Chapter 1: Evaluation of the urologic patient: History, physical examination, laboratory tests, imaging, and hematuria workup Flashcards
Table 1.1
What are the 8 main components of the International Prostate Symptom Score (IPSS)?
- Incomplete Emptying
- Frequency
- Intermittency
- Urgency
- Weak Stream
- Straining
- Nocturia
- Quality of Life due to Urinary Symptoms
Table 1.1
What are the columns of the IPSS in terms of quantity?
Not at all
< 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always
Table 1.1
How is nocturia graded on the IPSS?
None
1
2
3
4
=>5
Table 1.1
How is quality of life graded on the IPSS?
Delighted
Pleased
Mostly satisfied
Mixed-about equally satisfied and dissatisfied
Mostly dissatisfied
Unhappy
Terrible
Table 1.1
What is the question for Incomplete Emptying?
Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?
Table 1.1
What is the question for Frequency?
Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?
Table 1.1
What is the question for Intermittency?
Over the past month, how often have you found you stopped and started again several times when you urinated?
Table 1.1
What is the question for Urgency?
Over the past month, how often have you found it difficult to postpone urination?
Table 1.1
What is the question for Weak Stream?
Over the past month, how often have you had a weak urinary stream?
Table 1.1
What is the question for Straining?
Over the past month, how often have you had to push or strain to begin urination?
Table 1.1
What is the question for nocturia?
Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?
Table 1.1
What is the question for quality of life?
If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?
Memorize the 7 symptoms by creating a mnemonic sentence:
Incomplete Emptying (I)
Frequency (F)
Intermittency (I)
Urgency (U)
Weak Stream (W)
Straining (S)
Nocturia (N)
“I Feel It’s Urgent With Some Nocturnal trips.”
For the symptom frequency categories, remember the sequence 0-5:
Not at all (0)
Less than 1 time in 5 (1)
Less than half the time (2)
About half the time (3)
More than half the time (4)
Almost always (5)
For Nocturia, remember the sequence 0-5 with an additional category “None”:
None (0)
1 time (1)
2 times (2)
3 times (3)
4 times (4)
≥5 times (5)
For the quality of life due to urinary symptoms, memorize the 7 categories:
Delighted (0)
Pleased (1)
Mostly satisfied (2)
Mixed (3)
Mostly dissatisfied (4)
Unhappy (5)
Terrible (6)
Decreased libido
“Hippo Has Low Libido”
Antihypertensives: H
Hydrochlorothiazide: H
Erectile dysfunction
Mnemonic: “Pandas Prefer Ben’s Dysfunction”
Psychotropic drugs: P
Propranolol: P
Benzodiazepines: B
Ejaculatory dysfunction
Mnemonic: “Alligator Ponders Time Machine, Phenomenal Ants”
α-Adrenergic antagonists: A
Prazosin: P
Tamsulosin: T
α-Methyldopa: M
Psychotropic drugs: P
Phenothiazines: Ph
Antidepressants: A
Priapism
Mnemonic: “Aphrodite Has Thunderous Permanent Happiness”
Antipsychotics: A
Phenothiazines: Ph
Antidepressants: A
Trazodone: T
Antihypertensives: A
Hydralazine: H
Prazosin: P
Decreased spermatogenesis
Mnemonic: “Cats And Dogs Make Noisy Parties”
Chemotherapeutic agents: C
Alkylating agents: A
Drugs with abuse potential: D
Marijuana: M
Alcohol: A
Nicotine: N
Drugs affecting endocrine function: D
Antiandrogens: A
Prostaglandins: P
Incontinence or impaired voiding
Mnemonic: “Dancing Hippos Visit Overflowing Sinks”
Direct smooth muscle stimulants: D
Histamine: H
Vasopressin: V
Others: O
Furosemide: F
Valproic acid: V
Smooth muscle relaxants: S
Diazepam: D
Striated muscle relaxants: S
Baclofen: B
Urinary retention or obstructive voiding symptoms
Mnemonic: “An Odd Dolphin Flies, Catching Noisy Clouds, Laughing Alpha Llamas Dance”
Anticholinergic agents or musculotropic relaxants: A
Oxybutynin: O
Diazepam: D
Flavoxate: F
Calcium channel blockers: C
Nifedipine: N
Antiparkinsonian drugs: A
Carbidopa: C
Levodopa: L
α-Adrenergic agonists: α
Pseudoephedrine: P
Phenylephrine: Ph
Antihistamines: A
Loratadine: L
Diphenhydramine: D
Acute renal failure
“A Penguin Climbs An Amphitheater, Crying Out Near Pharaohs”
Antimicrobials: A
Aminoglycosides: A
Penicillins: P
Cephalosporins: C
Amphotericin: A
Chemotherapeutic drugs: C
Cisplatin: C
Others: O
Nonsteroidal anti-inflammatory drugs: N
Phenytoin: P
Gynecomastia
Mnemonic: “A Vivacious Camel Dances, Giggling Crows Mock Pheasants, Tricycles Aim Inward”
Antihypertensives: A
Verapamil: V
Cardiac drugs: C
Digoxin: D
Gastrointestinal drugs: G
Cimetidine: C
Metoclopramide: M
Psychotropic drugs: P
Phenothiazines: Ph
Tricyclic antidepressants: T
Amitriptyline: A
Imipramine: I
FIG. 1.1 Bimanual examination of the kidney.
