long
narrow muscular tube which starts at
the lower portion of the renal pelvis and
extends down to the bladder.
- Each ureter has 3 narrowed areas along its
length.
- These junctions cause an angling of the
ureter that prevents reflux (backwards
movement)t of urine up toward the
kidney.
- Also these three sites of ureteral
narrowing are clinically significant
because they are common locations for
urinary calculi to lodge during passage.
Bladder
- The urinary bladder is a mascular, hollow
sac located just behind the symphysis pubis.
- Normal bladder capacity if 300-600 ml of
urine. But an overdistended bladder can
hold in excess of 1500ml of urine. When we
insert a Foley, it is important to take note of
the amount of urine that is drained as the
distended bladder is emptied.
Note: When a patient loses too much fluid
too rapidly, his/her hemodynamics can’t
tolerate the rapid change (release of
pressure on abdominal vessels) and he/she
may develop hypovolemic shock. This can be
prevented by temporarily clamping the Foley
drainage tubing after 750 ml of urine has
entered the drainage bag.
- In the neck of the bladder is an area of
smooth muscle that makes up the internal
urinary sphincter which is under involuntary
control.
Urethra
-The urethra carries the urine from the bladder and
expels it from the body.
-On average, the female urethra traverses 4 cm from
the bladder neck to the vaginal vestibule.
-The male urethra extends from the internal urethral
orifice in the urinary bladder to the external urethral
orifice at the end of the penis. Its length varies from
17.5 to 20 cm.; and it is divided into four portions:
prostatic,
membranous,
bulbar
and penile urethra.
- Within the urethra is the external urinary sphincter,
which is the only structure within the urinary system
that is under voluntary control.
Physical Exam
General Observations
The visual inspection of the patient provides a general overview.
- The skin should be inspected for evidence of jaundice or pallor.
- The nutritional status of the patient should be noted. Cachexia is a frequent sign of
malignancy, and obesity may be a sign of underlying endocrinologic abnormalities.
In this instance, one should search for the presence of truncal
obesity, a “buffalo hump,” and abdominal skin striae, which are
stigmata of hyperadrenocorticism. In contrast, debility and hyperpigmentation
may be signs of hypoadrenocorticism.
- Gynecomastia may be a sign of endocrinologic disease and a possible indicator
of alcoholism or previous hormonal therapy for prostate cancer.
-Edema of the genitalia and lower extremities may be associated with cardiac
decompensation, renal failure, nephrotic syndrome, or pelvic and/or retroperitoneal
lymphatic obstruction.
- Supraclavicular lymphadenopathy may be seen with any GU neoplasm, most commonly
prostate and testis cancer; inguinal lymphadenopathy may occur secondary to carcinoma of
the penis or urethra.
Physical exam of urinary system
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A complete and thorough physical examination is
an essential component of the evaluation of
patients who present with urologic disease. When
performing a physical assessment of a patient,
urological problems may be detected by
examination of the abdomen, suprapubic region,
genitalia and lower back, as well as the lower
extremities.
Landmarks for physical assessment of the urinary
system on abdomen and suprapubic:
- Rectus Abdominis Muscles - Longitudinal
muscles extending from the Pubis to the ribs on either
side of the midline, guides the location kidney
palpation.
- Symphysis Pubis - Joint formed by the union of
two pubic bones at the midline which bladder is
cradled under this structure.
The kidneys are fist-sized organs located high in the
retroperitoneum bilaterally. In the adult, the kidneys
are normally difficult to palpate because of their
position under the diaphragm and ribs with abundant
musculature both anteriorly and posteriorly.
In children and thin women, it may be possible to
palpate the lower pole of the right kidney with deep
inspiration. However, it is usually not possible to
palpate either kidney in men, and the left kidney is
almost always impalpable unless it is abnormally
enlarged.
Auscultation of the right and left renal arteries:
Subcostal bruit suggests renal artery stenosis.
Fig. Palpating the left kidney.
Costovertebral Angle
- Area on the lower back formed by
the vertebral column and downward
curve of the last posterior rib.
Fig. Blunt percussion over the left costovertebral angle
Fig. Palpating the bladder.
* A normal bladder in the adult cannot be palpated or percussed until there is at least 150 mL of urine
in it. At a volume of about 500 mL, the distended bladder becomes visible in thin patients as a lower
midline abdominal mass.
Percussion is better than palpation for diagnosing a distended bladder. The examiner begins by
percussing immediately above the symphysis pubis and continuing cephalad until there is a
change in pitch from dull to resonant.
Alternatively, it may be possible in thin patients and in children to palpate the bladder by lifting
the lumbar spine with one hand and pressing the other hand into the midline of the lower
abdomen.
A careful bimanual examination, best done with the patient under anesthesia, is invaluable in
assessing the regional extent of a bladder tumor or other pelvic mass.
