Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5233_Библиотеки_им_академика_М_И_Перельмана.pdf
17 Urology Sheet
153
Irritative
LUTS
Obstructive
LUTS
Fig. 17.2 Symptoms of lower urinary tract
• Frequency
• Urgency
• Urge incontinence
• Nocturia
• Hesitancy
• Intermittency
• Weak prolonged stream Straining
• Incomplete emptying
• Urinary retention
• Overflow incontinence
Symptoms Related toact ofMicturition (Voiding Disorders)
Obstructive Lower Urinary Tract (LUTs) Symptoms (Fig.17.2)
• Causes:—infra-vesical obstruction.—The commonest cause in elderly
male is BPH.
• Criteria:
1. Weak urinary stream.
2. Difculty
– To initiate (Hesitancy)
– To maintain (Intermittency)
– To terminate (Post-micturition dribbling)
3. Sense of incomplete voiding.
4. Retention of urine (acute or chronic)
Irritative Lower Urinary Tract (LUTs) Symptoms (Fig.17.2)
• Due to bladder and urethral irritation (Malignancy, cystitis and stone)
• Criteria:
1. Frequency: by day (Diurnal) and by night (Nocturia).
2. Burning micturition.
3. Urgency: strong desire to micturate which can’t be postponed and can’t hold
urine whenever desire develops.
4. Urge incontinence: strong desire to micturate which can’t be postponed and
if postponed, involuntary escape of urine drops will occur.
154
S. Anderson et al.
Day andNight Incontinence
– Stress incontinence.
– Urge incontinence (neurogenic, stone, cystitis and malignancy).
– Total incontinence as in → vesico-vaginal stula.
– Paradoxical incontinence (false): retention with overow as in BPH and urethral
stricture.
Change inPhysical Character ofUrine
Volume
1. Normally—0.5–1ml/kg/h (800–1600ml/day).
2. Decrease in volume.
– <400 cm3/24 h → oliguria (least volume to excrete toxic metabolite from
the body).
– No urine/12h (with empty bladder)→anuria.
3. Polyuria: Denition: urine output > 3L/day.
Causes:
(a) Renal causes: as Nephrogenic diabetes insipidus and Diuretics.
(b) Endocrinal causes: DM. and Cranial diabetes insipidus.
(c) Psychogenic (compulsive water intake).
Color
• Normally → golden or amber yellow.
• Red urine → hematuriaHematuria is the most important symptom in urology
(see later).
Aspect
• Normally → clear.
• Turbid urine → pyuria, Crystaluria, proteinuria and Chyluria.
• Chyluria: The urine looks milky due to presence of lymph. The color clears on
addition of ether.
• Pneumaturia (air in urine)→ UTI by gas forming organism or vesico-colonic
stula.
• Fecaluria (passage of fecal debris).
• Necroturia: The passage of pieces of tumor tissue in cases of carcinoma of the
Bilaharzial bladder is described by the patient as “pieces of fat”.
17 Urology Sheet
155
Urethral Discharge
Urethral purulent discharge in men due to Neisseria gonorrhea or Chlamydia
trachomatis.
1. Amount
2. Color
3. Presence of blood
4. Relation of discharge to urination and ejaculation
5. Pain
6. Associated symptoms: Conjunctivitis and arthralgia
7. Relation to sexual contacts
8. Exposure to STDs
Swellings
Abdominal Swellings
Generalized (5Fs)
1. Fetus
2. Flatus
3. Feces
4. Fat
5. Fluid
Large masses
1. Renal tumor
2. Hydronephrosis
3. Pyonephrosis
4. Polycystic kidneys
5. Adrenal tumors
6. Full bladder
7. Hepatomegaly
8. Splenomegaly
9. Fibroids
Groin Swellings
1. Hernia (inguinal, femoral)
2. Enlarged inguinal lymph nodes
156
S. Anderson et al.
3. Saphena Varix
4. Hydrocele of the cord
5. Undescended testis
6. Lipoma of the cord
7. Femoral aneurysm
8. Psoas abscess
Scrotal Swelling
– Orchitis, TB epididymo-orchitis
– Testicular tumor
– Gumma of the testis
– Hydrocele: Fluid-lled cyst around the testis, which is difcult to feel.
– Epididymal cysts: A uid-lled cyst lies behind the body of the testis.
– Varicocele
– Sebaceous cyst
– Carcinoma of scrotal skin
Cervical Lymph Node
Mass in the left supraclavicular nodes can be due to metastatic spread of testis and
abdominal cancers.
The Symptoms ofChronic Renal Failure
• Lack of concentration is the earliest symptom.
• Headache
• Blurring of vision
• Epistaxis
• Dry mouth
• Tachypnea
• Palpitations
• GIT manifestations (anorexia, dyspepsia, bitter taste, constipation and bleeding)
• Genital problems (loss of libido, erectile dysfunction and infertility)
• Itching and hiccup are late.
