PHYSICAL EXAMINATION OF GENITOURINARY TRACT

Inspection
Abdominal  Swelling in upper abdomen → hydronephrosis, tumor of kindeys
inspection  In children → tumors are very prominent anteriorly, in hypochondrium
 Suprapubic region → congenital abnormalies: bladder extrophy
 Swelling on suprapubic area → distended bladder
External  Varicocele:
genitalia o Patient standing → reveal varicocele
inspection o Patient supine → mask varicocele
 Redness of scrotum → epididymitis
 Sinuses in scrotal skin are found in TB of testis and epididymis
 Scrotal swellings → elephantiasis, hydrocele, varicocele, spermatocele, tumor
of testis
 If patient is uncircumcised → foreskin is retracted → reveal the glans and
urethra
o Prepuce cannot retract → phimosis
 Glans penis → may show balanitis, tumor
 Vesicles of herpes simplex virus, condyloma acuminata
 Urethral meatus → may show stenosis
 Penis → may show congenital abnormalies: epispadias, hypospadias
o Epispadias: meatus proximal to the tip of the glans on dorsal surface
o Hypospadias: meatus proximal to the tip of glans on ventral surface
Pelvic  Urethra → inspected for abnormalities and atrophic changes
inspection in  Vaginal discharge → swabbed for culture, cervical smear
woman  Cystocele or rectocele
 Ask the patient to cough → accentuate any prolapse, or stress incontinence
Palpation
Abdominal  Gental palpation → reveal unsuspected abdominal tenderness
palpation  If this is sufficient to produce guarding → important to elicit rebound
tenderness
 Once tenderness is noted → deeper palpation → detect intraabdominal
masses
 Most abdominal signs in Urology are enlarged kidneys or palpable bladder
Kidney  Bimanual palpation
palpation o Patient lying in supine position
o Kidney is lifted by one hand at costovertebral angle (on the back)
o Deep inspiration → kidney moves downward
o The other hand is pushed beneath costal margin to trap it (on
abdomen)
→ check for size, shape, consistency
 Enlarged kidney:
o Compensatory hypertrophy (one kidney is removed)
o Hydronephrosis (firm/soft)
o Tumors → hard, firm consistency
o Cystic kidney
Urinary  One finger in rectum, one hand on suprapubic region
bladder  Enlarge baldder → may be palpable, arising from the pelvis
palpation  Distension of bladder → acute / chronic retention of urine
Rectal  Detect rectal tumors
 palpation  Patient in left lateral position / kneeling position
Prostate  DRE → check size, shape, consistency of prostate gland
palpation o Size: 4cm
o Shape: chestnut
o Weight: 15g
o Consistency: soft, smooth (like the tip of the nose)
 Firm/hard, enlarged → suspicion of prostatic carcinoma
 Tender, boggy, edema → prostatitis
 Seminar vesicles → enlarged, palpable above the prostate → chronic
inflammation (TB) or local invasion by bladder/prostatic carcinoma
***Normal vesicles cannot be detected
Palpation of  Examine cord, vas deferens, epididymis and testes → for size, shape,
external consistency
genitalia  Testes:
o Normal pathway = ectopic testes
o Palpable in inguinal region = undescended testes
o ↓size = mumps, orchitis, hypogonadism, torsion of spermatic cord,
after orchiopexy
 Shaft of penis → feel for plaques of fibrosis (Peyronie’s disease)
 Stone in anterior part of urethra → may be palpated
 Corpus spongiosum → thickened in urethritis, urethral stricture
Palpation of  Uterus and vaginal fornices → mass, tenderness
pelvis in  Stones in lower ureter → palpable in lateral vaginal fornix
women
Percussion
Kidney  Outline an enlarging mass
percussion
Abdominal  Tenderness on gentle percussion → suggestive of peritoneal irritation
percussion
Bladder  In obese patients → not always possible to palpate an enlarged bladder →
percussion percussion reveals suprapubic dullness
Auscultation  Above umbilicus and in the lone → for vascular bruit (associated with renal
artery stenosis or aneurysm of renal artery)

