Contributors of Campbell-Walsh-Wein, 12th edition
Sammy E. Elsamra, Erik P. Castle, Christopher E. Wolter, Michael E. Woods, Jay T. Bishoff, Ardeshir R. Rastinehad, Bruce R. Gilbert, Pat F. Fulgham, Michael A. Gorin, and Steven P. Rowe
Patient history and physical examination
A proper history and physical examination is essential in evaluating the urologic patient. Completing this assessment reliably and comprehensibly allows for gathering information essential for diagnosis, counseling, treatment, and next steps.
Clinic visit set-up
The clinic visit should be comforting and nonthreatening to the patient. The patient room or telehealth visit set-up should include ideal provider-patient positioning and ability to make proper eye contact.
Patient history
Chief complaint (CC)
The CC is the reason why a patient is seeking urologic care and is the focus of the visit.
History of present illness (HPI)
The HPI covers multiple factors related to the CC with the purpose of developing a differential diagnosis.
Constitutional symptoms.
These symptoms include fever, chills, night sweats, anorexia, weight loss, fatigue, and/or lethargy.
Pain.
Elicit pain location, radiation, palliative factors, provocative factors, severity (1-10 scale), and timing (including onset and change over time).
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Renal pain (flank pain) – Renal pain is located at the ipsilateral costovertebral angle (CVA) lateral to the spine and inferior to the 12th rib and often radiates toward the abdomen or scrotum/labia.
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Ureteral pain – This is often due to ureteral obstruction and may be present in the ipsilateral abdominal lower quadrant. The pain is often acute in onset and intermittent and may be referred to the scrotum/penis.
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Bladder pain – This type of pain may be due to inflammation (cystitis) or bladder distension (urinary retention). Suprapubic in location with possible improvement after voiding.
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Prostatic pain – This is a deep pelvic pain that may be confused with rectal pain. There are often associated irritative voiding symptoms (urinary frequency, urgency, dysuria).
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Penile pain – Penile pain has a variable presentation with wide differential, including paraphimosis, penile lesions, referred pain, Peyronie’s disease, or priapism.
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Scrotal pain – This type of pain may be superficial (skin) or involve the scrotal contents. Testicular torsion is a urologic emergency.
Hematuria.
Hematuria is defined as presence of blood in the urine and is divided into categories of gross (visible) versus microscopic (>3 RBC/HPF on microscopic examination) versus pseudohematuria (redness in urine of non-urologic origin). Obtain the presence or absence of associated voiding symptoms, smoking history, chemical exposure history, trauma, urinary tract infections, or recent urologic procedures. Please refer Hematuria section below for more details.
Lower urinary tract symptoms (LUTS).
LUTS may be obstructive or irritative in nature. Obstructive symptoms include urinary frequency, intermittency, incomplete emptying, weak stream, hesitancy, and straining with voiding. Irritative symptoms include urinary frequency, urgency, dysuria, or nocturia and may be caused by chronic bladder outlet obstruction, overactive bladder, cystitis, prostatitis, bladder stones, or bladder cancer. The International Prostate Symptom Score (IPSS) is the AUA symptom score with the addition of a quality-of-life score and is a useful tool for assessing LUTS ( Table 1.1 ) (see Chapter 21 ).
| SYMPTOM | NOT AT ALL | <1 TIME IN 5 | LESS THAN HALF THE TIME | ABOUT HALF THE TIME | MORE THAN HALF THE TIME | ALMOST ALWAYS | YOUR SCORE |
|---|---|---|---|---|---|---|---|
| 1. Incomplete Emptying | |||||||
| Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? | 0 | 1 | 2 | 3 | 4 | 5 | |
| 2. Frequency | |||||||
| Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating? | 0 | 1 | 2 | 3 | 4 | 5 | |
| 3. Intermittency | |||||||
| Over the past month, how often have you found you stopped and started again several times when you urinated? | 0 | 1 | 2 | 3 | 4 | 5 | |
| 4. Urgency | |||||||
| Over the past month, how often have you found it difficult to postpone urination? | 0 | 1 | 2 | 3 | 4 | 5 | |
| 5. Weak Stream | |||||||
| Over the past month, how often have you had a weak urinary stream? | 0 | 1 | 2 | 3 | 4 | 5 | |
| 6. Straining | |||||||
| Over the past month, how often have you had to push or strain to begin urination? | 0 | 1 | 2 | 3 | 4 | 5 | |
| NONE | 1 TIME | 2 TIMES | 3 TIMES | 4 TIMES | ≥ 5 TIMES | ||
| 7. Nocturia | |||||||
| Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? | 0 | 1 | 2 | 3 | 4 | 5 | |
| TOTAL INTERNATIONAL PROSTATE SYMPTOM SCORE | |||||||
| QUALITY OF LIFE DUE TO URINARY SYMPTOMS | DELIGHTED | PLEASED | MOSTLY SATISFIED | MIXED—ABOUT EQUALLY SATISFIED AND DISSATISFIED | MOSTLY DISSATISFIED | UNHAPPY | TERRIBLE |
| If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Urinary incontinence
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Stress incontinence – Involuntary passage of urine with activities that increases intra-abdominal pressure including Valsalva, cough, sneeze, laugh, and/or heavy lifting.
