‫بسم هللا الرحمن الرحيم‬

History and Physical

examination of
Urinary Tract

Nuzirwan Acang

Faculty of Medicine
Islamic University Bandung
 Introduction

◼ Most diagnosis can be reached by a complete

history, and a thorough theoritical-legaartis
physical examination
◼ Challenges in History
◼ Communication (language, educational and
background )
◼ Make the patient feel comfortable
◼ calm, caring, and competent image
◼ Family member
 Introduction

◼ Greet the patient and introduce yourself

◼ Time
◼ sufficient to express their problems and the
reasons for seeking your care
◼ Listen carefully
◼ without distractions in order to obtain and
interpret the clinical information provided by
the patient
 KIDNEY FUNCTIONS
◼ Urine formation
◼ Excretion of waste products
◼ Regulation of electrolytes
◼ Regulation of calcium and phosphorus balance
◼ Regulation of acid-base balance
◼ Control of water balance
◼ Control BP
◼ Regulation of RBC production
◼ Synthesis of vitamin D to active form
◼ Secretion of prostaglandins
 History
◼ Major components
◼ Chief complaint
◼ Review of systems
◼ Present illness
◼ Past medical history
◼ Family history
◼ Medications
◼ Allergies
◼ Socio-economic History
Chief Complaint and Present Illness
◼ The chief complaint is a constant reminder as
to why the patient initially sought care.
◼ This issue must be addressed even if
subsequent evaluation reveals a more serious
or significant condition that requires
◼ Present Illness :
◼ Duration
◼ Severity

◼ Chronicity

◼ Periodicity/precipitating factors

◼ Degree of disability
 Pain
◼ Can be severe
◼ urinary tract obstruction
◼ inflammation
◼ Inflammation of the GU tract is most severe when
it involves the parenchyma of a GU organ
◼ Pyelonephritis
◼ Prostatitis
◼ Inflammation of the mucosa of a hollow viscus
usually produces discomfort
◼ Cystitis
◼ Urethritis
 Pain

◼ Renal Pain
◼ Site: ipsilateral
costovertebral angle just
lateral to the
sacrospinalis muscle and
beneath the 12th rib
◼ Acute distention of the
renal capsule
◼ Referred pain
 Ureteral pain

◼ Usually acute and secondary to obstruction

◼ Midureter ( Rt side): referred to the right lower quadrant
(McBurney's point) and simulate appendicitis
◼ Midureter (Lt side) :referred over the left lower quadrant
and resembles diverticulitis.
◼ Lower ureteral obstruction frequently produces symptoms
of bladder irritability( frequency, urgency, and suprapubic
discomfort)
 Vesical Pain

◼ Vesical pain is due

◼ Overdistention

◼ inflammation
 Prostatic Pain
◼ Inflammation with secondary edema and
distention of the prostatic capsule
◼ poorly localized
◼ lower abdominal
◼ Inguinal
◼ Perineal
◼ Lumbosacral
◼ rectal pain.
◼ irritative urinary symptoms ( frequency and dysuria)
◼ acute urinary retention.
 Penile Pain
◼ Pain in the erect penis is usually due to
Peyronie's disease or priapism
◼ Pain in the flaccid penis
◼ usually secondary to inflammation in the bladder
or urethra
◼ referred pain that is maximally at the urethral
meatus
◼ paraphimosis
 Testicular Pain
◼ Acute pain
◼ epididymitis
◼ torsion of the testicle

◼ Chronic scrotal pain

◼ hydrocele
◼ varicocele,

◼ dull, heavy sensation that does not radiate

◼ Referred pain: kidneys or retroperitoneum

Associated symptoms

◼ Gastrointestinal symptoms
◼ Nausea

◼ Vomiting

◼ Ileus
 Hematuria
◼ Hematuria : the presence of blood in the urine
◼ In adults, should be regarded as a symptom of
urologic malignancy until proved otherwise
◼ Is the hematuria gross or microscopic?
◼ Timing: (beginning or end of stream or during entire
stream)?
◼ Is it associated with pain?
◼ Is the patient passing clots?
◼ If the patient is passing clots, do the clots have a specific
shape?
 Hematuria
◼ Initial hematuria:
◼ usually arises from the urethra
◼ least common
◼ usually secondary to inflammation.
◼ Total hematuria
◼ most common
◼ bladder or upper urinary tracts.
◼ Terminal hematuria
◼ the end of micturition
◼ secondary to inflammation bladder neck or prostatic
urethra.
Enuresis
◼ Urinary incontinence that occurs during sleep
◼ Mostly in children up to 5 years
Anuria
◼ Urine production less than 100 cc/day
Oligouria
◼ Urine production less than 500 cc/day
 Urethral Discharge

