CHAPTER 1  Evaluation of the Urologic Patient 9

Table 1.2  Drugs Associated With Urologic Side Effects—cont’d

PHYSICAL EXAMINATION

Vital Signs

Obtain temperature, heart rate, blood pressure, respiratory rate, and pain rating.

General Appearance

Note level of pain or distress, nutritional status, appearance and self-care, frailty, mobility. Look for stigmata associated with certain disease states.

Kidneys

The kidneys are located in the retroperitoneum and surrounded by the psoas and oblique muscles, peritoneum, and diaphragm. For adults, place the nonexamining hand posteriorly at the costovertebral angle and palpate the kidney with the examining hand through the anterior abdominal wall (Fig. 1.1). Kidneys are typically difficult to palpate and not visible on examination (unless large mass or very thin patient). Assess pain at kidney via percussion by contacting the patient with the closed hand of the examiner at the CVA. Be gentle; a simple tap should elicit a positive sign if present.

10 CHAPTER 1  Evaluation of the Urologic Patient

FIG. 1.1  ​Bimanual examination of the kidney.

Bladder

To examine the bladder, palpate and percuss starting at level of pubic symphysis and ascend toward umbilicus to determine the level of distension. The bladder is palpable when it distends to level above the pubis (,150 cc). The bladder may be visualized when distended at ,500 cc in thin patients. Additionally, A bimanual exam may be performed to assess mobility of the bladder as well as cancer staging.

Penis

Inspect the skin for hair distribution, lesions, presence/absence of foreskin (in adults, retract foreskin to evaluate glans), and Tanner stage. Evaluate the urethral meatus (location, stenosis, presence of urethral discharge). Palpate for any subcutaneous plaques or curvature. Remember to reduce the foreskin at the end of the examination.

Scrotum and Contents

Inspect the scrotal skin for hair distribution, lesions, and infection. Be sure to evaluate the entire scrotum toward the perineum, especially in those with limited mobility or poor self care. Palpate the testicles for size, orientation, pain, or masses. Evaluate for hydrocele, varicocele (patient supine, standing, standing with Valsalva). Palpate the vas deferens. Check for an inguinal hernia by sliding

CHAPTER 1  Evaluation of the Urologic Patient 11

Internal inguinal ring

Internal canal

External inguinal ring

FIG. 1.2  Examination of the inguinal canal. (From Swartz MH. Textbook of physical diagnosis. Philadelphia: Saunders, 1989:376.)

the index finger over testis and invaginating the scrotum up to- ward external ring (Fig. 1.2).

Digital Rectal Examination (DRE)

The DRE is used to assess prostate size and perform screening for prostate cancer. For positioning, the patient should bend 90 degrees at the waist while supporting hand or elbows on the table. Lateral decubitus position with legs flexed at hips is another alternative. The examiner’s gloved finger with adequate lubrication then is ad- vanced until the prostate is palpable. A normal prostate is smooth and somewhat soft, whereas nodular firmness is concerning and may warrant biopsy. A bimanual examination (DRE with concurrent