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Urge incontinence – Involuntary passage of urine associated with sudden urge to void. This is often associated with overactive bladder, cystitis, neurogenic bladder, or poorly compliant bladder.
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Mixed incontinence – When a patient experiences both stress and urge incontinence.
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Continuous incontinence – Constant leakage of urine independent of urination patterns or intraabdominal pressure. This is often due to congenital cause or urinary fistula.
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Pseudoincontinence – Incontinence-like symptoms due to non-urologic cause such as vaginal discharge or labial fusions causing retention of urine.
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Overflow incontinence – Leakage of urine due to volume of urine exceeding bladder capacity. This is common in bladder outlet obstruction.
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Functional incontinence – Leakage of urine due to patient immobility or inadequate access to facilities. Patients otherwise have normal urologic anatomy/physiology. See Chapter 16 .
Erectile dysfunction (ED).
ED is defined as the inability to attain/maintain penile erection sufficient for satisfactory sexual intercourse. It is important to obtain history related to timing and situational factors of erections. Validated questionnaires for characterizing ED includes the International Index of Erectile Function (IIEF) and the abbreviated IIEF-6 or Sexual Health Index for Men (SHIM). See Chapter 14 .
Other urologic conditions.
Additional topics often covered in a urologic-based HPI include loss of libido, abnormal ejaculation, anorgasmia, hematospermia, pneumaturia, and/or urethral discharge.
Past medical/surgical history
It is essential to obtain a complete medical and surgical history (including prior genitourinary or abdominal surgeries). Obtain operative reports when applicable.
Performance status
Determine the functional ability of patient as a benchmark for his or her tolerance for undergoing challenging or invasive treatments. Assess a patient’s ability to perform activities of daily living (ADLs), dressing, eating, toileting, hygiene, preparing meals, shopping, maintaining a house, and interactions with family and community. Grading performance status can be completed using the Eastern Cooperative Oncology Group (ECOG) score or Karnofsky performance status.
Medications
Obtain full medication history including urologic medications and anticoagulants. Also consider medications with urologic side effects ( Table 1.2 ).