17 Urology Sheet
157
Male Genital Symptoms
Sexual activity: Libido (interest in sex), function (ability to achieve and maintain
an erection), satisfaction with sexual life and performance, condom use, problems.
Testicular pain or masses, and testicular self-examination practices. History of sexually transmitted diseases (STDS), and treatments; and concerns about HIV infection.
A. Impotence: The consistent inability to achieve and maintain a penile erection
sufcient to permit satisfactory sexual intercourse.
1. Organic impotence develops gradually and is related to physical risk fac-
tors. Etiology is usually multifactorial.
2. Psychological impotence has an abrupt onset secondary to marital stress,
anxiety, insomnia, depression, and relationship difculties. Patients will note
early morning erections, and respond to different forms of sexual stimuli.
B. Loss of libido may indicate endocrine dysfunction e.g. Androgen deciency.
C. Disorders of ejaculation and orgasm:
1. Premature ejaculation is persistent occurrence of ejaculation with minimal
sexual stimulation before or shortly after penetration.
2. Retrograde ejaculation is backow of semen into the bladder.
3. Anejaculation: Failure to ejaculate.
4. Anorgasmia is the inability to achieve the pleasurable sensation of orgasm
during intercourse.
D. Hematospermia: The presence of blood in seminal uid
E. Peyronie’s disease: Curvature of the penis secondary to formation of brous
plaques within the tunica albuginea.
F. Priapism is persistent or prolonged (>4h), painful, purposeless (in the absence
of sexual stimulation) penile erection.
G. Infertility is the inability to conceive after one year of unprotected sexual
intercourse.
History ofPresent Illness
The chief complaint is the reason presenting the patient to the urologist.
Put the pertinent positives rst, and include all the relevant negatives e.g. no
hematuria, that help to clarify the differential diagnosis.
Symptoms are arranged in a chronological sequence. Renal colic followed by
hematuria is suggestive of stones, while hematuria followed by colic may result
from a tumor.
158
S. Anderson et al.
Details oftheCurrent Symptoms (OLD CARTS)
• Onset: date it began, sudden or gradual, over how long?
• Location and radiation: ask the patient to point to the site with one nger and
whether the pain moves anywhere else?.
• Duration.
• Characters: nature of the symptom.
• Aggravating factors: What makes the symptom worse?
• Relieving factors: What makes the symptom better?
• Timing and frequency: improving or deteriorating with time
Severity
– Setting in which the symptom occurs.
– Details of previous similar episodes.
– Associated manifestations.
– Details of investigations and treatment for the current problem.
– Extent of functional disability.
– Menstrual and reproductive history for women.
Past History
The therapeutic history, whether medical or surgical.
Medical History
• Diseases as diabetes, hypertension, hepatitis, bronchial asthma, and cardiac
conditions.
• Allergies and Reactions.
• Drugs: as hematuria with anticoagulants. Ant allergic, antihistaminic drugs pre-
cipitate LUTS, a fact that should be taken in consideration in elderly men.
• Bilharziasis: Bilaharzial cystitis and carcinoma.
• Calculi: Renal colic, passage of stones and treatment.
History ofTrauma
Family History
• Polycystic kidney disease.
• Von Hippel-Lindau disease.
17 Urology Sheet
• Renal tubular acidosis.
• Urolithiasis.
• Prostate cancer.
Social History
Special habits to identify risk factors for particular diseases.
Smoking and alcohol.
Systematic Symptoms
1. Gastrointestinal symptoms of urologic diseases:
– Acute pyelonephritis is associated with abdominal pain and distension.
– Ureteric colic is associated with nausea, vomiting and distension.
– Silent urologic diseases (e.g. hydronephrosis, staghorn stone, chronic pyelo-
nephritis and cancer) may present with gastrointestinal symptoms that mislead the clinician.
2. Neurologic disorders: may cause urinary and sexual dysfunction:
159
– Disease: Diabetes mellitus, Multiple sclerosis, Cerebro-vascular disease,
Spinal cord injury and Parkinsonism.
– Pelvic surgery (hysterectomy, abdomino-perineal resection).
3. Vascular disorders: Hypertension may be a manifestation of renal vascular
disorders or adrenal masses.
4. Congenital disorders:
– Adult polycystic kidney, von Hippel-Lindau and tuberous sclerosis complex
are autosomal dominant diseases.
– Undescended testis and hypospadias have hereditary tendency.
5. Symptoms of metastases:
– Bones: Pain, swelling, nerve compression, spontaneous fracture.
– Lungs: Persistent cough, hemoptysis, blood-staining, pleural effusion.
– Liver metastases develop late symptoms.
– Brain: Headache, vomiting, visual disturbances, convulsions.
– Adrenal metastases are usually bilateral and primary tumors of the breast and
lungs should be taken in consideration.
6. General symptoms:
Fever, Weight loss and cachexia in cases of malignant tumors and manifestations
of uremia.
