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.)
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 is colicky and may be prostrating; it is more constant if caused by infection. Acute urinary retention distal to the bladder causes agonizing suprapubic pain; chronic urinary retention causes less pain and may be asymptomatic. Dysuria 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 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, calculi, or urinary tract obstruction.
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 may be detected as a boggy, tender prostate. Focal nodules and less discrete hard areas must be distinguished from prostate cancer. The prostate may be symmetrically enlarged, rubbery, and nontender with benign prostatic hyperplasia.
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. The penis is examined with and without retracting the foreskin. Inspection of the penis can detect
Hypospadias or epispadias in young boys
Peyronie disease in men
Priapism, ulcers, and discharge in either group
Palpation may reveal an inguinal hernia. 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, hydroceles, 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.
Testing of the Urologic Patient
Urinalysis is critical for evaluating urologic disorders. Imaging tests (eg, ultrasonography, CT, MRI) are frequently required. For semen testing, see Sperm Disorders.
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, infection, trauma). PSA is measured to detect recurrence of cancer after treatment; its widespread use for cancer screening is controversial.