FIG. 1.2 Examination of the inguinal canal.
Colorless: VOD
Imagine a glass of clear water.
(Very dilute urine, Overhydration)
Cloudy/milky: PPC
Picture a glass of milk.
(Phosphaturia, Pyuria, Chyluria)
Red: HHAAPP
Visualize a glass of red wine.
(Hematuria, Hemoglobinuria/myoglobinuria, Anthocyanin, Chronic lead and mercury poisoning, Phenolphthalein, Phenothiazines)
Orange: DPS
Think of a glass of orange juice.
(Dehydration, Phenazopyridine, Sulfasalazine)
Yellow: NRP
Envision a glass of lemonade.
(Normal, Phenacetin, Riboflavin)
Green-blue: BIAAMMMPRT
Imagine a glass of green smoothie.
Biliverdin, Indicanuria, Amitriptyline, Indigo carmine, Methylene blue, Phenols, Resorcinol, Triamterene
Brown: UPAACFMN
Picture a glass of iced coffee.
(Urobilinogen, Porphyria, Aloe, Chloroquine and primaquine, Furazolidone, Metronidazole, Nitrofurantoin)
Brown-black: AHMTCCMMMS
Visualize a glass of dark soda.
(Alcaptonuria, Hemorrhage, Melanin, Tyrosinosis, Cascara, Methocarbamol, Methyldopa, Sorbitol)
Glomerular Disorders in Patients With Glomerular Hematuria
DISORDER PATIENTS
IgA nephropathy (Berger disease)
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FIG. 1.3 KUB demonstrating residual stone fragments (arrows) adjacent to a right ureteral stent 1 week after right extracorporeal shock wave lithotripsy.
FIG. 1.4 (A) Right retrograde pyelogram performed using an 8-Fr cone-tipped ureteral catheter and dilute contrast material. The ureter and intrarenal collecting system are normal. (B) Left retrograde pyelogram using an 8-Fr cone-tipped ureteral catheter. A filling defect in the left distal ureter (arrow) is a low-grade transitional cell carcinoma. The ureter demonstrates dilation, elongation, and tortuosity, the hallmarks of chronic obstruction.
FIG. 1.5 Loopogram in a patient with epispadius/exstrophy and ileal conduit urinary diversion. (A) Plain film prior to contrast administration. (B) After contrast administration via a catheter placed in the ileal conduit, free reflux of both ureterointestinal anastomoses is demonstrated. (C) A postdrain radiograph demonstrates persistent dilation of the proximal loop indicating mechanical obstruction of the conduit (arrows).
FIG. 1.6 Normal retrograde urethrogram demonstrating (A) the balloon technique for retrograde urethrography, (B) Brodney clamp (arrowhead) technique; note the bulbar urethral stricture (arrow), and (C) normal structures of the male urethra.
FIG. 1.7 A voiding cystourethrogram performed for the evaluation of recurrent urinary tract infection in this female patient. (A) An oblique film during voiding demonstrates thickening of the midureteral profile (arrows). (B) After interruption of voiding, a ureteral diverticulum is clearly visible extending posteriorly and to the left of the midline (arrows).
FIG. 1.8 (A) Technetium 99m-mercaptoacetyltriglycine ( 99mTc-MAG3) perfusion images demonstrate normal, prompt, symmetric blood flow to both kidneys. (B) Perfusion time-activity curves demonstrating essentially symmetric flow to both kidneys. Note the rising curve typical of 99mTc-MAG3 flow studies. Dynamic function images demonstrate good uptake of tracer by both kidneys and prompt visualization of the collecting systems. This renogram demonstrates prompt peaking of activity in both kidneys. The downslope represents prompt drainage of activity from the kidneys. Printout of quantitative data shows the differential renal function to be 47% on the left, 53% on the right. The normal half-life for drainage is less than 20 minutes when 99mTc-MAG3 is used. The half-life is 5 minutes on the left and 7 minutes on the right, consistent with both kidneys being unobstructed.
