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UROLOGY PHYSICAL

EXAMINATION

dr. Agus Rizal AH Hamid,


Sp.U, Ph. D
LECTURE FOR RESIDENCE OF UROLOGY
FACULTY OF MEDICINE
UNIVERSITY OF INDONESIA
Introduction
A complete physical examination; the essential component of
the evaluation of patients who present with urologic disease.
The physical examination;
simplifies the process
allows the urologist to select the most appropriate diagnostic
studies.
the physical examination remains a key component of the
diagnostic evaluation and should be performed conscientiously.
General Observation
From visual inspection:
The skin inspected; jaundice or pallor.
Gynecomastia; sign of
The nutritional status; endocrinology disease
Cachexia Edema of the genitalia and lower
obesity extremities
Buffalo hump and abdominal skin Supraclavicular lymphadenopathy
striae
Inguinal lymphadenopathy
Debility and hyperpigmentation
Kidneys
The kidneys are fit-sized organs located high in the
retroperitoneum bilaterally.
The right kidney is lower than the left.
In adult, the kidneys are normally difficult to palpate.
In children, it is easier to palpate the kidneys because of
decreased body thickness.
In neonates, the kidneys can be felt quite easily by palpating
the flank between the thumb anteriorly and the fingers over
the costovertebral angle posteriorly.
Kidneys
Supine position, the best position to palpate the
kidneys.
The kidney is lifted from behind with one
hand in the costovertebral angle (Fig. 1-1).
Costovertebral angle is formed by the 12 th rib
and lumbar spine
On deep inspiration, the examiners hand is
advanced firmly into the anterior abdomen just
below the costal margin.
At the point of maximal inspiration, the kidney may
be felt as it moves downward with the diaphragm.
With each inspiration, the examiners hand may be
advanced deeper into the abdomen.
Kidneys
A renal inflammation may cause pain in
poorly localized, percussion of the
costovertebral angle posteriorly more often
localizes the pain and tenderness more
accurately
Percussion should be done gently
Auscultation of the upper abdomen during
deep inspiration may occasionally reveal a
systolic bruit associated with;
renal artery stenosis
an aneurysm
a large renal arteriovenous fistula.
Bladder
A normal bladder in the adult cannot be palpated, until
there is at least 150 mL of urine in it.
The distended bladder becomes visible at volume 500
mL
The examiner begins by percussing immediately
above the symphysis pubis and continuing cephalad
until there is a change in pitch from dull to resonant.
A bimanual examination, best done with the patient
under anesthesia, is invaluable in assessing the
regional extent of a bladder tumor or other pelvic
mass.
The bladder is palpated between the abdomen and the vagina in
the female (Fig. 1-2) or the rectum in the male (Fig. 1-3).
Penis
The foreskin should be Venereal warts (condyloma
retracted to examine (If the acuminata) appear as irregular,
papillary, velvety lesions on the male
patient has not
genitalia
circumcised)
Palpated of the dorsal shaft of the
The position of the urethral penis
meatus should be noted. Fibrotic plaques or ridges; Peyronie
The penile skin should be disease.
examined Tenderness along the ventral aspect
The presence herpes simplex of the penis; periurethritis, urethral
The ulcers stricture
tumor
Scrotum and Contents
Inspection for dermatologic abnormalities.
The scrotum contains both hair and sweat glands, local infection, local
pustule, and sebaceous cysts.
The testes palpated gently between the fingertips both
hands.
Normal testis have a firm, rubbery consistency with a smooth
surface.
A firm or hard area within the testis should be considered a malignant
tumor until proved otherwise.
Abnormally small testes suggest hypogonadism or an endocrinopathy
such as Klinefelter disease.
Scrotum and Contents
To examine for a hernia, the
physicians index finger should be
inserted gently into the scrotum and
invaginated into the external inguinal
ring (Fig. 1-4).
The spermatic cord is also examined
with the patient in the standing
position. A varicocele is a dilated,
tortuous spermatic vein that
becomes more obvious as the patient
performs a Valsalva maneuver.
Scrotum and Contents
Transillumination
Determinate the scrotal masses are solid (tumor) or
cystic (hydrocele, spermatocele).
A small flashlight or fibrotic light cord is placed behind
the mass.
A cystic mass transilluminates easily, whereas light is
not transmitted through a solid tumor.
Rectal and Prostate Examination
in the Male
Digital rectal examination (DRE)
Should be performed in every male after age 40 years
in men of any age who present for urologic evaluation.
Procedure;
the patient standing and bent over the examining table or with the patient in the
knee-chest position.
In the standing position, the patient should stand with his thighs close to the
examining table. The feet should be about 18 inches apart, with the knees flexed
slightly.
The patient should bend at the waist 90 degrees until his chest is resting on his
forearms.
The physician should give the patient adequate time to get in the proper position
and relax as much as possible.
The physician should place a glove on the examining hand and should lubricate the
index finger thoroughly.
Rectal and Prostate Examination in
the Male
Performing Digital Rectal Examination (DRE):
The DRE begins by separating the buttocks
Inspecting the anus for pathology
(hemorrhoids, anal carcinoma or melanoma)
The gloved, lubricated index finger is then
inserted gently into the anus.
One phalanx should be inserted initially to
give the anus time to relax and to easily
accommodate the finger.
Estimation of anal sphincter tone; a flaccid
or spastic anal sphincter suggests similar
changes in the urinary sphincter and clue to
the diagnosis of neurogenic disease.
Rectal and Prostate Examination in Male Cont.'s..

