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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 14 GU symptoms
362
Painless hematuria
False positives include vaginal or anorectal bleeding.
Some differential diagnoses and typical outline evidence
Renal tumor Suggested by: palpable mass, fever (often previously of
unknown origin)
Confirmed by: ultrasound or CT of abdomen/kidney, IVU
Ureteral
tumor
Suggested by: colicky pain if obstructed
Confirmed by: ultrasound or CT abdomen/kidney, IVU
Bladder tumor Suggested by: pelvic pain, pelvic mass
Confirmed by: cystoscopy, IVU shows filling defects of
bladder
Bleeding
diathesis
Suggested by: anticoagulant therapy, easy bruising, or
other bleeding sites
Confirmed by: abnormal clotting screen ± low platelets
Urinary tract
infection (UTI)
Suggested by: frequency, ± low-grade fever, i nitrites,
white cells, blood on dipstick
Confirmed by: MSU microscopy and culture. Ultrasound
scan for possible anatomical abnormality
SECONDARY AMENORRHEA1
363
Secondary amenorrhea
This is absence of menstruation for ≥3 months.
Some differential diagnoses and typical outline evidence
Pregnancy Suggested by: presentation during childbearing age
Confirmed by: positive pregnancy test, pelvic ultrasound
Normal
menopause
Suggested by: >40 years of age, hot flashes
Confirmed by: FSH high
Premature
ovarian failure
Suggested by: hot flashes <40 years of age and no signs
of other endocrine disease (adrenal failure,
hypothyroidism, etc.)
Confirmed by: LH, FSH i, estradiol d, ovarian biopsy:
atrophic
Polycystic ovary
syndrome
Suggested by: oligo- or amenorrhea, hirsutism, obesity
Confirmed by: d sex hormone–binding globulin,
i testosterone, iLH, cystic ovaries on pelvic
ultrasound
Hyperprolacti-
nemia
Suggested by: galactorrhea, ± headache or bitemporal
visual-field defect (if due to large prolactinoma)
Confirmed by: i serum prolactin. Appearance of
pituitary fossa on skull X-ray or CT scan
Thyrotoxicosis Suggested by: heat intolerance, tremor, nervousness,
palpitation, frequent bowel movements, goiter
Confirmed by: dTSH, iFT4, (± iFT3)
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CHAPTER 14 GU symptoms
364
Excessive menstrual loss: menorrhagia
Menorrhagia can be due to uterine or systemic disorders.
Some differential diagnoses and typical outline evidence
Fibroids (uterine
leiomyomas)
Suggested by: (sometimes) urinary frequency,
constipation, recurrent abortion, infertility
Confirmed by: pelvic examination, ultrasound or CT
Endometrial
carcinoma
Suggested by: abnormal uterine bleeding, blood-stained
vaginal discharge, postmenopausal bleeding
Confirmed by: pelvic ultrasound, tissue sampling of
endometrium, hysteroscopy
Pelvic
endometriosis
Suggested by: dysmenorrhea, dyspareunia, infertility,
pelvic mass
Confirmed by: laparoscopy
Chronic pelvic
inflammatory
disease
Suggested by: lower abdominal pain, fever, vaginal
discharge, dysuria, iESR and iCRP, leukocytosis
Confirmed by: high vaginal swab, pelvic ultrasound,
± laparoscopy
Intrauterine
contraceptive
device (IUD)
Suggested by: history of its insertion ± dysmenorrhea
Confirmed by: symptoms subside after removal of IUD
Primary
hypothyroidism
Suggested by: cold intolerance, tiredness, constipation,
bradycardia
Confirmed by: iTSH, dFT4
Bleeding
diathesis
Suggested by: family history, tendency to bleed, easy
bruising
Confirmed by: abnormal clotting screen
INTERMENSTRUAL OR POSTCOITAL BLEEDING1
365
Intermenstrual or postcoital bleeding
Expert pelvic examination is required.
Some differential diagnoses and typical outline evidence
Carcinoma
of uterus
Suggested by: abnormal or intermenstrual uterine
bleeding, blood-stained discharge, postmenopausal
bleeding
Confirmed by: pelvic ultrasound, tissue sampling of
endometrium, hysteroscopy
Carcinoma
of cervix
Suggested by: irregular vaginal bleeding, offensive,
watery, or blood-stained vaginal discharge, obstructive
uropathy and back pain in late stage
Confirmed by: appearance on vaginal speculum
examination, biopsy of cervix
Cervical
or intrauterine
polyps
Suggested by: intermenstrual spotting or postmenstrual
staining
Confirmed by: appearance on vaginal speculum
examination, hysteroscopy
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Chapter 15
367
GU signs
General examination checklist 368
Scrotal mass 368
Enlargement of prostate 370
Vulval skin abnormalities 371
Ulcers and lumps of the vulva 372
Lumps in the vagina 373
Ulcers and lumps in the cervix 374
Tender or bulky mass (uterus, fallopian tubes, or ovary)
on pelvic examination 376
Vaginal discharge 380
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CHAPTER 15 GU signs
368
General examination checklist
Preliminary findings should have been discovered during the general
examination. These include jaundice, anemia, clubbing, xanthelasma,
gynecomastia, and lip, buccal mucosa, throat, tongue, or supraclavicular
lumps.
