Following the same chapter structure as the authoritative Campbell-Walsh Urology, 11th Edition, this trusted review covers all the core material. This enhanced eBook experience offers access to all of the text, figures, tables, The new edition of Campbell-Walsh Urology is the must have reference for. Editorial Reviews. Review. "the most complete text on urology as a specialty" SPEC - Campbell-Walsh Urology, 11th Edition, Month Access, eBook.

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"Since , Campbell-Walsh Urology has been internationally recognized as the pre-eminent text in its field. Edited by Alan J. Wein, MD, PhD(hon), Louis R. Get this from a library! Campbell-Walsh Urology.. [Meredith F Campbell; Alan J Wein; Louis R Kavoussi; Patrick C Walsh;]. Campbell Walsh Urology - Free ebook download as PDF File .pdf), Text File .txt) or read book online for free. Urology.

Craig A. Scott McDougal , Alan J. Wein , Louis R. Kavoussi , Alan W.

Partin , Craig A. Prepare for the written boards and MOC exams with the most reliable, efficient review available, from the same team that has made Campbell-Walsh Urology the most trusted clinical reference in the field. Stay up to date with new topics covered in the parent text, including evaluation and management of men with urinary incontinence, minimally-invasive urinary diversion, laparoscopic and robotic surgery in children, and much more.

Get a thorough review and a deeper understanding of your field with more than 3, multiple-choice questions and detailed answers, now with new highlighted "must-know" points in the answer explanations. Quickly review just before exams with help from new Chapter Reviews that detail key information in a handy list format. Benefit from an increased focus on pathology and imaging, including updates to conform pathology content to the new American Board of Urology requirements.

Basics of Urologic Surgery. Infections and Inflammation. Molecular and Cellular Biology. Reproductive and Sexual Function. Renal Physiology and Pathophysiology. Upper Urinary Tract Obstruction and Trauma. Benign and Malignant Bladder Disorders. Carducci, MD, and Mario A. Eisenberger, MD. Partin, MD, PhD. Klein, MD. Morgan, MD, Ganesh S. Palapattu, MD, Alan W. Wei, MD, MS. Techniques and Imaging, Leonard G. Eastham, MD. Park, MD. Norwood, MD, and Craig A. Canning, MD.

Ferrari, MD. Pope IV, MD.

Schneck, MD, and Michael C. Ost, MD. Hagerty, DO. Bauer, MD. Austin, MD, and Gino J. Vricella, MD.

Renal and Adrenal, Michael L. Ritchey, MD, and Robert C. Shamberger, MD. Bladder and Testis, Fernando A. Ferrer, MD. Chew John D. Reconstruction for Peyronie Disease: Retroperitoneal Lymph Node Dissection: Rice Clint K. Cary Timothy A. Masterson Richard S. George Michael J.

Schwartz Louis R. Wood Kenneth W. Patel Sean P. Kim William W. Linmouth Ramsay L. Kuo Ryan E. Paterson Larry C. Munch James E.

Chai Lori A. Epidemiology and Pathophysiology Jennifer T. Anger Gary E. Vasavada Raymond R. Rackley Sandip P. Autologous, Biologic, Synthetic, and Midurethral. Transobturator Sling: Hemal Gopal H. Lebed J. Nathaniel Hamilton Eric S. Lebed Eric S. Staskin Craig V. Skinner Donald G. Skinner Hugh B. Zhao Allen F. Robot-Assisted Laparoscopic Simple Prostatectomy: Technique and Outcomes Chapter , Simple Prostatectomy: Allaf Misop Han.

Techniques and Imaging Leonard G. Gomella Ethan J. Halpern Edouard J. Techniques and Imaging Daniel D. Sackett Ethan J. Halpern Steve Dong Leonard G.

Gomella Edouard J. Joseph Bladder Neck Dissection: Canning Sarah M. Henning Olsen. Thomas Mark C.

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Evaluation of the Urologic Patient: Each segment can provide significant positive and negative findings that will contribute to the overall evaluation and treatment of the patient.

Because there is no medical subspecialist with similar interests, the urologist has the ability to make the initial evaluation and diagnosis and to provide medical and surgical therapy for all diseases of the genitourinary GU system.

Historically, the diagnostic armamentarium included urinalysis, endoscopy, and intravenous IV pyelography. Recent advances in ultrasonography, computed tomography CT , magnetic resonance imaging MRI , and endourology have expanded our diagnostic capabilities. Despite these advances, however, the basic approach to the patient is still dependent on taking a complete history, executing a thorough physical examination, and performing a urinalysis. These basics dictate and guide the subsequent diagnostic evaluation.

HISTORY Overview The medical history is the cornerstone of the evaluation of the urologic patient, and a well-taken history will frequently elucidate the probable diagnosis. However, many pitfalls can inhibit the urologist from obtaining an accurate history.

The patient may be unable to describe or communicate symptoms because of anxiety, language barrier, or educational background. Therefore the urologist must be a detective and lead the patient through detailed and appropriate questioning to obtain accurate information. There are practical considerations in the art of history-taking that can help to alleviate some of these difficulties.

In the initial meeting, an attempt should be made to help the patient feel comfortable. During this time, the physician should project a calm, caring, and competent image that can help foster two-way communication.

Impaired hearing, mental capacity, and facility with English can be assessed promptly. These difficulties are frequently overcome by having a family member present during the interview or, alternatively, by having an interpreter present. Patients need to have sufficient time to express their problems and the reasons for seeking urologic care; the physician, however, should focus the discussion to make it as productive and informative as possible.

Direct questioning can then proceed logically. The physician needs to listen carefully without distractions to obtain and interpret the clinical information provided by the patient. A complete history can be divided into the chief complaint and history of the present illness, the patients past medical.

