Urology Department

Undergraduate courses

Urological symptoms
History Taking

• The medical history is the cornerstone of the

evaluation of the urologic patient.
• A complete history can be divided into:
o The chief complaint
o History of the present illness
o The patient's past medical and surgical history
o Family history.

Magdy Fath-Alla, 2009

Complaint

Urological complaint(s) can be categorized

into one or more of:
 Pain
 Changes in the act of micturition
 Changes in gross appearance of urine
 Changes in function and/or appearance of
male genitalia.
 Systemic symptoms

Magdy Fath-Alla, 2009

Pain
Pain arising from the GU tract may be quite severe and
is usually associated with
 Obstruction:
• Ureteric stone.
• Urinary retention.
 Inflammation
 parenchymatous organs inflamm. produces severe
pain (pyelonephritis, prostatitis, and epididymitis)
 Inflammation of the mucosa of a hollow viscus such as
the bladder or urethra usually produces discomfort.
 Tumors of GU tract usually do not cause pain unless
they produce obstruction or extend to adjacent nerves.

Magdy Fath-Alla, 2009

Renal Pain
• Site: ipsilateral costovertebral angle just lateral to
the sacrospinalis muscle and beneath the 12th rib.
• Pain due to inflammation is usually steady (dull
ache) due to acute distention of the renal capsule,
• Pain due to obstruction fluctuates in intensity
(colicky).
• may be associated with gastrointestinal
symptoms because of reflex stimulation of the
celiac ganglion.
• Radiation: across the flank anteriorly toward the
upper abdomen and umbilicus and may be to the
testis or labium.

Magdy Fath-Alla, 2009

Differential Diagnosis of Renal Pain

1) Pain of intraperitoneal origin (perforated

duodenal ulcer or pancreatitis) has the following
characters:
• Radiates into the back, but the site of greatest
pain and tenderness is in the epigastrium.
• Radiates into the shoulder because of irritation of
the diaphragm and phrenic nerve.
2) Renal pain may also be confused with pain
resulting from irritation of the costal nerves
(radicular pain), most commonly T10-T12.
However, the pain is not colicky in nature.

Magdy Fath-Alla, 2009

Ureteral Pain
• usually acute and secondary to obstruction.
• Distribution of the pain according to site:
o In upper ureteral obstruction, the pain may be referred
to the scrotum in the male or the labium in the female.
o Midureter obstruction: on the right side is referred to the
right lower quadrant (McBurney's point) and simulate
appendicitis; on the left side to left lower quadrant.
o Lower ureteral obstruction causes bladder irritability
(frequency, urgency, and suprapubic discomfort).

Magdy Fath-Alla, 2009

Vesical and Prostatic pain
Vesical pain
•due to retention or inflammation.
•Constant suprapubic pain that is unrelated to
urinary retention is seldom of urologic origin.
•Inflammatory conditions of the bladder usually produce
intermittent suprapubic discomfort.
Prostatic pain
•due to inflammation with secondary edema and
distention of the prostatic capsule.
•poorly localized to lower abdominal, inguinal, perineal,
lumbosacral, and/or rectal pain.

Magdy Fath-Alla, 2009

Penile and Testicular Pain
Penile pain
•Pain in the flaccid penis is referred pain from bladder or
urethra and maximally at the urethral meatus.
•Pain in the erect penis is usually due to Peyronie's disease
or priapism.
Scrotal pain
•Primary pain arises from within the scrotum:
o Acute epididymitis or torsion of the testis.
o Chronic scrotal pain (dull, heavy) due to hydrocele or
varicocele.
•Referred:
o from kidneys or retroperitoneum or from inguinal hernia.

Magdy Fath-Alla, 2009

 Irritative Symptoms

Frequency
• The normal adult voids five or six times
per day, with a volume of approximately
300 mL with each void.
• Urinary frequency is due either to
increased urinary output (polyuria),
detrusor instability or to decreased
bladder capacity.