FIG. 1.9 Normal Technetium 99m-mercaptoacetyltriglycine ( 99mTc-MAG3) renogram of a patient with history of hydronephrosis being evaluated for obstruction. In the upper portion of the figure, a series of 2-second–per–frame flow images demonstrate the movement of radiotracer from the site of injection, to the heart, aorta/renal arteries, and kidneys. A corresponding time-activity curve is shown. The white curve reflects activity in the aorta, and the purple and teal curves reflect radiotracer activity in the kidneys. Note the sharp upstroke of all three lines and that activity in the aorta precedes activity in the kidneys by several seconds. In the lower half of the figure, a series of 2-minute–per–frame images depicts radiotracer activity within the kidneys as it transitions bilaterally into the collecting systems and then drains down the ureters. In the corresponding time-activity curve, activity within the kidneys peaks at approximately 3 to 4 minutes and then washes out, reaching half-peak approximately 6 to 9 minutes later. The split function of the kidneys is within normal limits, measuring 46% on the left and 54% on the right (red rectangle). No evidence of obstruction is present, and no furosemide is administered.
FIG. 1.10 99mTc-MAG3 renogram of a patient with right-sided renal obstruction. (A) In the 2-second–per–frame flow images at the top of the panel, the left kidney appears much better perfused than the right kidney. This is borne out in the time-activity curve in the upper half of the panel in which the teal curve representing the left kidney has a significantly sharper upstroke relative to the purple curve of the right kidney. The white curve of the aorta is irregular and unreliable because of the abnormal course of the aorta caused by the patient’s scoliosis. In the bottom half of the panel, the 2-minute–per–frame images demonstrate normal transit of radiotracer through the left kidney parenchyma and into the collecting system, with drainage to the bladder. This is shown by the teal curve of the left kidney on the time-activity curve. The right kidney, which appears smaller and has a central photopenic area corresponding to a dilated renal pelvis, demonstrates increasing uptake throughout the study with very slow transit into the collecting system. This is shown by the purple curve of the right kidney in the time-activity curve. A markedly abnormal split function is present, measuring 79% on the left and 21% on the right (red rectangle). (B) Given the obstructive pattern of the right kidney, 40 mg of intravenous furosemide was administered. The 1-minute–per–frame images in the upper portion of the panel demonstrate no significant clearing of radiotracer from the left renal collecting system after furosemide administration. This is also seen in the time-activity curve, where the teal curve representing the left kidney is nearly horizontal. The lack of response to furosemide is diagnostic of an obstructed collecting system.
FIG. 1.11 In this simplified schematic diagram of ultrasound imaging, the ultrasound wave is produced by a pulse generator controlled by a master clock. The reflected waves received by the transducer are analyzed for amplitude and transit time within the body. The scan converter produces the familiar picture seen on the monitor. The actual image is a series of vertical lines that are continuously refreshed to produce the familiar real-time, gray-scale image.
FIG. 1.12 Midsagittal plane of the kidney. Note the relative hypoechogenicity of the renal pyramids (P) compared with the cortex (C). The central band of echoes (B) is hyperechoic compared with the cortex. The midsagittal plane will have the greatest length measurement pole to pole. A perfectly sagittal plane will result in a horizontal long axis of the kidney.
FIG. 1.13 (A) Transverse view of the bladder (BL) in this female patient demonstrates the uterus (U). (B) Sagittal view of the bladder shows the uterus posterior to the bladder.
FIG. 1.14 Demonstration of normal bilateral intratesticular blood flow by color Doppler.
FIG. 1.15 (A) In the transverse plane scanning from the dorsal surface of the midshaft of the penis, the corpora cavernosa (CC) are paired structures seen dorsally, whereas the corpus spongiosum (CS) is seen ventrally in the midline. A calcification (Ca ++) is seen between the two CC with posterior shadowing. (B) In the parasagittal plane, the CC is dorsal with the relatively hypoechoic CS seen ventrally. Within the CC, the cavernosal artery is shown with a Ca ++ in the wall of the artery and posterior shadowing.
FIG. 1.16 Normal transperineal ultrasound of the female pelvis in the midsagittal plane. The anterior compartment comprises the bladder (BL) and urethra, apical compartment comprises the vagina and uterus (UT), posterior compartment is the rectum. Source: (Image courtesy Lewis Chan, MD.)