Chief Complaint and Present Illness Most urologic patients identify their symptoms as arising from the urinary tract and frequently present to the urologist for the initial evaluation. For this reason, the urologist frequently has the opportunity to act as both the primary physician and the specialist. The chief complaint must be clearly defined because it provides the initial information and clues to begin formulating the differential diagnosis.

Most importantly, the chief complaint is a constant reminder to the urologist as to why the patient initially sought care. This issue must be addressed even if subsequent evaluation reveals a more serious or significant condition that requires more urgent attention.

In our personal experience, a young woman presented with a chief complaint of recurrent urinary tract infections UTIs. In the course of her evaluation, she was found to have a right adrenal mass. We subsequently focused on this problem and performed a right adrenalectomy for a benign cortical adenoma.

We forgot about the womans original symptoms until she presented for her subsequent postoperative examination. She reminded us of her original symptoms at that time, and subsequent evaluation revealed that she had a nylon suture that had eroded into the anterior wall of her bladder from a previous abdominal vesicourethropexy performed 2 years earlier for stress urinary incontinence. Her UTIs resolved after surgical removal of the suture. In obtaining the history of the present illness, the duration, severity, chronicity, periodicity, and degree of disability are important considerations.

The patients symptoms need to be clarified for details and quantified for severity. Listed next are a variety of typical initial complaints. Specific questions that focus on the differential diagnosis are provided. Pain Pain arising from the GU tract may be quite severe and is usually associated with either urinary tract obstruction or inflammation. Urinary calculi cause severe pain when they obstruct the upper urinary tract. Conversely, large, nonobstructing stones may be totally asymptomatic.

Thus a 2-mm-diameter stone lodged at the ureterovesical junction may cause excruciating pain, whereas a large staghorn calculus in the renal pelvis or a bladder stone may be totally asymptomatic. Urinary retention from prostatic. Inflammation of the GU tract is most severe when it involves the parenchyma of a GU organ.

This is due to edema and distention of the capsule surrounding the organ. Thus pyelonephritis, prostatitis, and epididymitis are typically quite painful.

Inflammation of the mucosa of a hollow viscus such as the bladder or urethra usually produces discomfort, but the pain is not nearly as severe. Tumors in the GU tract usually do not cause pain unless they produce obstruction or extend beyond the primary organ to involve adjacent nerves. Thus pain associated with GU malignancies is usually a late manifestation and a sign of advanced disease. Renal Pain.

Pain of renal origin is usually located in the ipsilateral costovertebral angle just lateral to the sacrospinalis muscle and beneath the 12th rib. Pain is usually caused by acute distention of the renal capsule, generally from inflammation or obstruction.

The pain may radiate across the flank anteriorly toward the upper abdomen and umbilicus and may be referred to the testis or labium. A corollary to this observation is that renal or retroperitoneal disease should be considered in the differential diagnosis of any man who complains of testicular discomfort but has a normal scrotal examination.

Pain due to inflammation is usually steady, whereas pain due to obstruction fluctuates in intensity. Thus the pain produced by ureteral obstruction is typically colicky in nature and intensifies with ureteral peristalsis, at which time the pressure in the renal pelvis rises as the ureter contracts in an attempt to force urine past the point of obstruction. Pain of renal origin may be associated with gastrointestinal symptoms because of reflex stimulation of the celiac ganglion and because of the proximity of adjacent organs liver, pancreas, duodenum, gallbladder, and colon.

Thus renal pain may be confused with pain of intraperitoneal origin; it can usually be distinguished, however, by a careful history and physical examination. Pain that is due to a perforated duodenal ulcer or pancreatitis may radiate into the back, but the site of greatest pain and tenderness is in the epigastrium.

Pain of intraperitoneal origin is seldom colicky, as with obstructive renal pain. Furthermore, pain of intraperitoneal origin frequently radiates into the shoulder because of irritation of the diaphragm and phrenic nerve; this does not occur with renal pain. Typically, patients with intraperitoneal pathology prefer to lie motionless to minimize pain, whereas patients with renal pain usually are more comfortable moving around and holding the flank.

Renal pain may also be confused with pain resulting from irritation of the costal nerves, most commonly TT Such pain has a similar distribution from the costovertebral angle across the flank toward the umbilicus.

However, the pain is not colicky in nature. Furthermore, the intensity of radicular pain may be altered by changing position; this is not the case with renal pain. Ureteral Pain. Ureteral pain is usually acute and secondary to obstruction. The pain results from acute distention of the ureter and by hyperperistalsis and spasm of the smooth muscle of the ureter as it attempts to relieve the obstruction, usually produced by a stone or blood clot.

The site of ureteral obstruction can often be determined by the location of the referred pain. With obstruction of the midureter, pain on the right side is referred to the right lower quadrant of the abdomen McBurney point and thus may simulate appendicitis; pain on the left side is referred over the left lower quadrant and resembles diverticulitis. Also, the pain may be referred to the scrotum in the male or the labium in the female.

Lower ureteral obstruction frequently produces symptoms of vesical irritability, including frequency, urgency, and suprapubic discomfort that may radiate along the urethra in men to the tip of the penis. Often, by taking a careful history, the astute clinician can predict the location of the obstruction.

Ureteral pathology that arises slowly or produces only mild obstruction rarely causes pain. Therefore ureteral tumors and stones that cause minimal obstruction are seldom painful. Vesical Pain. Vesical pain is usually produced either by overdistention of the bladder as a result of acute urinary retention or by inflammation. Constant suprapubic pain that is unrelated to.

Furthermore, patients with slowly progressive urinary obstruction and bladder distention e. Inflammatory conditions of the bladder usually produce intermittent suprapubic discomfort. Thus the pain in conditions such as bacterial cystitis or interstitial cystitis is usually most severe when the bladder is full and is relieved at least partially by voiding. Patients with cystitis sometimes experience sharp, stabbing suprapubic pain at the end of micturition, and this is termed strangury.

Furthermore, patients with cystitis frequently experience pain referred to the distal urethra that is associated with irritative voiding symptoms such as urinary frequency and dysuria.

