1. Introduction to symptoms and signs of Genito-Urinary diseases
Rami Al-Azab,MD
Division of Urology
Department of Surgery

2. Peculiarity to G U history
Handles all age groups.
Issue of privacy.
High prevalence of congenital anomalies.

3. PAIN Usually secondary to either obstruction and/or inflammation.
G U tumours are usually painless ( pain is the effect rather than from the tumor itself ex. Obstruction, infection, bleeding).
Pain from parenchymal organs is usually secondary to inflammation.

4. Renal Pain Caused by acute distension of the renal capsule.
Pain due to inflammation is usually steady while that due to obstruction fluctuates in intensity.
Radiation reflects the site of pathology since the ureter has segmental nerve supply.

5. Renal Pain DDx According to the site of pathology
Careful history will differentiate between different causes in most of the cases.
Intraperitoneal organs give more vague symptoms and certain pattern of radiation.
High incidence of GI symptoms association (splanchnic,vagal,dirct effect,pain and Uremia).

6. Ureteral pain
The ureter has segmental nerve supply, so the level of pain reported by the patient reflect to some degree the level of pathology.
The ureter has thin muscle coat so it reaches the stage of exhaustion fairly fast( a stone impacted for a week is less painful).

7. The Ureter

8. Ureteral pain
The mode of referral differs according to the level of pathology;
Upper ureter → flank pain (differs from renal pain in that it is more rhythmic than constant
Mid ureter → flank,lumbar and groin pain.
When the stone passes to the true pelvis the refferal is diiferent → in males to the scrotum ,and the penis

9. Pain arising from the GU tract and its sites of radiation

11. In females it radiates to the labia majora and the vagina.
When the stone is in the intramural part of the ureter it starts giving irritative LUTS.
O/E : characteristically the patient is ruling over unsuccessfully trying to find a comforting position unlike patient with peritonitis who is trying to minimize movement not to provoke the angry peritoneum

12. Scrotal pain
Can be referred from intra-abdominal pathology ( appendicitis, colonic…).
Testicular pain is considered due to torsion of the spermatic cord untill proven otherwise

13. ANATOMY

15. …scrotal 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 testicle or testicular appendices.

16. Torsion Vs Epididymitis
it is frequently difficult to distinguish these two conditions;Because of the edema and pain associated with both acute epididymitis and testicular torsion.
scrotal pain may result from inflammation of the scrotal wall itself.

17. Abnormal Physical Examination Findings of Scrotum and Contents
Testicular Cancer .
Torsion .
Hydrocele .
Varicocele.
All the items regarding examination of a mass applies here.
An inguinal hernia can present as a scrotal swelling.

18. DDX Spermatic Torsion. Acute Epididymitis. Trauma Fournier’s gangrene.
Skin Lesions.

19. Pelvic wall anatomy

20. Vesical pain Over distension of the bladder.
Distension over a long period of pain (chronic retention )is painless.
Irritation gives intermittent pain and irritative LUTS.
Usually referred at the tip of a flaccid penis.

21. Prostatic and pelvic pain
Secondary to inflammation and edema which causes distension of the prostatic capsule.
Poorly localized thus present as a lower abdominal, deep pelvic or perineal pain and/or irritative LUTS.

22. Hematuria Gross versus microscopic hematuria.
Timing: Initial Terminal and Total hematuria.
Association with pain ( symptoms).
Presence of clots.
Pertaining associations……

23. Hematuria
8% of patients with microscopic hematuria turn out to have malignant underlying cause. Ex. TCC,RCC,….
18% of patient stay without obvious cause.
The most common cause in an adult male is BPH and in a females UTI.
In children the etiology list is different

24. Definitions BPE = Benign Prostatic Enlargement LUTS =
Lower Urinary Tract Symptoms
BOO =
Bladder Outlet Obstruction
BPH =
Benign Prostatic Hyperplasia
This cartoon illustrates the difference between the histological change, BPH, benign enlargement of the prostate gland, which often is present without causing obstruction, and bladder outlet obstruction, which is due to benign enlargement of the prostate gland.
Alterations in bladder and urethral function can occur with age. These changes may be manifested as only lower urinary tract symptoms, or by damage to the lower and/or upper urinary tract.
Benign prostatic hyperplasia is the term used to describe the histological change associated with benign prostatic enlargement. Benign enlargement of the prostate gland also progresses with age and can cause bladder outlet obstruction. Aging and bladder outlet obstruction can each can trigger changes in the structure and function of the bladder wall and its nerve supply, which can lead to clinical symptoms.

