Physical Examination of the 4 Genitourinary Tract

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  Physical Examination of the 4 Genitourinary Tract Maxwell V. Meng, MD, MPH, & Emil A. Tanagho, MD A careful history and assessment of symptoms will suggest whether a complete or limited examination is indicated, and also help direct the appropriate selection of subsequent diag- nostic studies. EXAMINATION OF THE KIDNEYS Inspection A mass that is visible in the upper abdominal area may be difficult to palpate if soft, as with hydronephrosis. Fullness in the costovertebral angle may be consistent with cancer or  perinephric infection. The presence and persistence of inden- tations in the skin from lying on wrinkled sheets suggest edema of the skin secondary to perinephric abscess. Palpation The kidneys lie rather high under the diaphragm and lower ribs and are therefore well protected from injury. Because of the position of the liver, the right kidney is lower than the left. The kidneys are difficult to palpate in men because of (1) resistance from abdominal muscle tone and (2) more fixed position than in women, moving only slightly with change of posture or respiration. The lower part of the right kidney can sometimes be felt, particularly in thin patients,  but the left kidney usually cannot be felt unless it is enlarged or displaced. The most successful method of renal palpation is carried out with the patient lying in the supine  position on a hard sur- face (Figure 4  –  1). The kidney is lifted by one hand in the costo- vertebral angle (CVA). On deep inspiration, the kidney moves downward; the other hand is pushed firmly and deeply beneath the costal margin in an effort to trap the kidney. When success- ful, the  anterior hand can palpate the size, shape, and consis- tency of the organ as it slips back into its normal position. Alternatively, the kidney may be palpated with the exam- iner standing behind the seated patient. At other times, if the patient is lying on one side, the uppermost kidney drops downward and medially, making it more accessible to palpa- tion. Perlman and Williams (1976) described an effective method of identifying renal anomalies in newborns. The fin- gers are  placed in the costovertebral angle, with the thumb anterior and performing the palpation. An enlarged renal mass suggests compensatory hypertro- phy (if the other kidney is absent or atrophic), hydronephro- sis, tumor, cyst, or polycystic disease. However, a mass in this area may also represent a retroperitoneal tumor, spleen, lesion of the bowel (eg, tumor, abscess), lesion of the gallbladder, or pancreatic cyst. Tumors may have the consistency of normal tissue or be nodular, while hydronephrosis may be either firm or soft. Polycystic kidneys are usually nodular and firm. An acutely infected kidney is tender, but the presence of marked muscle spasm may make this difficult to elicit. In addition, this sign may not always be helpful since the normal kidney is also often tender. Although renal pain may be diffusely felt in the back, ten- derness is usually well localized, just lateral to the sacrospina- lis muscle and below the 12th rib (ie, CVA). Symptoms may be elicited  by palpation or sharp percussion over the CVA. Percussion At times, an enlarged kidney cannot be felt, particularly if it is soft as in some cases of hydronephrosis. However, such masses may be outlined by both anterior and posterior  percussion and this part of the examination should not be omitted. Percussion is of particular value in outlining an enlarging mass (progressive hemorrhage) in the flank following renal trauma, when tenderness and muscle spasm prevent palpation. Transillumination Transillumination may prove helpful in children younger than 1 year who present with a suprapubic or flank mass. A dark room is required along with a flashlight with an opaque flange  protruding beyond the lens. The flashlight is applied at right angles to the abdomen. The fiberoptic light cord, used    CHAPTER 00 41 SMITH & TANAGHO’S GENERAL UROLOGY Figure 4  –  1. Method of palpation of the kidney. The posterior hand lifts the kidney upward. The anterior hand feels for the kidney. The patient then takes a deep breath; this causes the kidney to descend. As the patient inhales, the fingers of the anterior hand are plunged inward at the costal margin. If the kidney is mobile or enlarged, it can be felt between the two hands. to illuminate various optical instruments, is an excellent source of cold light. A distended bladder or cystic mass will transilluminate; a solid mass will not. Flank masses may be assessed by applying the light posteriorly. Differentiation of Renal and Radicular Pain Radicular pain is commonly felt in the costovertebral and subcostal areas. It may also spread along the course of the ureter and is the most common cause of so- called “kidney pain.” Every  patient who complains of flank pain should be examined for evidence of nerve root irritation. Frequent causes are poor posture (scoliosis, kyphosis), arthritic changes in the costovertebral or costotransverse joints, impingement of a rib spur on a subcostal nerve, hypertrophy of costovertebral ligaments pressing on a nerve, and interver- tebral disk disease (Smith and Raney, 1976). Radicular pain may be noted as an aftermath of a flank incision where a rib is dislocated, causing impingement of costal nerve on the edge of a ligament. Pain experienced during the  preeruptive phase of herpes zoster involving any of the segments between T11 and L2 may simulate pain of renal srcin. Radiculitis usually causes hyperesthesia of the area of skin served by the irritated peripheral nerve. This hypersensitivity can be elicited by means of the pinwheel or grasping and pinching  both skin and fat of the abdomen and flanks. Pressure exerted by the thumb over the costovertebral joints reveals local tenderness at the point of emergence of the involved nerve. Auscultation Auscultation of the costovertebral areas and upper abdomi- nal quadrants may reveal a systolic  bruit, often associated with stenosis or aneurysm of the renal artery. Bruits over the femoral arteries may be found in association with Leriche syndrome, which may be a cause of impotence. EXAMINATION OF THE BLADDER  The bladder cannot be felt unless it is moderately distended. In adults, it contains at least 150 mL of urine if it can be per- cussed. In acute or chronic urinary retention, the bladder may reach or even rise above the umbilicus, when its outline may be seen and usually felt. In chronic retention, the blad- der may be difficult to palpate due to the flabby bladder wall, in which case  percussion is of value. In male infants or young boys, palpation of a hard mass deep in the center of the pelvis is compatible with a thick- ened, hypertrophied bladder secondary to obstruction caused by  posterior urethral valves. A sliding inguinal hernia containing some bladder wall can be diagnosed by compression of the scrotal mass when the bladder is full, leading to additional distension. A few instances have been reported where marked edema of the legs has developed secondary to compression of the iliac vessels by a distended bladder. Bimanual (abdomino- rectal or abdominovaginal) palpation may reveal the extent of a vesical tumor; to be successful, it should  be done under anesthesia. EXAMINATION OF THE EXTERNAL MALE GENITALIA Penis A. Inspection If the patient has not been circumcised, the foreskin should be retracted. This may reveal tumor or balanitis as the cause of foul discharge. If retraction is not possible due to phimosis, surgical correction (dorsal slit or circumcision) is indicated. The observation of a poor urinary stream is significant: in newborns, neurogenic bladder or the  presence of posterior urethral valves should be considered, whereas in men such a finding suggests urethral stricture or prostatic obstruction. The scars of healed syphilis may be an important clue. An active ulcer requires bacteriologic or  pathologic study (eg, syphilitic chancre, epithelioma). Superficial ulcers or vesicles are compatible with herpes simplex and often interpreted by the patient as a serious sexually transmitted disease (eg, syph- ilis). Venereal warts may be observed. Meatal stenosis is a common cause of bloody spotting in male infants. On occasion, it may be of such degree as to cause advanced bilateral hydronephrosis. The position of the meatus should be noted. It may be located proximal to the tip of the glans on either the dorsal (epispadias) or the ventral surface (hypospadias). In either instance, there is apt to be abnormal curvature (chordee) of the penis in the direction of the displaced meatus.
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