Prostatic Pain. Prostatic pain is usually secondary to inflammation with secondary edema and distention of the prostatic capsule. Prostatic pain is frequently associated with irritative urinary symptoms such as frequency and dysuria, and, in severe cases, marked prostatic edema may produce acute urinary retention.

Penile Pain. Pain in the flaccid penis is usually secondary to inflammation in the bladder or urethra, with referred pain that is experienced maximally at the urethral meatus. Alternatively, penile pain may be produced by paraphimosis, a condition in which the uncircumcised penile foreskin is trapped behind the glans penis, resulting in venous obstruction and painful engorgement of the glans penis see later.

Pain in the erect penis is usually due to Peyronie disease or priapism see later. Testicular Pain. Scrotal pain may be either primary or referred. Primary pain arises from within the scrotum and is usually secondary to acute epididymitis or torsion of the testis or testicular appendices. Because of the edema and pain associated with both acute epididymitis and testicular torsion, it is frequently difficult to distinguish these two conditions. Alternatively, scrotal pain may result from inflammation of the scrotal wall itself.

This may result from a simple infected hair follicle or sebaceous cyst, but it may also be secondary to Fournier gangrene, a severe, necrotizing infection arising in the scrotum that can rapidly progress and be fatal unless promptly recognized and treated. Chronic scrotal pain is usually related to noninflammatory conditions such as a hydrocele or a varicocele, and the pain is generally characterized as a dull, heavy sensation that does not radiate. Because the testes arise embryologically in close proximity to the kidneys, pain arising in the kidneys or retroperitoneum may be referred to the testes.

Similarly, the dull pain associated with an inguinal hernia may be referred to the scrotum. Hematuria Hematuria is the presence of blood in the urine; greater than three red blood cells RBCs per high-power microscopic field HPF is significant.

Patients with gross hematuria are usually frightened by the sudden onset of blood in the urine and frequently present to the emergency department for evaluation, fearing that they may be bleeding excessively. Hematuria of any degree should never be ignored and, in adults, should be regarded as a symptom of urologic malignancy until proved otherwise.

In evaluating hematuria, several questions should always be asked, and the answers will enable the urologist to target the subsequent diagnostic evaluation efficiently: Is the hematuria gross or microscopic?

At what time during urination does the hematuria occur beginning or end of stream or during entire stream? Is the hematuria associated with pain? Is the patient passing clots? If the patient is passing clots, do the clots have a specific shape? Gross versus Microscopic Hematuria. The significance of gross versus microscopic hematuria is simply that the chances of. Thus patients with gross hematuria usually have identifiable underlying pathology, whereas it is quite common for patients with minimal degrees of microscopic hematuria to have a negative urologic evaluation.

Timing of Hematuria. The timing of hematuria during urination frequently indicates the site of origin. Initial hematuria usually arises from the urethra; it occurs least commonly and is usually secondary to inflammation. Total hematuria is most common and indicates that the bleeding is most likely coming from the bladder or upper urinary tracts. Terminal hematuria occurs at the end of micturition and is usually secondary to inflammation in the area of the bladder neck or prostatic urethra.

It occurs at the end of micturition as the bladder neck contracts, squeezing out the last amount of urine. Association with Pain. Hematuria, although frightening, is usually not painful unless it is associated with inflammation or obstruction. Thus patients with cystitis and secondary hematuria may experience painful urinary irritative symptoms, but the pain is usually not worsened with passage of clots.

More commonly, pain in association with hematuria usually results from upper urinary tract hematuria with obstruction of the ureters with clots. Passage of these clots may be associated with severe, colicky flank pain similar to that produced by a ureteral calculus, and this helps identify the source of the hematuria.

A determination of AMH should be based on microscopic, not dipstick, examination of the urine. Careful history, physical examination, and laboratory examination should be done to rule out benign causes of AMH, such as infection, medical renal disease, and others. Once these causes are ruled out, urologic evaluation that includes a measurement of renal function is recommended.

If factors such as dysmorphic RBCs, proteinuria, casts, or renal insufficiency are present, nephrologic workup should be considered in addition to the urologic evaluation.

AMH that occurs in patients who are anticoagulated still warrants urologic evaluation. The evaluation of patients over 35 years of age with AMH should include cystoscopy, which is optional in younger patients. However, all patients should have cystoscopy if risk factors such as irritative voiding symptoms, tobacco use, or chemical exposures are present.

Radiologic evaluation should be performed in the initial evaluation, and the procedure of choice is multiphasic CT urography with and without IV contrast.

Magnetic resonance urography, with or without IV contrast, is an acceptable alternative in patients who cannot undergo multiphasic CT scan. In cases where collecting system detail is needed, noncontrast CT, MRI, or renal ultrasonography with retrograde pyelograms is an acceptable alternative if there is a contraindication to the use of IV contrast.

Among the modalities not recommended in the routine evaluation of patients with AMH are urine cytology, urine markers, and blue light cystoscopy. However, cytology may be useful in those patients with persistent AMH following a negative workup or those with other risk factors for carcinoma in situ, such as irritative voiding symptoms, use of tobacco, or chemical exposures.

For patients with persistent AMH, yearly urinalysis should be performed. The presence of two consecutive annual negative urinalyses indicates that no further urinalyses are needed for this purpose. For patients with persistent or recurrent AMH, repeat evaluation within 3 to 5 years should be considered. Presence of Clots. The presence of clots usually indicates a more significant degree of hematuria, and, accordingly, the probability of identifying significant urologic pathology increases.

Shape of Clots. Usually, if the patient is passing clots, they are amorphous and of bladder or prostatic urethral origin. However, the presence of vermiform wormlike clots, particularly if associated with flank pain, identifies the hematuria as coming from the upper urinary tract with formation of vermiform clots within the ureter. It cannot be emphasized strongly enough that hematuria, particularly in the adult, should be regarded as a symptom of malignancy until proved otherwise and demands immediate urologic examination.

