S. Zaki, MD

1
Male GU Examination

• S. Zaki, MD
• Director of Continence Program
• Division of Urology
• University of Cincinnati College of Medicine
• Veterans Administration Medical Center

2
Urology

• What do Urologists do?

• They are surgeons who treat and operate on
• diseases of genitourinary organs in men
• Kidney Penis
• Ureter Urethra
• Bladder Vas deferens
• Prostate Testes

3
Urology

• What do Urologists do?

• They are surgeons who treat and operate on
• diseases of genitourinary organs in women
• Kidney
• Ureter
• Bladder
• Urethra

4
Initial Evaluation

• Urologic patient

• Begins with focused history and physical
  examination
• of pertinent genitourinary organs

5
Initial Evaluation
FEMALE
MALE
Kidneys Ureters Bladder Urinary
sphincter Prostate Urethra
6
Initial Evaluation

• Urologic patient

• Begins with focused history and physical
  examination of pertinent genitourinary organs
• Kidney Penis
• Ureter Urethra
• Bladder Vas deferens
• Prostate Testes

7
Medical History
Chief complaint (CC) History of present illness
(HPI) Past medical history (PMH) Past surgical
history (PSH) Family history (FH) Social
history (SH) Medications Allergies Review of
systems (ROS)
8
35 yo white female with history of hematuria. She
needs an intravenous pyelogram (IVP) to evaluate
the source of bleeding
CC Hematuria HPI Began 2 days ago. Has
stopped now. History of smoking x 8 years. Does
not think she is pregnant. PMH None PSH Non
e FH None SH () smoke or (-)
ETOH Medications OCP Allergies None no
reaction to IVP dye ROS Non contributory
9
45 yo male with benign prostatic hyperplasia
(BPH) has difficulty urinating
CC Difficult urination HPI Weak stream
sense of incomplete emptying, straining to
urinate AUA symptom score 30/35 most recent
PSA 2.5 ng/ml PMH Enlarged prostate
(BPH) PSH None - specifically no TURP FH (-)
Prostate cancer SH (-) smoke or drink
ETOH Medications Flomax Allergies None
ROS Non contributory
10
Generalized Physical Examination
HEENT Cor Lungs ABD Flank GU Penis Pelvic
Testicles Rectal Prostate Ext Neuro
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Generalized Physical Examination
HEENT Benign Cor RRR Lungs CTA ABD soft,
NT/ND, NABS Flank (-) CVAT GU Penis normal
phallus, adequate meatus Testicles descended
bilaterally WNL Prostate smooth and benign,
(-) nodules Ext (-) CCE Neuro No focal
neurologic deficits
12
Physical Examination

• Focused Urologic examination

• Inspection - general observation
• Palpation - gently touch and feel
• Percussion - lightly tap over a finger
• Auscultation - listen with stethescope

