History and examination in Urology

HISTORY AND PHYSICAL EXAMINATION IN UROLOGY

History taking
History taking is very important part of any medical investigation. How to take general informations about patient (family history, occupational informations, previous surgery, labours and current medication) is well known, in Tab. 1 are listed groups of specific urological symptoms.

Tab.1: Urological symptoms
• Obstructive symptoms • Irritative symptoms • Erectile dysfunction and sexual problems • Urinary incontinence • Pain/renal colic • Haematuria
Obstructive symptoms: hesitancy of micturition is a delay in initiation of the urinary stream, poor urinary stream means slow urination, intermittent stream is interrupted voiding, terminal dribbling is dropping of urine in the end of micturition, a feeling of incomplete bladder emptying means usually presence of residual urine volume.
Irritative symptoms: dysuria is term generally used for any problems during voiding, a burning sensation on micturition is usually sign of lower urinary tract infection, urgency of micturition means that patient feels, that he may leak urine if he is not able to reach a lavatory imminently, strangury is the sensation of needing to pass urine again just after micturition, urinary frequency is frequent voiding ≥ 8 voiding during 24 hours and nycturia means ≥ 2 voiding during the sleep.
Erectile dysfunction and sexual problems: erectile dysfunction presents as an inability to initiate or sustain an erection sufficient to enable vaginal penetration and subsequent orgasm. The presence of nocturnal or early morning erections makes an organic cause of erectile dysfunction less likely. Retrograde ejaculation occurs commonly in men after transurethral resection of the prostate and sometimes in those who have taken α-adrenergic blockers. Failure of ejaculation may occur after sympathectomy or retroperitoneal surgery, as the sympathetic pathways to the prostate and seminal vesicles are interrupted. Premature ejaculation occurs most often as a functional problem. There are questionnaires used to determine problem with these problems.
Urinary incontinence is involuntary leakage of urine. To establish the circumstances under which urine loss occurs is important. Post-micturition dribble is a small urinary leakage at the end of the stream mostly in men and usually does not constitute an abnormality. Stress urinary incontinence is leakage of the urine during coughing, sneezing, physical activity (more often in women). Urge urinary incontinence is leakage of the urine linked to urgency (more often in old age). About 1/3 women with urinary incontinence have mixed stress and urge incontinence. Overflow incontinence is leakage from overfilled bladder (most often in old men with benign prostatic hyperplasia).
Pain: loin pain (acute or chronic) is sharp or blunt pain in loin area and usually arises from kidney. Renal colic is the pain usually from a stone that is moving within the urinary tract. It is among the most severe pains that patients may experience. Ureteric pain radiates from the loin down towards the scrotum or labia. Suprapubic pain is often caused by urinary retention or cystitis.
Hematuria: red coIour of the urine is symptom which will bring generally patient to examination. Painless hematuria is often caused by urothelial (mostly bladder) tumours, painfull hematuria is suggestive from inflammatory or calculous lesion, hematuria with obstructive symptoms is often due to benign prostatic hyperplasia. Heavy bleeding will result in the passage of clots and may cause clot retention. Uretrorhagia is spontanneous bleeding from uretra, mostly after trauma.

Physical examination
Much of the genitourinary tract is hidden from view. The testes and epididymes can be identified separately. If epididymal infection is present or testicular torsion is suspected, the examination must be gentle. Observation of the colour of the scrotal wall may reveal hyperaemia. The absence of a cremasteric reflex contraction when the scrotum, or the area close to the scrotum, is touched is also an important sign to elicit. The loss of this reflex is not diagnostic of one pathology, but its presence is strongly against a diagnosis of torsion. Examination of the penis should include assessment of the degree to which the prepuce can be retracted. The external urethral meatus must be identified: in patients with hypospadias and epispadias, the meatus will be sited abnormally. If an attempt is made to pull the sides of the meatus apart, the presence of meatal stenosis can be identified. The shaft of the penis is palpated to identify fibrous plaques of Peyronie's disease, which usually are found dorsally. Rectal examination is performed best with the patient in the left lateral position. The examiner's finger should be inserted while the patient exhales to encourage maximum relaxation of the anal sphincter. Characteristics assessed by digital rectal examination are in Tab. 2.

Tab. 2. Rectal examination
• Anal sphincter tone • Anal sphincter contractility • Perianal sensation • Prostate: size, surface, symmetry and consistency Examination of the prostate per rectum provides only a rough estimate of the size: the prostate can be categorised as small, medium, or large. The consistency of the prostate can be described as soft, firm, or hard; the surface as smooth or irregular; and the lateral lobes as symmetrical or asymmetrical.

Courses

• Surgery 5 (Trauma Surgery, Urology) [ChK/S-GM5/18]