Magdy Fath-Alla, 2009

 Irritative Symptoms
Nocturia is nocturnal frequency.
• Normally, adults arise no more than twice at night to void
(decrease urine concentration with age).
• Nocturia occur in the patient with congestive heart failure
and peripheral edema, old aged and drinking fluids at night.
Dysuria is painful urination commonly referred to the urethral
meatus.
• at the start of urination indicate urethral pathology.
• at the end (strangury) indicate bladder origin.
• Dysuria is frequently accompanied by frequency & urgency.
Urgency the sudden intense desire to void that the patient can
not defer.

Magdy Fath-Alla, 2009

Obstructive Symptoms
Urinary hesitancy delayed start of urination.
Decreased force and caliber of urinary stream
is due to bladder outlet obstruction and
commonly results from benign prostatic
hyperplasia (BPH) or a urethral stricture.
Straining refers to the use of abdominal
musculature to urinate.
Intermittency means interrupted stream.
Postvoid dribbling refers to the release of few
drops of urine after micturition.

Magdy Fath-Alla, 2009

 Incontinence
Urinary incontinence is the involuntary loss of urine
Continuous Incontinence most commonly due to:
• urinary tract fistula (as vesico-vaginal fistula usually due
to gynecologic surgery, radiation, or obstetric trauma.
• ectopic ureter that opens either at the urethra or the
female genital tract.
Stress Incontinence is sudden leakage of urine with
coughing, sneezing, exercise (increase intra-abdominal
pressure).
• most common in women after childbearing or
menopause and men after prostatic surgery and injury to
the external urethral sphincter.

Magdy Fath-Alla, 2009

 Incontinence
Urge Incontinence
• loss of urine preceded by a strong urge to void.
• Due to: cystitis, neurogenic bladder.
Overflow Urinary Incontinence
• Due to advanced urinary retention and high residual
urine volumes.
• Urine dribble due to bladder overflow.
Enuresis
• micturition that occurs during sleep.
• It occurs normally in children up to 3 years old.

Magdy Fath-Alla, 2009

Changes in the gross appearance
of urine
Hematuria
•the presence of blood in the urine > 3 RBCs per high-
power microscopic field (HPF).
•painless hematuria in adults, should be regarded as a
symptom of urologic malignancy until proved otherwise.
•In evaluating hematuria:
gross or microscopic.
Initial, terminal or allthrough.
Painful or not.
Associated with clots or not and shape of clots.

Magdy Fath-Alla, 2009

 Changes in the gross
appearance of urine
Cloudy Urine
Pyuria
• Pyuria is a urinary tract infection in which large quantities
of white blood cells cause urine to have a cloudy
appearance.
• Microscopic examination of the urine will demonstrate pus
cells.
Phosphaturia
• due to precipitation of phosphates in alkaline urine.
• Acidification of urine with acetic acid at the time of urine
analysis causes clearing of the specimen.

Magdy Fath-Alla, 2009

Abnormal appearance and/or function
of the male external genitalia

Male sexual dysfunction and impotence

•impotence is the inability to achieve and maintain
an erection adequate for intercourse.
•Other male sexual disorders, including loss of
libido, absence of emission, absence of orgasm &
premature ejaculation.
•Bloody ejaculate (Hematospermia) refers to the
presence of blood in the seminal fluid. It almost
always results from nonspecific inflammation of the
prostate and/or seminal vesicles.

Magdy Fath-Alla, 2009

Abnormal appearance and/or function of
the male external genitalia
Penile complaints
•Cutaneous lesions.
•Penile curvature.
•Urethral discharge most common symptom of venereal infection.
o purulent thick, profuse, and yellow to gray discharge is typical of
gonococcal urethritis.
o scanty and watery discharge is due to nonspecific urethritis.
o bloody discharge suggests carcinoma of the urethra.
Scrotal complaints
•Cutaneous lesions.
•Absent or retractile testis.
•Scrotal swellings or masses.
Magdy Fath-Alla, 2009
 Systemic symptoms

• Fever and chills occur with infection anywhere in

the GU tract but most common with
pyelonephritis, prostatitis, or epididymitis.
• Fever, weight loss, and malaise are nonspecific
systemic manifestations of: acute and chronic
inflammation, renal failure, and genito-urinary
malignancy with or without metastases.

