ABC of Urology

Chris Dawson, Janine Nethercliffe

• Publisher: BMJ Books
• Year: 2012
• ISBN:
  9781118274514
• Edition: 3
• Topic: Medicina
• Subtopic: Urología

The ABC of Urology provides a comprehensive review of current practice in urology and is a structured and practical guide to the diagnosis, treatment and management of the most common urological conditions. This new third edition has been fully revised and expanded with additional chapters and improved coverage of renal and testis cancer, management of haematuria, laparoscopy, trauma and new urological advances. Prostate, bladder, renal and penile cancers are also covered in detail and new techniques and procedures for safer and effective treatment options are featured.

The ABC of Urology is the ideal reference for general practitioners and general practitioner trainees, junior doctors and practice nurses, medical students and all primary health care professionals working to provide the best possible care for patients with urological conditions.

Chapter 1

Assessment of the Urological Patient

Deborah Skennerton

Overview

• A careful history and examination is required to elicit the correct symptoms and signs
• The majority of the urinary system is not amenable to clinical examination and further investigations are normally required

Assessment of the urological patient starts with a careful history of the presenting complaint and where appropriate assessment of the impact of these symptoms on quality of life. Clinical examination and appropriate investigation help to make a diagnosis.

Urological symptoms

• Pain
• Haematuria
• Storage LUTS
• Voiding LUTS
• Urinary incontinence
• Sexual dysfunction

Pain

Genitourinary tract pain is usually associated with obstruction or inflammation. Tumours rarely cause pain unless causing obstruction or invading surrounding nerves.

Renal Pain

Renal pain is located in the costovertebral angle and may radiate anteriorly across the abdomen to the groin and genitalia. It is caused by distension of the renal capsule due to obstruction or inflammation. Pain is typically colicky in obstruction as ureteric peristalsis increases renal pelvic pressure, but steady in inflammation. Musculoskeletal disorders affecting T10–12 may also cause pain in the renal area but the pain is positional.

Bladder Pain

Bladder pain is caused by overdistension due to acute retention or inflammatory conditions. Slowly progressive obstruction causing chronic retention is painless despite residuals of over 1 litre. Inflammatory conditions of the bladder cause intermittent suprapubic pain, typically worse when the bladder is full. Cystitis can also cause sharp, suprapubic pain at the end of micturition or, in men, penile tip pain, termed strangury. Strangury is also seen in renal colic as a stone traverses the intramural part of the ureter.

Prostatic Pain

Prostatic pain is due to inflammation causing distension of the prostate capsule. It is poorly localised to the lower abdomen, perineum or rectum, and frequently associated with irritative voiding symptoms.

Testicular Pain

Testicular pain may be due to scrotal pathology or referred pain. Inflammatory conditions of the scrotal contents or torsion cause acute pain. Chronic pain is usually due to non-inflammatory conditions such as varicocele or hydrocele. However, renal colic can also cause pain referred to the scrotum.

Haematuria

Haematuria may be painful or painless, visible or non-visible (found on urine dipstick or microscopy). Visible haematuria increases the likelihood of finding underlying pathology.

Causes of haematuria

• Infection/inflammation
• Malignancy
• Stones
• Benign prostatic enlargement
• Trauma

Consumption of beetroot can also result in discoloured urine so haematuria should be confirmed by microscopy.

Lower Urinary Tract Symptoms (LUTS)

Storage symptoms

• Frequency
• Nocturia
• Urgency +/- incontinence
• Dysuria

Adults normally void up to 7 times a day. Voiding once a night may be considered normal. Urinary frequency is either due to a reduced bladder capacity or due to excess urine production. Completing a 3-day bladder diary will enable objective assessment of bladder capacity and frequency. Urge incontinence is particularly bothersome as it often results in large volume urine loss and is exacerbated by reduced mobility in the elderly population. Frequency may also be due to infection.

Voiding symptoms

• Hesitancy
• Slow flow
• Intermittent flow
• Straining

Patients reliably describe needing to wait before voiding (hesitancy) or straining to achieve urine flow. They are often unaware of a decrease in their urine flow until severely restricted such that the flow no longer shoots forward but trickles down towards their toes. A sensation of incomplete bladder emptying correlates poorly with measurements of residual volume.

Incontinence

Careful questioning will usually determine the circumstances of urine loss. Patients' response to urine loss will depend on their fastidiousness but may be influenced by race and culture. Men will often dribble a small amount of urine from the meatus after voiding—post-micturition dribble. This can be eased by ‘milking’ the urethra. An idea of volume loss will be gained by enquiring about the number of incontinence pads used.

Types of urinary incontinence

• Stress
• Urge
• Continuous
• Overflow

Stress incontinence results from increasing intra-abdominal pressure above urethral resistance. Urine loss is in small amounts and may affect both sexes but is more common in women with a weak pelvic floor following childbirth. Urge incontinence results in larger volume loss and needs to be distinguished from stress leakage as it may indicate underlying bladder pathology. Continuous urine leakage in women is seen in vesicovaginal fistulae. Overflow incontinence is seen with a chronically distended bladder. Urine leakage usually occurs at night resulting in bed-wetting.

Sexual Dysfunction

Patients often find discussing their sexual dysfunction difficult due to embarrassment but also because they lack the language to explain their symptoms. The presence of early morning erections or erection with masturbation rules out organic impotence. Retrograde ejaculation is common after prostate surgery and with the use of alpha-blockers for LUTS. Premature ejaculation is subjective and usually psychogenic.

Symptoms of sexual dysfunction

• Erectile dysfunction
• Loss of libido
• Disorders of ejaculation
• Penile curvature

Examination

Although it is tempting to skip examination in favour of radiological investigation, along with a careful history, examination is a key component in diagnostic evaluation.

Abdomen

Much of the renal tract lies deep to the examining hand and abnormalities will only be detected on imaging. However, in a thin patient it may be possible to see a grossly distended bladder although in obese patients this may be difficult to detect even with percussion.

External Genitalia

The penis and scrotum lie easily accessible between the thighs. The foreskin should be retracted to examine the glans and meatus. The meatus should be gently parted to ensure there is no stenosis. Palpation of the penile shaft will reveal any Peyronie's plaques, typically found dorsally.

Scrotal examination should be carried out gently when an inflammatory condition or torsion is suspected. Each testis and epididymis should be examined for tenderness or masses. A firm or hard area in a testis should be considered a malignant tumour until proven otherwise. Masses in the epididymis are almost always benign.

Vaginal Examination

With the patient's legs abducted, the introitus should be inspected for atrophic changes or inflammatory lesions, which may cause dysuria. The patient should be asked to perform ...