| UROLOGIC SIDE EFFECTS | CLASS OF DRUGS | SPECIFIC EXAMPLES |
|---|---|---|
| Decreased libido | Antihypertensives | Hydrochlorothiazide |
| Erectile dysfunction | Psychotropic drugs | Propranolol |
| Benzodiazepines | ||
| Ejaculatory dysfunction | α-Adrenergic antagonists | Prazosin |
| Tamsulosin | ||
| α-Methyldopa | ||
| Psychotropic drugs | Phenothiazines | |
| Antidepressants | ||
| Priapism | Antipsychotics | Phenothiazines |
| Antidepressants | Trazodone | |
| Antihypertensives | Hydralazine | |
| Prazosin | ||
| Decreased spermatogenesis | Chemotherapeutic agents | Alkylating agents |
| Drugs with abuse potential | Marijuana | |
| Alcohol | ||
| Nicotine | ||
| Drugs affecting endocrine function | Antiandrogens | |
| Prostaglandins | ||
| Incontinence or impaired voiding | Direct smooth muscle stimulants | Histamine |
| Vasopressin | ||
| Others | Furosemide | |
| Valproic acid | ||
| Smooth muscle relaxants | Diazepam | |
| Striated muscle relaxants | Baclofen | |
| Urinary retention or obstructive voiding symptoms | Anticholinergic agents or musculotropic relaxants | Oxybutynin |
| Diazepam | ||
| Flavoxate | ||
| Calcium channel blockers | Nifedipine | |
| Antiparkinsonian drugs | Carbidopa | |
| Levodopa | ||
| α-Adrenergic agonists | Pseudoephedrine | |
| Phenylephrine | ||
| Antihistamines | Loratadine | |
| Diphenhydramine | ||
| Acute renal failure | Antimicrobials | Aminoglycosides |
| Penicillins | ||
| Cephalosporins | ||
| Amphotericin | ||
| Chemotherapeutic drugs | Cisplatin | |
| Others | Nonsteroidal anti-inflammatory drugs | |
| Phenytoin | ||
| Gynecomastia | Antihypertensives | Verapamil |
| Cardiac drugs | Digoxin | |
| Gastrointestinal drugs | Cimetidine | |
| Metoclopramide | ||
| Psychotropic drugs | Phenothiazines | |
| Tricyclic antidepressants | Amitriptyline | |
| Imipramine |
Social history
Review where the patient lives, who lives at home with patient, and if there are family/friends in the area. Also obtain occupational history to give insight on socioeconomic status and possible industrial exposures. Review sexual history in a non-accusatory manner such as “Do you partake in sexual relations with men, women, or both? A single partner or multiple?” Obtain drug use history including tobacco, alcohol, illicit drug use. This is important for considering withdrawal or difficulty coping during possible procedures/hospitalizations.
Family history
Ask about urologic conditions/diseases/cancers as well as bleeding disorders, reactions to anesthesia and significant non-urologic conditions/disease/cancers.
Review of systems
Comprehensive system-based checklist related to other symptoms that may or may not be included in HPI or related to CC.
Physical examination
Vital signs
Obtain temperature, heart rate, blood pressure, respiratory rate, and pain rating.
General appearance
Note level of pain or distress, nutritional status, appearance and self-care, frailty, mobility. Look for stigmata associated with certain disease states.
Kidneys
The kidneys are located in the retroperitoneum and surrounded by the psoas and oblique muscles, peritoneum, and diaphragm. For adults, place the nonexamining hand posteriorly at the costovertebral angle and palpate the kidney with the examining hand through the anterior abdominal wall ( Fig. 1.1 ). Kidneys are typically difficult to palpate and not visible on examination (unless large mass or very thin patient). Assess pain at kidney via percussion by contacting the patient with the closed hand of the examiner at the CVA. Be gentle; a simple tap should elicit a positive sign if present.
Bladder
To examine the bladder, palpate and percuss starting at level of pubic symphysis and ascend toward umbilicus to determine the level of distension. The bladder is palpable when it distends to level above the pubis (∼150 cc). The bladder may be visualized when distended at ∼500 cc in thin patients. Additionally, A bimanual exam may be performed to assess mobility of the bladder as well as cancer staging.
Penis
Inspect the skin for hair distribution, lesions, presence/absence of foreskin (in adults, retract foreskin to evaluate glans), and Tanner stage. Evaluate the urethral meatus (location, stenosis, presence of urethral discharge). Palpate for any subcutaneous plaques or curvature. Remember to reduce the foreskin at the end of the examination.
Scrotum and contents
Inspect the scrotal skin for hair distribution, lesions, and infection. Be sure to evaluate the entire scrotum toward the perineum, especially in those with limited mobility or poor self care. Palpate the testicles for size, orientation, pain, or masses. Evaluate for hydrocele, varicocele (patient supine, standing, standing with Valsalva). Palpate the vas deferens. Check for an inguinal hernia by sliding the index finger over testis and invaginating the scrotum up toward external ring ( Fig. 1.2 ).
Digital rectal examination (DRE)
The DRE is used to assess prostate size and perform screening for prostate cancer. For positioning, the patient should bend 90 degrees at the waist while supporting hand or elbows on the table. Lateral decubitus position with legs flexed at hips is another alternative. The examiner’s gloved finger with adequate lubrication then is advanced until the prostate is palpable. A normal prostate is smooth and somewhat soft, whereas nodular firmness is concerning and may warrant biopsy. A bimanual examination (DRE with concurrent lower abdominal exam) is performed in the context of bladder cancer staging.
