m

The Urological
Examination In Family
Practice C. T. WOLAN, MD
SUMMARY
This article outlines the various procedures available to the family physician who wishes
to perform a complete urological examination on a patient. Techniques for specimen
collection, etc., are described. Those procedures which would not be performed by the
family physician are noted, showing when they might be ordered as an aid in diagnosis.
Dr. Wolan is clinical associate professor of surgery at the University of Saskatchewan
and head of the Department of Urology at the University Hospital.
THE FAMILY physician is confronted with problems of The same is true of a patient with chronic bladder outlet
the genitourinary tract more frequently than might be obstruction - he fills until the bladder is painful, then
expected. It has been estimated by various observers that dribbles out a few ml with much effort and experiences
between three and eight percent of patients coming to a relief, only to void again in 15 minutes because the bladder
family physician's office have a primary or secondary is again full. Some people have become so used to this
urological complaint. The family physician should be able frequency or are so reticent to admit a urinary problem in
to carry out much of the preliminary investigation at least case it means an operation that they say "I don't have any
to make a preliminary diagnosis, deciding from this if and trouble at all. I urinate every hour during the day and get
when to refer the patient to a urologist or nephrologist for up and pass water several times at night". Frequency with
further investigation and/or treatment. no urological findinigs should alert one to the possibility of
diabetes.
History
1. Frequency 2. Nocturia
Frequency of urination is a symptom indicating a This is similar to frequency, but because it is more
urinary problem, usually inflammation or irritation of the troublesome to get up at niglht to void, the patient is more
bladder, prostate, or urethra. An inflamed bladder has likely to seek help sooner.
limited distention and needs more frequent emptying to
keep it empty and less painful. Prostatitis gives the urge to 3. Dysuria
void more frequently, as does urethritis. A stone or other Pain on urinating is usually a burning type of 'scalding'
foreign body is especially irritating to the bladder when it discomfort, usually due to inflammation of the urethra or
produces a mechanical inflammation of the trigone. bladder. Terminal dysuria (discomfort at the end of voiding
Also, a bladder which does not empty completely or after voiding) is usually due to a trigonitis or prostatitis,
requires only half its usual time to reach full distention since this is the part of the urinary tract which contracts at
again and needs emptying more frequently. It takes only a the end of urination to get the last bit of urine out.
few ml let out of a bladder to give a feeling of relief from
urgency; for example, a patient with a painful bladder 4. Pyuria
distended well above his pubis may experience relief after Patients often complain of cloudy urine, which is not
only a few ml have been drawn off by catheter, even necessarily pyuria. Older men, particularly, keep a jar at the
though he still has about 1000 ml of urine in his bladder. bedside to save themselves a trip to the toilet. They pass
30 CANADIAN FAMILY PHYSICIAN/DECEMBER, 1975
 family physician for some other complaint, but because he
was thorough and did a proper urinalysis instead of the
'sink test', lie sent them for investigation, which uncovered
an early bladder tumor, with subsequent complete cure.
A word about hematuria in patients who are anti-
coagulated: some physicians are inclined to attribute this to
anticoagulation and leave it at that. In my experience the
anticoagulation is often 'the straw that broke the camel's
back' and incites a pre-existing lesion to bleed. These
people need urological investigation, or at least, a urological
consultation.
6. Urgency
This has the same causes as frequency but much more
acutely. Sometimes urgency results in urgency incon-
tinence; this more than anything else brings the patient to
the physician for relief. They can put up with a little
frequency but are less tolerant of urgency and almost
totally intolerant of urgency incontinence.
7. Incontinence
Urgency incontinence has already been mentioned. In
older males, incontinence may be overflow due to a
distended bladder. In a middle-aged or older female, it may
be due to relaxation of the pelvic floor with a cystourethro-
cele and loss of vesicle-urethral angle. This can be surgically
corrected with good results.
Another incontinence in older women is often due to
what I like to call a 'lead pipe' urethra. The urethra is
chronically inflamed, fibrotic, and strictured as a result of
repeated urethritis and periurethritis. The sphincter action