In a patient who presents with gross hematuria, cystoscopy should be performed as soon as possible because frequently the source of bleeding can be readily identified. Cystoscopy will determine whether the hematuria is coming from the urethra, bladder, or upper urinary tract.

In patients with gross hematuria secondary to an upper tract source, it is easy to see the jet of red urine pulsing from the involved ureteral orifice. Although inflammatory conditions may result in hematuria, all patients with hematuria, except perhaps young women with acute bacterial hemorrhagic cystitis, should undergo urologic evaluation.

Older women and men who present with hematuria and irritative voiding symptoms may have cystitis secondary to infection arising in a necrotic bladder tumor or, more commonly, flat carcinoma in situ of the bladder. The most common cause of gross hematuria in a patient older than age 50 years is bladder cancer. Frequency is one of the most common urologic symptoms. The normal adult voids five or six times per day, with a volume of approximately mL with each void. Urinary frequency is due to either increased urinary output polyuria or decreased bladder capacity.

If voiding is noted to occur in large amounts frequently, the patient has polyuria and should be evaluated for diabetes mellitus, diabetes insipidus, or excessive fluid ingestion.

By separating irritative from obstructive symptoms, the astute clinician should be able to arrive at a proper differential diagnosis. Nocturia is nocturnal frequency. Normally, adults arise no more than twice at night to void. As with frequency, nocturia may be secondary to increased urine output or decreased bladder capacity.

Frequency during the day without nocturia is usually of psychogenic origin and related to anxiety. Nocturia without frequency may occur in the patient with congestive heart failure and peripheral edema in whom the intravascular volume and urine output increase when the patient is supine. Renal concentrating ability decreases with age; therefore urine production in the geriatric patient is increased at night, when renal blood flow is increased as a result of recumbency.

Nocturia may also occur in people who drink large amounts of liquid in the evening, particularly caffeinated and alcoholic beverages, which have strong diuretic effects. Dysuria is painful urination that is usually caused by inflammation. This pain is usually not felt over the bladder but is commonly referred to the urethral meatus. Pain occurring at the start of urination may indicate urethral pathology, whereas pain occurring at the end of micturition strangury is usually of bladder origin.

Dysuria is frequently accompanied by frequency and urgency. Obstructive Symptoms. Decreased force of urination is usually secondary to bladder outlet obstruction and commonly results from benign prostatic hyperplasia BPH or a urethral stricture. In fact, except for severe degrees of obstruction, most patients are unaware of a change in the force and caliber of their urinary stream.

These changes usually occur gradually and go generally unrecognized by most patients. The other obstructive symptoms noted later are more commonly recognized and are usually secondary to bladder outlet obstruction in men due to either BPH or a urethral stricture. Urinary hesitancy refers to a delay in the start of micturition. Normally, urination begins within a second after relaxing the. Intermittency refers to involuntary start-stopping of the urinary stream.

It most commonly results from prostatic obstruction with intermittent occlusion of the urinary stream by the lateral prostatic lobes. Postvoid dribbling refers to the terminal release of drops of urine at the end of micturition.

This is secondary to a small amount of residual urine in either the bulbar or the prostatic urethra that is normally milked back into the bladder at the end of micturition Stephenson and Farrar, In men with bladder outlet obstruction, this urine escapes into the bulbar urethra and leaks out at the end of micturition.

Men will frequently attempt to avoid wetting their clothing by shaking the penis at the end of micturition.

In fact, this is ineffective, and the problem is more readily solved by manual compression of the bulbar urethra in the perineum and blotting the urethral meatus with a tissue.

Postvoid dribbling is often an early symptom of urethral obstruction related to BPH, but, in itself, seldom necessitates any further treatment. Straining refers to the use of abdominal musculature to urinate. Normally, it is unnecessary for a man to perform a Valsalva maneuver except at the end of urination.

Increased straining during micturition is a symptom of bladder outlet obstruction. It is important for the urologist to distinguish irritative from obstructive lower urinary tract symptoms. This most frequently occurs in evaluating men with BPH. Although BPH is primarily obstructive, it produces changes in bladder compliance that result in increased irritative symptoms.

In fact, men with BPH more commonly present with irritative than obstructive symptoms, and the most common presenting symptom is nocturia. The urologist must be careful not to attribute irritative symptoms to BPH unless there is documented evidence of obstruction.

In general, lower urinary tract symptoms are nonspecific and may occur secondary to. In this regard, two important examples are mentioned. Patients with high-grade flat carcinoma in situ of the bladder may present with urinary irritative symptoms. The urologist should be particularly aware of the diagnosis of carcinoma in situ in men who present with irritative symptoms, a history of cigarette smoking, and microscopic hematuria. In our personal experience, we cared for a year-old man who presented with this history and was treated for BPH for 2 years before the diagnosis of bladder cancer was established.

Once the correct diagnosis was made, the patient had developed muscleinvasive disease and required a cystectomy for cure. The second important example is irritative symptoms resulting from neurologic disease such as cerebrovascular accidents, diabetes mellitus, and Parkinson disease.

Most neurologic diseases encountered by the urologist are upper motor neuron in etiology and result in a loss of cortical inhibition of voiding with resultant decreased bladder compliance and irritative voiding symptoms. The urologist must be extremely careful to rule out underlying neurologic disease before performing surgery to relieve bladder outlet obstruction.

Such surgery not only may fail to relieve the patients irritative symptoms but also may result in permanent urinary incontinence. Since its introduction in , the AUA symptom index has been widely used and validated as an important means of assessing men with lower urinary tract symptoms Barry etal, The original AUA symptom score is based on the answers to seven questions concerning frequency, nocturia, weak urinary stream, hesitancy, intermittency, incomplete bladder emptying, and urgency.