Pelvic examination in the female
The pelvic examination is used to evaluate for pelvic organ prolapse, urinary incontinence, dyspareunia, blood per urethra or vagina, and vaginal masses. Visually inspect external genitalia and introitus (atrophic changes, erosions, ulcers, discharge, lesions). The labia minora should be separated and the urethral meatus inspected for prolapse, caruncle, hyperplasia, or cysts. Use a speculum to visualize vagina and have the patient perform the Valsalva maneuver to evaluate for prolapse. Perform Pelvic Organ Prolapse Quantification (POP-Q) if there is prolapse present. Perform a bimanual examination by placing two of the examiner’s fingers of the dominant hand into the vaginal vault and placing the nondominant hand over the lower abdomen and palpating for pelvic mass or tenderness.
Laboratory tests
Urinalysis
The urinalysis (UA) is a fundamental test performed on patients presenting with urinary symptoms. For collection, adults should clean the urethral meatus and surrounding area thoroughly and collect a midstream voided urine sample. Catheterized specimens are preferred for infants and neonates.
UA evaluation
The evaluation of the UA involves gross examination ( Table 1.3 ), dipstick chemical analysis, and microscopic analysis.
| COLOR | CAUSE |
|---|---|
| Colorless | Very dilute urine |
| Overhydration | |
| Cloudy/milky | Phosphaturia |
| Pyuria | |
| Chyluria | |
| Red | Hematuria |
| Hemoglobinuria/myoglobinuria | |
| Anthocyanin in beets and blackberries | |
| Chronic lead and mercury poisoning | |
| Phenolphthalein (in bowel evacuants) | |
| Phenothiazines (e.g., Compazine) | |
| Rifampin | |
| Orange | Dehydration |
| Phenazopyridine (Pyridium) | |
| Sulfasalazine (Azulfidine) | |
| Yellow | Normal |
| Phenacetin | |
| Riboflavin | |
| Green-blue | Biliverdin |
| Indicanuria (tryptophan indole metabolites) | |
| Amitriptyline (Elavil) | |
| Indigo carmine | |
| Methylene blue | |
| Phenols (e.g., IV cimetidine [Tagamet], IV promethazine [Phenergan]) | |
| Resorcinol | |
| Triamterene (Dyrenium) | |
| Brown | Urobilinogen |
| Porphyria | |
| Aloe, fava beans, and rhubarb | |
| Chloroquine and primaquine | |
| Furazolidone (Furoxone) | |
| Metronidazole (Flagyl) | |
| Nitrofurantoin (Furadantin) | |
| Brown-black | Alcaptonuria (homogentisic acid) |
| Hemorrhage | |
| Melanin | |
| Tyrosinosis (hydroxyphenylpyruvic acid) | |
| Cascara, senna (laxatives) | |
| Methocarbamol (Robaxin) | |
| Methyldopa (Aldomet) | |
| Sorbitol |
Specific gravity and osmolality.
Related to patient’s hydration or amount of material dissolved in the urine or renal concentrating ability.
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Normal specific gravity 1.001–1.035
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<1.008 = dilute, >1.020 = concentrated
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Normal osmolality 50–1200 mOsm/L
pH.
Urinary pH ranges from 4.5–8. Typically reflects serum pH.
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Average urinary pH = 5.5–6.5
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Acidotic urinary pH = 4.5–5.5
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Alkalotic urinary pH = 6.5–8
Blood/hematuria.
Normal urine contains less than 3 erythrocytes per HPF. A positive dipstick indicates hematuria, hemoglobinuria, or myoglobinuria. Microscopic examination with greater than 3 RBC/HPF indicates microscopic hematuria. A dipstick result needs to be confirmed with microscopic examination [ https://www.auanet.org/guidelines/asymptomatic-microhematuria-(2012-reviewed-for-currency-2016 )]. Hematuria of nephrologic (compared with urologic) source is often associated with casts and significant proteinuria ( Table 1.4 ). Erythrocytes from glomerular disease are typically dysmorphic, whereas tubulointerstitial renal disease and urologic origins have a round shape. Other sources of hematuria include vascular disease like arteriovenous fistulas (AV) fistulas and that is induced by a bought of strenuous exercise. Hematuria in patients on anticoagulants still requires workup. Please refer Hematuria section below for more details.