RADIOLOGY OF URINARY TRACT

X-ray of  Used to diagnose calculi and calcification in the urinary tract

abdomen  A laxative → empty the bowels (minerals in bowels cast a shadow → mistaken
for calculi)
 Plain x-ray includes: kidneys, ureters and bladder
 90% of calculi are radio-opaque, however, it’s difficult to see a small radio-
opaque calculus (<1cm)
 A lateral x-ray → differentiate a renal calculus from a gall bladder stone
 Possible findings: kidney stones, urinary tract obstructions, bladder tumors
and anatomical abnormalities
Intravenous  Is a radiographic study of renal parenchyma, pelvic calyceal system, ureters
urography and the urinary bladder which involves a contrast agent that’s given
intravenously
 The contrast is cleared by kidneys, excreted as part of urine → visualize the
urinary tract
  Indications:
o Check for normal function of kidneys
o Check for congenita anomalies (horse-shoe kidney)
o Check for course of ureters
o Detect and localize a ureteric obstruction (urolithiasis)
 Contraindications:
o Hypersentivity to iodine
o Renal insufficiency
o Hepato-renal syndrome
o Thyrotoxicosis
Retrograde  A method of demonstrating the calyceal system, renal pelvis and ureter by
urography using contrast medium that is injected into the ureter through a ureteric
catheter with cystoscopy
 The contrast flows up to the kidney in an opposite way → retrograde
 Indications:
o Localize the obstruction in ureter
o In case of poor-outlined image by IV urography (due to poor renal
function)
Antegrade/  Used in obstructive uropathy where retrograde urography is NOT possible /
Percutaneous Failed to show renal pelvis and the portion of ureters above the obstruction
urography  The contrast medium is introduced directly into renal pelvis by percutaneous
needle puncture
Cystography  This technique is used to demonstrate the urinary bladder with contrast
medium
o Excretory cystography → done with IV urography
o Retrograde cystography → contrast introduced directly into bladder
through catheter
 Introduce water-soluble iodine contrast into bladder via a retrograde catheter
 Used in tumor, vesical diverticulum, non-opaque calculus

Urethrograms  Micturating cystourethrogram (MCU) → bladder is filled by dye by excretory

method → patient passes urine → film is taken to see bladder + urethra →
show urethral strictures, vesicoureteral reflux
 Retrograde urethrogram (RU) → urethra is filled with dye retrogradely +
urethrogram is taken while injecting the dye → show stricture, its length and
size
 Choke urethrogram → MCU and RU are carried out simultaneously → show
both ends of structure
Seminal  Contrast injected into → vas deferens
vesiculography  The seminal vesicles and epididymis → outlined by contrast
and
Epididymograph
y
Renal  Used to visualize renal arteries
arteriography  Indications:
o Differentiate between tumor & cyst (MOST IMPORTANT)
o Anatomy of renal vessels (their origin, number)
o Renal vascular lesions
o Renal damage after trauma
Venacavography  Catheter is inserted into femoral vein
 and renal  Indicated in the investigation of renal vein thrombosis / occlusion due to
venography tumor
 Displacement of inferior vena cava = evidence of enlarged para-aortic nodes,
presence of retroperitoneal mass
MRI  MRI uses strong magnetic field and radio waves to create images of the body
 Safe technique: no ionising radiation or contrast media
 Indications:
o Visualize renal cortex and medulla
o In bladder tumor → detect metastases in pelvic wall
o Stage prostatic carcinoma
CT  Uses a combination of x-rays and computer calculations to create detailed
cross-sectional images of urinary system
 CT scans → often combined with contrast (injected into veins) for clearer
images
 Visualize: kidney stones, tumor (benign/malignant), cysts, urinary tract
obstructions, anatomical abnormalities and infections

***X-ray, non-contrast CT, MRI, US = non-invasive methods

***Cystoscopy, IV urography, contrast-enhanced CT = minimally invasive

Instrumental investigations in Urology

Urethroscopy:

