Signs and Symptoms InvesAgaAons
Urological History- Pain. Pain from inflamma+on = constant. Pain from obstruc+on = fluctua+ng ExaminaAon: General physical examina+on: JACCOL (jaundice, anaem
intensity lymphedema/lymphadenopathy), cachexia
Renal pain may be confused with abdominal pain: Peritoni+s: pt lies mo+onless; Renal colic: on and Specific examina+on of: kidneys (probably will not feel tumour unless
off pain; pa+ent rolls around in agony able to palpate filled bladder with abdo examina+on even if can perc
Back pain may be altered by a change in posture (palpate prostate, pick up low rectal tumour) +/- vaginal exam
Hamaturia Urine ExaminaAon: importance of dips+ck urinalysis; 10 different tes
More than 2 RBC per hpf (high power field). Frank or microscopic: should never be ignored Glucose, Sp. Gravity, pH, nitrites, ketones, bilirubin, urobilinogen (Tes
Microscopic; may be completely asymptoma+c; if see blood in urine (macroscopic), more likely to - Glycosuria can be picked up by dips+ck; can pick up DM by urine
have serious pathology. Where in the urinary stream? Ini+al/ total/ terminal - Some infec+ons produce nitrites; also see protein – RBC/WBC/ni
Associated with pain?Are there any clots? half way to diagnosis.
Lower Urinary Tract Symptoms - RBC alone does not indicate infec+on
Obstruc+ve symptoms: hesitancy, poor flow (do you ever pee with a good flow? Everyone will - GPs olen refer pt to OP when only RBC with microscopic haema
experience poor flow at some point), terminal dribbling not have an infxn; should not be given an+bio+cs); when take an
Irrita+ve symptoms: frequency, urgency, urge incon+nence vagina – get fungal infec+on; given further an+bio+cs/an+fungal
Nocturnal frequency = mul+factorial; common with prostate disease and with age Careful collec+on of specimen to avoid contamina+on; Urine culture,
Other important symptoms: sensi+vi+es; 24 hour collec+ons
Haematospermia: blood-stained semen Blood InvesAgaAons
Ohenumoturia: passage of flatus per urethram (passing wind from front) Baseline (basic blood tests): CBC, U&Es, LFTs (check metabolic func+o
Urethral discharge: venereal disease; urethral carcinoma crea+nine, etc
Other important symptoms: Specific:
Rigors, fevers and chills – ?caused by an underlying UTI - may be asymptoma+c. - Stone; calcium, uric acid, etc
Cloudy urine may be caused by UTI, alkaline pH with phosphate crystal precipita+on, or - Prostate (prostate cancer?): PSA (PSA for prostate cancer is most
rarely by chyluria (lympha+c leak) - Testes (tes+cular cancer?) tumour markers: AFP, HCG, LDH
Sexual DysfuncAon: Loss of desire/ arousal; Erec+le problems – absent, weak or short- Ultrasound ExaminaAons
las+ng; Ejacula+on problems – premature, absent, delayed; Psychological factors. Advantages: Non-invasive, quick, cost effec+ve
Good assessment of kidneys (hydronephrosis, two kidneys, stones [w
Urological History: Pain
system = obstruc+on), bladder (full or empty/ filling defect – tumour
Prosta+c pain may be referred to perineum, testes, groin, pain si[ng down whether tumour of testes, US = treatment of choice), prostate (canno
Tes+cular pain can be primary or referred. Primary: trauma, torsion, hydrocele, varicocoele but transrectal US of prostate can mirror what we have already seen
infec+on. Referred: from kidney, ureter, retroperitoneum, indirect inguinal hernia solid from cys+c lesions: US is very good at determining between soli
Ureteric pain: mid-ureter can mimic appendici+s or diver+culi+s. Lower ureter gives bladder Plain Abdominal X-rays: KUB X-ray
irritability, +p of penis CT scan now much easier and more accurate thus overtaking X-rays;
Bladder pain: Bladder distension (Acute reten+on); Inflamma+on (cys++s). not used for repeated inves+ga+ons and instead do plain x-rays.