The index finger sweeps over the prostate; the entire posterior
surface of the gland can be examined if the patient is in the proper
position.
o the prostate size is about a chestnut
o Consistency of the prostate is similar to that of the contracted thenar eminence
of the thumb (with the thumb opposed to the little finger)
The index finger is extended as far as possible into the rectum, the
entire circumference is examined to detect an early rectal carcinoma.
The index finger is then withdrawn gently, and the stool on the
glove is transferred to a guaiac-impregnated (hemoccult) card for
determination of occult blood.
Pelvic Examination in Female
Male urologists should always perform the female pelvic
examination with a female nurse or other health care
professional present.
The examination performed in standard lithotomy position with the
patients legs abducted.
The external genitalia and introitus should be examined for:
atrophic changes
erosions
ulcers
discharge
warts
all which may cause dysuria and pelvic discomfort
Pelvic Examination in Female,
cont.'s..
Inspection for the urethral Palpation of the urethra;
meatus; detect induration, which may be a sign of
caruncles chronic inflammation or malignancy
mucosal hyperplasia disclose a urethral diverticulum; palpation of a
cysts diverticulum may cause a purulent discharge
mucosal prolapse
Bimanual examination of the bladder,
The patient is asked to cough; uterus, and adnexa;
precipitate stress urinary
performed with two fingers in the vagina and
incontinence. the other hand on the lower abdomen. Any
Valsalva maneuver examined for; abnormality of the pelvic organs should be
cystocele (prolapse of the bladder) evaluated further with a pelvic ultrasound or
rectocele (prolapse of the rectum) CT scan.
Neurologic Examination
In some cases, the level of
neurologic abnormalities can be
localized by the pattern of
sensory deficit noted during
physical examination using a
dermatome map (Fig. 1-5).
Sensory deficits in the penis,
labia, scrotum, vagina, and
perianal area generally indicate
damage or injury to sacral roots
or nerves.
Neurologic Examination;
The bulbocavernosus reflex (BCR)
The bulbocavernosus reflex (BCR); a reflex
contraction of the striated muscle of the pelvic
flor that occurs in response to various stimuli in
the perineum or genitalia.
This reflex tested;
Placing a finger in the rectum
Squeezing the glans penis or clitoris.
For result; If the BCR is intact, tightening the anal sphincter should be
felt and/or observed.

The BCR tests the integrity of the spinal cord


mediated reflex arc involving S2-S4
The BCR may be absent in the presence of sacral
cord or peripheral nerve abnormalities.
Neurologic Examination; The
cremasteric reflex
The cremasteric reflex can be elicited
by;
Slightly stroking the superior and
medial thigh in a downward direction
The normal response in males is
contraction of the cremasteric muscle
that results in immediate elevation of
the ipsilateral scrotum and testis.
Reference
Glenn S. Gerber, MD, and Charles B. Brendler, MD; Evaluation of
The Urologic Patient: History, Physical Examination, and
Urinalysis; Chapter 1; Campbell-Walsh Urology 11 th Edition
(2016)
Swartz MH. Textbook of physical diagnosis. Philadelphia:
Saunders; 1989. p. 376.
THANK YOU

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