Focused Urological

Examination
DR Tarek Ahmed Siefin
Lecturer of urology, Sohag University
 Agenda

Abdominal
Male external
examination and
genital DRE.
examination of
examination.
the Back.
  The loin is the anatomical region with the
following boundaries:
 Superiorly: the lower border of the last rib
 Inferiorly: the iliac crest

Anatomical  Posteriorly: the later border of sacrospinalis

Landmarks muscle
 Anteriorly: the mid-axillary line
 The renal (costo-vertebral) angle lies
between the lower border of the last rib and
the lateral border of sacrospinalis muscle.
  The abdomen is divided into classic 9 regions by 2 horizontal and 2
sagittal planes.
 The upper horizontal one is between the lower borders of the ribs, at the
level of the first lumbar vertebra, midway between the suprasternal notch
and symphysis pubis (transpyloric).
 The lower passes through the upper borders of iliac crests.
 The sagittal planes go vertically from the mid-clavicular to the mid-inguinal
points.

Anatomical
Landmarks
Anatomical
Landmarks
  Position:
 Supine position, head supported by a pillow and knees
are slightly flexed with feet on table.

 Inspection for e.g. scars, incisional hernias, swellings

Abdominal and sinuses.

Examination  Palpation:
in Urological  - Superficial for e.g. tenderness, rigidity and
disease superficial swellings.
 - Deep: for organomegally
 Percussion for shifting dullness or any palpable
swelling.
 Auscultation for renal artery bruit.
  The urachus is a tube extending from the
superior aspect of the bladder towards the
umbilicus.
 The urachus may remain open at various points,
leading to the following abnormalities:
 Completely patent urachus: communicates
Urachal with the bladder and leaks urine through the

anomalies umbilicus; usually does not present until

adulthood
 Vesicourachal diverticulum: a diverticulum in
the dome of the bladder; usually symptomless.
 Umbilical cyst or sinus: can become infected,
forming an abscess or may chronically
discharge infected material from the umbilicus.
  The kidney is palpated while the patient is breathing
deeply.
 The left hand is placed posteriorly with the index
finger overlies the last rib.
 The tips of the other three fingers (the thumb is not
Bimanual employed) stop at the lateral border of the

palpation of
sacrospinalis muscle i.e. in the renal angle.
 The left hand only pushes anteriorly for renal
the kidney ballottement (i.e. bounced like a ball [balla = ball
(italian)], between your hands).
 The right hand is placed anteriorly starting below the
level of the umbilicus and moved towards the costal
margin.
  Site: retroperitoneal, so it is best felt at the renal
angle unless the kidney is ectopic.
 Border: always it is rounded and never sharp.
 The swelling disappears below the costal margin so
Signs that one can insinuate the hand between the
characterizin swelling and the costal margin unless the swelling is

g a renal huge.

swelling  Shape: reniform or oval.

 Movement and mobility: Up and down with
respiration (within the paranephric space). This can
be restricted or lost in pyonephrosis, infiltrating renal
tumors or recurrent cases.
 Ballottement is lost when a disease affects
the perinephric space and fat (e.g.
perinephritis, pyonephrosis, infiltrated by
renal tumor) or previous renal surgery
(adhesions). A huge renal swelling has no
space for ballottement and it is felt by both
hands at the same time which is called
renal contact.
 All renal swellings are dull on percussion.
However, a band of colonic resonance can
be detected over the swelling.
  Site: Suprapubic, arises out of the pelvis.
Characteristic  Dull to percussion.
s of an  Pressure of examining hand may cause a
enlarged desire to void.
bladder
  Hydronephrosis
 Infected hydronephrosis
Different types  Pyonephrosis
of renal  Simple renal cysts
swellings  Polycystic kidney diseases
 Renal tumors
  I- Parietal loin swellings:
 Move antero- posteriorly with respiration.
 Persist or become more prominent on abdominal wall muscles
contraction.
 May overlie the costal margin.
 II- Intra-abdominal swellings:
Differential  Liver: Right sided, sharp border, the hand cannot be insinuated
diagnosis of between the
 swelling and the costal margin and always dull on percussion.
renal  Spleen: Left sided, sharp notched border, the hand cannot be
swelling insinuated between the swelling and the costal margin, always
dull on percussion and the direction of movement is toward the
right iliac fossa.
 Colon: on right or left side, sausage shape, ill-defined borders
and resonant on percussion.
 Retroperitoneal swellings: irregular shape & surface, firm to
hard in consistency and not ballottable (fixed to the posterior
abdominal wall).
Examination
of the Back