NB: chronic reten+on of urine is usually painless Radio-opaque stones: calcium like bone, thus white
NB: chronic suprapubic pain is not usually coming from bladder, and may have other causes Radio-lucent stone: contains uric acid and no calcium - not seen on p
Urinary InconAnence: Con+nuous incon+nence due to fistula uretero/vesico-vaginal or IVP: contrast given to show up whole PC system
ectopic ureter; Genuine stress incon+nence (GSI) due to sphincter weakness Intravenous urogram (IVU): Used to be Gold standard (now CT); Gold
Urge incon+nence due to detrusor instability. Overflow incon+nence due to bladder ou^low tract. Gives informa+on re: anatomy and func+on.
obstruc+on/ atonic bladder IVU series: plain film, nephrogram, plus films at 5+10 mins and the po
US: Basic characteris+c of sound is its wavelength. The frequency of sound waves are IVU: Contrast excreted by kidneys; can see both anatomy and func+o
measured in cycles per sec (Hertz); Sound of greater frequency of 20Hz is referred to as US. Endoscopy of the urinary tract:
Cystoscopy (rigid, flexible thus done under GA/LA)
Frequency inversely propor+onal to wavelength i.e. the higher the frequency the shorter the
- Diagnos+c cystoscopy usually uses LA (more so in female as urethra
wavelength. Low frequency US (3 – 4.5 MegaHz) waves have greater ability to penetrate require GA)
+ssues but produce picture with less resolu+on, i.e. suitable for abdo scans. Higher Pyelography: if want to look above the bladder and outline the tract
frequency US(7.5 – 10 megaHz) have clearer images but lack penetrance i.e. suitable for - Retrograde pyelography; look from below; contrast from below u
scrotum/ prostate ureter
Obstructed and Infected Kidney: Urological emergency; Risk of permanent kidney damage; - Anterograde pyelography: need to outline from above; e.g. if hav
Requires early relief of obstruc+on; The use of an antegrade nephrostomy or cystoscopic from above downwards
placement of stent Ureterorenoscopy: rigid, flexible – can look and treat around corner
Urethral CatheterizaAon: To collect urine specimen; assess degree of reten+on; to exclude around corners); can look into the kidney
urethral stricture; as permanent indwelling drainage; as intermifent self-catheterisa+on Urethrogram: clamp head of penis and inject contrast.
MicturaAng cysto-urethrogram: done in children who may have reflu
CT scanning: thin x-ray beam rotates around an area of the body gen
structures; detail of tumour; can use solware to make CT reconstruc
Prostate Specific AnAgen (PSA) Radionuclear studies:
Raised PSA doesn’t necessarily mean prostate cancer. PSA: lower specificity, high sensi+vity. Best 1) Renography;
tumour marker for prostate cancer. Released by prostate cells thus is by all men (amount varies a. DTPA: dynamic scanning - Info re: func+on, assesses degree of o
dep on size). Single chain glycoprotein. Organ-specific; only produced by prosta+c epithelial cells. b. DMSA: sta+c scanning- Info re: func+onal anatomy of the kidne
A PSA concentra+on is found in both benign and malignant condi+ons 2) PET sta+c scanning: Can pick up tumour in whole of body by ligh+n
What can affect PSA? Inflamma+on; Infec+on, catheter, biopsy ar+fact (3-6 weeks to return to radio-labelled fructose
baseline PSA); if insert needle into prostate, PSA levels increase. Age-specific reference ranges: Isotope bone scan: to look for metastasis
prostate gets larger with age; thus PSA increases with age. PET Scan/ CT scan: can pick up areas of cancer in areas which you ma
PSA density: size of the prostate; big prostate will produce more PSA Urodynamic
PSA velocity (Ca >0.75ng/ml/year): rate of change of PSA over +me; most olen used; Uroflowmetry: measure force of flow; weak/strong flow
Free and bound PSA (<% free in cancer): free-total ra+o- more PSA in bound than unbound state Prostate Biopsy: Prostate biopsy is done to help confirm a diagnosis p
when have cancer. <10%, the lower the ra+o, the higher the risk of cancer. Free: Bound HIGH = (usually). Trasrectal ultrasound of the prostate helps determine whic
benign; Free: Bound LOW = cancer Urodynamic studies: The micturi+on cycle has storage and voiding ph
PSA and staging of prostate cancer: Correla+on of PSA and tumour volume; PSA <20 unlikely to dysfunc+on of lower urinary tract during storage & voiding phases of
have bone mets. Monitor response to Rx; PSA good at monitoring disease – can pick up early Other Radiological ExaminaAons: CT scan/ MRI; Mictura+ng cystogra
recurrence if asymptoma+c but failed to respond to Rx. Good prognosis (<4ng/ml at 6 months) studies
History
Urological History- Pain. Pain from inflamma+on = constant. Pain from obstruc+on = fluctua+ng ExaminaAon: General physical examina+on: JACCOL (jaundice, anaem
intensity lymphedema/lymphadenopathy), cachexia
Renal pain may be confused with abdominal pain: Peritoni+s: pt lies mo+onless; Renal colic: on and Specific examina+on of: kidneys (probably will not feel tumour unless
off pain; pa+ent rolls around in agony able to palpate filled bladder with abdo examina+on even if can perc
Back pain may be altered by a change in posture (palpate prostate, pick up low rectal tumour) +/- vaginal exam
Hamaturia Urine ExaminaAon: importance of dips+ck urinalysis; 10 different tes
More than 2 RBC per hpf (high power field). Frank or microscopic: should never be ignored Glucose, Sp. Gravity, pH, nitrites, ketones, bilirubin, urobilinogen (Tes
Microscopic; may be completely asymptoma+c; if see blood in urine (macroscopic), more likely to - Glycosuria can be picked up by dips+ck; can pick up DM by urine
have serious pathology. Where in the urinary stream? Ini+al/ total/ terminal - Some infec+ons produce nitrites; also see protein – RBC/WBC/ni
Associated with pain?Are there any clots? half way to diagnosis.