 Stone in urethra, foreign body, urethral tumour

 Urethroscopy is the initial step of cystoscopy

Calibration to urethra

 Means to define the diameter of the urethra

 May be performed by soft catheters
 With these instruments we may find the anatomical part of the structure of the urethra

Drilling

 Catherisation means placement of catheter in the UB. If the catheter stops along the urethra → have
to do Drilling

Instrumentation’s of UB

Catheterisation of UB

 Definition: placement of catheter in UB

 Can be with diagnostic and therapeutic purpose
 To measure post-residual volume → this retrograde manipulation may be replaced with US (modern
replacement) → e.g: when measure Post residual volume → 2 tupes: catheter / US. Catheter gives
precise values, US gives values based on the shape of the bllader
 To obtain urine sample for investigation
 To perform urodynamic investigation of LUT
 To introduce contrast media for imaging of urinary bladder
  To do retrograde cystography: indications are trauma to UB, to look for vesico-ureteric reflux

Cystoscopy

 Hematuria – raises suspicion for malignancy

 Chronic cystitis → define the type, there are several types. Cystoscopy is combined with biopsy here
for histological investigation
o Cystoscopy is STRONGLY FORBIDDEN in acute cystitis
 Vesicovaginal fistulas
 Adjacent tumours to the UB (staging cystoscopy) to find infiltration of adjacent tumours. Females is
gynaecological malignancies, male and female colorectal carcinoma

Instrumentation of Ureter

 Ureteric catheterisation is made with ureteric catheters, ureteroscopy, uretrocystoscopy

 To obtain urine for cytology
 Retrograde ureteral pyelography
 Location and type of obstruction
 Ureteric injury → level of injury, severity
 X-ray differences between ureteric tumours and stone in ureter, esp radiolluscent stone
 Marked irregular filling defect connected with the wall of the ureter = malignancy
 Regular filling defect but not connected with wall = stone
 Long term draining of urine achieved by self-retaining stents → resolve obstruction

Ureteroscopy

 Endoscopic guidance
 Stone, tumour in the ureter + biopsy
 Ureteroscopy may evolve to pyeloscopy (collecting system of kidney), ureterorenoscopy

ANTEROGRADE INSTRUMENTATIONS

 Nephroscopy → inspection of the collecting system of the kidney via nephrostomy tube
 Most common indication → anterograde percutaneous nephroscopy → percutaneous
nephrolithotomy / nephrolithotripsy
 Administration of contrast media through nephrostomy tube to outline collecting system of kidney →
antegrade pyeloureterography

Renal function tests

DEF: a group of tests that may be performed together to evaluate kidney (renal) function

Clinically, the most practical tests to assess renal function is to get an estimate of the glomerular filtration
rate (GFR) and to check for proteinuria (albuminuria)

Glomerular filtration rate (GFR), which is the rate in ml/min at which substances in plasma are filtered
through the glomerulus → evaluate chronic kidney disease

 Normal value = 125 ml/min

 Stage 1 → GFR = 60-90 ml/min
 Stage 2 → GFR = 45-60
  Stage 3a → GFR = 30-45
 Stage 3b → GFR = 15-30
 Stage 4 → GFR < 15 → end stage renal disease → renal transplantation +/- dialysis

Albuminuria: abnormal presence of albumin in the urine

 Urine albumin may be measured as albumin/creatinine ratio

Kidney function panel:

Electrolytes – electrically charged chemicals → vital to nerve + muscle function, regulation of fluid in the
body and maintaining the acid-base balance

 Sodium
 Potassium
 Chloride
 Bicarbonate (Total CO2)

CKD → hyperkalemia, metabolic acidosis, hyponatremia (first) → hypernatremia (worsening situation)

2. Minerals:

 Phosphorus
 Calcium

CKD → hyperphosphatemia, hypocalcemia (in kidney: alpha 1 hydroxylase → converts 25-hydroxyvitaminD to

1,25-dihydroxyvitaminD. The deficiency of a1-hydroxylase → ↓vit D → hypocalcemia)

3. Protein:

 Albumin – a protein that makes up about 60% of protein in the blood and has many roles such as
keeping fluid from leaking out of blood vessels and transporting hormones, vitamins, drugs, and ions
like calcium throughout the body

4. Waste products:

 Urea – urea is a nitrogen-containing waste product that forms from the metabolism of protein; it is
released by the liver into the blood and is carried to the kidneys, where it is filtered out of the blood
and eliminated in the urine
 Creatinine – another waste product that is produced by the body's muscles; almost all creatinine is
eliminated by the kidneys

5. Energy Source

 Glucose

!!!