25. Lower Urinary Tract Obstructive Symptoms (LUTS)
1- AUA or IPSS score:
Poor stream.
Intermittency.
Feeling of incomplete void.
Urgency.
Frequency.
Nocturia.
Straining.
Others: post void dribbling, hesitancy, splashing…..

26. Lower Urinary Tract Irritative Symptoms (LUTS)
Urgency.
Frequency.
Dysuria.
Burning on micturation.
Some symptoms can be both obstructive and irritative.

27. Initial Evaluation of Patients Presenting with LUTS/BPH
History
IPSS and bother question
PE and DRE
Urinalysis
PSA*
Voiding diary †
LUTS Associated With
Suspicious DRE
Hematuria
Abnormal PSA
Pain
Infection‡
Palpable bladder
Neurologic disease
The presence of lower urinary tract symptoms only, with or without some degree of nonsuspicions prostate enlargement, is highly suggestive of bladder outlet obstruction due to BPH. These patients are managed according to the how much their symptoms bother them. The initial evaluation in noted here. In some circumstances, as noted in the second, lower box, patients should be referred for immediate urologic care.
Chatelain C, Denis L, Foo KT, et al. 5th International Consultation on BPH. Recommendations of the International Scientific Committee: Evaluation and treatment of lower urinary tract symptoms (LUTS) in older men. In: Chatelain C, Denis L, Foo KT, et al, eds. Benign Prostatic Hyperplasia. Plymouth, UK: Health Publication Ltd; 2001;
*In men with life expectancy of >10 years in whom the diagnosis of prostate cancer can alter management.
†Particularly useful in patients with nocturia as the leading symptom.
Chatelain C et al. In: Chatelain C et al, eds. Benign Prostatic Hyperplasia. Plymouth, UK: Health Publication Ltd; 2001;522.

28. Lower Urinary Tract Innervation
+M3
Pelvic Nerve
(Parasympathetic)
ACh
-3
+1
Hypogastric Nerve (Sympathetic) NE +N
Pudendal Nerve
(Somatic)
ACh
KEY POINT:
These nerves and neurotransmitters regulate lower urinary tract (LUT) function by stimulating the bladder, relaxing the urethra, contracting the urethra, and contracting the rhabdosphincter when appropriate.
ADDITIONAL INFORMATION:
The pelvic nerve (parasympathetic) originates from the sacral spinal cord; it stimulates the bladder using acetylcholine and relaxes the urethra employing nitric oxide.
The M3 receptor subtype is currently seen as the receptor responsible for contraction of the detrusor muscle.
The hypogastric nerve (sympathetic) originates from the lumbar spinal cord and uses norepinephrine to contract the urethra.
-adrenergic receptors also exist in the bladder; stimulation of these receptors results in direct relaxation of the detrusor smooth muscle. It appears that the action of the 3 receptor is responsible for detrusor muscle relaxation. This does not appear to be true for 1 or 2 selective antagonists.
Somatic control via the pudendal nerve originates from the sacral spinal cord causing contraction of the striated urethral sphincter. Activity is mediated by acetylcholine.
REFERENCES:
Van Arsdalen K, Wein AJ. Physiology of micturition and continence. In: Krane RJ, Siroky MD, eds. Clinical Neurourology; 1991:25-82.

29. Functional LUT

30. Incontinence and Enuresis
Continuous.
Stress Urinary incontinence SUI.
Urgency incontinence.
Overflow incontinence

31. Sexual Dysfunction ED. Loss of Libido. Failure of ejaculation.
Premature ejaculation.
Hematospermia

32. Other symptoms
Pneumaturia.
Urethral discharge.

33. Past Medical History
The G U system (s) is related anatomically and functionally with too many systems.
Diabetes is of particular importance ; due to increase incidence of UTI and voiding dysfunctions in diabetic patients.
CNS and PN disease are intimately related to bladder functions

34. Family History Is of particular importance in prostate cancer.
Certain stone diseases are inherited.
Familial renal cell carcinoma, polycystic kidney diseases and VHL disease.