The bladder is palpated between the abdomen and the vagina in the female or the rectum in the
male.
In addition to defining areas of induration, the bimanual examination allows the examiner to
assess the mobility of the bladder; such information cannot be obtained by radiologic
techniques such as CT and MRI, which convey static images.
Bimanual examination of the bladder in
the female.
Bimanual examination of the bladder in
the male.
Digital rectal examination (DRE)
- DRE should be performed in every male after age 40 years and in men of any age who present for
urologic evaluation.
-Prostate cancer is the second most common cause of male cancer deaths after age 55 years and the
most common cause of cancer deaths in men older than 70 years. Many prostate cancers can be
detected in an early curable stage by DRE, and about 25% of colorectal cancers can be detected by DRE
in combination with a stool guaiac test.
-DRE should be performed at the end of the physical examination. It is done best with the patient
standing and bent over the examining table or with the patient in the knee-chest position.
-The gloved, lubricated index finger is then inserted gently into the anus. Only one phalanx should be
inserted initially to give the anus time to relax and to easily accommodate the finger. Estimation of
anal sphincter tone is of great importance; a flaccid or spastic anal sphincter suggests similar changes
in the urinary sphincter and may be a clue to the diagnosis of neurogenic disease.
If the physician waits only a few seconds, the anal
sphincter will normally relax to the degree that the
finger can be advanced to the knuckle without causing
pain. The index finger then sweeps over the prostate;
the entire posterior surface of the gland can usually be
examined if the patient is in the proper position.
Normally, the prostate is about the size of a chestnut
and has a consistency similar to that of the contracted
thenar eminence of the thumb (with the thumb
opposed to the little finger).
The index finger is extended as far as possible into the
rectum, and the entire circumference is examined to
detect an early rectal carcinoma.
Vaginal Exam
Pelvic organ prolapse is a downward descent of
female pelvic organs, including the bladder, uterus
and the small or large bowel, resulting in
protrusion of the vagina, uterus, or both.
Prolapse development can be attributed to
several factors, including;
vaginal delivery, hysterectomy, chronic straining,
obesity, normal aging and abnormalities of
connective tissue .
-Four main types of pelvic organ prolapse can occur:
* When the protrusion involves the front (anterior
wall) of the vagina and bladder, the condition is
called a cystocele or "dropped bladder."
* When the back (posterior wall) of the vagina and
rectum are involved, the condition is called a
rectocele.
* When the upper portion of the vaginal wall (the
peritoneum cul-de-sac) and small bowel are involved
the condition is called an enterocele.
*When the uterus descends downward, the
presentation is called uterine prolapse.
History( Common urologic problems)
The medical history is the cornerstone of the evaluation of the urologic patient, and a well-taken
history will frequently elucidate the probable diagnosis.
Fever and Chills
Fever and chills may occur with infection anywhere in the GU tract but are most commonly
observed in patients with pyelonephritis, prostatitis, or epididymitis. When associated with urinary
obstruction, fever and chills may portend septicemia and necessitate emergency treatment to
relieve obstruction.
Pain
Pain arising from the GU tract may be quite severe and is usually associated with either urinary tract
obstruction or inflammation. Urinary calculi cause severe pain when they obstruct the upper urinary
tract. Conversely, large, nonobstructing stones may be totally asymptomatic.
Hematuria
Hematuria is the presence of blood in the urine; greater than three red blood cells per high-power
microscopic field (HPF) is significant. Patients with gross hematuria are usually frightened by the
sudden onset of blood in the urine and frequently present to the emergency department for
evaluation, fearing that they may be bleeding excessively. Hematuria of any degree should never be
ignored and, in adults, should be regarded as a symptom of urologic malignancy until proved
otherwise.
Irritative urinary Symptoms;
1. Frequency: is one of the most common urologic symptoms. The normal adult voids five or six
times per day, with a volume of approximately 300 mL with each void. Urinary frequency is
due to either increased urinary output (polyuria) or decreased bladder capacity.
If voiding is noted to occur in large amounts frequently, the patient has polyuria and should be
evaluated for diabetes mellitus, diabetes insipidus, or excessive fluid ingestion.
Causes of decreased bladder capacity include bladder outlet obstruction with decreased
compliance, increased residual urine, and/or decreased functional capacity due to irritation,
neurogenic bladder with increased sensitivity and decreased compliance, pressure from
extrinsic sources, or anxiety.
2. Nocturia: is nocturnal frequency. Normally, adults arise no more than twice at night to void. As
with frequency, nocturia may be secondary to increased urine output or decreased bladder
capacity.
* Frequency during the day without nocturia is usually of psychogenic origin and related to
anxiety. Nocturia without frequency may occur in the patient with congestive heart failure and
peripheral edema in whom the intravascular volume and urine output increase when the patient
is supine.