◼ Urethral discharge is the most common

symptom of venereal infection.
Fever and Chills

◼ Usually in UTI
◼ Pyelonephritis
◼ Prostatitis

◼ Epididymitis
Lower Urinary Tract Symptoms

◼ Irritative Symptoms
◼ Urinary frequency
◼ Nocturia

◼ Frequency

◼ Dysuria: painful urination

◼ Incontinence
◼ Stress
◼ Urge
 Past Medical History

◼ Systemic diseases that may affect the UT

system
◼ diabetes mellitus.
◼ multiple sclerosis

◼ TB

◼ Schistosomiasis
 Family History

◼ prostate cancer
◼ Stones( cystine)
◼ Renal tumors (some types)
 Smoking and Alcohol Use
◼ Cigarette smoking
◼ urothelial carcinoma, mostly bladder cancer
◼ Erectile dysfunction.

◼ Chronic alcoholism
◼ impaired urinary function
◼ Sexual dysfunction.

◼ testicular atrophy, and decreased libido.

 PHYSICAL EXAMINATION

◼ General Observations
◼ Visual inspection of the patient

◼ Cachexia

◼ Malignancy, TB

◼ Pallor

◼ Gynecomastia

◼ hormonal therapy for prostate cancer

 General physical examination

◼ DOCTORS SHOULD BEOBSERVANT,LIKE A

DETECTIVE; “CONAN DOYLE”
◼ Look at the patients general appearance…at the
face ,hands and body
◼ Each examining system can be described using
four elements;
- inspection/looking
- palpation/feeling
- percussion/tapping
- auscultation/listening
 VITAL SIGNS

◼ Pulse
◼ Blood pressure
◼ Temperature
◼ Respiratory rate → kussmaul
◼ Should be assessed immediately once you
discover that your patients unwell.
◼ They provide important basic physiological
information.
QUADS
RAN
OF THE
ABDO
MEN
Abdominal examination
Palpation
1. Ensure that your hands are warm

2. Extremitas -> flexion position

3. Stand on the patient’s right side
4. Help to position the patient
5. Ask whether the patient feels any
pain before you start
6. Begin with superficial examination
7. Move in a systematic manner
through the abdominal quadrants
8. Repeat palpation deeply.
 Kidneys
◼ Palpation of the kidneys
◼ supine position

◼ The kidney is lifted from behind with

one hand in the costovertebral angle
 Method of palpation of the kidney
◼ The posterior hand lifts the kidney upward.
◼ The anterior hand feels for the kidney.
◼ The patient then takes a deep breath; this
causes the kidney to descend.
◼ As the patient inhales, the fingers of the
anterior hand are plunged inward at the
costal margin.
◼ If the kidney is mobile or enlarged, it can
be felt between the two hands.
 ( Continuous )
The patient lying in the supine position on a hard
surface .
The kidney is lifted by one hand in the
costovertebral angle (CVA).
On deep inspiration, the kidney moves downward;
the other hand is pushed firmly and deeply
beneath the costal margin in an effort to trap the
kidney.
When successful, the anterior hand can palpate the
size, shape, and consistency of the organ as it slips
back into its normal position.
 Palpation of the kidneys
⚫ Extend from the twelfth
thoracic vertebrae to the L R
third lumbar vertebrae.
⚫ Not normally palpable
unless the patient is thin
⚫ The right kidney is lower
than the left due to the
position of the liver
⚫ They have a firm
consistency and smooth
surface
⚫ They move downwards
towards the end of
inspiration
Posterior view
35
 Kidneys angle
⚫ They are retroperitoneal
L R
organs and deep
bimanual palpation is
required.
⚫ To examine position the
patient close to the edge
of the bed
⚫ Tuck the palmar surfaces
of one hand into the
patients flank
⚫ Nestle the finger tips in
the renal angle
Posterior View
 Bimanual examination of the kidneys
One hand under the patients The other hand with fingers flat
flank, fingers in the renal angle placed below the costal margin,
(between posterior costal lateral to the rectus muscle
margin and spine

