24 CHAPTER 1 Preliminary investigation
Abdominal examination in urological disease
Because of their retroperitoneal (kidneys, ureters) or pelvic location (bladder and prostate) normal urologic organs are relatively inaccessible to the examining hand when compared with, for example, the spleen or liver. For the same reason, for the kidneys and bladder to be palpable typically implies a fairly advanced disease state in the adult.
It is important that the urologist appreciates the characteristics of other intra-abdominal organs when involved with disease, so that they may be distinguished from urologic organs.
Characteristics and causes of an enlarged kidney
The mass lies in a paracolic gutter, it moves with respiration, is dull to percussion, and can be felt bimanually. It can also be balloted (i.e., bounced, like a ball [balla = “ball” in Italian]) between the hands, one placed on the anterior abdominal wall and one on the posterior abdominal wall.
Common causes of an enlarged kidney
Causes include tumors (renal carcinoma, angiomyolipoma, sarcoma, nephroblastoma), hydronephrosis, pyonephrosis, perinephric abscess, and polycystic disease.
Characteristics and causes of an enlarged liver
The mass descends from underneath the right costal margin; one cannot get above it. It moves with respiration, is dull to percussion, and has a sharp or rounded edge. The surface may be smooth or irregular.
Causes of an enlarged liver
These include infection, congestion (heart failure, hepatic vein obstruc- tion—Budd–Chiari syndrome), cellular infiltration (amyloid), cellular proliferation, space-occupying lesion (polycystic disease, metastatic infiltration, primary hepatic cancer, hydatid cyst, abscess), and cirrhosis.
Characteristics and causes of an enlarged spleen
The mass appears from underneath the costal margin, enlarges toward the right iliac fossa, is firm and smooth, and may have a palpable notch. It is not possible to get above the spleen, it moves with respiration, is dull to percussion, and cannot be felt bimanually.
Causes of an enlarged spleen
These include infections (bacterial, viral infection, protozoal, spirochete); hematological disease; cellular proliferation (leukemias); congestion (portal hypertension due to cirrhosis, portal vein thrombosis, hepatic vein obstruction, congestive heart failure); cellular infiltration; and space-occu- pying lesions (cysts, lymphoma, polycystic disease).
ABDOMINAL EXAMINATION IN UROLOGICAL DISEASE 25
Characteristics of an enlarged bladder
The bladder arises out of the pelvis and is dull to percussion. Pressure of the examining hand may cause a desire to void. In infants and young children it is easier to palpate.
Abdominal distension: causes and characteristics
•Fetus/gravid uterus—very smooth, firm mass, dull to percussion, arising out of the pelvis
•Flatus—hyperresonant (there may be visible peristalsis if the accumulation of flatus is due to bowel obstruction)
•Feces—palpable in the flanks and across the epigastrium, firm and may be identifiable, there may be multiple separate masses in the line of the colon
•Fat
•Fluid (ascites)—fluid thrill, shifting dullness
•Large abdominal masses (massive hepatomegaly or splenomegaly, fibroids, polycystic kidneys, retroperitoneal sarcoma)
The umbilicus and signs and symptoms of associated pathology
The umbilicus represents the location of four fetal structures—the umbilical vein, two umbilical arteries, and the urachus, which is a tube extending from the superior aspect of the bladder toward the umbilicus. The urachus represents the obliterated vesicourethral canal). The urachus may remain open at various points leading to the following abnormalities (Fig. 1.2):1
•Completely patent urachus communicates with the bladder and leaks urine through the umbilicus. This usually does not present until adulthood because strong contractions of bladder of a child close the mouth of the fistula.
•Vesicourachal diverticulum is a diverticulum in the dome of the bladder. This is usually asymptomatic.
•Umbilical cyst or sinus can become infected, forming an abscess or may chronically discharge infected material from the umbilicus. A cyst can present as an immobile, midline swelling between the
umbilicus and bladder, deep to the rectus sheath. It may have a small communication with the bladder, thus its size can fluctuate as it can become swollen with urine.
Other causes of umbilical masses
These include metastatic deposit (from abdominal cancer, metastatic spread occurring via lymphatics in the edge of the falciform ligament, running alongside the obliterated umbilical vein) and endometriosis (becomes painful and discharges blood at the same time as menstruation).
1 Hinman F Jr (1993). Atlas of Urosurgical Anatomy. Philadelphia: W.B. Saunders.
26 CHAPTER 1 Preliminary investigation
(a) |
(b) |
Patent
urachus
Vesicourachal diverticulum
(c) |
(d) |
Umbilical |
|
sinus |
|
Umbilical |
|
cyst |
Sinus tract |
|
Figure 1.2 Urachal abnormalities. This figure was published in Hinman F Jr, Atlas of Urosurgical Anatomy. Copyright Elsevier 1993.
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