Introduction to Patient Care

Evaluation of the Genitourinary

System
C. A. Ahaghotu, M.D., F.A.C.S.
Associate Professor and Chief of
Urology
Howard University Hospital
What is Urology?
Definition: the study of the
male and female urinary
tract and the male
genitalia
Introduction
Training Requirements
1-2 years of general surgery
3-4 years of general urology
1-3 years of fellowship (optional)

Urology Subspecialties
Urologic Oncology
Erectile Dysfunction
Infertility
Endourology/Urolithiasis
Voiding Dysfunction (incontinence)
Pediatric Urology
Reconstructive urology/ trauma
History taking
Pain
Location-flank, suprapubic, inguino-scrotal,
perineal, labial
Radiating pattern*
T10-L2 & S2-4,
-groin, flank, meatus
Quality-colicky, sharp, dull, squeezing, burning
Severity index-1-10
Timing-intermittent vs.. consistent
Precipitating/palliating factors*
Very few palliating factors
Aggravating factors include micturation
Often associated with GI symptoms (nausea,
vomiting, diarrhea)

Evaluation of the genitourinary
system

History taking
Lower urinary tract symptoms
(prostatism)
Obstructive: hesitancy, slow stream,
intermittency, post void dribbling, incomplete
emptying
Irritative: frequency, urgency, dysuria, nocturia
Causes include
bladder outlet obstruction-prostate, stones, strictures,
tumors
inflammation-infection, stones, tumors, radiation, drugs
neurovesical dysfunction-CNS disease, trauma, aging
Evaluation of the genitourinary
system
History taking
Upper urinary tract
Pain, fever, chills, nausea, vomiting,
hypertension
Causes include:
Ureteral obstruction-stones, tumor, clot,
stricture
Inflammation-infection, radiation, trauma
Ischemia-vascular injury


Evaluation of the genitourinary
system


History taking
Incontinence-involuntary leakage of
urine
Urge-related
Preceded by urgency
Associated with irritative symptoms
Irritative and obstructive causes
Stress-related
Precipitated by increased intra-abdominal
pressure (Valsava maneuver)
Causes include pelvic floor weakness,
urethral sphincter deficiency
Evaluation of the
genitourinary system

History taking
Incontinence
Overflow-related
Associated with obstructive symptoms
Causes include obstructive vs. detrusor
insufficiency
Total incontinence
Bypassing the continence mechanism (vesico-
vaginal, rectovesical, vesico-cutaneous fistulae)
Mixed picture

Evaluation of the genitourinary
system

Urgency
Stress
Overflow
History taking
Urinary retention
Acute
Suprapubic pain, urgency, tender suprapubic mass
Precipitated by ETOH intake, medications (e.g.. -
agonists)
Associated with causes of lower urinary tract
symptoms
Chronic
Incomplete emptying, overflow incontinence,
suprapubic mass
Causes may be obstructive vs. detrusor insufficiency
Complications include UTI, sepsis, renal
insufficiency
Evaluation of the genitourinary system

History taking
Hematuria (gross)
Timing
Initial-anterior urethra
Terminal-prostatic urethra, bladder neck
Total-bladder, upper urinary tract
Clots
Vermiform-ureter
Amorphous-bladder
Clot retention
Associated symptoms
Irritative-suggests inflammatory
Painless-malignancy
Obstructive-prostatic varices
Co-morbid causes for coagulopathy
Evaluation of the genitourinary
system


Initial
hematuria
Terminal
hematuria
Total
hematuria
History taking
Erectile dysfunction
Inability to achieve and/or maintain an
erection adequate for satisfactory intercourse
Medical history is important
Causes include vascular disease, neurological
disease, drugs, trauma
Infertility
Inability to conceive despite 12 months of
consistent effort
Primary vs.. secondary
Causes include hypogonadism, ductal
obstruction, drugs, varicocele, unusual sexual
practices
History taking
Past medical history
Medications (diuretic, adrenergic agents)
Prior surgery, radiation, trauma
Family/social history
Familial diseases (e.g.. prostate cancer,
urolithiasis, vesico-ureteral reflux)
Smoking history-quantity and duration
Drug abuse
STD exposure-dates, treatments



