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Urologic Evaluation

Pain in the genitourinary tract is usually associated with distention of a hollow viscus (ureteral obstruction, urinary retention) or the capsule of an organ (acute prostatitis, acute pyelonephritis). Pain may be local or referred. Pain associated with malignancy is usually a late manifestation and indicative of advanced disease.

Renal Pain

Pain of renal origin is usually located in the ipsilateral costovertebral angle. It may radiate to the umbilicus and may be referred to the ipsilateral testicle in men or the labium in women. In infection, the pain is typically constant, whereas in obstruction it may come and go. Nausea and vomiting may result from reflex stimulation of the celiac ganglion. Patients with intraperitoneal pathology will typically lie motionless to avoid pain, while patients with renal disease will move about to try to find a more comfortable position.

Ureteral Pain

Ureteral pain is usually acute and a result of obstruction. Distention of the ureter along with hyperperistalsis and spasm of the smooth muscle of the ureter may result in two different pain patterns. Distention may cause a constant dull ache, while the spasms result in colic. The site of obstruction is often predicted by the site of pain. Upper ureteral obstruction may result in pain referred to the scrotum in males or to the labium in females. Midureteral obstruction may cause pain in the lower quadrant and thus may be confused with appendicitis in right-sided ureteral obstruction or diverticulitis in left-sided ureteral obstruction. Lower ureteral obstruction may cause inflammation of the ureteral orifice and thus be associated with symptoms of vesical irritability.

Vesical Pain

Acute urinary retention results in severe suprapubic discomfort. Chronic urinary retention is usually painless despite tremendous vesical distention. Suprapubic pain not related to the act of micturition is rarely vesical in origin. Acute cystitis pain is usually referred to the distal urethra and is associated with micturition.

Prostatic Pain

Prostatic pain is associated with inflammation and is located in the perineum. Pain radiates to the lumbosacral spine, inguinal canals, or lower extremities. Because of its location near the bladder neck, inflammatory processes of the prostate result in irritative voiding complaints.

Penile Pain

Pain in the flaccid penis is secondary to inflammatory processes caused by sexually transmitted diseases or paraphimosis, a condition of the uncircumcised male in which the retracted foreskin is trapped behind the glans penis, resulting in vascular congestion and painful swelling of the glans. Pain in the erect penis may be due to Peyronie's disease (fibrous plaque of the tunica albuginea, resulting in painful curvature of the erect penis) or to priapism (prolonged painful erection).

Testicular Pain

Acute conditions such as trauma, torsion of the testis or one of its appendices, or epididymo-orchitis cause acute pain within the scrotum with radiation to the ipsilateral groin. Chronic pain may persist for months following successful treatment of acute epididymitis. Chronic pain produced by a varicocele or hydrocele results in "heaviness" without radiation. Disorders of the kidney, retroperitoneal structures, or inguinal canal may result in pain referred to the testis.

Hematuria

Gross hematuria in adults is considered a sign of malignancy until proved otherwise.

The character of the hematuria may provide a clue to the site of origin. Initial hematuria, the presence of blood at the beginning of the urinary stream that clears during the stream, implies an anterior (penile) urethral source. Terminal hematuria, the presence of blood at the end of the urinary stream, implies a bladder neck or prostatic urethral source. Total hematuria, the presence of blood throughout the urinary stream, implies a bladder or upper tract source.

Associated symptoms provide clues to the cause. Hematuria associated with renal colic suggests ureteral stone, but the passage of blood clots from a bleeding tumor mimics this scenario. Irritative voiding symptoms in a young woman may suggest acute bacterial infection and associated hemorrhagic cystitis, yet the same picture in an older woman or in any male raises concerns about neoplasm. In any situation, if cultures are negative or hematuria persist after therapy, further evaluation is warranted. In the absence other symptoms, gross hematuria may be more indicative of tumor, but staghorn calculi, glomerulonephropathies, and polycystic kidney disease are in the differential.