The patient is examined while he is sitting and the two sides are
compared. There are 5 areas: the spines, 2 para-spinal muscular
regions and 2 flanks (extension of lumbar areas).
  Inspection:
 Swelling or fullness of CVA.
 Signs of inflammation.
 Scoliosis.
 Search for a dimple over the lumbo-sacral area and palpate the
sacrum in children with possible neuropathic damage.

Examinatio  Palpation: Murphey's kidney punch determines deep-seated

n of the tenderness: The thumb is placed under the 12th rib and sharp
jabbing movements are made.
Back  Percussion:
 - Resonant CVA is a good negative sign.
 - Dull CVA:
 Loaded colon.
 Renal mass.
 Peri-renal collection of fluids (Urine, blood, pus, or combination).
  The informed and consenting patient should be examined by
both hands in both standing and supine positions.
 I- Penis and urethra:
 The prepuce normally conceals the glans completely and the
preputial opening is not narrow.
 It may be abnormal in e.g. phimosis, hypospadias and

Male external epispadias.

 The external urethral (urinary) meatus normally appears as
genitalia a dry vertical slit situated at the tip of the glans with two lips
examination that can be separated apart to see inside.
 It may be abnormally e.g. stenosed, located ventrally
(hypospadias) or located dorsally (epispadias).
 The glans is normally conical in shape and flaccid with the
meatus at its tip.
 Abnormally, it may have e.g. inflammation (balanitis) and
fistula.
  The penile shaft is normally flaccid straight
(without curvature), with identifiable ventral
corpus spongiosum, smooth surface (without
induration) and no tenderness.
 The penile size is age related. The lower
Male external normal length of the stretched penis is 1.9 cm
genitalia in infants and 7 cm in adults.
examination
 Abnormally, the penis may be e.g. small sized
(micropenis), buried below the surface of the
prepubic skin (with obesity) or cerved (with
chordee).
  The scrotum
 Normally has two compartments with an apparent median
raphe in between, and corrugated pliable skin.

 Some of the scrotal lesions include e.g. scrotal sinus, bifid

Scrotum, scrotum, and different skin diseases.

testes,  The testis

epididymis and  Normally lies at the bottom of the scrotum. It has oval shape,

spermatic smooth surface, firm consistency and a characteristic

testicular sensation. The testicular size is age related with no
cords significant difference between the two testes. The testis is
covered by tunica vaginalis; which has two layers (parietal
and visceral) with minimal potential space in between.
 Abnormally, the testis may be e.g. agenetic, ectopic,
inflamed and torsed.
Scrotum, testes,
epididymis and
spermatic cords
  The epididymis
 Is a ribbon-like structure that normally lies posterior
to the testis. A laterally situated palpable sulcus
separates the testis from the epididymis.
 The epididymis has a head (behind the upper pole of
the testis), body and tail. It may be inflamed or the
site of tuberculous scrotal sinus.
Scrotum, testes,  The spermatic cord
epididymis and  Has two parts; scrotal and inguinal. The scrotal part
spermatic cords is available for palpation.
 The spermatic cord is normally soft except the cord
like vas deferens.
 Lesions that can be detected include e.g. varicocele,
thickened or beaded vas, lipoma and encysted
hydrocele of the cord.
 (A) Vaginal, (B) Infantile, (C) Congenital (D) Hydrocele of the cord.
  Inguinal hernia,
 Femoral hernia,
 Enlarged lymph nodes,
 Hydrocele of the cord (or of the canal of
Lumps in the nuck in women),
groin
 Congenital hydrocele,
 Undescended testis,
 Lipoma of the cord,
 Femoral aneurysm.
  Vaginal Hydrocele,
 Epididymal cyst,
Lumps in the  Testicular tumour,
scrotum
 Sebaceous cyst,
 Tuberculous epididymo- orchitis,
 Gumma of the testis.
Digital Rectal
Examination
  1- Positioning the patient:
 A. Dorsal position:
 Patient is semi-recumbent with flexed knees.
 Convenient to the patient and urologist.