is ineffective in these patients, who are almost miraculously
cured by urethral dilatation. It is very hard to convince
some gynecologists that this syndrome exists; instead, they
keep on doing repeated Marshall-Marchette types of opera-
tion, etc., without success when one urethral dilatation
cures them, even though it may have to be repeated
periodically.
Neurogenic incontinence from a nerve lesion, spinal
warm urine which cools by morning, making the sediment trauma, etc., requires urological and neurological investiga-
precipitate out and become visible. Also, if they do have tion and various treatments, often with appliances such as
some infection the change in pH from urea splitting catheters and collection devices.
bacteria which have been growing in the urine for several The aged in their second childhood have bladder control
hours precipitates out the solute normally held in solution similar to that found in young children. They just do not
and makes a cloudy sediment. A few drops of dilute HC 1 or cerebrate well enough.
acetic acid will dissolve the sediment and the urine will
become clear, whereas real pyuria will remain cloudy. 8. Incomplete Emptying
Pus in the urine indicates urinary tract infection which This may be neurological or obstructive, both of which
needs further investigation, except for pyuria following require further investigation. The older man who must
prostatectomy or urinary tract surgery. These urines usually urinate two or three times while shaving in the morning
culture negatively; the pyuria after prostatectomy might almost certainly has prostatism and does not empty his
last for two to three months and is a normal finding. bladder completely the first time.
The 'busy little girl' who runs into the toilet, squirts a
5. Hematuria little and runs out to play again in a hurry, is one who
Hematuria, whether microscopic or gross, is always needs training, because this eventually leads to more serious
important. Asymptomatic hematuria without frequency or urinary problems.
dysuria and in the absence of trauma is much more
important than that with symptoms. The hematuria of 9. 'Organ Music'
prostatism is almost always due to infection rather than to This is a term originated by one of my colleagues. It
carcinoma of the prostate. Prostatic carcinoma does not refers to vague groin, suprapubic, and testicular discomfort.
bleed by itself, but when it produces retention and It is quite often a 'fixation syndrome' and may indicate low
infection, there may be hematuria. grade urinary or prostatic infection producing vasitis, but
How much blood is important? Persistent microscopic more often these people are overly apprehensive to very
hematuria requires an explanation. I have seen several cases little real discomfort, which may be aggravated by cre-
of microscopic hematuria found in patients visiting their masteric spasm. Sometimes, it is due to some vague
CANADIAN FAMILY PHYSICIAN/DECEMBER, 1975 31
intrascrotal pathology which may not be obvious at the 12. Colic
time but may show up with re-examination. For this Colic is usually ureteral in origin, not due so much to
reason, these people should be properly followed and spasms of the ureter fighting an obstruction, but almost
re-examined until one is quite sure that it is nothing more always to increased intraluminal pressure, which may be
than 'organ music'. due to a spasm but also to the continuing production of
urine by the kidney over-distending the uret-er with
10. Suprapubic Discomfort pressure. It is usually due to a stone but we must not forget
A very common complaint often due to cystitis, spastic that it can be due to the passage of a blood clot originating
bladder or distended poorly emptying bladder. in renal bleeding, or it may be due to ureteral pathology.
Colic should be investigated until a diagnosis of the etiology
11. Testicular or Vulva Pain is made.
It is sometimes difficult to find the cause for this Ordinary muscle antispasmodics have little effect on
condition. There may be local pathology, but there may relaxing ureteral muscle except in large, almost toxic doses.
also be a lower ureteral problem such as a stone. Dr. Donald In my experience, pain relief with analgesics is much more
Smith, professor of urology at the University of California effective.
School of Medicine in San Francisco, has recently presented
a collection of cases of nerve compression by paravertebral 13. Injury
ligaments, proven by exploration. Until now these cases had Injury may produce pain and blood. One should always
been completely misdiagnosed. I am sure there will be investigate all urological complaints in injury.
reports in the literature of this cause as we start looking for Here I would like to put in my personal plea for not
it. overlooking a pre-existing testicular lesion just because we