History taking
Obstetric/gynecologic history
Parity
Nature of deliveries
Vaginal vs.. caesarian
Forceps delivery
Prolonged/obstructed labor
Episiotomies vs. vaginal injury
Menstrual status
STD exposure
Physical examination
General assessment
Hygiene
Cognitive status
Gait
Nutritional status
Vital signs
Neurological exam
Spasticity vs.. flaccidity
Lateralizing signs
Sacral arc integrity (S2-4)
Perineal/introital sensation
Anal sphincter tone
Bulbo-cavernosus reflex

Evaluation of the genitourinary
system


Physical examination
Abdominal exam
Inspection-incisional scars, ostomies
Palpation
Masses-location, size, consistency, expansile,
tenderness, intra-abdominal vs.. pelvic origin
Bimanual examination of the flank-tenderness,
palpable masses
Percussion
to elicit renal tenderness
To determine consistency of a masses (e.g..
distended bladder)
Auscultation
mid-clavicular line, below 10th rib
Renal vascular stenosis, aneurysms, A-V
malformations

Evaluation of the genitourinary
system

???
Bimanual examination of the kidney
External genital exam
(male)
Inspection (supine & standing)
Penis-prepuce, glans, shaft, external urethral
meatus
Scrotum-rugations, symmetry
Perineum-warts, excoriation
Palpation
Retraction of prepuce
Testicular exam-position, volume, consistency,
symmetry, adnexal structures
Hernia examination
Cremasteric reflex


Inguinal hernia exam
External genital exam
(male)
Transillumination
Distinguishes fluid vs.. solid intra-scrotal
masses
Hydroceles ++++
Spermatoceles ++
Hematoceles
Hernias -/+
Testes tumors -
External genital exam
(male)
Digital rectal exam
Be gentle
Assess anal sphincter tone
Palpate prostate
Size
Consistency
Tenderness
Symmetry
Prostatic message when indicated
Palpate rectal walls
Stool sample for occult blood
Digital rectal examination
External genital exam
(female)
Inspection (dorsal lithotomy)
Pubic hair distribution
Introital tissues
Atrophic changes, ulcers, erosions,
discharge, lesions, masses
Tactile sensation
Urethral meatus
Mucosal status
Stress incontinence


External genital exam
(female)
Palpation
Urethral mobility & consistency
Pelvic floor support
Reducible masses (e.g.. cystocele)
Speculum exam
Examine vaginal walls for support, mucosal
integrity
Bimanual exam
Assess bladder, uterus, and adnexa
tenderness


Female bimanual exam
Laboratory studies
Urinalysis (midstream
clean catch
specimen)
pH
Specific gravity 1.003-
1.040
Protein
Blood
Leukocyte esterase
Nitrite (Griesse test)
Glucose
Ketones
Bilirubin
Urine microscopy
10cc fresh urine
Centrifuge at 2000 RPM
for 3-5 mins.
Discard supernatant
Micro-analysis-cells,
casts, crystals, bacteria
Micro-hematuria > 2
RBCs / hpf
Pyuria > 5 WBCs / hpf
Bacteruria 5/hpf
(100, 000/cc)


Urine microscopy
Laboratory studies
Serum Chemistry
Na, Cl, HCO3, BUN, creatinine
Creatinine clearance = Ucr(mg/dl) x V(ml)
Pcr(mg/dl)


Laboratory studies
Prostate Specific Antigen
Prostate enzyme measured in serum
Normal range 0-4 ng/ml
Elevated in prostatitis, BPH and prostate
cancer
Imaging Studies
Ultrasonography
Scrotum
kidney
IVP
CT scan
MRI
Renal arteriogram
Radionuclide studies
Cystogram
Retrograde urethrogram
Renal ultra-sonography
Scrotal ultra-sonography
Intravenous pyelogram
CT Kidneys
MRI Kidneys
Renal arteriogram
Renal scan
Cystogram

normal
?????
Retrograde urethrogram
Endoscopic evaluation
Cystoscopy
Urethroscopy
Ureteroscopy
nephroscopy
Cysto-urethroscopy
Direct visualization
of the lower
urinary tract
Identify bladder
outlet obstruction,
strictures,
neoplasm, fistulae
Vesico-vaginal fistula
fistula
trigone
Rt U.O. Lt U.O