Digital  Bimanual examination is done easily.

rectal
 B. Lithotomy position:
 To perform bimanual examination under anesthesia,
Examinatio cystoscopy and biopsy.

n  Helpful also in difficult clinical situations e.g. obesity.

 C. The knee- elbow position:
 The prostate is decongested and changes in its consistency
are easier to palpate.
 D. The left lateral (Sims's) position:
 The left leg is lower and semi-extended while the right one is
upper and flexed.
  II- Inspection for:
 Normal corrugation around the anal orifice.
Loss of corrugations is present if the external
anal sphincter is atonic. This raises the
possibility of neuropathic bladder.
Digital rectal  Perianal and perineal abscess, sinus or fistula
Examination  Discharge, prolapsed piles or rectal prolapse.
 Signs of trauma e.g. perineal urinary
extravasation and hematoma.
 Scar of previous operation (e.g. urethroplasty)
or skin disease (e.g. tinea cruris)
  III- Finger introduction:
 The hands should be gloved and the examining
index finger well lubricated.
 The bulb of the index finger is applied to the anal
verge in a light or superficial palpation manner to test
Digital rectal for any tenderness or spasm.

Examination  The pressure is increased (deep palpation) till the

anal sphincter is relaxed, then the distal phalanx is
flexed to be introduced into the anal canal.
 Proceed to introduce the middle phalanx to reach the
prostate region, then the proximal phalanx to reach
the bladder base.
  1. Anal sphincter tone:
 There is a normal degree of gripping or resistance to
the examining finger by the anal sphincter tone.
 This anal tone may be abnormally:
 Lost or decreased in lower motor neuron lesions, direct

 Findings: trauma to the sphincter and in the elderly.

 Exaggerated in uncooperative patient, upper motor
neuron lesions, painful perianal conditions.
 Reflex (the bulbocavernosus reflex): It is provoked by
squeezing the glans or by gentle controlled traction on
an indwelling catheter if the patient is catheterized.
  2. The membranous urethra:
 A stone or catheter can be felt in the midline below the
prostate.
 3. Prostate:
 A normal prostate is not tender, with smooth flat surface &
rubbery consistency and its base is easily reached. The soft
base of the bladder is felt above.
 The prostate has two lateral sulci (between the lateral
 Findings: prostatic edges and the soft rectum) and a median furrow
(bilobed).
 DRE signs of benign prostate enlargement include:
 Convexity of surface = ↑ of antero-posterior dimension.
 Exaggeration of the lateral sulci = ↑ of antero-posterior and
the transverse dimensions.
 Difficulty or failure to reach the prostate base = ↑ of cephalo-
caudal dimension.
  (NB) In prostate cancer, signs of malignancy
include nodular surface, hard consistency obliteration
of one or both lateral sulci, obliteration of the median
furrow and frozen pelvis. There is no tenderness unlike
bladder cancer.
 4. Bladder base is:
 Normally soft, with smooth surface and not tender.
 Findings:  Tender in acute bacterial cystitis, acute urine retention
and bladder cancer - indurated, firm with irregular
surface in posterior wall bladder cancer.

 5. The seminal vesicles are normally impalpable.

They may palpable with obstruction, bilharzial affection
or malignant involvement.
  6. The rectum: the examining finger is rotated around
to detect any rectal pathology e.g. rectal polyp or
 Findings: cancer.
 7. Inspection of the examining finger for blood, pus or
mucus.
 IV- Bimanual examination:
 It is an essential step of DRE
to assess the bladder
between the examining finger
(in the rectum) and the left
hand (at the supra-pubic
region).
 It helps to detect:
 Cystic bladder mass (urine)
in chronic urine
 Retention or huge bladder
diverticulum.
 Solid bladder mass (cancer)
which is usually tender. It
may be mobile or fixed.
THANK
YOU