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Symptomology and methods of physical

examination of urological diseases:

The basic symptoms of kidney and urinary tract diseases:
 Quantitative changes in urine  Hyperthermia (chill, fever)
 Qualitative changes in urine  Urethral discharge
 Pain (renal colic)  Ejaculation disorders
 Urination disorder  Erection disorders
 Lose weight  Changes in spermatogenesis

1. Quantitative changes in urine

 The normal range for 24-hour urine volume is 800 to 2,000 milliliters
 Diuresis depends on the amount of fluid taken and the amount of food consumed
 Normal urine specific gravity 1005-1025

Anuria: - non-passage of urine, in practice is defined as passage of less than 100 ml of

urine in a day;
Oliguria: - low output of urine, less than 500ml/day;
Polyuria: - increased production and passage of urine, more than 2000ml/day;

Causes of oliguria/anuria:
 Hypovolemia - bleeding, loss of water and electrolytes
 Cardiovascular Failure - Heart Failure, Hepato-Renal Syndrome
 Acute impairment of blood circulation in the kidney - kidney artery or vein
occlusion, shock, collapse
 Prolonged haemodynamic disorders
 Toxemia - hemolysis, myolysis, medication
 Parenchymal kidney diseases - acute interstitial nephritis, rapidly progressive
glomerulonephritis, vasculitis, etc.

 Mechanical obstruction of the upper urinary tract with stones, cancer, ligation of
the lower segments of the ureter during gynecological operations
Polyuria also develops during oligoanuria
 After removing urinary tract obstruction and restoring urine passage, during renal
functional recovery - the phase of polyuria
2. Qualitative changes in urine
presence of red blood cells in the urine. (The presence of 3 or less RBCs per high-power field
is normal)
 Microhaematuria - erythrocytes are detected only through a microscope.
 Macrohaematuria - different intensity of blood-stained urine.

 Reasons: Cancers, inflammatory and urolithiasis, traumatic injury, anticoagulants

Types of haematuria:
 Initial haematuria – blood at beginning of micturition
 Terminal haematuria - blood seen at end of micturition
 Total hematuria - blood visible throughout micturition

During intensive haematuria, blood clots may form

 Different-shaped - from the urethra or prostate (in men)
 Wormlike shaped - coming from upper urinary tract
 When blood clots are obstructed in the urinary tract, macrohematuria is accompanied
by pain.

Presence of proteins in the urine >0,033 gr/L.
 True proteinuria - because of the kidney

Functional: Neonatal physiological proteinuria; orthostatic albuminuria; transitory- after

severe anemia, burns, traumas, physical activity, consuming protein foods

The protein is filtered through the damaged membranes of the glomerulus,
Kidney pathology - nephritis, glomerulonephritis, pregnant nephropathy

False proteinuria – non-renal

 The presence of leukocytes, erythrocytes, bacteria in the urine
 Different diseases of the urinary tract - urolithiasis, inflammatory, tuberculosis, tumors

Presence of leykocites in the urine
 It is marked in inflammatory diseases of the urinary organs(pyelonephritis,
tuberculosis, cystitis, urethritis, prostatitis)
Presence of myoglobin in the urine
 Develops during the long time pressure (Crush syndrome)

The presence of renal cylinders in the urine
 Occurs in nephritis, glomerulonephritis, when using nephrotoxic drugs
 True cylindruria - Hyaline, granular, waxy
 False cylindruria- uric acid salts, myoglobin, bacteria
 Urological diseases are mainly characterized by hyaline cylinders

The presence of bacteria in urine
 Normally the urine is sterile
 Bacterioscopy reveals the presence of microorganisms
 Bacteriological test determines the type and number of microorganisms

Excretion of gases with urine
 Instrumental examinations (cystoscopy, catheterization)
 Fistulas between the urinary tract and digestive tract

The presence of fat in the urine
 Visually: the presence of fat on the surface of the urine
 Reason: Fatty embolisms of the renal capillaries after fracture of the long bones
(etc. femur)

The presence of chyle in the urine
 Urine color and consistency is like milk
 Reason: Inflammatory and tumor processes, traumatic fistulas between the urinary
system and large lymph ducts

Blend of echinococcus small vesicles with urine after opening hydatid cyst in the urinary
The presence of feces in the urine
 Reason: Urinary bladder-rectal fistula in cancerous diseases

3. Pain
Kidney Pain
 Localization: In the lumbar region in the costovertebral corner, laterally to the
sacrospinal muscle and below the XII rib.
 Irradiation: Towards the umbilical cord, inguinal region, testis and labium.

According to the intensity:

 Dull pain - In inflammatory, urolithiasis, cystic and cancerous diseases.
Post-urinating pain in the kidney area – vesicoureteral reflux

 Offensive pain – Renal Colic.

It develops unexpectedly during acute obstruction of the urinary tract(stone,
colt...). Elevated renal pressure is transmitted through the pelvic baroreceptors to
the central nervous system, where it transforms like pain. Reflexive spasm of the
renal blood vessels further increases the intensity of the pain.