| DISORDER | PATIENTS |
|---|---|
| IgA nephropathy (Berger disease) | 30 |
| Mesangioproliferative GN | 14 |
| Focal segmental proliferative GN | 13 |
| Familial nephritis (e.g., Alport syndrome) | 11 |
| Membranous GN | 7 |
| Mesangiocapillary GN | 6 |
| Focal segmental sclerosis | 4 |
| Unclassifiable | 4 |
| Systemic lupus erythematosus | 3 |
| Postinfectious GN | 2 |
| Subacute bacterial endocarditis | 2 |
| Others | 4 |
| Total | 100 |
Leukocyte esterase (LE) and nitrite.
LE is produced by neutrophils and indicates presence of white blood cells in the urine (false positive indicates specimen contamination). Gram negative bacteria convert nitrates to nitrite and therefore presence of nitrites is strongly suggestive of bacteriuria. If a sample is positive for LE but negative for nitrites, noninfectious causes of inflammation should be considered.
Bacteria.
A fresh uncontaminated urine specimen should not contain bacteria. Presence of bacteria is indicative of a UTI.
Yeast.
Funguria is more commonly seen in patients with diabetes mellitus or vaginal candidiasis and typically Candida albicans .
Protein.
Proteinuria increases suspicion for underlying medical renal disease or overflow of abnormal proteins in the urine (multiple myeloma). If proteinuria is present, consider nephrology consultation.
Glucose and ketones.
Often used for screening patients for diabetes mellitus. The renal threshold for glucose detection in urine is serum glucose >180 mg/dL. Ketones are found in urine when carbohydrate sources in the body are depleted and body fat utilization occurs.
Bilirubin and urobilinogen.
Normal urine contains no bilirubin and only small amounts of urobilinogen.
Urine cytology
Ordered when urologic malignancy is suspected. Do not order as a screening tool or during initial workup for gross/microscopic hematuria. This test is highly specific for high-grade urothelial cell carcinoma (UCC).
Serum studies
Creatinine and glomerular filtration rate (GFR)
Obtained to evaluate baseline or current renal function and can aid in investigating renal compromise in the context of urinary tract obstruction.
Prostate-specific antigen (PSA)
Tumor marker for diagnostic evaluation of prostate pathology including cancer, benign prostatic hyperplasia (BPH), and inflammatory conditions of the prostate.
Alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and lactate dehydrogenase (LDH)
Serum tumor markers for workup of testicular mass/cancer.
Endocrinologic studies
Total testosterone, free testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin (PRL), and thyroxine T4 may be ordered in the workup of the male patient with suspected hypogonadism.
Parathyroid hormone
Ordered for patients with hypercalcemia and calcium-based nephrolithiasis.
Office diagnostic procedures
Uroflowmetry
Used to assess voiding pattern including workup of suspected bladder outlet obstruction. Information obtained includes flow rates, voided volume, and voiding curve/pattern.
Post void residual (PVR)
The PVR is the volume of residual urine in the bladder measured via bladder scan (may be inaccurate in patients with obesity or ascites) or catheterization following voiding. Acceptable volumes are patient dependent; however, volumes <100 cc are generally considered within acceptable range.
Cystometography and urodynamic studies
Components of urodynamic studies include cystometrography, electromyography, urethral pressure profile, and pressure flow studies. This study is used for patients requiring a comprehensive workup of urinary storage and evacuation.
Cystourethroscopy
This procedure allows for direct visualization and evaluation of the lower urinary tract using a flexible cystoscope.
Imaging of the urinary tract
Imaging plays a critical role in the diagnosis and management of urologic disease.
Plain abdominal radiography.
Conventional radiography study intended to display the kidneys, ureters, and bladder (KUB). Indications for obtaining a plain film include scout film, assessment of residual contrast from previous imaging procedure, pre- and post-treatment assessment of renal calculus disease, assessment of the position of drains and stents ( Fig. 1.3 ), and/or adjunct to the investigation of blunt or penetrating trauma to the urinary tract.
Related posts:
Lower urinary tract dysfunction and anomalies in children
Principles of endourology and fundamentals of laparoscopic and robotic urologic surgery
Principles of urologic surgery: Perioperative management
Urologic evaluation of the child
Injuries to the Genitourinary Tract
Practical Functional Evaluation of Adrenal Mass
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