Scrotal mass
Some differential diagnoses and typical outline evidence
Inguinal hernia
descended into
scrotum
Suggested by: inability to get above it. Does not
transilluminate
Confirmed by: above clinical examination
Testicular
torsion
Suggested by: exquisitely tender, unilateral mass in the
scrotal sac, chord thickened, and opposite testis lies
horizontally (bell-clapper testis)
Confirmed by: above clinical examination, Doppler
ultrasound reveals d blood flow
Hematocele Suggested by: history of trauma or scrotal surgery.
Tenderness
Confirmed by: above history and examination, Doppler
ultrasound
Acute
epididymitis
Suggested by: diffuse tenderness in the epididymis,
marked redness, and edema
Confirmed by: urine microscopy and culture (white cells
and organisms)
Acute orchitis Suggested by: large and tender testes fever
Confirmed by: above history and examination
Chronic
epididymitis
Suggested by: chronic, diffuse scrotal tenderness
Confirmed by: identification of infecting organism by
urine cultures or culture of urethral discharge after
prostatic massage
Varicocele (90%
on the left)
Suggested by: non-tender, unilateral fleshy mass that
feels like a bag of worms, and decreases in size with
scrotal elevation
Confirmed by: above clinical examination (patient must
be examined while standing)
SCROTAL MASS1
369
Hydrocele
Other causes:
obesity, inconti-
nence, diabetes
mellitus, psoria-
sis, lichen planus,
scabies, pubic
lice
Suggested by: non-tender, unilateral mass in scrotal sac
Confirmed by: above clinical findings and demonstra
t
ion
of transillumination
Spermatocele Suggested by: non-tender, small nodules posterior to
the head of the epididymis
Confirmed by: above clinical examination, may or may
not transilluminate
Epididymal cyst Suggested by: non-tender nodule in the head of
epididymis, adjacent to inferior pole of testis, and
transillumination
Confirmed by: above clinical examination and
demonstration of transillumination
Seminoma Suggested by: firm, non-tender, non-transilluminable
nodule or mass adjacent to a testis
Confirmed by: ultrasound of scrotal contents showing a
solid testicular mass, direct surgical examination,
normal serum α-fetoprotein
Teratoma Suggested by: firm, non-tender, non-transilluminable
nodule or mass adjacent to a testis
Confirmed by: ultrasound of scrotal contents showing
a solid testicular mass, direct surgical examination,
iserum α-fetoprotein
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CHAPTER 15 GU signs
370
Enlargement of prostate
The rectal examination continues by feeling for a prostatic protrusion
anteriorly and sweeping around for other masses, including impacted
feces.
Some differential diagnoses and typical outline evidence
Prostatitis Suggested by: smooth, enlarged, and tender
Confirmoed by: positive urine culture, culture of
prostatic secretions
Benign prostatic
hypertrophy
Suggested by: smooth, enlarged, firm, non-tender,
usually with a palpable median groove
Confirmed by: normal or slightly iserum PSA
, prostatic
biopsy
Prostatic
carcinoma
Suggested by: irregular, hard, sometimes obliteration of
median groove, non-tender
Confirmed by: iiserum PSA,
prostatic biopsy
VULVAL SKIN ABNORMALITIES1
371
Vulval skin abnormalities
Some differential diagnoses and typical outline evidence
Thrush,
Candida albicans
often in pregnancy,
contraceptive
and steroids,
immunodeficiencies,
antibiotics, and
diabetes mellitus
Suggested by: vulva and vagina red, fissured and
sore
Confirmed by: mycelia or spores on microscopy
and culture
Allergy Suggested by: exacerbation after wearing nylon
underwear, using chemicals or soap
Confirmed by: response to avoidance of precipi-
tants
Lichen
sclerosis
Suggested by: being intensely itchy. Bruised red,
purpuric appearance. Bullae, erosions, and
ulcerations. Later, white, flat, and shiny with an
hourglass shape around the vulva and anus
Confirmed by: above clinical appearance and biopsy
Leukoplakia Suggested by: itchiness and white vulval patches
due to skin thickening and hypertrophy
Confirmed by: above clinical appearance and biopsy
Carcinoma of the
vulva
Suggested by: an indurated ulcer with an everted
edge
Confirmed by: biopsy
Other causes: obesity, incontinence, diabetes mellitus, psoriasis, lichen
planus, scabies, pubic lice
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