 Swelling and enlargement of renal parenchyma causes stretching fibrotic capsule

rich in pain receptors and an even greater increase in pain intensity.

 The patient is restless, trying to get a comfortable position, changing pulse, blood
pressure, body temperature.

 Positive Pasternack sign- pain is elicited by light stroke of the area of the back
overlying the kidney

Kidney colic should be differentiated with the following

 Acute cholecystitis
 Pankreatitis
 Gastric ulcer perforation
 Retroperitoneal and intercostal neuralgia
 Pain of intraperitoneal origin is rarely of an offensive nature
 Pain of intraperitoneal origin is characterized by irradiation of the arm and diaphragm
 Patients with intraperitoneal pain prefer lying motionless
Ureteral pain
 Reason: Obstruction with stone or blood clot
Obstruction increases the internal pressure of the ureter, developing hyperperistalsis and
spasm of smooth muscles.

Upper 1/3 obstruction of the ureter:

Irradiation of pain in upper half of abdomen
Differentiation is needed : Cholecystitis, pancreatitis, gastric ulcer

Middle 1/3 obstruction of the ureter:

Irradiation of pain in lower half of the abdomen and small pelvis, testis, labium

Lower 1/3 obstruction of the ureter:

Frequent urination, urinary urgency, discomfort in the suprapubic area, pain along the ureteral

Urinary bladder pain:

Reasons: Bladder stretching during acute urinary retention; Inflammatory, stone and
cancerous diseases.
In bacterial or interstitial cystitis, pain is present when the bladder is full and disappear
completely or partially after urinating.

Prostate pain
• Reason: Extension of the prostate capsule as a result of inflammation.
• Localization: Lower abdominal, inguinal, perineal, rectal areas.
• Often accompanied by urinating disorders

Penile pain
 Reasons: Paraphimosis, Balanopostitis, Tumors, Trauma.
 The pain during penile erection basically marked during the Peyronie’s disease and

Scrotal pain
 Orchiepididymitis, varicocele, tumor, hydrocele (Dull pain).
 Testicular torsion, trauma, infection of the hair follicle or testicle, Fournier’s gangrene
(acute pain).
4. Urination disorders
 Urination disorder - dysuria
 Normally an adult urinates 4-5 times a day, Vol. Approx. 200-250 ml.
 Urination disorders:
Urinary incontinence
Urinary retention

 Urinary frequency.
 Characteristic of lower urinary tract and prostate diseases.
 *****A small amount of urine is excreted on urination****
 It is often accompanied by imperative need to urinate.
 It may occur after large amount of fluid intake, in diabetes and chronic kidney
diseases, however, output urine volume is not small at this time.

 Difficulty in micturition in which urine is passed only drop by drop with pain and
 Caused by urinary bladder pathologies
 Spasmodic contraction of urinary bladder, small amounts of urine, imperative need to

 Frequent urinate at night.
 Prostate hyperplasia, diabetes mellitus, cardiovascular failure.

Urinary Incontinence
(stress, imperative, paradoxical, enuresis)
 Stress incontinence – Sudden increase of abdominal pressure
 Urinary incontinence during physical tensing (coughing, laughing, sneezing...),
intra-abdominal pressure increases and in case of functional failure of the
sphincter, involuntary urination occurs.
 Mostly in women with weakening pelvic muscle and bladder sphincter tone,
due to the vaginal or uterine prolapse.
 During menopause, when hormonal changes cause functional discoordinate of
the detrusor and sphincter, which leads to stress incontinence.
 In men: After radical prostatectomy due to damage to the urethral sphincter.
 Imperative urinary incontinence
 Involuntary urination due to an imperative urge to urinate - at this time occurs
sudden emergence need to urnate, the patient is unable to reach the toilet and
retention urine.
 Reasons: Cystitis, neurogenic urinary bladder, infra-vesical obstruction.

 Paradoxical urinary incontinence (Ischuria)

 Involuntary urination during chronic retension.
 Large amounts of residual urine and streched urinary bladder in prostate
hyperplasia causes detrusor and sphincter failure. These cause nonpassage of urine,
or decreased output of urine and involuntary urination.
 Enuresis
 Involuntary urination while asleep.
 13-20% of 5-year-old children, 5% of 10-year-old children. By 15 years of age 1 to
2 percent continue to wet the bed. Under 15 is considered physiologically.
 In other cases, it is a symptom of other diseases of the urinary tract.

5. Lose Weight
 In advanced case inoperable tumors of the urinary tract organs.

6. Temperature Rise
 Inflammatory and cancerous diseases of the organs of the urinary system.
 High temperature (38-40°C) occurs: Acute pyelonephritis, paranephritis, acute
prostatitis, acute orchiepididymitis.
 Urinary tract obstruction, vesicoureteral reflux in infected urine conditions cause a
sudden chill and rise in temperature.
 The subfebrile temperature is associated with urinary tract tuberculosis, chronic
orchiepididymitis, a kidney tumor.
7. Genital Symptoms
Urethrorrhagia- urethral bleeding in the absence of urine, associated
with urethral cancer, traumatic injury.

