Urologic patients may have symptoms referable to the kidneys as well as to other parts of the genitourinary tract (GU) tract. (See also Evaluation of the Renal Patient Evaluation of the Renal Patient In patients with renal disorders, symptoms and signs may be nonspecific, absent until the disorder is severe, or both. Findings can be local (eg, reflecting kidney inflammation or mass), result... read more 
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History in the Urologic Patient
Pain originating in the kidneys or ureters is usually vaguely localized to the flanks or lower back and may radiate into the ipsilateral iliac fossa, upper thigh, testis, or labium. Typically, pain caused by calculi Urinary Calculi Urinary calculi are solid particles in the urinary system. They may cause pain, nausea, vomiting, hematuria, and, possibly, chills and fever due to secondary infection. Diagnosis is based on... read more is colicky and may be prostrating; it is more constant if caused by infection. Acute urinary retention Urinary Retention Urinary retention is incomplete emptying of the bladder or cessation of urination. Urinary retention may be Acute Chronic Causes include impaired bladder contractility, bladder outlet obstruction... read more distal to the bladder causes agonizing suprapubic pain; chronic urinary retention causes less pain and may be asymptomatic. Dysuria Dysuria Dysuria is painful or uncomfortable urination, typically a sharp, burning sensation. Some disorders cause a painful ache over the bladder or perineum. Dysuria is an extremely common symptom... read more is a symptom of bladder or urethral irritation. Prostatic pain manifests as vague discomfort or fullness in the perineal, rectal, or suprapubic regions.
Symptoms of bladder obstruction in men include urinary hesitancy, straining, decrease in force and caliber of the urinary stream, and terminal dribbling. Incontinence Urinary Incontinence in Adults Urinary incontinence is involuntary loss of urine; some experts consider it present only when a patient thinks it is a problem. The disorder is greatly underrecognized and underreported. Many... read more has various forms. Enuresis after age 3 to 4 years may be a symptom of urethral stenosis in girls, posterior urethral valves in boys, psychologic distress, or, if onset is new, infection.
Pneumaturia (air passed with urine) suggests a vesicovaginal, vesicoenteric, or ureteroenteric fistula; the last 2 may be caused by diverticulitis, Crohn disease, abscess, or colon cancer. Pneumaturia could also be due to emphysematous pyelonephritis.
Physical Examination of the Urologic Patient
Physical examination focuses on the costovertebral angle, abdomen, rectum, groin, and genitals. In women with urinary symptoms, pelvic examination is usually done.
Costovertebral angle
Pain elicited by blunt striking of the back, flanks, and angle formed by the 12th rib and lumbar spine with a fist (costovertebral tenderness) may indicate pyelonephritis Acute pyelonephritis Bacterial urinary tract infections (UTIs) can involve the urethra, prostate, bladder, or kidneys. Symptoms may be absent or include urinary frequency, urgency, dysuria, lower abdominal pain... read more , calculi Urinary Calculi Urinary calculi are solid particles in the urinary system. They may cause pain, nausea, vomiting, hematuria, and, possibly, chills and fever due to secondary infection. Diagnosis is based on... read more , or urinary tract obstruction Obstructive Uropathy Obstructive uropathy is structural or functional hindrance of normal urine flow, sometimes leading to renal dysfunction (obstructive nephropathy). Symptoms, less likely in chronic obstruction... read more .
Abdomen
Visual fullness of the upper abdomen is an extremely rare and nonspecific finding of a kidney or abdominal mass. Dullness to percussion in the lower abdomen suggests bladder distention; normally, even a full bladder cannot be percussed above the symphysis pubis. Bladder palpation can be used to confirm distention and urinary retention.
Rectum
During digital rectal examination, prostatitis Prostatitis Prostatitis refers to a disparate group of prostate disorders that manifests with a combination of predominantly irritative or obstructive urinary symptoms and perineal pain. Some cases result... read more may be detected as a boggy, tender prostate. Focal nodules and less discrete hard areas must be distinguished from prostate cancer Prostate Cancer Prostate cancer is usually adenocarcinoma. Symptoms are typically absent until tumor growth causes hematuria and/or obstruction with pain. Diagnosis is suggested by digital rectal examination... read more . The prostate may be symmetrically enlarged, rubbery, and nontender with benign prostatic hyperplasia Benign Prostatic Hyperplasia (BPH) Benign prostatic hyperplasia (BPH) is nonmalignant adenomatous overgrowth of the periurethral prostate gland. Symptoms are those of bladder outlet obstruction—weak stream, hesitancy, urinary... read more .