TABLE. I
Urdog-iculWorkup ______________________

*1..,HistoryZ 4. Urine cultu hs

5. Hematolog-l"
ie*|,- rctl xaionato
&Uu,9; geitalia
a. Hemaglobin
b :WBC and diffrenta ten

aboe
b. Femae - en t

c. ESR
d. ASO titre
-pelvic examinato e. Acid and alkaline phosphtate
-urethrecaruncle
'~~~_eatu
m stenisl
- rethr6cl f. Fasting blood sugar
. Blood urea .dser m ca
B. KUB film (Aview of ado n to include the areas of
':tumor - thickening on bmmnua the kidneys, uretera bIadde, hen 'KUB).
atom mevableand tne
7. Inravenupyram
::-lower ends ofurears : e c be -felt
if we Jiwwwht aretinga b. Drip-;inrfusion.
'Ob ..:' ....l
c. Both oftabov-e- with final Wbadder flm after
o whih affects
:;trw:w-
dt,ct voiding
1ey
-.n. n U,. .i tf 10 t ar 96 ) a
8. Voidi yo
.

c: Obvious neroUlogicl*w ' smkary f h i-X.

* tbxtrmltie
..P.
..:::i.
9.aRenal angiography
Z tlrl#Wienats
tee et a nourofice.)
a Color ;- *0. Endo*o;. not, usua .. tin: the capabits: ofthe

i i -t >- primr
Ill- physiian'
Retrgrade ar urnwf
pyeagrammtm pyi"
At o done.as oftenas
presiouul end certinty flotythlam
ryephysican
12. Percutaneou rnal biy* l m Iordd b a
famil phyisiaf :wh Is g a cse
goenlepft.Aor tVtuie ne.....6ihropa.
o chrnic
11. ..M. ,. .4 ;: -.t -0 :4:k:.-.
I.: 044I! .iiii.io...064:.. ....
-%':-If .., .:; A.... ::: .:..:..
...m.
... ... .-,.
.1. -..
.-. i:.
. :i . C. ...
ii, - 1,