160
S. Anderson et al.
The Physical Examination
General
– The patient should be courteously invited to lie comfortably on their back with
arms by their sides, on a couch in a warm private room.
– In so doing, their mobility in transferring from their chair (or wheel-chair) to the
couch is assessed and any help they require is noted.
– If the patient cannot lie comfortably because of a skeletal deformity or injury,
examination must be carried out in an alternative position.
– If the patient cannot straighten one of his legs, or if it causes pain to do so, he
may have psoas irritation due to a retroperitoneal abscess, mass or retrocaecal
appendicitis.
– If the patient is female, a male doctor may wish to request the presence of a
chaperone, or vice versa.
– The patient should be asked to expose his or her abdomen, groins and genitalia.
– Inspection of the hands, face and neck and palpation of the radial pulse, cervical
and supraclavicular areas are routine.
– Signs of any gross cardiovascular, respiratory, obesity or wasting disease are
usually evident.
The Abdominal Examination
Inspection
– The abdomen is inspected and any asymmetry, distension or surface lesions
(scars, skin lesions, sinuses) noted on a diagram together with other ndings.
– The patient should be asked to point to the area of pain.
Palpation
– The abdomen is palpated in the nine anterior areas and in the two renal angles.
During this, keep a close watch on the patient’s face and eyes to detect tender-
ness, while causing the minimum of pain.
– Note any mass: assess its site, size, surface, consistency, mobility and tenderness.
– If it is in the loin, can it be palpated bimanually? Can you get above or below the
lump? A renal mass is detected in the right or left upper quadrants; it may or may
not be tender; only its lower margin is palpable and it may not be possible to get
above it; the mass should be palpable bimanually unless it is too small; it should
be slightly mobile downwards on inspiration.
17 Urology Sheet
– A distended bladder is palpable suprapubically as a dome-like mass this can be
difcult in obese patients. The palpable.
– Bladder may or may not be tender; it is not possible to get below it.
Percussion
– A renal mass should be resonant to percussion (in theory) because, unlike the
spleen or liver, it is a retroperitoneal structure, overlying which is gas-lled bowel.
– A distended bladder is dull to percussion, because it lifts the peritoneal contents
away from the abdominal wall.
Auscultation
Not particularly helpful in the diagnosis of urological disease, but nevertheless.
An important part of the abdominal examination.
Local Examination
161
The Groins andGenitalia
(a) Examination of the male groins and genitalia:
• General inspection for signs of chronic disease, abnormal body hair or
Gynaecomastia.
• Examination of the external genitalia is made to assess the presence, size and
• Consistency of the testes in the scrotum. Absent testes indicate cryptorchidism and small soft testes suggest testicular failure. Bulky epididymis may
indicate vasal obstruction. The presence of both vasa is conrmed by palpation of structures in each spermatic cord that feel like string.
• A careful inspection is made for the presence of a Varicocele by standing the
patient up. A large Varicocele is obvious with the patient lying, while a moderate one may only be detectable with the patient standing, classically
described to feel like a bag of worms.
• Examining the penis, a Phimosis or hypospadias
• The foreskin, if present, should be retracted to ensure it is not tight and to
reveal the glans penis. The urethral meatus is inspected to ensure it is in the
normal position and is not scarred.
• The penile urethra and the corpora cavernosa are examined if the history
suggests a relevance.
162
(b) Examination of the female genitalia:
• it is done at the same time as a vaginal examination. This is not always necessary, but is indicated if the complaint relates to incontinence or other perineal symptoms.
• The ideal situation is with adequate light and the patient as relaxed as possible, lying in the left lateral position. A lubricated Simms speculum is
inserted and the vaginal introitus is inspected for surface lesions or masses.
• The patient is asked to cough; any descent of the anterior or posterior vaginal
walls or the cervix are noted; any urinary leakage is noted.
• If indicated, a bimanual vaginal examination is performed to palpate the
cervix and adnexae (with the patient supine).
S. Anderson et al.
The Digital Rectal Examination (DRE)
• For diagnosis of prostatic lesion as BPH and cancer, bladder lesion and other
pelvic lesions.
• the patient is examined in supine position, the left lateral position, or in the kneeelbow position
• Examination will be uncomfortable but quick. Patients with rectal stenosis, anal
ssure, acute prostatitis, prostatic abscess or an inammatory pelvic condition
(diverticulitis, appendicitis, abscess, Salpingitis) do nd the DRE painful and
this nding should be noted.
• The perianal skin and the anal sphincter are innervated by S2, 3 and 4. If neurological disease affecting the urinary sphincter is suspected, an assessment is
made of perianal sensation and anal tone while performing a DRE.If either or
both are reduced, then a lesion affecting these sacral nerves and indeed urinary
sphincter function is highly likely.
Investigations
Laboratory Investigations
1. Biochemical blood tests for renal function
• Serum urea
• Serum creatinine.
• Serum electrolytes.
• Arterial blood gas
2. Urinalysis
• For abnormal substances such as blood, protein or signs of infection.