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Inspection
Cushings syndrome Excess cortisol
production Clinical signs Buffloe hump Truncal
obesity Moon face
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Inspection
Phimosis Inability to retract the
foreskin Paraphimosis Inability to pull down the
foreskin
Phimosis
Paraphimosis
15
Inspection
Pelvic organ prolapse Condition where one of the
pelvic organs has herniated out of the
vagina Cystocele - bladder Rectocele -
rectum Enterocele - bowel Procidentia - uterus
Pelvic organ prolapse
16
Palpation
Kidney examination
Prostate examination
Male - Bimanual examination
Female - Bimanual examination
Hernia examination
17
Kidney Examination
Method of palpation of the kidney The patient
lying supine Posterior hand tilts the kidney
upward Anterior hand feels for the kidney Have
patient take a deep breath. This causes the
kidney to descend As the patient inhales, push
the anterior hand at the costoverterbral
margin If the kidney is mobile or enlarged, it
can be felt between 2 hands
18
Kidney Examination
Kidneys Lie under the diaphragm and ribs Well
protected from injury Right kidney lower than
left due to liver Left kidney usually not
palpable Normal kidneys difficult to palpate
especially in men due to ABD muscle
tone Sometimes normal kidneys may be palpable in
thin patients and in children Palpable kidneys
are usually displaced or enlarged
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Renal Masses
Hydronephrotic kidney
Renal mass may be fluid-filled or may be solid
Solid renal tumor
20
Kidney Examination
Renal tumor Clinically asymptomatic May present
with hematuria Not palpable unless enlarged Firm,
non-tender, often immobile Pyelonephritis Infectio
n of the kidneys Patient septic (fever,
toxic) Costovertebral angle tenderness (CVAT)
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Kidney Examination
Renal abscess Infection of the kidneys Patient
septic (fever, toxic) Costovertebral angle
tenderness (CVAT) Anterior abdominal wall
tenderness Perinephric abscess Infection of the
kidneys Patient septic (fever, toxic) Costovertebr
al angle tenderness (CVAT) Anterior abdominal
wall tenderness
22
Kidney Examination
Kidney stone Complain of flank pain Renal colic -
cannot get comfortable Costovertebral angle
tenderness (CVAT) Ureteral stone Complain of
flank pain Renal colic - cannot get
comfortable Costovertebral angle tenderness
(CVAT) Referred pain to groin area Urinary
frequency and urgency
kidney
ureter
23
Prostate Examination
Method of palpation of the prostate The patient
is in left lateral decubitus position or bent
forward at the waist with feet shoulder-width
apart A well-lubricated gloved index finger is
inserted gently into the rectum Have the patient
Valsalva or bear down as you are inserting the
gloved finger Palpate the prostate in systematic
fashion right, middle, left apex to base
24
Prostate Examination
Normal prostate Normal prostate is size of a
chest nut Has consistency of nose or contracted
thenar eminence Benign prostatic hyperplasia
(BPH) BPH is enlarged prostate Has consistency of
nose or contracted hyperthenar eminence May be as
big as an orange
25
Prostate Examination
Acute prostatitis Patient appears septic (fever,
toxic appearing) Prostate is enlarged, fluctuant,
warm, and painful Do not be aggressive with
prostate exam! Chronic prostatitis May complain
of LUTS or hematospermia Prostate feels boggy and
is tender to touch May see expressed prostatic
secretions white discharge
26
Prostate Examination
Prostate cancer Clinically asymptomatic - silent
cancer One area of the prostate may feel firm,
nodular, or stony hard. Need to get PSA and
perform prostate biopsy
27
Hernia Examination
Technique of examining inguinal hernia Inguinal
hernia extrusion of bowel into the inguinal
canal Gently insert a gloved index finger into
the inguinal canal by invaginating the scrotal
skin Palpate the external inguinal ring - feels
like a small round opening Have the patient turn
his head to one side and cough Protrusion of
bowel against the index finger signifies hernia
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Bimanual Examination
Male bimanual examination Performed in a setting
of bladder tumor Insert a lubricated gloved
finger into the rectum Apply fingers of the
anterior hand on the suprapubic area Attempt to
palpate the bladder between 2 hands Is the
bladder palpable? Is it mobile or fixed? Gives
clinical information regarding local invasion and
extent of the tumor
29
Bimanual Examination
Female bimanual examination Performed in a
setting of bladder tumor Insert lubricated 2
gloved fingers into the vagina Apply fingers of
the anterior hand on the suprapubic area Attempt
to palpate the bladder between 2 hands Is the
bladder palpable? Is it mobile or fixed? Gives
clinical information regarding local invasion and
extent of the tumor
30
Bladder Examination
Technique of bladder examination Apply fingers of
the anterior hand on the suprapubic area Apply
gentle pressure to the suprapubic area Attempt to
palpate the bladder Is the bladder palpable or
not?
31
Bladder Examination
Normal bladder Normally holds 400-500 ml of urine
Is not clinically palpable Urinary
retention Bladder may hold as much as
2000-3000ml Complain of difficulty urination,
urinary dribbling, and straining to urinate
Suprapubic fullness Bladder is palpable and may
be tender to touch Bladder may be palpable up to
umbilicus
Normal bladder
Urinary retention
32
Bladder Masses
Solid bladder tumor
Urinary retention
33
Percussion
Percussion Used to assess kidneys Used to assess
bladder
34
Kidney Examination
Gentle tapping over the kidney area -
costovertebral angle - normally should elicit no
response. Presence of costovertebral angle
tenderness (CVAT) upon percussion suggests
stones infections obstruction
35
Bladder Examination