Irritative Voiding Symptoms

Urgency is the sudden desire to void. It is observed in inflammatory conditions such as cystitis or in hyperreflexic neuropathic conditions such as neurogenic bladders resulting from upper motor neuron lesions. Dysuria (painful urination) is usually associated with inflammation. The pain is typically referred to the tip of the penis in men or to the urethra in women. Frequency is the increased number of voids during the daytime, and nocturia is nocturnal frequency. Adults normally void five or six times a day and once at most during the nighttime hours. Increased numbers of voidings may result from increased urinary output or decreased functional bladder capacity. Diabetes mellitus, diabetes insipidus, excess fluid ingestion, and diuretics (including caffeine and alcohol) are a few of the causes of increased urinary output. Decreased functional bladder capacities may result from bladder outlet obstruction (increased residual urine volume results in a lower functional capacity), neurogenic bladder disorders (spasticity and reduced compliance), extrinsic bladder compression (uterine fibroids, radiation-induced fibrosis, pelvic neoplasms), or psychological factors (anxiety).

Obstructive Voiding Symptoms

Hesitancy is a delay in the initiation of micturition. It results from the increased time required for the bladder to attain the high pressure necessary to exceed that of the urethra in the obstructed setting. Decreased force of stream results from the high resistance the bladder faces and is often associated with a decrease in caliber of the stream. Intermittency and postvoid dribbling are interruption of the urinary stream and the uncontrolled release of the terminal few drops of urine, respectively. Obstructive symptoms are most commonly due to benign prostatic hyperplasia, urethral stricture, or neurogenic bladder disorders. Prostatic or urethral carcinoma and foreign body are other causes.

Incontinence

Urinary incontinence is the involuntary loss of urine. The history permits subclassification into one of four categories of incontinence. Such a distinction is necessary, as the evaluation and treatment vary with each of the categories. With total incontinence, patients lose urine at all times and in all positions. Stress incontinence is the loss of urine associated with activities that result in an increase in intra-abdominal pressure (coughing, sneezing, lifting, exercising). Uncontrolled loss of urine preceded by a strong urge to void is known as urge incontinence. Chronic urinary retention may result in overflow incontinence.

Systemic Manifestations

Fever when associated with other symptoms of a urinary tract infection (see below) helps localize the site of infection. In women, high fevers occur in acute pyelonephritis. Fevers are not typical of uncomplicated cystitis. In men, a febrile urinary tract infection implies acute pyelonephritis, acute prostatitis, or acute epididymitis. Fever may also be associated with malignancy of the kidney, bladder, or testis.

Weight loss and malaise may also be associated with tumor or disease states associated with chronic renal failure.

Other Symptoms

Hematospermia, the presence of blood in the ejaculate, results from inflammation of the prostate or seminal vesicles. Blood in the initial portion of the ejaculate implicates the prostate, whereas terminal hematospermia implies a seminal vesicle origin. Workup should include urinalysis, digital rectal examination (DRE) with prostate massage, and microscopic evaluation of the expressed prostatic secretions. More invasive procedures such as cystoscopy or transrectal ultrasound with prostate biopsy are reserved for patients with hematuria or abnormal rectal examinations, respectively. Persistent hematospermia warrants similar testing. The risk of malignancy with isolated hematospermia, normal urinalysis, and normal DRE is low.

Pneumaturia, the presence of gas in the urine, is usually secondary to a fistula between the bladder and the gastrointestinal tract. Diverticulitis is the most common cause, followed by colonic carcinoma, Crohn's disease, and radiation enteritis. The patient reports bubbles or particulate matter in the urine. On occasion, pneumaturia may be due to infection by gas-producing organisms.

Urethral discharge is the most common symptom of sexually transmitted diseases. Dysuria and urethral itching are seen in association with the discharge. A bloody urethral discharge, especially in an elderly patient, suggests urethral carcinoma.

Cloudy urine may be secondary to a urinary tract infection, yet in the absence of infection it can be a result of an alkaline urinary pH. Such conditions result in phosphate crystal precipitation. Chyluria, the presence of lymph in the urine, results from a fistula between the urinary tract and the lymphatic system. Filariasis, tuberculosis, and retroperitoneal tumors are some of the possible causes of this rare symptom.

Physical Examination

General Examination

The pallor of anemia and cachexia may be seen in malignancy. Gynecomastia may occur with testicular carcinomas or as a complication of hormonal therapy in prostatic cancer. Hypertension can be a result of renovascular disease or adrenal cancer.