3. Dysuria: is painful urination that is usually caused by inflammation. This pain is usually not felt
over the bladder but is commonly referred to the urethral meatus. Pain occurring at the start of
urination may indicate urethral pathology, whereas pain occurring at the end of micturition
(strangury) is usually of bladder origin. Dysuria is frequently accompanied by frequency and urgency.
Obstructive Urinary Symptoms;
1. Decreased force of urination: is usually secondary to bladder outlet obstruction and commonly
results from benign prostatic hyperplasia (BPH) or a urethral stricture. In fact, except for severe
degrees of obstruction, most patients are unaware of a change in the force and caliber of their
urinary stream. These changes usually occur gradually and go generally unrecognized by most
patients.
2. Urinary hesitancy: refers to a delay in the start of micturition. Normally, urination begins within a
second after relaxing the urinary sphincter, but it may be delayed in men with bladder outlet
obstruction.
3. Intermittency: refers to involuntary start-stopping of the urinary stream. It most commonly
results from prostatic obstruction with intermittent occlusion of the urinary stream by the lateral
prostatic lobes.
4. Postvoid dribbling: refers to the terminal release of drops of urine at the end of micturition. This is
secondary to a small amount of residual urine in either the bulbar or the prostatic urethra that is
normally “milked back” into the bladder at the end of micturition. In men with bladder outlet
obstruction, this urine escapes into the bulbar urethra and leaks out at the end of micturition.
5. Straining: refers to the use of abdominal musculature to urinate. Normally, it is unnecessary for a
man to perform a Valsalva maneuver except at the end of urination. Increased straining during
micturition is a symptom of bladder outlet obstruction.
Urinary Incontinence
Urinary incontinence is the involuntary loss of urine. A careful history of the incontinent patient will
often determine the etiology. Urinary incontinence can be subdivided into four categories.
1. Continuous Incontinence: Continuous incontinence is most commonly due to a urinary tract fistula
that bypasses the urethral sphincter.
2. Stress Incontinence: Stress incontinence refers to the sudden leakage of urine with coughing,
sneezing, exercise, or other activities that increase intra-abdominal pressure. During these activities,
intra-abdominal pressure rises transiently above urethral resistance, resulting in a sudden, usually
small amount of urinary leakage. Stress incontinence is most common in women after childbearing or
menopause and is related to a loss of anterior vaginal support and weakening of pelvic tissues. Stress
incontinence is also observed in men after prostatic surgery, most commonly radical prostatectomy, in
which there may be injury to the external urethral sphincter.
3. Urgency Incontinence. Urgency incontinence is the precipitous loss of urine preceded by a strong
urge to void. This symptom is commonly observed in patients with cystitis, neurogenic bladder,
and advanced bladder outlet obstruction with secondary loss of bladder compliance.
4. Overflow Urinary Incontinence. Overflow urinary incontinence, often called paradoxical
incontinence, is secondary to advanced urinary retention and high residual urine volumes. In these
patients, the bladder is chronically distended and never empties completely. Urine may dribble out in
small amounts as the bladder overflows.
Enuresis
Enuresis refers to urinary incontinence that occurs during sleep. It occurs normally in children up to 3
years of age but persists in about 15% of children at age 5 and about 1% of children at age 15.
Enuresis must be distinguished from continuous incontinence, which occurs in the day and night and
which, in a young girl, usually indicates the presence of an ectopic ureter. All children older than age
6 years with enuresis should undergo a urologic evaluation, although the vast majority will be found
to have no significant urologic abnormality.
Neurogenic Bladder
Neurogenic bladder is a dysfunction that results from interference with the normal nerve pathways
associated with urination.
Normal bladder function is dependent on the nerves that sense the fullness of the bladder (sensory
nerves) and on those that trigger the muscle movements that either empty it or retain urine (motor
nerves). The reflex to urinate is triggered when the bladder fills to 300-500 ml. The bladder is then
emptied when the contraction of the bladder wall muscles forces urine out through the urethra.
The bladder, internal sphincters, and external sphincters may all be affected by nerve disorders that
create abnormalities in bladder function.
There are two categories of neurogenic bladder dysfunction:
overactive (spastic or hyper-reflexive) and underactive (flaccid or hypotonic)
An overactive neurogenic bladder is characterized by uncontrolled, frequent expulsion of urine
from the bladder. There is reduced bladder capacity and incomplete emptying of urine.
An underactive neurogenic bladder has a capacity that is extremely large (up to 2000 ml). Due to a
loss of the sensation of bladder filling, the bladder does not contract forcefully, and small amounts
of urine dribble from the urethra as the bladder pressure reaches a breakthrough point.
There are numerous causes for neurogenic bladder dysfunction such as:
stroke, Parkinson's disease, surgery on the spinal cord, sacral spinal tumors, congenital defects or a
complication of various diseases, such as syphilis, diabetes mellitus, or polio.