this is for non-commercial usage by Russian-speakers only ! if you are not a Russian-speaker delete this file immediately ! AaHHbIN cKaH NPeAHOSHAYEH AMUIb ANA: 1. pyccknx nonbsosatenen- Bpaven H yueHbIX, B OCOGeHHOCTH 2. cBoGoAHOTO, HEKOMMEPYECKOTO 1 BECIVIATHOLO pacnpoctpaneniia MYCAH] ot ¢porT.py < not for ealet > < uo zn nponmunt 1 >< ceay m emane-noweepcun KYCAIU of dpowrpy > I. Patient Evaluation 1. PHYSICAL EXAMINATION Kenneth W. Angermeier, M.D. L. Are the kidneys palpable in a normal patient? ‘The right kidney may be palpable in children and thin adults. The left kidney is difficult to palpate, as it lies higher within the retroperitoneum than the right kidney. Examination is best per- formed bimanually, with one hand behind the patient in the costovertebral angle and the other an- teriorly just below the costal margin, With ins the Kidney may be felt as it moves down- ward. In neonates, examination is performed by palpating the flank between the thumb anteriorly and the remaining fingers posteriorly in the costovertebral angle. Both kidneys can be outlined re- liably in this fashion. 2. What is the significance of an abdominal bruit? Although not a specific finding, auscultation of a bruit in the epigastrium or upper abdomen may suggest the presence of renal artery stenosis in the appropriate clinical setting. ‘This finding is particularly indicative when the bruit is continuous (systolic-diastolic). A bruit may vary in in- tensity with fluctuation of the systemic blood pressure, or disappear if renal artery stenosis pro- _gresses (0 near or total ocelusion. An abdominal bruit may also occur in association with @ renal artery aneurysm or arteriovenous malformation. 3. Where is renal pain usually localized on examination? Renal pain due to inflammation or obstruction may result in vague, diffuse back discomfort. ‘A renal source often can be identified by the finding of localized tenderness in the costovertebral angle, just lateral to the sacrospinalis muscle and inferior to the twelfth rib. This is usually best clicited by percussion of the area with the fist. 4, At what filling volume can the adult bladder be detected on physical examination? In the adult, « normal bladder cannot be palpated or percussed until there is a urine volume of at least 150 ml. For the most part, percussion is superior to palpation when a patient is evalu- ated for bladder distention, Patients with frank urinary retention may have visible bladder disten- tion that may extend to the level of the umbilicus. 5. When is examination of the bladder under anesthesia important? Bimanual examination under anesthesia is useful in assessing the local extent of carcinoma of the bladder and its mobility. In the female, this is done by compressing the bladder between ‘one hand on the abdomen and the other in the vagina. Male patients are exainined with a hand on the abdomen and a finger in the rectum. 6. What is paraphimosis? Paraphimosis is @ condition that may arise when the foreskin of the penis has been retracted beyond the corona of the glans and is not subsequently reduced. This can lead to constriction of the glans penis, resulting in pain, edema, and possible vascular compromise. Failure to reduce the foreskin after inscrtion of a urethral catheter is one situation in which paraphimosis may occur.< not for satel >< se in npomame 1 >< CHa x ReKARO-ROKERCHR NUCH OF GpOuE.PY > 2 Physical Examination Paruphimosis is a urologic emergency that requires immediate dorsal slit or circumcision if the foreskin cannot be manually reduced. 7, What disease process is characterized by a palpable sear or “plaque” along the shaft of the penis? Peyronie's disease is a condition in which a fibrotic scar develops within the tunica albug- {nea of the corpora cavernosa, and may result in curvature of the erect penis. The scar most com- monly involves the dorsal aspect of the penis, elthough it can extend laterally or occur on the ven- trum in some cases. Calcification is present in approximately 30% of patients and indicates that the scat is mature. 8 Describe the physical findings in hypospadias. Hypospadias occurs as a result of incomplete fusion of the urethral plate during embryo- genesis. The urethral meatus is abnormally located and may be present along the ventral shaft ‘of the penis, scrotum, or perineum, The foreskin is usually incomplete ventrally, being described as “hooded.” Dysgenetic tissue along the urethral plate may result in ventral penile curvature (chordee), 9. What is the appearance of genital herpes? Genital herpes is characterized by superficial vesicles grouped on an erythematous base. The lesions are often painful and may coalesce. The incubation period is 2-7 days. The majority of patients with genital herpes have herpes simplex virus type I 10. What is priapism? Priapism is a