Urological History Taking and Examination

Despite the increasingly widespread use of imaging of the urinary tract, a thorough history and examination is essential in the assessment of all patients presenting with urological symptoms. The presentation must be assessed in the context of the age, gender, and the past medical, surgical and obstetric history of the patient. Urinary symptoms may not be indicative of urological abnormality but be due to other causes such as frequency of micturition in anxiety or urinary symptoms caused by neurological disease.

The nature and severity of symptoms can be best assessed by direct questions, e.g. the number of times the patient gets up at night to pass urine. Presenting symptoms may include:

• Lower urinary tract symptoms in men and in women:
  • Abnormalities of micturition, e.g. urinary obstruction, which in men is most often due to prostatism (see also Benign Prostatic Hypertrophy and Prostate Cancer) and leads to hesitancy, reduced strength of urine flow and terminal dribbling.
  • Symptoms of prostatism can be assessed by using the International Prostate Symptom Score (IPSS), but this does not give an indication of the degree of prostate size or nature of underlying pathology. Complete obstruction may lead to complete inability to pass urine or to overflow incontinence.
• Loin pain; urinary calculi can cause ureteric obstruction and lead to severe loin pain which radiates to the symphysis pubis or testis. The sudden onset of pain in renal colic or acute urinary retention contrasts with the gradual build up of pain from a renal tumour or the slow development of urine symptoms from outflow obstruction. Ask about associated features such as pain, haematuria or incontinence.
• Urinary incontinence; may be stress incontinence, detrusor instability, detrusor underactivity or urethral obstruction.
• Urethral discharge may occur as a result of a sexually transmitted disease.
• Systemic symptoms of acute renal failure or chronic renal failure, e.g. anorexia, vomiting, fatigue, pruritus and peripheral oedema.
• Recent onset of back pain in an elderly patient may be indicative of prostate cancer with bone metastases.
• Some patients have no symptoms but abnormalities are discovered on measuring blood pressure or abnormalities on routine urinalysis, renal function or serum biochemistry.

Occupational history

• Exposure to chemical carcinogens such as 2-naphthylamine or benzidine in the chemical or rubber industries may induce bladder cancer many years later.

Foreign travel

• Travel to Egypt or Africa may result in exposure to schistosomiasis.
• Dehydration during a holiday in a hot climate may lead to the development of renal stones.

Family history

• A family history of renal failure or polycystic kidney disease may be relevant to the underlying problem.

Past medical history

• Neurological diseases may cause abnormal bladder function, e.g. Parkinson's disease, multiple sclerosis or cerebrovascular disease.
• Any history of renal disease, hypertension, diabetes, gout or past back injury may also be relevant. Abdominal or pelvic surgery can cause denervation injury to the bladder.
• Previous surgery, e.g. for urinary incontinence in women or prostatic hypertrophy in men.
• Ureteric injury may occur in abdominal or gynaecological operations.

Medication history

• A full current and past medication history is important.
• Past history of analgesic abuse may be cause of renal failure.
• Dosages of some drugs may need to be adjusted or stopped in renal failure.

Obstetric history

• Stretching of the pelvic muscles during pregnancy can cause stress incontinence.
• Problems with vaginal delivery or a forceps delivery may damage the perineum causing urine symptoms.

General examination

• Is the patient distressed due to pain or do they appear unwell suggesting systemic illness and possibly renal failure?
• Look for evidence of anaemia.
• All patients with urological symptoms must have their blood pressure measured.
• Signs of dehydration such as a dry mouth and tongue may indicate renal failure or polyuria associated with diabetes.
• Lymphadenopathy; lymph nodes may be enlarged due to metastatic spread from any urological cancer.

Abdominal examination

• Abdomen may be distended due to large polycystic kidneys or ascites due to nephritic syndrome or nephrotic syndrome. Palpate for an enlarged bladder or an abdominal aortic aneurysm.
• The kidneys are examined by bimanual examination with a hand posteriorly lifting up the kidney towards the examining abdominally placed hand.
• Tenderness over the kidney should be tested by gentle pressure over the renal angle.
• Palpation for renal enlargement or masses. An enlarged kidney usually bulges forwards. In polycystic kidney disease, there may also be hepatomegaly from hepatic cysts.
• Percussion for the presence of ascites (shifting dullness) and for an enlarged bladder.
• Auscultation for a renal bruit in renal artery stenosis (heard above umbilicus, 2cm to left or right of the midline and also in both flanks with the patient sitting up).

Scrotum and genitalia

• Examine the foreskin to exclude a phimosis and signs of hypospadias.
• The testes should be equal in size, smooth and relatively firm.
• Absence of a testis may indicate previous excision, undescended or retractile.
• Small firm testes suggest hypogonadism or testicular atrophy.
• With the patient standing, if it is not possible to define the upper border of a mass in the scrotum then it is likely to be an inguinal hernia.
• Palpate the spermatic cord while the patient coughs for an impulse in a varicocele.
• If it is possible to define the upper border then the next step is to decide whether it is separate from or part of the testis.
• Testing for translucency with a torch will determine whether the mass is cystic or a solid mass. Likely diagnoses are:
  • Attached to the testis:
    • Solid (non-translucent): testicular tumour
    • Cystic (translucent): hydrocele
  • Separate from the testis:
    • Solid (non-translucent): epididymal cyst
    • Cystic (translucent): chronic epididymitis

Rectal examination

• Is performed to palpate the prostate gland and identify any malignant changes in the gland.
• A hard lump in either or both lobes suggests a cancer and a biopsy is needed to obtain histological proof.
• Bimanual pelvic examination may be indicated in women.

Neurological examination

• Dermatome sensory loss of the perineum or lower limbs and lower limb motor dysfunction suggest possible spinal cord or root pathology.
• Trauma or compression of the spinal cord may cause urinary retention if acute or urgency of micturition if a more chronic process.
• Acute compression of either the spinal cord or cauda equina may cause bladder and bowel dysfunction and are both neurosurgical emergencies, requiring urgent treatment to prevent irreversible neurological damage.