Lower Urinary Tract Symptoms - RBC alone does not indicate infec+on
Obstruc+ve symptoms: hesitancy, poor flow (do you ever pee with a good flow? Everyone will - GPs olen refer pt to OP when only RBC with microscopic haema
experience poor flow at some point), terminal dribbling not have an infxn; should not be given an+bio+cs); when take an
Irrita+ve symptoms: frequency, urgency, urge incon+nence vagina – get fungal infec+on; given further an+bio+cs/an+fungal
Nocturnal frequency = mul+factorial; common with prostate disease and with age Careful collec+on of specimen to avoid contamina+on; Urine culture,
Other important symptoms: sensi+vi+es; 24 hour collec+ons
Haematospermia: blood-stained semen Blood InvesAgaAons
Ohenumoturia: passage of flatus per urethram (passing wind from front) Baseline (basic blood tests): CBC, U&Es, LFTs (check metabolic func+o
Urethral discharge: venereal disease; urethral carcinoma crea+nine, etc
Other important symptoms: Specific:
Rigors, fevers and chills – ?caused by an underlying UTI - may be asymptoma+c. - Stone; calcium, uric acid, etc
Cloudy urine may be caused by UTI, alkaline pH with phosphate crystal precipita+on, or - Prostate (prostate cancer?): PSA (PSA for prostate cancer is most
rarely by chyluria (lympha+c leak) - Testes (tes+cular cancer?) tumour markers: AFP, HCG, LDH
Sexual DysfuncAon: Loss of desire/ arousal; Erec+le problems – absent, weak or short- Ultrasound ExaminaAons
las+ng; Ejacula+on problems – premature, absent, delayed; Psychological factors. Advantages: Non-invasive, quick, cost effec+ve
Good assessment of kidneys (hydronephrosis, two kidneys, stones [w
Urological History: Pain
system = obstruc+on), bladder (full or empty/ filling defect – tumour
Prosta+c pain may be referred to perineum, testes, groin, pain si[ng down whether tumour of testes, US = treatment of choice), prostate (canno
Tes+cular pain can be primary or referred. Primary: trauma, torsion, hydrocele, varicocoele but transrectal US of prostate can mirror what we have already seen
infec+on. Referred: from kidney, ureter, retroperitoneum, indirect inguinal hernia solid from cys+c lesions: US is very good at determining between soli
Ureteric pain: mid-ureter can mimic appendici+s or diver+culi+s. Lower ureter gives bladder Plain Abdominal X-rays: KUB X-ray
irritability, +p of penis CT scan now much easier and more accurate thus overtaking X-rays;
Bladder pain: Bladder distension (Acute reten+on); Inflamma+on (cys++s). not used for repeated inves+ga+ons and instead do plain x-rays.
