Evaluation of the Urologic Patient

Question 1

What are the necessary components of a complete Urologic history?

Answer 1

1. Chief complaint
2. History of present illness
3. Patients past medical history
4. Family history

Question 2

How can GU tract pain manifest?

Answer 2

1. Obstruction - severe pain
2. Inflammation of parenchyma of GU organ - severe pain (pyelo, prostatitis, epididymitis)
3. Tumors - painless unless interfering with an adjacent structure

Question 3

What is the ethology of renal pain?

Answer 3

Pain usually caused by distension of the renal capsule secondary to inflammation or obstruction.

Question 4

How do you differentiate renal inflammatory pain from renal obstructive pain?

Answer 4

Renal inflammatory pain is constant whereas renal obstructive pain is colicky (worsens with ureteral peristalsis)

Question 5

If a patient complains of scrotal pain but has a normal scrotal pain an no other etiological explanation what should you consider?

Answer 5

Renal or retroperitoneal diseases.

Question 6

Why is renal pain associated with GI symptoms?

Answer 6

Reflex stimulation of the celiac ganglion and proximity of adjacent organs (liver, pancreas, duodenum, gallbladder and colon)

Question 7

How do you differentiate renal pain from T10-T12 intercostal neuropathy?

Answer 7

Neuropathic pain is constant and may change with position whereas renal pain is colicky if obstruction and accompanied by signs of infection if pyelo

Question 8

Describe the different pain characteristics secondary to proximal, mid and distal ureteric obstruction?

Answer 8

1. Proximal ureter - renal pain
2. Midureter - corresponding lower quadrant (can mimic appendicitis, or diverticulitis)
3. Distal ureter - irritative LUTS, SP discomfort and dysuria to the tip of the penis.

Question 9

Describe the mechanism of ureteric pain?

Answer 9

Acute distension of the ureter and peristalsis against obstruction

Question 10

What are causes of bladder pain?

Answer 10

Over-distension secondary to acute retention or inflammation (intermittent SP discomfort). Constant SP pain unrelated to urinary retention is seldom or urologic origin.

Question 11

What is strangury?

Answer 11

Sharp stabbing suprapubic pain at the end of micturition.

Question 12

How do patients describe prostatic pain and what causes it?

Answer 12

Non-specifically - low abdomen, inguinal, perineal, or rectal pain +/- LUTS. Usually caused by inflammation of prostate and secondary edema and distension of the prostatic capsule.

Question 13

How can penile pain be subdivided and what causes pain in each grouping?

Answer 13

Flaccid penis - bladder, urethral infection, paraphimosis

Erect penis - peyronies disease, priapism

Question 14

How can you subdivide testicular pain and what are diagnoses within each category?

Answer 14

Acute and chronic

Acute - torsion, epididymitis, scrotal infections (fourniers, abscesses etc.)

Chronic - non-inflammatory conditions : hydrocele, varicocele, - dull achey pain with heavy sensation

Question 15

What history should be taken regarding gross hematuria (5 things)?

Answer 15

1. Timing of hematuria:
   - initial (urethral source)
   - total (bladder or upper tract)
   - terminal (prostate or bladder neck)
2. Association with pain - no pain = malignancy, pain = obstruction/inflammation (stones, upper tract bleeding with clots)
3. Presence of clots - if yes = more severe bleeding
4. Shape of clots - wormlike with renal colic think clot colic
5. Symptomatic from anemia secondary to bleeding

Question 16

What are the two causes of urinary frequency?

Answer 16

Increased urine output, or decreased bladder capacity.

Question 17

What is the ddx of increased urine output?

Answer 17

DM, DI, increased fluid intake

Question 18

What is the ddx of a decreased bladder capacity?

Answer 18

Either a squeezing problem or an outflow problem

1. BOO with decreased compliance
2. increased residual urine
3. decreased functional capacity secondary to irritation
4. neurogenic bladder with increased sensitivity
5. external compression

Question 19

If a patient has increased nocturia with normal frequency what should you think about?

Answer 19

CHF, peripheral edema, where urine volume increases when patient is supine (nocturnal polyuria)

Question 20

Why does post-void dribbling occur?

Answer 20

Residual urine in the prostatic or bulbar urethra after voiding is normally milked back into the bladder but instead leaks out when there is obstruction.

Question 21

In men with irritative LUTS what should you consider on the ddx?

Answer 21

1. BPH related secondary LUTS
2. CIS (bladder CA)
3. Neurologic disease (parkinson’s, CVA’s DM)

Question 22

What tool is most widely regarded for assessing men with LUTS?

Answer 22

The IPSS

AUA symptom index also used

Question 23

What are the questions on the I-PSS? How is each question scored? and what do the total scores mean?

Answer 23

1. Incomplete emptying, frequency, intermittency, urgency, weak stream, straining, nocturia, QOL
2. 1-5 (Not at all to almost always - likert scale)
3. 0-7 = mild symptoms, 8-19 = moderate symptoms, 20-35 = severe symptoms

Question 24

What are the four categories of urinary incontinence?

Answer 24

1. Continuous

ddx - fistula (VVF), ectopic ureter in F (in M always enter proximal to external urethral sphincter)

Question 25

Define stress incontinence and how is it best managed?

Answer 25

SUI is the sudden leakage of urine with exercises that increase intraabdominal pressure (coughing, sneezing, standing etc.) These are best managed surgically

Question 26

Define urge incontinence?

Answer 26

Leakage of urine preceded by a strong urge to void

Question 27

Define and describe overflow urinary incontinence?

Answer 27

This incontinence is related to a chronically distended bladder that when too full causes some leakage of urine in dribbles - more commonly at night.

Question 28

Define enuresis?

Answer 28

Urinary incontinence that occurs during sleep. Normal up to the age of 7.

Question 29

Define loss of libido?

Answer 29

Decreased interest in sexual activity

Question 30

Define impotence?

Answer 30

Inability to achieve and maintain an erection satisfactory for intercourse

Question 31

What are four causes of failure to ejaculate?

Answer 31

1. Androgen deficiency
2. Sympathetic denervation
3. Pharmacologic agents
4. Bladder neck and prostatic surgery