32 CANADIAN FAMILY PHYSICIAN/DECEMBER, 1975

attribute everything to the injury. I know of a young
athelete who lost his life because his embryonal carcinoma
was overshadowed by injury and thus overlooked by his
physician for many months. Remember that the overweight,
low-hanging, or enlarged testicle gets more easily injured.
14. Disease Contact
One should always enquire about this - you may be
surprised! I once had a celibate priest with specific
urethritis, rather than prostatitis as suspected by his
physician!
There are several other urological conditions brought out
in the history:
a. 'Honeymoon cystitis' and other postcoital cystitis.
b. Diabetics with urinary symptoms who are more prone
to urinary infection.
c. Analgesic abusers. These patients hide their abuse and
only on persistent questioning, possibly of other family
members, may one be able to diagnose analgesic nephro-
pathy.
d. History of urolithiosis.
e. History of childhood infections. This is particularly
important; infection may lie dormant only to show up later
in life as a congenital defect such as ureteropelvic junction
obstruction or some other anomaly such as renal rubular
ectasia or a pyelonephritis due to reflux.
f. History of infection or renal type pain during preg-
nancy. The ovarian vein syndrome is now well-established
and accepted. It is always on the right and passes off,
usually completely, after delivery.
g. History of hypertension. This frequently needs full
urological investigation and often angiography, particularly
in younger and middle-aged patients.
The Intravenous Pyelogram (IVP)
When To Do It
1. Investigation of pyuria or significant urinary infec-
tion, particularly if it recurs.
2. Investigation of abdominal pain or renal-ureteral-
bladder distribution pain which cannot be definitely
attributed to another cause.
3. Renal colic, particularly when colic persists and the
KUB film shows a possible calcific shadow in the urinary
pathway. It is helpful to do an IVP to prove the presence or
absence of a stone and/or obstruction. If there is obstruc-
tion due to the stone and the stone is not passing, surgical
intervention may be required earlier, rather than waiting
while the kidney suffers damage.
4. Hematuria. This is more urgent than pyuria since even
microscopic hematuria can be due to tumor. However, renal
parenchymal tumors such as renal cell carcinoma do not
produce early hematuria, but surface papillary tumors
anywhere along the urinary tract do. You will see distortion
of the renal collecting system if the tumor is far enough
advanced (usually more than two cm in diameter).
5. Following trauma with hematuria and/or pain. In this
case do a drip infusion pyelogram with tomography and
delayed films if necessary for better visualization.
6. In infants and young children with an abdominal mass
or with abdominal pain even without obvious urinary
infection. An IVP should precede a GI examination because
statistically it produces more positive findings.
When to Repeat an IVP
1. To monitor the progress of renal damage following
trauma.
CANADIAN FAMILY PHYSICIAN/DECEMBER, 1975
2. Occasionally to monitor chronic pyelonephritis once a
year or so.
3. To ascertain renal function after blockage of ureter
due to a stone or trauma due to external violence or
surgery.
4. Several months after plastic repair of congenital
anomalies such as ureteropelvic junction obstruction, mega-
ureter (various causes), etc.
What Information Do We Get?
1. When doing an IVP one should try to get as much
information as possible at that time. Often with very little
more effort and no more expense or inconvenience to the
patient, one can get much more information by doing a few
extras. I refer here particularly to delayed films from one to
24 hours after injection of dye to show some outline in
what at first looks like a non-functioning kidney, or
eventually to get enough dye into the ureter to show where
the obstruction is. Another useful effort is to get a final
bladder film after voiding. This not only tells us if there is
residual urine, but also clears the area of the lower ureters
which are obscured by the bladder full of dye in the later
films and may obscure a stone or other lesion.
2. Standing the patient up for one of the films will show
ptosis which otherwise might be missed and by rotating the
patient slightly for an oblique view may show a renal,
ureteral, or bladder lesion that might otherwise be missed in
the AP view.
3. Sometimes a tomographic cut or two will settle a
suspicion of a lesion or deformity.
Voiding Cystourethrogram
This diagnostic procedure is mainly done when vesicoure-
teral reflux is suspected and/or to visualize the bladder
capacity, shape, and urethral shape or pathology. There are
two types of voiding cystourethrograms.
1. Secondary or post IVP type. This is done when the
IVP is finished and the bladder is full of contrast medium.
Instead of just taking a bladder film after voiding, an
oblique or lateral projection is taken of the urethra during
voiding. In the male patient, let the penis hang freely
without obscuring it by the hand. In the female, the patient
voids into a receptacle with thighs apart while a film is
taken usually in the oblique or lateral projection. A final
film after completion of voiding should still be taken to see
if any residual dye remains in the bladder or in a diverti-
culum. In some rare cases, the dye outlines a previously
missed bladder lesion.
2.P?-imary type. In the male, and particularly in male
children, when we are looking mainly for reflux, it is
advisable to insert a bladder Foley catheter during the
anesthesia after cystoscopy, wait until the child recovers
well from anesthesia and then send him for the cysto-
urethrogram. In this way, we save hurting the child by
inserting the catheter which, in a small child, can be rather
traumatic.
In the female, do this before the IVP and on the same
visit to the X-ray department. Have the catheter put in
under sterile conditions either on the ward or in the X-ray
department. At the same time get a catheter bladder urine
for microscopy, culture, and sensitivity.
In high and low pressure reflux, the usual procedure is to
fill the bladder slowly with contrast medium, take a film in
the AP and lateral and oblique projections to outline the
shape and size of the bladder. The oblique films throw the
ureteral shadow away from the bladder and better visualize
33
the ureter so that both the right and left obliques should be urinary infection in the adult male arises from chronic
taken. Fluoroscopy is then carried out with the child prostatic infection. To prove this, we should either examine