The total symptom score ranges from 0 to 35 with scores of 0 to 7, 8 to 19, and 20 to 35 indicating mild, moderate, and severe. NONE 7. NOCTURIA Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? Prostate symptom score and quality of life assessment.

Channel Island, Jersey: Scientific Communication International; The I-PSS is a helpful tool both in the clinical management of men with lower urinary tract symptoms and in research studies regarding the medical and surgical treatment of men with voiding dysfunction.

The use of symptom indices has limitations, and it is important for the physician to discuss the patients responses with him. It has been demonstrated that a grade 6 reading level is necessary to understand the I-PSS, and some patients with neurologic disorders and dementia may also have difficulty completing the symptom score MacDiarmid etal, In addition, the symptom score and obstructive and irritative voiding symptoms are nonspecific, and the symptoms may be caused by a variety of conditions other than BPH.

Similar symptom scores have been demonstrated to be present in age-matched men and women between 55 and 79 years of age Lepor and Machi, Despite these limitations, the I-PSS is a simple adjunct in assessing men with lower urinary tract symptoms and may be used in the initial evaluation of men with lower urinary tract symptoms, as well as in the assessment of treatment response. Urinary incontinence is the involuntary loss of urine.

A careful history of the incontinent patient will often determine the etiology. Urinary incontinence can be subdivided into four categories. Continuous Incontinence. Continuous incontinence is most commonly due to a urinary tract fistula that bypasses the urethral sphincter. The most common type of fistula that results in urinary incontinence is a vesicovaginal fistula usually secondary to gynecologic surgery, radiation, or obstetric trauma.

Less commonly, ureterovaginal fistulae may occur from similar causes. A second major cause of continuous incontinence is an ectopic ureter that enters either the urethra or the female genital tract.

An ectopic ureter usually drains a small, dysplastic upper pole segment of kidney, and the amount of urinary leakage may be quite small. Such patients may void most of their urine normally but have a continuous amount of small urinary leakage that may be misdiagnosed for many years as a chronic vaginal discharge.

In our experience, we cared for a year-old woman who had been misdiagnosed with enuresis in childhood and as having a chronic vaginal discharge in adult lifewhose urinary leakage was totally corrected by surgical removal of the dysplastic, upper pole segment of her right kidney.


Ectopic ureters never produce urinary incontinence in males because they always enter the bladder neck or prostatic urethra proximal to the external urethral sphincter. Stress Incontinence.

Stress incontinence refers to the sudden leakage of urine with coughing, sneezing, exercise, or other. During these activities, intra-abdominal pressure rises transiently above urethral resistance, resulting in a sudden, usually small amount of urinary leakage.

Stress incontinence is most common in women after childbearing or menopause and is related to a loss of anterior vaginal support and weakening of pelvic tissues.

Stress incontinence is also observed in men after prostatic surgery, most commonly radical prostatectomy, in which there may be injury to the external urethral sphincter. Stress urinary incontinence is difficult to manage pharmacologically, and patients with significant stress incontinence are usually best treated surgically.

Urgency Incontinence. Urgency incontinence is the precipitous loss of urine preceded by a strong urge to void. This symptom is commonly observed in patients with cystitis, neurogenic bladder, and advanced bladder outlet obstruction with secondary loss of bladder compliance. It is important to distinguish urgency incontinence from stress incontinence for two reasons.

First, urgency incontinence may result from a secondary underlying pathologic process, which should be identified; treatment of this primary problem such as infection or bladder outlet obstruction may result in resolution of urgency incontinence. Overflow Urinary Incontinence. Overflow urinary incontinence, often called paradoxical incontinence, is secondary to advanced urinary retention and high residual urine volumes.

In these patients, the bladder is chronically distended and never empties completely. Urine may dribble out in small amounts as the bladder overflows. This is particularly likely to occur at night when the patient is less likely to inhibit urinary leakage.

Overflow incontinence has been termed paradoxical incontinence because it can often be cured by relief of bladder outlet obstruction. It is, however, often difficult to make the diagnosis of overflow incontinence by history and physical examination alone, particularly in the obese patient, in whom percussion of the distended bladder may be difficult.

Overflow incontinence usually develops over a considerable length of time, and patients may be totally unaware of incomplete bladder emptying. Thus any patient with significant incontinence should undergo measurement of postvoid residual urine.

Enuresis refers to urinary incontinence that occurs during sleep. Enuresis must be distinguished from continuous incontinence, which occurs in the day and night and which, in a young girl, usually indicates the presence of an ectopic ureter. All children older than age 6 years with enuresis should undergo a urologic evaluation, although the vast majority will be found to have no significant urologic abnormality.

Sexual Dysfunction Male sexual dysfunction is frequently used synonymously with impotence or erectile dysfunction, although impotence refers specifically to the inability to achieve and maintain an erection adequate for intercourse. Patients presenting with impotence should be questioned carefully to rule out other male sexual disorders, including loss of libido, absence of emission, absence of orgasm, and, most commonly, premature ejaculation.

It is important to identify the precise problem before proceeding with further evaluation and treatment. Loss of Libido. Because androgens have a major influence on sexual desire, a decrease in libido may indicate androgen deficiency arising from either pituitary or testicular dysfunction.

This can be evaluated directly by measurement of serum testosterone that, if abnormal, should be further evaluated by measurement of serum gonadotropins and prolactin. Because the amount of testosterone required to maintain libido is usually less than that required for full.

Conversely, if semen volume is normal, it is unlikely that endocrine factors are responsible for loss of libido. A decrease in libido may also result from depression and a variety of medical illnesses that affect general health and well-being. Impotence refers specifically to the inability to achieve and maintain an erection sufficient for intercourse. A careful history will often determine whether the problem is primarily psychogenic or organic. In men with psychogenic impotence, the condition frequently develops rather quickly secondary to a precipitating event such as marital stress or change or loss of a sexual partner.