Detailed Examination

Kidney

Because of the liver, the right kidney is lower than the left. The lower pole of the right kidney may be palpable in thin patients, yet the left kidney is usually not palpable unless abnormally enlarged. To palpate the kidney, one hand is placed posteriorly over the costovertebral angle to push the kidney anteriorly, while the second hand is placed anteriorly under the costal margin. With inspiration, the kidney may be palpated between the two hands.

Auscultation of the upper abdominal quadrants in hypertensive patients may reveal a systolic bruit associated with renal artery stenosis or an arteriovenous malformation; however, aortic bruits or transmitted heart murmurs may give similar findings.

Patients with flank pain should be tested for hyperesthesia of the overlying skin by pin testing, as this may be secondary to nerve root irritation and radiculitis rather than being of renal origin.

Bladder

The normal adult bladder is not palpable unless filled with at least 150 mL of urine. Percussion is better than palpation in diagnosing the distended bladder. Dullness is appreciated over the full bladder and changes to tympany if the air-filled bowel is anterior to the bladder.

Bimanual examination under anesthesia is helpful in the evaluation of patients with suspected bladder neoplasms. In the male, the bladder is palpated between the abdominal wall and the rectum while in the female it is palpated between the abdominal wall and the vagina. This is the best means of assessing vesical mobility and thus resectability.

Penis

The foreskin must be retracted in the uncircumcised male to permit inspection of the urethral meatus and glans. The position of the urethral meatus and the presence of urethral discharge, inflammation, penile tumor, and skin lesions must be noted. In phimosis, the foreskin cannot be retracted over the glans. In paraphimosis, the foreskin has been left retracted behind the glans, resulting in painful engorgement and edema of the glans. If not attended to, this may result in glandular ischemia. Congenital anomalies of position of the urethral meatus are called hypospadias when the meatus is located on the ventral aspect of the penis, scrotum, or perineum and epispadias when it is located on the dorsal aspect of the penis. A thick yellow urethral discharge is seen in gonococcal urethritis, whereas a thin clear or white discharge is noted in nongonococcal urethritis. Palpation of the dorsal penile shaft for plaques of Peyronie's disease and of the ventral surface for urethral tumors should be performed.

Scrotum and Its Contents

The most common referral to the urologist concerning the scrotum is for evaluation of a mass. It is important to determine whether the lesion resides within the testicle or is related to the epididymis or cord structures. The testes are palpated between the fingertips of both hands. Normal testes measure 4.5 x 2.5 cm and are rubbery in consistency. The epididymis rests posterolateral to the testis and varies in its degree of testicular attachment. Masses arising from within the testes are usually malignant; those from the epididymis and spermatic cord structures are usually benign. Transillumination will frequently distinguish solid and cystic lesions.

The history and physical examination can determine the diagnosis in the majority of cases. Tumors of the testis are usually painless, firm, solid lesions within the substance of the testis. These lesions do not transilluminate.

Acute epididymitis is an acute infectious process and is associated with painful enlargement of the epididymis. Fever and irritative voiding symptoms are common. In advanced states, the infection can spread to the testis, making the distinction between the epididymis and the testicle difficult on physical examination. The entire scrotal contents may be painful on palpation, yet relief may be offered to the supine patient by elevation of the scrotum above the pubic symphysis (Prehn's sign).

A hydrocele is a collection of fluid between the two layers of the tunica vaginalis. The diagnosis is readily made by transillumination. Evaluation of the testis is necessary, as approximately 10% of testicular tumors may have an associated hydrocele.

A varicocele is engorgement of the internal spermatic veins above the testis. These almost always occur on the left side as the left spermatic vein empties into the left renal vein while the right empties into the inferior vena cava below the level of the renal vein. Varicoceles should diminish in size or disappear with the patient in the supine position. The sudden onset of a right varicocele should raise the question of a retroperitoneal malignancy resulting in obstruction of the right spermatic vein.

Torsion of the testis typically occurs in the 10- to 20-year age group and presents with acute onset of pain and swelling within the testis. Examination reveals a painful testis that may have a "high lie" in relation to the other testis. The acute onset, lack of voiding symptoms, and the different age distribution may help distinguish it from epididymitis.