Gentle tapping over the bladder area - suprapubic
area - normally should elicit no
response. Bladder in retention sounds hollow like
a drum.
Urinary Retention sounds like a drum to
percussion
Normal Bladder sounds flat to percussion
36
Penile Examination
Inspection If the patient has not been
circumcised, the foreskin should be
retracted This may reveal a tumor or balanitis
Erythroplasia of Queyrat
Penile cancer
37
Penile Examination
Inspection If retraction is not possible as in
the case of phimosis, circumcision is indicated.
38
Penile Lesions
Paraphimosis
Penile condyloma
Reduction of Paraphimosis
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Penile Examination
Inspection The position of the meatus should be
noted Normally the meatus should be located at
the tip of the penis It may be located proximal
to the tip of the glans on either the dorsum
(epispadius) or the ventral surface (hypospadius)
40
Penile Examination
Palpation Palpation of the dorsal surface of the
shaft may reveal a fibrous plaque involving the
fascial covering of the corpora cavernosa This is
typical of Peyronies disease Tender areas of
induration felt along the urethra may signify
urethritis - inflammaiton of the urethra.
41
Penile Examination
Peyronies disease Calcified plaque on the dorsum
of penis Often associated with abnormal penile
curvature, erectile dysfunction, and pain with
intercourse
Peyronies disease calcification of tunica
albuginea
42
Testicular Examination
Technique of testicular exam The testes should be
carefully palpated with the fingers of both
hands Should look for location, size, texture,
consistency, and tenderness Normal testis has a
soft rubbery consistency with a smooth surface
43
Testicular Examination
Cryptorchid testis This means undescended
testis Testis may lie anywhere along the course
of inguinal canal - ectopic if lies outside
canal Most common site is the external inguinal
ring Retractile testis This means testis is
present but it has tendency to retract upward
into the inguinal canal due to overactive
cremasteric muscles
44
Testicular Examination
Kliefelters syndrome 47, XXY Clinical
features male phenotype gynecomastia small,
firm testes lt 3 cm in length azospermia (no
sperm production) tall and lanky
45
Testicular Examination
Hydrocele Fluid within tunica vaginalis Asymptomat
ic but may cause scrotal pain. Feels firm,
non-tender Transillumination in a dark room
helpful. Shine a flashlight behind the scrotum.
It glows red. When in doubt, obtain scrotal
ultrasound Spermatocele Epididymal cyst filled
with sperm. Glows green with transillumination.
46
Testicular Examination
Testicular cancer A firm area in the testis
proper must be regarded as a malignant tumor
unless proven otherwise Typically asymptomatic
and painless. Brought to the attention to the
patient after infection or trauma If
transillumination is performed, light will not
transmit through a solid tumor Tumors are often
smooth but may be nodular Need to obtain scrotal
ultrasound
47
Testicular Examination
Torsion Abnormal twisting of the spermatic
cord Patient in severe pain, nausea,
vomiting Testicle high riding - retracted
upward Abnormal horizontal lie Tender to
palpation May not be able to examine due to
patient distress Urologic emergency Need to
obtain scrotal US with Doppler studies
48
Epididymal Examination
Epididymis Small cap-like structure located
posterior to the testicle Should be carefully
palpated for size and induration Induration means
infection - epididymitis
Epididymis
49
Epididymal Examination
Epididymitis In acute stage of epididymitis, the
testis and epididymis are indistinguishable by
palpation The testis and epididymis may be
adherent to the scrotum The scrotal wall is
erythematous and tender
Epididymis
50
Spermatic Cord Examination
Varicocele Varicose veins of pampiniform
plexus Left side more commonly affected Present
with scrotal discomfort, heavy dragging sensation
of the scrotum esp end of the day Can cause
secondary infertility See mass of dilated
tortuous veins lying superior to and above the
testis - bag of worms Degree of dilation
accentuated by Valsalva maneuver. Feels like bag
of worms Confirmed by scrotal ultrasound
Pampiniform plexus
51
Spermatic Cord Examination
Varicocele Right sided varicocele or prominent
varicose veins around the umbilicus suggests
renal cell carcinoma
Pampiniform plexus
52
Questions
Focused Urologic examination consists
of a.) Inspection b.) Palpation c.) Percuss
ion d.) Auscultation e.) All of the above
53
Questions
Paraphimosis is a.) Inability to retract
foreskin b.) Inability to pull down the
foreskin
54
Questions
Epispadius is a condition where a.) Urethral
meatus is located on the ventral surface of the
penis b.) Urethral meatus is located on the
dorsal aspect of the penis
55
Questions
Right-sided varicocele suggests a.) Renal cell
carcinoma b.) Testicular tumor c.) Prostate
cancer d.) Epididymitis
56
Questions
Testicular torsion is a.) Benign
condition b.) Urologic emergency c.) Should be
treated non-surgically d.) Same as orchitis
57
Questions
All men presenting with Urologic complaints
require a prostate examination whereas women
require a pelvic examination A true B false
58
Questions
A 45 year-old African American male presents with
lower urinary tract obstructive voiding symptoms.
What questions should be included in your medical
history? A. history of benign prostatic
hyperplasia (BPH) B. American Urologic
Association (AUA) 7 symptom score C. family
history of prostate cancer D. prostatic
specific antigen (PSA) level E. all of the
above
59
Questions
A 35 year-old female with presents with history
of gross hematuria. You decide she needs an
intravenous pyelogram (IVP). During the
medical history you should have asked her about
A. drug allergies B. current medications
C. any possibility she could be pregnant D. any
history of reaction to contrast dyes E. all of
above