In men with organic impotence, the condition usually develops more insidiously and frequently can be linked to advancing age or other underlying risk factors. In evaluating men with impotence, it is important to determine whether the problem exists in all situations.

Many men who report impotence may not be able to have intercourse with one partner but will with another. Similarly, it is important to determine whether men are able to achieve normal erections with alternative forms of sexual stimulation e. Finally, the patient should be asked whether he ever notes nocturnal or early morning erections.

In general, patients who are able to achieve adequate erections in some situations but not others have primarily psychogenic rather than organic impotence. Failure to Ejaculate. A failure to ejaculate may result from several causes: Androgen deficiency results in decreased secretions from the prostate and seminal vesicles, causing a reduction or loss of seminal volume. Sympathectomy or extensive retroperitoneal surgery, most notably retroperitoneal lymphadenectomy for testicular cancer, may interfere with autonomic innervation of the prostate and seminal vesicles, resulting in absence of smooth muscle contraction and absence of seminal emission at time of orgasm.

Pharmacologic agents, particularly -adrenergic antagonists, may interfere with bladder neck closure at time of orgasm and result in retrograde ejaculation. Similarly, previous bladder neck or prostatic urethral surgery, most commonly transurethral resection of the prostate, may interfere with bladder neck closure, resulting in retrograde ejaculation.

Finally, retrograde ejaculation may develop spontaneously in diabetic men. Patients who complain of absence of ejaculation should be questioned regarding loss of libido or other symptoms of androgen deficiency, present medications, diabetes, and previous surgery.

A careful history will usually determine the cause of this problem. Absence of Orgasm. Anorgasmia is usually psychogenic or caused by certain medications used to treat psychiatric diseases.

Sometimes, however, anorgasmia may be due to decreased penile sensation owing to impaired pudendal nerve function. Most commonly, this occurs in diabetics with peripheral neuropathy. Men who experience anorgasmia in association with decreased penile sensation should undergo vibratory testing of the penis and further neurologic evaluation as indicated.

Premature Ejaculation. Men who complain of premature ejaculation should be questioned carefully because this is obviously a subjective symptom. It is common for men to ejaculate within 2 minutes after initiation of intercourse, and many men who complain of premature ejaculation in actuality have normal sexual function with abnormal sexual expectations.

However, there are men with true premature ejaculation who reach orgasm within less than 1 minute after initiation of intercourse. This problem is almost always psychogenic and best treated by a clinical psychologist or psychiatrist who specializes in treatment of this problem and other psychological aspects of male sexual dysfunction.

With counseling and appropriate modifications in sexual technique, this problem can usually be overcome. Alternatively, treatment with serotonin reuptake inhibitors such as sertraline and fluoxetine has been demonstrated to be helpful in men with premature ejaculation Murat Basar etal, Hematospermia Hematospermia refers to the presence of blood in the seminal fluid.

It frequently occurs after a prolonged period of sexual abstinence, and we have observed it several times in men whose wives are in the final weeks of pregnancy.

Patients with hematospermia that persists beyond several weeks should undergo further urologic evaluation because, rarely, an underlying etiology will be identified. A genital and rectal examination should be done to exclude the presence of tuberculosis; a prostate-specific antigen PSA and a rectal examination done to exclude prostatic carcinoma; and a urinary cytology done to exclude the possibility of transitional cell carcinoma of the prostate.

It should be emphasized, however, that hematospermia almost always resolves spontaneously and rarely is associated with any significant urologic pathology. Pneumaturia Pneumaturia is the passage of gas in the urine. In patients who have not recently had urinary tract instrumentation or a urethral catheter placed, this is almost always due to a fistula between the intestine and the bladder.

Common causes include diverticulitis, carcinoma of the sigmoid colon, and regional enteritis Crohn disease. In rare instances, patients with diabetes mellitus may have gas-forming infections, with carbon dioxide formation from the fermentation of high concentrations of sugar in the urine. Urethral Discharge Urethral discharge is the most common symptom of venereal infection. A purulent discharge that is thick, profuse, and yellow to gray is typical of gonococcal urethritis; the discharge in patients with nonspecific urethritis is usually scant and watery.

A bloody discharge is suggestive of carcinoma of the urethra. Fever and Chills Fever and chills may occur with infection anywhere in the GU tract but are most commonly observed in patients with pyelonephritis, prostatitis, or epididymitis.

When associated with urinary obstruction, fever and chills may portend septicemia and necessitate emergency treatment to relieve obstruction. Medical History The past medical history is extremely important because it frequently provides clues to the patients current diagnosis.

The past medical history should be obtained in an orderly and sequential manner. Previous Medical Illnesses with Urologic Sequelae Many diseases may affect the GU system, and it is important to listen to the patient and record previous medical illnesses.

Patients with diabetes mellitus frequently develop autonomic dysfunction that may result in impaired urinary and sexual function. A previous history of tuberculosis may be important in a patient presenting with impaired renal function, ureteral obstruction, or chronic, unexplained UTIs.

Patients with hypertension have an increased risk of sexual dysfunction because they are more likely to have peripheral vascular disease and because many of the medications that are used to treat hypertension frequently cause impotence. Patients with neurologic diseases such as multiple sclerosis are also more likely to develop urinary and sexual dysfunction. As mentioned earlier, in men with bladder outlet obstruction, it is important to be aware of.

Surgical treatment of bladder outlet obstruction in the presence of detrusor hyperreflexia may result in increased urinary incontinence postoperatively. Finally, patients with sickle cell anemia are prone to a number of urologic conditions, including papillary necrosis and erectile dysfunction secondary to recurrent priapism.

There are many other diseases with urologic sequelae, and it is important for the urologist to take a careful history in this regard. Examples of genetic diseases include adult polycystic kidney disease, tuberous sclerosis, von Hippel-Lindau disease, renal tubular acidosis, and cystinuria; these are but a few common and well-recognized examples.