Magdy Fath-Alla, 2009

 Urology Department

Undergraduate courses

Genito-Urinary Examination
General Examination

• Apperance: distressed due to pain or does

appear unwell suggesting systemic illness
and possibly renal failure.
• Complexion: Pallor is evidence of anemia
(due to hematuria).
• Vital data: blood pressure.
• Signs of dehydration: dry mouth and tongue
may indicate renal failure or polyuria of
diabetes.
• Cervical lymph nodes enlargment due to
metastatic spread from any urological cancer.
Magdy Fath-Alla, 2009
 Abdominal Examination

Inspection
• scars (specially round umbilicus for laparoscopy
scars)
• Distension, prominent veins, local swelling and
hernia, pulsation, visible peristalsis, skin lesions.
• Exclude lesions of abdominal wall: Patient raises
head, patient does straight leg-raising, "blowing
test" or Valsalva.
• Check for inguinal node enlargement.

Magdy Fath-Alla, 2009

Abdominal Examination
General Palpation
• Use warm hands.
• Examine the tender areas last.
• Light palpation then deep.
• Check for guarding, rigidly and rebound
tenderness.
• Determine for any mass: site, tenderness, size
and shape, surface (irregular or smooth), edge
(regular or irregular), consistency (soft or hard),
mobility, whether pulsatile or ballotable.
• Differential diagnosis of abdominal masses.

Magdy Fath-Alla, 2009

Abdominal Examination

Specific Palpation:
• Kidney bimanual examination (for renal
enlargement or masses) by with a hand
posteriorly lifting up the kidney towards the
examining abdominally placed hand.
• An enlarged kidney usually
bulges forwards.

Magdy Fath-Alla, 2009

Abdominal Examination
• Tenderness over the kidney should be tested by
gentle pressure over the renal angle.
• Bladder palpation: felt in retention (acute or
chronic.
Percussion for ascites (shifting dullness) or
enlarged bladder.
Auscultation for a renal bruit in renal artery
stenosis (above umbilicus, 2cm to left or right of the
midline and also in both flanks with the patient sitting
up).

Magdy Fath-Alla, 2009

Scrotum and Genitalia examination

Penis examination: inspection and palpation of:

Prepuce to exclude phimosis and hypospadias.
Glans.
Skin (looking for ulcers, rashes) and Urethral
discharge.
Examine the scrotum:
Inspect scrotal skin
Palpate testes, epididymis and vas
Identify scrotal swellings: scrotal or inguinoscrotal.

Magdy Fath-Alla, 2009

Scrotum and Genitalia examination

– Is it possible to get above the swelling?

– Is the swelling solid or cystic?
– Is there a hydrocele, varicocele or epididymal
cyst?
– Testing for translucency with a torch will
determine whether the mass is cystic or a solid
mass.

Magdy Fath-Alla, 2009

Scrotum and Genitalia examination

Differential diagnosis (common swellings)

A) Attached to the testis:
• Solid (non-translucent): testicular tumor.
• Cystic (translucent): hydrocele.
B) Separate from the testis:
• Solid (non-translucent): chronic epididymitis.
• Cystic (translucent): epididymal cyst.

Magdy Fath-Alla, 2009

 Rectal Examination
Rectal examination is performed to palpate the prostate
gland and anal canal to assess :
• prostate Size.
• prostate Consistency.
• prostate medial sulcus.
• prostate tenderness.
• Bladder base
• Anal tone.
• Anal pathology.
A hard area in either or both lobes suggests a cancer and a
biopsy is needed to obtain histological diagnosis.

Magdy Fath-Alla, 2009

Bimanual examination of the
bladder for masses

in the male in the female

Thank You