Torsion of the appendices of the testis or epididymis may be indistinguishable from torsion of the testis and affects a similar age group as torsion of the testis. On occasion a small palpable lump on the superior pole of the testis or epididymis is discernible that may appear blue when the skin is pulled tautly over it ("blue dot sign").

Rectal Examination in the Male

Inspection for anal pathology (fissures, warts, carcinoma, hemorrhoids) should be performed first. Upon insertion of the finger, anal tone can be estimated and a bulbocavernosus reflex can be elicited. As the anal and urinary sphincter derive from a common innervation, clues to neurogenic disorders may be obtained. The entire prostate is then examined, with attention being directed toward size and consistency. The normal prostate is approximately 4 x 4 cm and weighs 25 g. Normal consistency is that of the contracted thenar eminence with the thumb opposed to the little finger. Rubbery enlargement of the prostate is noted in benign prostatic hyperplasia. Induration may be perceived with carcinoma but also with chronic inflammation. The remainder of the rectum is then examined to exclude primary rectal disease.

Pelvic Examination in the Female

Examination of the introitus should include inspection for atrophic changes, ulcers, discharge, and warts. The urethral meatus can be inspected for caruncles (more commonly seen in postmenopausal patients, and as a reddened area at the inferior margin of the meatus) and palpated for tumors or diverticula. Bimanual examination of the bladder, uterus, and adnexa should be performed with two fingers in the vagina and one hand on the abdomen, and attention is directed toward abnormal masses.

Urinalysis

Collection of Specimens

In the male, a clean-catch urine is obtained in separate aliquots. Such a scheme may permit localization of disease. The first 5–10 mL is collected and represents the urethral specimen; a midstream specimen reflects conditions in the bladder and upper urinary tracts. If necessary, the prostate is then massaged and the expressed secretions collected. If no fluid is obtained, the next 2–3 mL of urine is collected, which reflects prostatic pathology. (See also Hematuria.)

Dipstick Urinalysis

PH

There is no role for dipstick urinalysis screening for urinary tract disorders in asymptomatic adults except for pregnant women. Urinary pH (range 5.0–8.0) may be helpful in the diagnosis and treatment of some urologic conditions. Alkaline urine in a patient with a urinary tract infection suggests the presence of a urea-splitting organism, most commonly Proteus mirabilis, though some strains of Klebsiella, Pseudomonas, Providencia, and Staphylococcus may also produce urease. Acidic urine in a patient with urolithiasis suggests uric acid or cystine stones. Failure to acidify the urine below a pH of 5.5 despite a metabolic acidosis suggests a distal renal tubular acidosis.

Protein

Dipsticks using bromphenol blue can detect protein in concentrations exceeding 10 mg/dL. It measures albumin and is not sensitive for the light chain of immunoglobulins (Bence Jones proteins). False-positive results are seen in urine containing numerous leukocytes or epithelial cells. (See Proteinuria in Nephrology.)

Urobilinogen and Bilirubin

Urobilinogen is formed from the catabolism of conjugated bilirubin in the gut by bacteria, and the majority is cleared by the liver. Normally, only 1–4 mg of urobilinogen is excreted in the urine per day. Hemolytic processes or hepatocellular disease can lead to increased urinary levels, while complete biliary obstruction or broad-spectrum antibiotics that alter the gut bacterial flora may result in absent urinary urobilinogen. Unconjugated bilirubin is not filtered by the glomerulus, while only 1% of conjugated bilirubin is filtered. Normally no bilirubin is detected by urinary dipstick, since only concentrations greater than 0.4 mg/dL are detectable. Conditions manifesting elevated conjugated bilirubin in the serum will result in higher urinary levels. Ascorbic acid may cause false-negative results, while phenazopyridine may cause false-positive results.

Glucose and Ketones

Only small amounts of glucose are normally excreted in the urine, and these levels are below the sensitivity of the dipstick. Any positive finding requires evaluation for diabetes. The test is specific for glucose and does not cross-react with any other sugars. Ascorbic acid or elevated ketones may result in false-negative results.

Ketones are not normally found in the urine, but fasting, postexercise states, and pregnancy may result in elevated urinary ketones. Diabetics often demonstrate elevated urinary ketone levels prior to an elevation in serum levels. False-positive results occur in dehydration or in the presence of levodopa metabolites, mesna (sodium mercaptoethanesulfonate), and other sulfhydryl-containing compounds.