35. Physical Examination The Kidney:
Are located in the upper retroperitoneum, the bowel anteriorly and a heavy muscle coat posteriorly lie between the kidneys and the examining hands.
The hilum of the kidney lies against L1-L2 area.

36. Physical examination.

37. The Kidneys

38. Bimanual examination can lift the kidney from the back while the other hand examine the kidney anteriorily.
The right kidney is slightly lower than the left. The lower pole of both kidneys can be palpated easily in children and thin adults.
Differentiation between an enlarged kidney Vs spleen should be made

39. Ultrasound assessment of the kidney should be regarded as an extension of physical examination.

40. Bladder
When full the bladder lie immediately under the abdominal wall.
in children the bladder is an abdominal organ.
A full bladder can reach the umbilicus.
Percussion is more accurate than palpation in assessing a full bladder

42. Prostate gland
Pictured is a cross sectional view of the prostate gland with the rectum and the bladder. When the physician inserts his finger into the rectum to feel the prostate, he feels only the peripheral zone where 75 to 85% of prostate cancer arises. An irregularity in the peripheral zone should raise suspicion of prostate cancer.
Immediately interior to the peripheral zone is the central zone, which is a fairly large area in a normal prostate. Its function has not been determined. It is the area through which the ejaculatory ducts traverse through the prostate on their way to the internal component of the prostatic urethra, where the semen is then released into the urethra.
Immediately internal to the central zone is the transition zone, which is relatively small in the normal prostate, but is enlarged in benign prostatic hyperplasia (BPH) and encroaches on the urethra to obstruct the flow. 10 to 15% of prostate cancers arise in the transition zone. Men with unexplained elevations in prostate-specific antigen and negative biopsies in the peripheral zone are candidates for transition zone biopsies.
A small area surrounding the urethra, called the periurethra zone does not play a role in BPH, but does play a role in the symptoms associated with BPH, which are known as lower urinary tracts symptoms.
The fibromuscular zone is an area of stroma that involves smooth muscles and connective tissue. The ratio of fibromuscular tissue to glands in the nonenlarged prostate is 2 to 1, which increases to 5 to 1 as a man develops symptoms and BPH.

43. Physical examination.

44. Physical examination.

45. Digital Rectal Examination DRE
should be performed in every male after age 40 years and in men of any age who present for urologic evaluation .
Many prostate cancers can be detected in an early curable stage by DRE, and about 25% of colorectal cancers can be detected by DRE in combination with a stool guaiac.

46. Prostate Cancer Diagnosis Digital Rectal Exam (DRE)
DRE is still important, even with the availability of PSA testing. But it’s of limited value, because only approximately 50% of palpable lesions are carcinoma. In addition, most men with prostate cancer have no nodules.
BUT only 1/2 of nodules are CA, and most men with CA have no nodules.

47. Digital Rectal Examination DRE
The exam should be explained to the patient, privacy and integrity of the patient observed, and exam result conveyed.
Normally, the prostate is about the size of a chestnut and has a consistency similar to that of the contracted thenar eminence of the thumb (with the thumb opposed to the little finger).

48. Abnormal Physical Examination Findings—Prostate
Acute Prostatitis .
Benign Prostatic Hyperplasia .
Carcinoma of the Prostate

49. The 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).
The position of the urethral meatus should be noted (hypospadias epispadias).
The urethral meatus should be separated between the thumb and the forefinger to inspect for neoplastic or inflammatory lesions within the fossa navicularis.

50. Abnormal Physical Examination Findings of Penis
Phimosis .
Paraphimosis .
Peyronie's Disease .
Priapism .
Carcinoma

51. Physical examination.

52. Urinalysis Bacteriuria Hematuria Pyuria Glycosuria Proteinuria
KEY POINT:
A urinalysis will rule out infection and can be done by dipstick or microscope. A urinalysis often includes tests to detect nitrates and leukocyte esterase.
ADDITIONAL INFORMATION:
(Glycosuria is also called glucosuria.)

53. The kidney (Intra-operative)