Groin and genitals
Inguinal and genital examination should be done with patients standing. Inguinal hernia or adenopathy may explain scrotal or groin pain. Gross asymmetry, swelling, erythema, or discoloration of the testes may indicate infection, torsion, tumor, or other mass. Horizontal testicular lie (bell-clapper deformity) indicates increased risk of testicular torsion. Elevation of one testis (normally the left is lower) may be a sign of testicular torsion Testicular Torsion Testicular torsion is an emergency condition due to rotation of the testis and consequent strangulation of its blood supply. Symptoms are acute scrotal pain and swelling, nausea, and vomiting... read more . The penis is examined with and without retracting the foreskin. Inspection of the penis can detect
Hypospadias Hypospadias Congenital anomalies of the urethra in boys usually involve anatomic abnormalities of the penis and vice versa. In girls, urethral anomalies may exist without other external genital abnormalities... read more
or epispadias Epispadias Congenital anomalies of the urethra in boys usually involve anatomic abnormalities of the penis and vice versa. In girls, urethral anomalies may exist without other external genital abnormalities... read more in young boys
Palpation may reveal an inguinal hernia Groin hernias A hernia of the abdominal wall is a protrusion of the abdominal contents through an acquired or congenital area of weakness or defect in the wall. Many hernias are asymptomatic, but some become... read more 
. Cremasteric reflex may be absent with testicular torsion. Location of masses in relation to the testis and the degree and location of tenderness may help differentiate among testicular masses (eg, spermatoceles, epididymitis Epididymitis Epididymitis is inflammation of the epididymis, occasionally accompanied by inflammation of the testis (epididymo-orchitis). Scrotal pain and swelling usually occur unilaterally. Diagnosis is... read more 
, hydroceles Testicular and Scrotal Anomalies The most common testicular and scrotal anomalies are Congenital hydrocele Undescended testes ( cryptorchidism) Testicular torsion Rare anomalies include scrotal agenesis, hypoplasia, ectopia... read more 
, tumors). If swelling is present, the area can be transilluminated to help determine whether the swelling is cystic or solid. Fibrous plaques felt in the penile shaft are signs of Peyronie disease Peyronie Disease Peyronie disease is fibrosis of the cavernous sheaths leading to contracture of the investing fascia of the corpora, resulting in a deviated and sometimes painful erection. Peyronie disease... read more .
Testing of the Urologic Patient
Urinalysis Urinalysis In patients with renal disorders, symptoms and signs may be nonspecific, absent until the disorder is severe, or both. Findings can be local (eg, reflecting kidney inflammation or mass), result... read more is critical for evaluating urologic disorders. Imaging tests (eg, ultrasonography, CT, MRI) are frequently required. For semen testing, see Sperm Disorders Sperm Disorders Sperm disorders include defects in quality or quantity of sperm produced and defects in sperm emission. Diagnosis is by semen analysis and genetic testing. The most effective treatment is usually... read more .
Bladder tumor antigen testing for transitional cell cancer of the urinary tract is more sensitive than urinary cytology in detecting low-grade cancer; it is not sensitive enough to replace endoscopic examination. Urine cytology is the best test to detect high-grade cancer.
Prostate-specific antigen (PSA) is a glycoprotein with unknown function produced by prostatic epithelial cells. Levels can be elevated in prostate cancer and in some common noncancerous disorders (eg, benign prostatic hyperplasia Benign Prostatic Hyperplasia (BPH) Benign prostatic hyperplasia (BPH) is nonmalignant adenomatous overgrowth of the periurethral prostate gland. Symptoms are those of bladder outlet obstruction—weak stream, hesitancy, urinary... read more , infection, trauma). PSA is measured to detect recurrence of cancer after treatment; its widespread use for cancer screening Screening Prostate cancer is usually adenocarcinoma. Symptoms are typically absent until tumor growth causes hematuria and/or obstruction with pain. Diagnosis is suggested by digital rectal examination... read more is controversial.
