Following the undergraduate curriculum set by the British Association of Urological Surgeons, Urology at a Glance offers practical advice on diagnosis and management of one of the most rapidly developing medical specialties.
Building on basic science, the book provides an overview of clinical approaches to assist the medical student or junior doctor on rotation, as well as looking at practical procedures and specific details of the most commonly encountered urological disorders.
Vibrantly illustrated and containing common clinical scenarios, Urology at a Glance provides all the information and latest guidelines needed for a medical student or junior doctor to excel in this field.
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Part 1 Urological history, examination and investigations
Chapters
1 Taking a urological history
2 Male genital examination
3 Female genital examination
4 Urological investigations
5 Abdominal pain
1 Taking a urological history
2 Male genital examination
The penis
Inspection
Note particularly size, shape, presence or absence of a foreskin, colour of the skin, the position and calibre of the urethral meatus, any discharge, abnormal curvature and other superficial abnormality such as erythema or ulceration, particularly at the glans (Figure 2.1).
Palpation
Note any abnormalities of the underlying tissues (e.g. firm areas). This can indicate the plaques of Peyronie’s disease. Retract the foreskin to expose the glans penis and urethral meatus. The foreskin should pull back with a smooth and painless retraction. Look especially for any secretion or discharge and collect a specimen if possible. Replace the foreskin to its normal position at the end of the examination.
Key points
Explain to the patient that you would like to examine the penis and testes and reassure them that the procedure will be quick and gentle.
You should have a chaperone present.
Ensure that the examination room is warm and that you are unlikely to be disturbed. With the patient on a bed or couch, raised to a comfortable height, ask them to pull their clothing down. You should be able to see the genitalia and lower part of the patient’s abdomen at the very least.
The scrotum and contents
Inspection
This can be carried out with the patient lying down or standing up. Examine the scrotal skin. The left testis usually hangs lower than the right. Remember to lift the scrotum, inspecting the inferior and posterior aspects. Look especially for oedema, sebaceous cysts, ulcers, scabies and scars (Figure 2.1).
Palpation
The scrotal contents should be gently supported with your left hand and palpated with the fingers and thumb of your right hand. It may help to ask the patient to hold their penis to one side. Examine the normal testis first if the patient is complaining of an abnormality in one of them.
Check that the scrotum contains two testes. Absence of one or both testes can be because of previous surgery, failure of the testis to descend or a retractile testis. If there appears to be a single testis, carefully examine the inguinal canal for evidence of a discrete swelling that could be an undescended testis.
Make careful note of any discrete lumps or swellings in the body of the testis. Any swelling in the body of the testis must be considered to be suggestive of a malignancy.
Compare the left and right testes, noting the size and consistency. The testes are normally equal in size, smooth, with a firm, rubbery consistency. If there is a significant discrepancy, ask the patient if he has ever noticed this.
Feel for the epididymis which lies at the posterolateral aspect of each testis.
Scrotal swellings
If a lump is palpable:
Decide if the lump is confined to the scrotum. Are you able to feel above it? Does it have a cough impulse? Is it fluctuant? (You will be unable to get above swellings that descend from the inguinal canal.)
Define the lump and any other mass.
Transillumination is often important here. Darken the room and shine a small torch through the posterior part of the swelling. A solid mass remains dark while a cystic mass or fluid will transilluminate. If it transilluminates, it would suggest there is a hydrocele.
Feel for any varicoceles (feels like worms in a bag): the patient should be examined in the lying and standing positions for this to see if it disappears. Varicoceles on the left side warrant a renal scan as well as a scrotal scan.
The local lymphatics
This is best performed with the patient lying comfortably on a bed or couch.
Lymph from the skin of the penis and scrotum drains to the inguinal lymph nodes.
Lymph from the covering of the testes and spermatic cord drains initially to the internal, then common, iliac nodes.
Lymph from the body of the testes drains to the para-aortic lymph nodes. These are impalpable.
The perineum and rectum
Key points in digital rectal examination (DRE)
Usually performed in the left lateral position – with the patient lying on their left side, and with the hips and knees flexed to 90° or more (if you are right handed).
Examine the anal region for fistulae and fissures.
Apply plenty of lubricating gel to the gloved finger.
Palpate the surface of the prostate. Note its consistency (normal or firm), its surface (smooth or irregular) and estimate its size.
Normal bi-lobed prostate has a groove (the median sulcus) between the two lobes. In the patient with prostate cancer, this groove can be obscured.
The prostate will be very tender if it is involved by an acute, inflammatory condition such as acute, infective prostatitis or a prostatic abscess.
Practical tips
A normal prostate is the size of a walnut, a moderately enlarged prostate that of a tangerine and a large prostate the size of an apple or orange (Figure 2.2).
DRE should be avoided in the profoundly neutropenic patient (risk of septicaemia) and in patients with an anal fissure where DRE would be very painful.
The integrity of the sacral nerves that innervate the bladder and the sacral spinal cord can be established by eliciting the bulbocavernosus reflex (BCR) during a DRE. The sensory side of the reflex is elicited by squeezing the glans of the penis. The motor side of the reflex is tested by feeling for contraction of the anus duri...