Creatinine: Serum creatinine is elevated when there’s ↓GFR or when urine elimination is obstructed.

→ serum creatinine is a marker of acute kidney injury

 Stage 1: SCr ↑1.5 fold, UO <0.5ml/kg/h for 6h

 Stage 2: SCr ↑2 folds, UO <0.5ml/kg/h for 12h
 Stage 3: SCr ↑3 folds, UO <0.3ml/kg/h for 24h
BUN : Serum urea/BUN level increases in acute and chronic renal disease

GFR → determine the presence of renal disease, stage of CKD, and to monitor response to treatment

Bacterial and specific infections of genitourinary tract. Sexually transmitted diseases. Urosepsis

Genitourinary tract infections can be broadly classified into:

 Urinary tract infections (UTI): cystitis, pyelonephritis, prostatitis

 Genital tract infections: urethritis, cervicitis, epididymitis

Epidemiology:

 UTI in females occurs in Cystitis → due to shorter and wider urethra + close proximity to anus
 Male adults → get UITs → commonly due to sexual intercourse
 Elderly → get UITs → due to surgery, urinary incontinence, catheterization

Mechanisms of infection:

 Ascending route – colonization of bacteria occurs in urethra → migrate to bladder

 Hematogenous – spreads by blood
 Lymphatic – speads through LNs
 Direct extension – spreads from adjacent organs with intraperitoneal abscesses or with
vesicointestinal /vesicovaginal fistula

Mechanisms preventing infection:

 Female vaginal flora (lactobacillus) → keep vaginal pH acidic → bacteria cant grow
 Male prostate secretion (zinc) → antimicrobial activity
 Urine → washing out ascending bacteria

Pathogens:

 E.coli → most common

 Klebsiella proteus
 Enterococci spp.

RF:

 Anatomical abnormalities in urinary tract → impede urinary flow

 Presence of foreign bodies (catheter, stones, stents)
 Sexual activity
 Estrogen depletion (menopause) → atrophy of urinary tract, change in pH flora
 Old age

Clinical features:

 General Sx: urgency, frequency, dysuria

 Cystitis: suprapubic pain, hematuria, smelly urine
 Pyelonephritis: flank pain, fever w/o chill, N+V, costovertebral tenderness
 Epididimytis/orchitis → testicular pain
 Acute bacterial prostatitis: severe, sudden → fever, chill, lower back/loin pain + General Sx (urgency,
frequency, dysuria)
  Chronic bacterial prostatitis: less severe, more slowly → perineal pain, painful ejaculation + General
Sx (urgency, frequency, dysuria)
 Urethritis: due to sexual intercourse → yellowish discharge, dysuria

Diagnosis:

 Urinalysis, urine dipstick test → (+) UTIs = leucocyte esterase, nitrate (gram- bacteria: e.coli,
klebsiella), >100.000 bacteria in urine (bacteriuria), > 10WBCs/hpf
 Urine culture
 CT → suspected pyelonephritis
o Acute pyelonephritis → enlarged kidneys
o Chronic pyelonephritis → atrophic, smaller kidneys with scars

Treatment:

 Uncomplicated → Trimethroprim/sulfamethazole, nitrofurantoin

 Complicated → Ciprofloxacin, ampicillin

STDs:

 Chlamydia
 Genital herpes
 Gonorrhea
 HIV
 HPV
 Syphilis

Urosepsis

Sepsis is a systemic syndrome caused by dysregulated inflammatory response to infection that can lead to
multiorgan dysfunction, failure or even death