FIG. 1.17 Computed tomography (CT) of the abdomen and pelvis demonstrating normal genitourinary anatomy. (A) The adrenal glands are indicated with arrows. The upper pole of the right and left kidneys is indicated with rk and lk, respectively. a, Aorta; li, liver; p, pancreas; s, spleen; v, inferior vena cava. (B) Scan through the upper pole of the kidneys. The left adrenal gland is indicated with an arrow. a, Aorta; c, colon; d, duodenum; li, liver; lk, left kidney; p, pancreas; rk, right kidney; v, inferior vena cava. (C) Scan through the hilum of the kidneys. The main renal veins are indicated with solid arrows, and the right main renal artery is indicated with an open arrow. a, Aorta; c, colon; d, duodenum; li, liver; lk, left kidney; p, pancreas; rk, right kidney; v, inferior vena cava. (D) Scan through the hilum of the kidneys slightly caudal to C. The left main renal vein is indicated with a solid straight arrow, and the left main renal artery is indicated with an open arrow. The hepatic flexure of the colon is indicated with a curved arrow. a, Aorta; c, colon; d, duodenum; li, liver; lk, left kidney; p, pancreas; rk, right kidney; v, inferior vena cava. (E) Scan through the mid to lower polar region of the kidneys. a, Aorta; ac, ascending colon; d, duodenum; dc, descending colon; lk, left kidney; p, pancreas; rk, right kidney; rp, renal pelvis; v, inferior vena cava. (F) CT scan obtained below the kidneys reveals filling of the upper ureters (arrows). The wall of the normal ureter is usually paper thin or not visible on CT. a, Aorta; ac, ascending colon; dc, descending colon; v, inferior vena cava. (G) Contrast filling of the midureters (arrows) on a scan obtained at the level of the iliac crest and below the aortic bifurcation. ac, Ascending colon; dc, descending colon; la, left common iliac artery; ra, right common iliac artery; v, inferior vena cava. (H) The distal ureters (arrows) course medial to the iliac vessels on a scan obtained below the promontory of the sacrum. b, Urinary bladder; la, left external iliac artery; lv, left external iliac vein; ra, right external iliac artery; rv, right external iliac vein. (I) Scan through the roof of the acetabulum reveals distal ureters (solid arrows) near the ureterovesical junction. The bladder (b) is filled with urine and partially opacified with contrast material. The normal seminal vesicle (open arrows) usually has a paired bow-tie structure with slightly lobulated contour. a, Right external iliac artery; r, rectum; v, right external iliac vein. (J) Scan at the level of the pubic symphysis (open arrow) reveals the prostate gland (solid arrow). a, Right external iliac artery; m, obturator internus muscle; r, rectum; v, right external iliac vein.
FIG. 1.18 Computed tomography of the abdomen and pelvis in patient with an obstructing ureteral stone at the level of the ureterovesicle junction. (A) Level of the left upper pole. Mild renal enlargement, caliectasis, and perinephric stranding are apparent. (B) Level of the left renal hilum. Left pyelectasis with a dependent stone, mild peripelvic and perinephric stranding, and a retroaortic left renal vein. (C) Level of the left lower pole. Left caliectasis, proximal ureterectasis, and mild periureteral stranding are present. (D) Level of the aortic bifurcation. The dilated left ureter (arrow) has lower attenuation than do nearby vessels. (E) Level of the upper portion of the sacrum. A dilated left ureter (arrow) crosses anteromedial to the common iliac artery. (F) Level of the midsacrum. A dilated left ureter (arrow) is accompanied by periureteral stranding. (G) Level of the top of the acetabulum showing a dilated pelvic portion of the left ureter (arrow). (H) Level of the ureterovesical junction. The impacted stone with a “cuff” or “tissue rim” sign that represents the edematous wall of the ureter. Source: (Reprinted from Talner LB, O’Reilly PH, Wasserman NF. Specific causes of obstruction. In: Pollack HM, et al., eds: Clinical urography, 2nd ed. Philadelphia: Saunders, 2000.)
FIG. 1.19 A 50-year-old man with a left side pheochromocytoma and select images from a 1.5T magnetic resonance imaging. (A) Heavily weighted T2 single-shot fast spin echo with an isointense signal (not bright). (B) Moderately weighted T2 fat-suppressed fast recovery fast spin echo with hyperintense signal (bright). (C) T1-weighted precontrast images. (D) T1-weighted postcontrast images with marked early enhancement.