NB: chronic reten+on of urine is usually painless Radio-opaque stones: calcium like bone, thus white
NB: chronic suprapubic pain is not usually coming from bladder, and may have other causes Radio-lucent stone: contains uric acid and no calcium - not seen on p
Urinary InconAnence: Con+nuous incon+nence due to fistula uretero/vesico-vaginal or IVP: contrast given to show up whole PC system
ectopic ureter; Genuine stress incon+nence (GSI) due to sphincter weakness Intravenous urogram (IVU): Used to be Gold standard (now CT); Gold
Urge incon+nence due to detrusor instability. Overflow incon+nence due to bladder ou^low tract. Gives informa+on re: anatomy and func+on.
obstruc+on/ atonic bladder IVU series: plain film, nephrogram, plus films at 5+10 mins and the po
US: Basic characteris+c of sound is its wavelength. The frequency of sound waves are IVU: Contrast excreted by kidneys; can see both anatomy and func+o
measured in cycles per sec (Hertz); Sound of greater frequency of 20Hz is referred to as US. Endoscopy of the urinary tract:
Cystoscopy (rigid, flexible thus done under GA/LA)
Frequency inversely propor+onal to wavelength i.e. the higher the frequency the shorter the
- Diagnos+c cystoscopy usually uses LA (more so in female as urethra
wavelength. Low frequency US (3 – 4.5 MegaHz) waves have greater ability to penetrate require GA)
+ssues but produce picture with less resolu+on, i.e. suitable for abdo scans. Higher Pyelography: if want to look above the bladder and outline the tract
frequency US(7.5 – 10 megaHz) have clearer images but lack penetrance i.e. suitable for - Retrograde pyelography; look from below; contrast from below u
scrotum/ prostate ureter
Obstructed and Infected Kidney: Urological emergency; Risk of permanent kidney damage; - Anterograde pyelography: need to outline from above; e.g. if hav
Requires early relief of obstruc+on; The use of an antegrade nephrostomy or cystoscopic from above downwards
placement of stent Ureterorenoscopy: rigid, flexible – can look and treat around corner
Urethral CatheterizaAon: To collect urine specimen; assess degree of reten+on; to exclude around corners); can look into the kidney
urethral stricture; as permanent indwelling drainage; as intermifent self-catheterisa+on Urethrogram: clamp head of penis and inject contrast.
MicturaAng cysto-urethrogram: done in children who may have reflu
CT scanning: thin x-ray beam rotates around an area of the body gen
structures; detail of tumour; can use solware to make CT reconstruc
Prostate Specific AnAgen (PSA) Radionuclear studies:
Raised PSA doesn’t necessarily mean prostate cancer. PSA: lower specificity, high sensi+vity. Best 1) Renography;
tumour marker for prostate cancer. Released by prostate cells thus is by all men (amount varies a. DTPA: dynamic scanning - Info re: func+on, assesses degree of o
dep on size). Single chain glycoprotein. Organ-specific; only produced by prosta+c epithelial cells. b. DMSA: sta+c scanning- Info re: func+onal anatomy of the kidne
A PSA concentra+on is found in both benign and malignant condi+ons 2) PET sta+c scanning: Can pick up tumour in whole of body by ligh+n
What can affect PSA? Inflamma+on; Infec+on, catheter, biopsy ar+fact (3-6 weeks to return to radio-labelled fructose
baseline PSA); if insert needle into prostate, PSA levels increase. Age-specific reference ranges: Isotope bone scan: to look for metastasis
prostate gets larger with age; thus PSA increases with age. PET Scan/ CT scan: can pick up areas of cancer in areas which you ma
PSA density: size of the prostate; big prostate will produce more PSA Urodynamic
PSA velocity (Ca >0.75ng/ml/year): rate of change of PSA over +me; most olen used; Uroflowmetry: measure force of flow; weak/strong flow
Free and bound PSA (<% free in cancer): free-total ra+o- more PSA in bound than unbound state Prostate Biopsy: Prostate biopsy is done to help confirm a diagnosis p
when have cancer. <10%, the lower the ra+o, the higher the risk of cancer. Free: Bound HIGH = (usually). Trasrectal ultrasound of the prostate helps determine whic
benign; Free: Bound LOW = cancer Urodynamic studies: The micturi+on cycle has storage and voiding ph
PSA and staging of prostate cancer: Correla+on of PSA and tumour volume; PSA <20 unlikely to dysfunc+on of lower urinary tract during storage & voiding phases of
have bone mets. Monitor response to Rx; PSA good at monitoring disease – can pick up early Other Radiological ExaminaAons: CT scan/ MRI; Mictura+ng cystogra
recurrence if asymptoma+c but failed to respond to Rx. Good prognosis (<4ng/ml at 6 months) studies
History