Nitrites

Normally, the urine does not contain nitrites. Many gram-negative bacteria can reduce nitrate to nitrite, which is thus an indicator of bacteriuria. However, the low sensitivity of the test requires clarification. Adequate numbers of bacteria must be present (10⁵ organisms/mL), nitrates must be available in the urine, and the bacteria must be in contact with the urine for a sufficient time (usually 4 hours). Therefore, the first morning voided sample is preferable. False-negative results may be due to non–nitrate-reducing organisms, frequent urination, dilute or acidic urine (pH < 6.0), and the presence of urobilinogen. False-positive results are usually secondary to contaminated specimens, so that bacteria are indeed present in the sample yet not present in the urinary tract.

Leukocyte Esterase

Leukocyte esterase is an enzyme produced by white cells. The dipstick detects leukocytes in the urine, which is thus suggestive but not diagnostic for bacteria. False-positive tests result from specimen contamination. False-negative tests result from high specific gravity, glycosuria, the presence of urobilinogen, and medications, including rifampin, phenazopyridine, and ascorbic acid.

Blood

The urinary dipstick for blood measures intact erythrocytes, free hemoglobin, and myoglobin. False-positive results in women may occur as a result of contamination at collection with menstrual blood. Concentrated urine may also cause a false-positive result, as patients normally excrete 1000 erythrocytes per milliliter of urine. Vigorous exercise and vitamins or foods associated with high oxidant levels may also give a false-positive result. High ascorbic acid levels may give a false-negative result.

Microscopic Urinalysis

Leukocytes

The presence of more than five leukocytes per high-power field is considered significant pyuria. Leukocytes in the urine are indicative of injury to the urinary tract, which may or may not be due to infection. Other causes of pyuria include calculous disease, strictures, neoplasm, genitourinary tuberculosis, glomerulonephropathy, or interstitial cystitis. Leukocyte counts will vary by the state of hydration, method of collection, and degree of injury to the urinary tract.

Erythrocytes

The presence of more than five erythrocytes per high-power field on a single occasion or more than three erythrocytes per high-power field on multiple examinations is considered significant and warrants further investigation. (See Evaluation of Hematuria, below.) The appearance of the red cells sometimes provides a clue to their origin within the urinary tract. Dysmorphic (irregularly shaped) cells have an uneven distribution of hemoglobin and cytoplasm, and usually indicate glomerular disease. Red cells that are round, with evenly distributed hemoglobin, suggest disease along the epithelial lining of the urinary tract. All patients with hematuria (even with concurrent anticoagulants) require further diagnostic workup (see below); morphology, though of interest, is not of sufficient accuracy to allow firm diagnostic conclusions.

Epithelial Cells

The presence of squamous epithelial cells in the urinary sediment is indicative of contamination and thus requires a repeat collection. Transitional epithelial cells are occasionally noted in normal urinary sediment, but if present in large numbers or clumps they cause concern about possible neoplasm. Cytologic examination may be necessary to confirm the finding.

Bacteria and Yeasts

The identification of organisms in an uncontaminated specimen implies infection, which must be confirmed by culture. The presence of several organisms per high-power field usually correlates with a culture count of 10⁵ organisms per milliliter. Gram staining may further aid in characterizing the organism. Candida albicans is the most common yeast seen in the urine, and characteristic budding and clumps are typically observed. For yeast, colony count per milliliter does not necessarily correlate with the severity of infection.

Casts

Casts are formed in the distal tubules and collecting ducts as a result of Tamm–Horsfall mucoprotein precipitation (the most common excreted protein in urine). They congregate near the edges of the coverslip and are detected best in a fresh specimen viewed under low power. If the urine is devoid of cells, hyaline casts are formed (see micrograph). Casts with entrapped red cells are indicative of glomerulonephritis or vasculitis. Leukocyte casts are suggestive of pyelonephritis. Epithelial casts in small numbers are normal, but in large numbers they suggest intrinsic renal disease (see micrograph). Granular casts result from degeneration of other cellular casts and also suggest intrinsic renal disease.