Hands should be opposite one another

 Bimanual examination of the kidneys
⚫ Palpate the lower pole
of the kidney between
the fingers of both
hands
⚫ Asks the patient to
breathe in deeply and
press the fingers of
both hands firmly
together
⚫ The rounded lower
pole of the kidney
may be felt passing
between the opposing
fingers as the patient
breaths in and out
 Percussion
⚫ Assess the need to perform percussion
depending on your clinical findings.
⚫ It is important to distinguish kidney
enlargement from splenomegaly on the left
and hepatomegaly on the right
◆ Percussion of an enlarged liver or spleen will
be dull whereas over the kidney it should be
resonant due to the overlying bowel
◆ The kidneys can be “balloted” this a
technique where by a structure that is not
fixed can be patted between the examining
Percussion technique
⚫ Take note of the technique
⚫ Use the tip of the finger
⚫ The blow is delivered by a
sharp wrist movement
⚫ Strike the middle phalanx
firmly. Two – three taps
only.
⚫ Remove striking finger
immediatel
 Auscultation

◼ Location : epigastrium for bruit

◼ renal artery stenosis

◼ aneurysm.

◼ renal arteriovenous fistula.

 Bladder

◼ At least 150 ml of urine in it to be felt.

◼ Percussion is better than palpation
◼ A bimanual examination, best done under
anesthesia, is very valuable to asses bladder
tumor extension
Bladder
 Penis

◼ The position of the urethral meatus

◼ Priapism: sickle cell disease
Hypospadias
Rectal and Prostate Examination
in the Male

◼ Digital rectal examination (DRE) :

◼ Every male after age 40 years

◼ Man of any age who present for

urologic evaluation
◼ Position, left lateral decubitus
 Indications for R.E.

◼ Assessment of the prostate (particularly

symptoms of outflow obstruction). →
Pancreatitis or ca prostat
◼ When there has been rectal bleeding →
malignancy of rectum or sigmoid (prior to
proctoscopy, sigmoidoscopy and colonoscopy).
◼ Constipation or change of bowel habit.
◼ Problems with urinary or faecal continence.
 Contraindications
◼ Imperforate Anus
◼ Unwilling patient
◼ Absence of anus following surgical
excision
◼ Stricture
◼ Moderate to severe anal pain
◼ Prolapsed thrombosed internal
hemorroids
 External Inspection

◼ Skin disease.
◼ Skin tags
◼ Anal fissures
◼ Anal fistula
◼ External haemorrhoids
◼ Rectal prolapse
◼ Skin discolouration with Crohn's disease
◼ External thrombosed piles
 Internal Inspection
◼ Simple piles (but best examined at
proctoscopy)
◼ Rectal carcinoma
◼ Rectal polyps
◼ Tenderness
◼ Diseases of the prostate gland
◼ Malignant or inflammatory conditions of
the peritoneum (felt anteriorly)
 Procedure DRE

◼ Examine tonus of the sphincter gently (

whether weak, strong, dry, smooth)
◼ rectal mucosa circumferentially( smooth,
granule surface )
◼ rectal ampulla.( filled, empty, collapse or
not)
◼ Note any nodules, irregularities, or
induration
 Examination of the Prostate
Gland
◼ Normal size is 4 cms wide, protruding
about 1 cm into the lumen of the rectum.
◼ Consistency: it is normally rubbery and
firm with a smooth surface and a
palpable sulcus between right and left
lobes.
◼ There should not be any tenderness.
◼ There should be no nodularity.
 (Conti…….)
◼ Sweep your finger carefully (12 o‘clock) over the
prostate gland on anterior section of body,
identifying its lateral lobes and median sulcus
between them.
◼ The normal prostate gland is about 4 cm length
and in width (about the size of terminal segment
of the thumb), smooth, somewhat mobile, non
tender & rubbery.
◼ Note the size, shape, consistency, identify any
nodules or tenderness of the prostate.
‫ب اْلعَالَ هم ْين‬ ‫ا َ ْل َح ْم ُد ه ه‬
‫لِل َر ه‬

‫‪Syukron‬‬