Main cause of urosepsis → UTIs following obstructive uropathy

Associated with ARDS and DIC

Sx:

 UTI symptoms: urgency, frequency, dysuria

 Sepsis symptoms: ↑body temperature, ↑tachycardia, ↑tachypnea, hypotension, ↑WBC
 Severe sepsis: kidney failure → ↑BUN, ↑creatinine, ↓urine output
 Altered mental status

Dx:

 Urinalysis + urine culture

 CBC, CMP, blood cultures, lactic acid level (tissue hypoxia)
 US, CT/MRI

Tx:

 Ciprofloxacin, ampicillin
 Blood, IV fluid, O2 therapy, mechanical ventilation
 Vasopressors (epinephrine/norepinephrine) → treat hypotension
  Thrombolysis prophylaxis → heparin

Trauma to penis

 Amputation → machinery accident, car accident, assault

o Crushed penis → impossible to reimplant
o Assault/self-amputation → reimplantation of amputated penis in 24h after injury (ideally)
within 6h)
o After 24h → 100% tissue dead
 Avulsion of the penile skin
o Removal of penis skin
o Tx: closure of torn skin / skin graft
 Phimosis:
o Inability to retract the foreskin/prepuce to reveal the penis glans
o Tx: circumcision
 Self-injection of foreign bodies (piercing) or to enlarge penis (filler)
 Strangulation:
o Caused hair, rubber bands
o Vasculature of penis is compressed → mild/reversible vascular obstruction, ischemic
necrosis, gangrene
 Entrapment
o Penis is caught in a zipper
o Usually occurs in children, who are uncircumcised
o Always superficial
o Tx: remove zipper with local anesthesia + bone cutter, lubrication
o Prevention: circumcision
 Animal bites
o Tx: irrigation, debridement, Abx, Tetanus + rabies vaccination, primary wound
closure/surgical reconstruction
 Penile fracture – is the result of rupture of tunica albuginea → severe bleeding → swollen and red
penis → requires emergency surgery
o Can co-occur with partial/complete urethral rupture
o Is caused by trauma to erect penis, typically by bending it laterally during sexual intercourse
o Tunica albuginea ruptures → popping sound at the time of injury
o Sx: hematuria, blood at meatus, dysuria
o Others: pain, redness, swelling, loss of erection
o Conservative treatment → can form fibrotic tissues in basis + cavernous bodies of penis →
can lead to no erection

Trauma to scrotum

 Blunt (more common) or penetrating

 Blunt injuries occurs as a blow forcing the testicle against the pubis or the thigh → bleeding occurs
into the parenchyma of the testis if sufficient force is applied → the tunica albuginea of the testis
ruptures
  Penetrating injuries occur as a consequence of gunshot and knife wounds → associated limb (e.g.
femoral vessel), perineal (penis, urethra, rectum), pelvic, abdominal, and chest wounds may occur
 If bleeding is confined by the tunica vaginalis → haematocele
 If rupture of tunica albuginea, tunica vaginalis, seminiferous tubules and blood extrude into all layers
of scrotum → hematoma
 History and examination:
o Severe pain
o Nausea and vomiting
o Tenderness
o Swelling
o Haematocele is palpable
o Testis surrounded by haematoma → not palpable
o The scrotal haematoma can be very large + the bruising + swelling → spread into inguinal
region and lower abdomen
 Testicular ultrasound:
o A normal parenchymal echo pattern → no testicular rupture
o Hypoechoic areas within the testis → indicating intraparenchymal haemorrhage → suggests
testicular rupture
 Indications for exploration in scrotal trauma:
o Testicular rupture → exploration:
 Evacuation of the haematoma
 Excision of extruded seminiferous tubules
 Repair of the tear in the tunica albuginea
o Penetrating trauma → exploration → repair to damaged structures

Inflammation of epididymis and testis

Acute epididymitis:

 DEF: inflammation of the epididymis, often involving the testis, caused by bacterial infection
 Acute onset
 Clinical course < 6weeks
 Infective cause: ascending infection from urethra/bladder → usually N. gonorrheae, C. trachomatis,
E. coli, Klebsiella spp., TB
 Non-infective cause = antiarrhythmic drugs (amiodarone) → accumulation in epididymis →
inflammation
 Presentation:
o Fever
o Testicular swelling
o Erythema
o Scrotal pain → radiate to the groin + lower abdomen
o Thickening of spermatic cord
o Evidence of underlying infection (ascending infection) – urethral discharge, Sx of urethritis,
cystitis (urgency, frequency, dysuria)
 DDx:
o Testicular torsion
o Testicular trauma
 o Mumps orchitis
 Investigation:
o Urinalysis, urine dipstick test → (+) UTIs = leucocyte esterase, nitrate (gram- bacteria: e.coli,
klebsiella), >100.000 bacteria in urine (bacteriuria), > 10WBCs/hpf
o Urine culture
o Urethral swab/culture of any urethral discharge
o Scrotal US
 Treatment:
o Analgesia, scrotal elevation, antibiotics
o Uncomplicated → Trimethroprim/sulfamethazole, nitrofurantoin
o Complicated → Ciprofloxacin, ampicillin

Chronic epididymitis:

 Clinical course > 6 weeks

 Sx: long-term pain in epididymis (+/- testicles), thickened, tender
 Tx: analgesia, antibiotics (cephalosporin)
 Epididymectomy → for severe cases

Orchitis:

 Inflammation of testis
 Causes: Mumps virus, TB, syphilis, autoimmune
 Mumps orchitis (unilateral/bilateral) can manifest 3-4 days after the onset of parotitis → result in
tubular atrophy → infertility
 Sx: pain, swelling, N+V, fever
 Tx: treat underlying cause

Inflammation of the bladder – acute and chronic cystitis → same UTIs

 Cystitis: is infection and/or inflammation of the bladder.

 Presentation:
o Urgency
o Frequency
o Dysuria
o Offensive urine
o Suprapubic pain
o Haematuria
o Fever
o Evidence of underlying infection (ascending infection) – urethral discharge, Sx of urethritis,
cystitis (urgency, frequency, dysuria)
 Diagnosis:
o Urinalysis, urine dipstick test → (+) UTIs = leucocyte esterase, nitrate (gram- bacteria: e.coli,
klebsiella), >100.000 bacteria in urine (bacteriuria), > 10WBCs/hpf
o Urine culture
o Urethral swab/culture of any urethral discharge
 Treatment:
o Uncomplicated → Trimethroprim/sulfamethazole, nitrofurantoin
 o Complicated → Ciprofloxacin, ampicillin

Male sexual dysfunction – physiology of penile erection (innervation of penis, anatomy and hemodynamics
of penile erection, mechanism of penile erection). Erectile dysfunction

 Anatomy of penis → composed of 3 cylindrical structures:

o 1 corpus spongiosum → which houses the urethra
o 2 corpora cavernosa
 Innervation of penis → both autonomic (sympathetic + parasympathetic) and somatic (sensory +
motor)
o Sympathetic + parasympathetic nerves → merge to form cavernous nerves → effects during
erection and detumescence
 Stimulation of sympathetic nerve → detumescence
 Stimulation of parasympathetic nerve → erection
o Somatic nerves (pudendal n.) → responsible for sensation and contraction of bulbo/ischio-
cavernosus
 Hemodynamics of penile erection:
o Corpora cavernosa:
 Sexual stimulation triggers the release of neurotransmitters from cavernous nerve
terminals → relax smooth muscles
 Dilation of arterioles and arteries by ↑blood flow
 Trapping of incoming blood by the expanding sinusoids
 Compression of venous plexuses → ↓venous outflow
 ↑PaO2 = 90mmHg and ↑intracavernous P = 100mmHg → erect the penis
o Corpus spongiosum:
 Arterial flow increases in a similar manner however, the pressure in corpus
spongiosum is 1/3 or 1/2 of corpora cavernosa
 No vein occlusion