In addition to these diseases of known genetic predisposition, there are other conditions in which the precise pattern of inheritance has not been elucidated but that clearly have a familial tendency. It is well known that individuals with a family history of urolithiasis are at increased risk for stone formation. Other familial conditions are mentioned elsewhere in the text, but suffice it to state again that obtaining a careful history of previous illnesses and a family history of urologic disease can be extremely valuable in establishing the correct diagnosis.

Medications It is similarly important to obtain an accurate and complete list of present medications because many drugs interfere with urinary and sexual function. For example, most of the antihypertensive medications interfere with erectile function, and changing antihypertensive medications can sometimes improve sexual function. Similarly, many of the psychotropic agents interfere with emission and orgasm. In our own recent experience, we cared for a man who presented with anorgasmia. He had been to several physicians without improvement in this problem.

When we obtained his past medical history, he mentioned that he had been taking a psychotropic agent for transient depression for several years, and his anorgasmia resolved when this no-longer-needed medication was discontinued. The list of medications affecting urinary and sexual function is exhaustive, but, once again, each medication should be recorded and its side effects investigated to be sure that the patients problem is not drug related.

A listing of common medications that may cause urologic side effects is presented in Table Previous Surgical Procedures It is important to be aware of previous operations, particularly in a patient who may have surgery, because previous operations may make subsequent ones more difficult.

If the previous surgery was in a similar anatomic region, it is worthwhile to try to obtain the previous operative report. In our own experience, this small additional effort has been rewarded on numerous occasions by providing a clear explanation of the patients previous surgery that greatly simplified the subsequent operation.

In general, it is worthwhile to obtain as much information as possible before any intended surgery because most surprises that occur in the operating room are unhappy ones.

Smoking and Alcohol Use Cigarette smoking and consumption of alcohol are clearly linked to a number of urologic conditions.

Cigarette smoking is associated with an increased risk of urothelial carcinoma, most notably bladder cancer, and it is also associated with increased peripheral vascular disease and erectile dysfunction. Chronic alcoholism may result in autonomic and peripheral neuropathy. Direct smooth muscle stimulants Others Smooth muscle relaxants Striated muscle relaxants. Calcium channel blockers Antiparkinsonian drugs -Adrenergic agonists Antihistamines Acute renal failure.

Antihypertensives Cardiac drugs Gastrointestinal drugs Psychotropic drugs Tricyclic antidepressants. Chronic alcoholism may also impair hepatic metabolism of estrogens, resulting in decreased serum testosterone, testicular atrophy, and decreased libido.

In addition to the direct urologic effects of cigarette smoking and alcohol consumption, patients who are actively smoking or drinking up to the time of surgery are at increased risk for perioperative complications. Smokers are at increased risk for both pulmonary and cardiac complications. If possible, they should discontinue smoking at least 8 weeks before surgery to optimize their. If they are unable to do this, they should at least quit smoking for 48 hours before surgery because this will result in a significant improvement in cardiovascular function.

Similarly, chronic alcoholics are at increased risk for hepatic toxicity and subsequent coagulation problems postoperatively. Furthermore, alcoholics who continue drinking up to the time of surgery may experience acute alcohol withdrawal during the postoperative period that can be life threatening.

Prophylactic administration of lorazepam Ativan greatly reduces the potential risk of this significant complication. Allergies Finally, medicinal allergies should be questioned because these medications should be avoided in future treatment of the patient. All medicinal allergies should be marked boldly on the front of the patients chart to avoid potential complications from inadvertent exposure to the same medications.

In summary, a careful and thorough medical history including the chief complaint and history of present illness, past medical history, and family history should be obtained for every patient. Unfortunately, time constraints often make it difficult for the physician to spend the necessary time to obtain a full history. A reasonable substitute is to have a trained nurse or other health professional see the patient first.

By using a standard history form, much of the information discussed previously can be obtained in a preliminary interview. It then remains for the urologist to only fill in the blanks, have the patient elaborate on potentially relevant aspects of the past medical history, and then perform a complete physical examination.

A complete history and appropriate physical examination is critical in the assessment of urologic patients. A complete urinalysis including chemical and microscopic analyses should be performed because this may provide important information critical to the diagnosis and treatment of urologic patients. A complete and thorough physical examination is an essential component of the evaluation of patients who present with urologic disease.

Although it is tempting to become dependent on results of laboratory and radiologic tests, the physical examination often simplifies the process and allows the urologist to select the most appropriate diagnostic studies. Along with the history, the physical examination remains a key component of the diagnostic evaluation and should be performed conscientiously. General Observations The visual inspection of the patient provides a general overview.

The skin should be inspected for evidence of jaundice or pallor. The nutritional status of the patient should be noted. Cachexia is a frequent sign of malignancy, and obesity may be a sign of underlying endocrinologic abnormalities.

In this instance, one should search for the presence of truncal obesity, a buffalo hump, and abdominal skin striae, which are stigmata of hyperadrenocorticism. In contrast, debility and hyperpigmentation may be signs of hypoadrenocorticism. Gynecomastia may be a sign of endocrinologic disease and a possible indicator of alcoholism or previous hormonal therapy for prostate cancer. Supraclavicular lymphadenopathy may be seen with any GU neoplasm, most commonly prostate and testis cancer; inguinal lymphadenopathy may occur secondary to carcinoma of the penis or urethra.

Because of the position of the liver, the right kidney is somewhat lower than the left. In children and thin women, it may be possible to palpate the lower pole of the right kidney with deep inspiration. However, it is usually not possible to palpate either kidney in men, and the left kidney is almost always impalpable unless it is abnormally enlarged. The best way to palpate the kidneys is with the patient in the supine position. The kidney is lifted from behind with one hand in the costovertebral angle Fig.

On deep inspiration, the examiners hand is advanced firmly into the anterior abdomen just below the costal margin. At the point of maximal inspiration, the kidney may be felt as it moves downward with the diaphragm. With each inspiration, the examiners hand may be advanced deeper into the abdomen. Once again, it is more difficult to palpate kidneys in men because the kidneys tend to move downward less with inspiration and because they are surrounded with thicker muscular layers.