Prostatorrhea - emission of prostatic secretions during urination or

defecation (associated with straining). Occurs in chronic bacterial prostatitis
or during prolonged restraint from sex life.

Spermatorrhoea - abnormally frequent and involuntary

nonorgasmic emission of semen, during severe spinal cord injury.

Hematospermia - presence of blood in ejaculation; It may be

accompanied by prostatitis, prostate tuberculosis or cancer.

8. Ejaculation disorders
Absence of ejaculate or retrograde ejaculation (semen enters the bladder).
 Reasons:
 Deficiency of androgens
 Sympathetic denervation
 Pharmacological agents
 Bladder neck and prostate surgery

9. Erectile dysfunction
• 20% of men over the age of 60 complain of sexual disorders, low libido, erectile
10. Changes in Spermatogenesis
Aspermatism - The absence of seminal secretion

Azoospermia - Semen contains no sperm

Oligospermia - Semen with a low concentration of sperm

(less than 30%)

Teratozoospermia – The presence of increased percentage

of abnormal sperm (more than 70%)

Necrospermia - The presence of motionless, dead


Hematospermia - The presence of blood in the sperm

Physical examinations of the urogenital system

 Anterior abdominal wall and lumbar - spine area
 Asymmetry - Large-sized hydronephrosis, polycystic kidney, renal tumor.
 Swelling and hyperthermia of lumbar-spine area – perinephric infection, abscess.
 Urinary bladder
 Outline of urinary bladder filled with urine during urinary retention
 Inspection of scrotum

• Palpate for kidneys
Normally only the lower pole can be felt when breathd deeply.
Bimanual palpation : Evaluating kidney size, shape, elasticity, location, pain.
Bimanual palpation Diseases
Enlaged kidney 1. Compensatory hypertrophy in the absence or
atrophy of the second kidney
2. Hydronephrosis
3. Cancer
4. Kidney cyst
5. Policystic kidney disease
Nodular or thick 1. Policystic kidney disease
2. Cancer
Bimanally kidney-free palpation of tissue mass 1. Retroperitoneal tumor
2. Spleen
3. Bowel cancer, abscess
4. Enlarged gall bladder
5. Pancreatic cyst

Urinary bladder palpation:

 Surface of the bladder filled with urine during acute or chronic urinary retention
Scrotal palpation:
 Evaluating:
 The presence, number, size, density, pain of the testicle.
 Structure, size of the epididymis and interconnection with the testicles.
 Hydrocele  Orchitis, orchiepididymitis
 Hematocele  Testicular cyst, tumor
 Varicocele  Testicular torsion
 Cryptorchidism
Male genital palpation:
 Evaluating Cavernous bodies and urethral elasticity
 Fibroblastic induration of the penis may be established (Peyronie’s disease, tumor,
Palpation of inguinal region:
 Enlargement of lymph nodes: Inflammation of the penis or scrotum; Penis, scrotal
skin, female distal urethral tumor.
Supraclavicular region
 Left-sided lymph nodes may have metastases from the testicles and prostate (Virchow
or Troisier nodes)

• Kidneys
Front and back percussion: In terminal hydronephrosis, when the kidney is unable to
palpate because of its soft consistency.
To identify progressive hemorrhagic masses in the kidney injury, when palpation fails
because of muscle spasms.
• Urinary bladder
Evaluating urinary bladder’s fullness, in case of at least 150ml of urine existence in it
• Diagnosis of renal arterial hypertension, stenosis of renal artery, arteriovenous fistula,
atherosclerotic lesion of the abdominal aorta.
Digital rectal exam of men
• Sphincter and anus
Anal sphincter tone relaxation indicates changes in urinary bladder sphincter and detrusor,
neurogenic disease.
Should be excluded: Anus stenosis, internal hemorrhoids, rectal fistula, polyp, tumor,
what may become the secondary cause of urinate disorders.
Normal size 3,0X4,0X2,0 sm., weight 18-20 gr.
By digital rectal exam:
• The right lob of the prostate
• The left portion of the prostate
• Interlobar duct
• Evaluating size, elasticity, consistency,
• Stone density - prostate cancer
Prostate Massage and Prostate Secretion
Prostate secretion mixes with sperm and is an important site for sperm motility.
With digital rectal massage it is possible to get prostate secretion.
Normally prostate secretion contains:
• Lecithin granules
• Small amounts of epithelial cells
• Rarely corpora amylacea
• Rarely sperm
Bacteriological examination of prostate secretion - Necessary method of diagnosing
prostate inflammatory diseases.
Prostate rectal massage is not recommended during acute urethral discharge, acute
prostatitis, urinary retention, prostate cancer.
Seminal vesicles
• Seminal vesicles are located behind the urinary bladder base and are deviated to the
lower peak
• Rectal examination is unable, If there is no deviation distally
Female genital system
• Diseases of the female genital system may be occured by symptoms typical of diseases
of the urinary organs.
Vaginal examination