almost upright on the tilted X-ray table during voiding to the prostatic fluid in a wet smear or a stained smear, or,
see if reflux is present. Spot films are taken. At least one better still, get a culture of the fluid.
film should be taken of the bladder and the urethra during The finding of pus cells in prostatic fluid after prostatic
voiding to visualize the urethra and to reveal stricture massage is corroborative evidence only. The finding of
and/or dilation of the urethra in boys, the direction of the bacteria in a stained smear is more conclusive. The most
stream leaving the meatus and its volume (if the stream is conclusive evidence of chronic prostatic bacterial infection
crooked or small, this usually means a stricture) and the is a culture of prostatic fluid. There are two ways of
shape of the female urethra. The 'spindle-top' shape with a obtaining this culture.
small meatus is typical of a meatal stenosis. The simplest is by having the patient first void a short
squirt to wash out the anterior urethra and then massage
Urine Culture the prostate, collecting the secretion. If there is not enough
Cure and prevention of urinary tract infection depends secretion, it is best to do the four step technique with the
on a meaningful culture at repeated intervals. Although the third representing the prostatic fluid.
family physician usually has little to do with the actual 1. Void first 10 ml or so to wash out the urethra.
culturing of the urine, the obtaining of the specimen must 2. Void second specimen to get representative bladder
usually be done in the family physician's office except in an urine.
urban clinic set-up. 3. Massage the prostate and void third sample to get the
Careful taking of the specimen is important. This is no prostatic secretion 'wash out'.
problem in males if the patient can cooperate and is not 4. Empty bladder for the fourth culture.
bedridden. We seldom need to catheterize. If circumcised, If the growths from the second and third specimens are
get the patient to void and after about two or three seconds the same, this indicates prostatic origin of the urinary
get a 'mid-stream catch' into a wide-mouthed sterile bottle infection. Also, the third specimen growth will be the
or tube. No glans preparation is needed. If the patient is heaviest if the prostate is the cause. If different organisms
uncircumcised, retract the foreskin, wash the glans off with are found in the bladder representative, then the prostate is
soap and water and dry well, then do a 'mid-stream catch' not the cause of the recurrent urinary infection.
as above.
In the female, a 'mid-stream catch' after proper prepara- Acid Phosphatase
tion of the labia and vestibule is quite satisfactory. We prep There are many acid phosphatases and through the years
the patient in the lithotomy position. This is done by our we have been trying to identify specifically the prostatic
female attendent using a Proviodine scrub solution soaked 4 acid phosphatase. I will not go into the details of the
x 4 gauze square eight to 12 layers thick. Then the vestibule biochemistry except to state from a practical standpoint
is blotted dry and the patient either voids while lying down that it is not an index of early prostatic carcinoma but
with the labia spread or she can get up. usually becomes elevated in late metastatic stages -
More often, however, in our office it is more convenient particularly to bone. There are false positive results from
to do a catheterized sample using a sterile No. 14 Coude hemolysis because red blood cells contain a similar acid
plastic disposable Rusch catheter. Rusch makes a urine phosphatase. False negatives may be obtained because
culture sample bag with enclosed connected catheter that prostatic acid phosphatase is quite heat labile and may be
projects out of the sterile bag and is disposable. The destroyed in transport of the blood to the laboratory.
catheter is a No. 14 French, short, and the bag is
self-sealing. It is called 'The Collector' or the 'Female Urine Two Recent Advances
Sampler', catalogue No. 220008, complete with an attached The Uricult tube and the Doeppler ultrasonic stetho-
card for the patient's and doctor's names. They come in scope have greatly improved diagnosis of urological prob-
lots of 50 and cost less than 50 cents. lems. The Uricult tube, a patented device manufactured by
Orion Pharmaceutical in Helsinki, allows urine to be
In neonates, this may be the only time one really needs
to do a suprapubic needle aspiration. A word of caution: collected in a clean container rather than a sterile collection
the infant bladder, being quite automatic and without device. The sample can be stored in an office incubator at
cerebral control, empties with whatever volume trips the 37 degrees C for 16-24 hours, or even at room temperature
reflex. This volume in a spastic inflamed bladder may be overnight and observed the next day for growth, to save
shipping specimens which show no growth. The two sides
quite small, making the target hard to hit! Try to do it as
of the slide are covered with different media - agar and
long as possible after the last voiding. The infant's nurse
may be of great help in establishing this time interval. MacConkey's stain - to pick up all organisms or specifically
One should be careful not to aim -the needle more thangram negative and enterococci. The accompanying chart
gives some indication of colony counts, enabling earlier
100 caudal, since if this angle is too great, the needle will
identification of bacterial infection. The tubes will keep for
slip alongside the anterior wall of the bladder, missing the
bladder entirely. The best angle is directly backwards at least six months in an ordinary refrigerator.
immediately suprapubically, missing the peritoneal reflec- The Doeppler ultrasonic stethoscope now enables better
diagnosis of torsion of the testicle. Previously, diagnosis of
tion which is pushed up by the full bladder. Put suction on
acute testicular pain in young or middle aged males was a
the syringe while advancing a fine No. 21 1.5 inch needle so
that you stop as soon as you enter the bladder. By doing severe test of diagnostic ability: many cases were operated
this there is less chance of pushing through too far. You on in error, or worse, were neglected with subsequent loss
only need 10 ml at most. of a testicle. The Doeppler instrument will indicate with
approximately 90 percent accuracy whether the circulation
Prostatic Secretion Culture is impaired through torsion of the cord or whether it is
It has been quite conclusively proven that recurrent increased, as with inflammation of epididimytis. <
34 CANADIAN FAMILY PHYSICIAN/DECEMBER, 1975