prolonged, painful erection, often of several hours’ duration. Physical exami- nation reveals rigid corpora cavernosa that may be somewhat tender, The glans penis is usually flaccid. This condition is often seen in patients with sickle cell anemia, but may also be idiopathic. Priapism may occur in patients on a pharmacologic erection program. Emergent treatment is in- dicated, as prolonged priapism may result in intracorporal fibrosis and impotence, 11, When should a rectal examination be performed in the male? Digital rectal examination should be performed annually beginning at age 40, or in any male presenting for urologic evaluation. It should include an estimation of anal sphincter tone, palpa- tion of the prostate and rectum, and testing of the stool for occult blood. 12, Compare the findings on rectal examination in benign prostatic hyperplasia (BPH) and prostatic carcinoma. In BPH, the prostate is variably enlarged and has a rubbery consistency. The enlargement is usually symmetric and may be associated with deepening of the lateral sulci and obliteration of the median furrow. Prostatic carcinoma may be palpable as a discrete, firm, or hard nodule within ‘one prostatic lobe. This can progress to firm induration of an entire lobe or diffuse involvement of the prostate. The presence of extracapsular extension of seminal vesicle involvement should be noted. Prostatic carcinoma can also be present in a patient with a benign rectal examination, With the diagnosis usually being made because of an elevated prostate-specific antigen level or following transurethral resection of the prostate. 13. What condition is suggested by the presence of a soft, cystic mass palpable in the mid- line near the base of the prostate? ‘This finding may indicate the presence of a miillerian duct cyst or an enlarged utricle. ‘These entities arise from remnants of the fetal miillerian system, which regresses in the male during normal development, An enlarged utricle is occasionally seen in patients with proximal hypospadias.< not for gale! > < we nam opomame 1 > < cRaK » Texano-roKBepCHA MYCHILI OF gpouE.tY > Physical Examination 3 14. What is the significance of a palpable testicular mass? The majority of solid testicular masses represent malignant germ cell tumors. It is important to ascertain on physical examination whether the mass is located within the testicle or is arising from the spermatic cord or epididymis. Extratesticular masses are more often benign, although malignancies may occur in these locations as well. 15. Deseribe the characteristics of a hydrocele and a spermatocele. Ahydrocele is a collection of fiuid within the scrotum that is contained by the parietal and visceral components of the tunica vaginalis. I is palpable as a relatively smooth fluid collection filling the hemiscroturs and surrounding the testicle. The hydrovele may be tense or somewhat fluctuant. The testicle may be difficult to patpate in the presence of hydrocele. A spermatocele is a cystic fluid collection primarily involving the epididymis, and it may be tense or firm on pal- pation. The diagnosis of both of these entities is confirmed by transillumination using a bright light in a dark room. A hydrocele or spermatocele should completely transilluminate, whereas a solid mass will not. 16. What is a varicocele? A varicocele occurs as a result of enlargement of the spermatic vein (pampiniform plexus) above the testicle, more commonly on the left side. The enlarged, tortuous veins are palpable as a “bag of worms” within the superior aspect of the involved hemiscroturs. Typically, the veins fill and enlarge with the patient in the upright position or with the Valsalva maneuver, and de- compress with recumbency. The ipsilateral testicle may be smaller in size than the opposite one, and in some patients, a varicocele is associated with infertility. 17. What is the significance of a varicocele that does not decompress with the patient in the supine position? Pationts with a varicocele that does not decompress with recumbency should be suspected of having obstruction of the spermatic vein where it enters the renal vein on the left, of the inferior vera cava on the right, This may be caused by a retroperitoneal neoplasm, such as renal cell car- cinoma with tumor thrombus in the renal vein or inferior vena cava. Acute onset of a varicocele (ora right-sided varicocele shoutd raise similar suspicions. BIBLIOGRAPHY 1. Brendler CB: Evaluation of the urologic patient: History, physical examination, and urinalysis. In Walsh PC, Retik AB, Vaugtan ED Jr., Wein AJ (eds): Campbell's Urology, 7th ed. Philadelphia, W.B. Saun- ders. 1998, pp 138-144. 2. ‘Tanagho EA; Physical examination of the genitourinary tract. In Tanagho EA, MeAninch JW (eds) ‘Smith's General Urology, Mth ed. Norwalk, CT, Appleton & Lange, 1995, pp 41-49.