In children, it is easier to palpate the kidneys because of decreased body thickness. In neonates, the kidneys can be felt quite easily by palpating the flank between the thumb anteriorly and the fingers over the costovertebral angle posteriorly. Transillumination of the kidneys may be helpful in children younger than 1 year of age with a palpable flank mass. Such masses are frequently of renal origin. A flashlight or fiberoptic light source is positioned posteriorly against the costovertebral angle.

Fluid-filled masses such as cysts or hydronephrosis produce a dull reddish glow in the anterior abdomen. Solid masses such as tumors do not transilluminate.

Other diagnostic maneuvers that may be helpful in examining the kidneys are percussion and auscultation. Although renal inflammation may cause pain that is poorly localized, percussion of the costovertebral angle posteriorly more often localizes the pain and tenderness more accurately.

Percussion should be done gently because in a patient with significant renal inflammation, this may be quite painful. Auscultation of the upper abdomen during deep inspiration may occasionally reveal a systolic bruit associated with renal artery stenosis or an aneurysm.

A bruit may also be detected in association with a large renal arteriovenous fistula. Every patient with flank pain should also be examined for possible nerve root irritation. The ribs should be palpated carefully to rule out a bone spur or other skeletal abnormality and to determine the point of maximal tenderness. Unlike renal pain, radiculitis usually causes hyperesthesia of the overlying skin innervated by the irritated peripheral nerve. This hypersensitivity can be elicited with a pin or by pinching the skin and fat overlying the involved area.

Finally, the pain experienced during the pre-eruptive phase of herpes zoster involving any of the segments between T11 and L2 may also simulate pain of renal origin.

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Kidneys The kidneys are fist-sized organs located high in the retroperitoneum bilaterally. In the adult, the kidneys are normally difficult to. Bladder A normal bladder in the adult cannot be palpated or percussed until there is at least mL of urine in it.

At a volume of about mL, the distended bladder becomes visible in thin patients as a lower midline abdominal mass. Percussion is better than palpation for diagnosing a distended bladder.

The examiner begins by percussing immediately above the symphysis pubis and continuing cephalad until there is a change in pitch from dull to resonant. Alternatively, it may be possible in thin patients and in children to palpate the bladder by lifting the lumbar spine with one hand and pressing the other hand into the midline of the lower abdomen.

A careful bimanual examination, best done with the patient under anesthesia, is invaluable in assessing the regional extent of a bladder tumor or other pelvic mass. The bladder is palpated between the abdomen and the vagina in the female Fig.

In addition to defining areas of induration, the bimanual examination allows the examiner to assess the mobility of the bladder; such information cannot be obtained by radiologic techniques such as CT and MRI, which convey static images.

Penis If the patient has not been circumcised, the foreskin should be retracted to examine for tumor or balanoposthitis inflammation of the prepuce and glans penis. Most penile cancers occur in uncircumcised men and arise on the prepuce or glans penis. Therefore in a patient with a bloody penile discharge in whom the foreskin cannot be withdrawn, a dorsal slit or circumcision must be performed to adequately evaluate the glans penis and urethra.

Figure Bimanual examination of the bladder in the female. From Swartz MH. Textbook of physical diagnosis. Saunders; The position of the urethral meatus should be noted. It may be located proximal to the tip of the glans on the ventral surface hypospadias or, much less commonly, on the dorsal surface epispadias.

The penile skin should be examined for the presence of superficial vesicles compatible with herpes simplex and for ulcers that may indicate either venereal infection or tumor. The presence of venereal warts condylomata acuminata , which appear as irregular, papillary, velvety lesions on the male genitalia, should also be noted. The urethral meatus should be separated between the thumb and the forefinger to inspect for neoplastic or inflammatory lesions within the fossa navicularis.

The dorsal shaft of the penis should be palpated for the presence of fibrotic plaques or ridges typical of Peyronie disease. Tenderness along the ventral aspect of the penis is suggestive of periurethritis, often secondary to a urethral stricture.

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Scrotum and Contents The scrotum is a loose sac containing the testes and spermatic cord structures. The scrotal wall is made up of skin and an underlying thin muscular layer. The testes are normally oval, firm, and smooth; in adults, they measure about 6 cm in length and 4 cm in width. They are suspended in the scrotum, with the right testis normally anterior to the left.

The epididymis lies posterior to the testis and is palpable as a distinct ridge of tissue. The vas deferens can be palpated above each testis and feels like a piece of heavy twine.

The scrotum should be examined for dermatologic abnormalities. Because the scrotum, unlike the penis, contains both hair and sweat glands, it is a frequent site of local infection and sebaceous cysts.

Hair follicles can become infected and may present as small pustules on the surface of the scrotum. These usually resolve spontaneously, but they can give rise to more significant infection, particularly in patients with reduced immunity and diabetes.

Patients often become concerned about these lesions, mistaking them for testicular tumors.

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The testes should be palpated gently between the fingertips of both hands. The testes normally have a firm, rubbery consistency with a smooth surface. Abnormally small testes suggest hypogonadism or an endocrinopathy such as Klinefelter disease. A firm or hard area within the testis should be considered a malignant tumor until proved otherwise.

The epididymis should be palpable as a ridge posterior to each testis. Masses in the epididymis spermatocele, cyst, and epididymitis are almost always benign. To examine for a hernia, the physicians index finger should be inserted gently into the scrotum and invaginated into the external inguinal ring Fig.

The scrotum should be. Chapter 1 Evaluation of the Urologic Patient: Examination of the inguinal canal.Sign in.

A bloody discharge is suggestive of carcinoma of the urethra. We'll publish them on our site once we've reviewed them. Louis, Missouri. The E-mail Address es you entered is are not in a valid format.