OnExam

Identifying Information

Gather the patient's general identifying data.

Chief Complaint

Elicit the patient's chief complaint or reason for visit.

History of Presenting Illness (HPI)

Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach.

Pain

Flank Pain

  • Renal pain:
    • Cause: inflammation or obstruction causing distension of renal capsule
    • Location: ipsilateral costovertebral angle
    • Radiation: across flank anteriorly to umbilicus to groin, testis, or labium
    • Characteristics:
      • Dull, aching, radiation to umbilicus
      • Inflammation: steady pain
      • Obstruction: fluctuates in intensitiy (colicky)
      • Patients are more comfortable moving around and holding flank (colicky/retroperitoneal) as opposed to lying motionless to minimize pain (peritoneal)
    • Ureteral colic
      • Cause: distension of ureter, hyperperistalsis and spasm of ureteral smooth muscle
      • Location/Radiation
        • Dependent on site of ureteral obstruction
        • Upper ureter: upper abdomen
        • Mid-ureter: lower abdomen (simulates appendicits/diverticulitis)
        • Approaching bladder: urinary frequency, urgency, suprapubic discomfort, may radiate along urethra (penile/labium pain)
      • Characteristics:
        • Excruciating
        • Intermittent (occurs cyclically q20-60mins)
      • Pertinent Positives
        • Nausea/vomiting (urinary calculi, pyelonephritis)
        • Gross hematuria (urinary calculi)
        • Fever/chils (pyelonephritis)

Suprapubic Pain

  • Most common cause of bladder pain: UTI
  • See UTI symptoms and likelihood ratios table in next section.
  • Characteristics
    • Sudden bladder distention: agonizing
    • Chronic bladder distention: often painless
    • Inflammatory: intermittent
    • Relieved partially by voiding (cystitis)
  • Irritative Symptoms
    • Frequency
    • Urgency
    • Nocturia
    • Dysuria

Anal/Rectal Discomfort/Pain

  • Tenderness
  • Pain on defecation (proctitis)
  • Itching on defecation (proctitis)
  • Mucopurulent discharge, bleeding
  • Ulcerations or growths
  • Anal intercourse

Penile Pain

  • Etiology
    • Flaccid penis
      • Referred pain from inflammation of bladder or urethra
      • Paraphimosis (uncircumcised foreskin is trapped behind glans penis = venous obstruction and engorgement of glans penis)
    • Erect penis
      • Peyronie diseease
      • Priapism

Scrotal/Testicular Pain

  • Etiology:
    • Referred (kidney, ureter, urethra)
    • Edema/inflammation (scrotal pathology, testicular torsion, epididymitis, scrotal abscess)
    • Distension (hydrocele, varicocele)
  • Characteristics
    • Rapid onset of severe local pain (testicular torsion)
    • Dull, heavy sensation that does not radiate (varicocele/hydrocele)
  • Pertinent positives
    • Scrotal edema/induration
    • Nausea/Vomiting
    • Irritative urinary symptoms
    • Fever (testicular torsion, epididymitis)
    • Urethral discharge

Hematuria

  • Gross hematuria: visibly red, pink, brown/tea-coloured
  • Microscopic hematuria: detection by dip stick or urinalysis
  • Sign of urological malignancy until proven otherwise
  • Chance of malignancy increases with degree of hematuria
  • Cause
    • Recent UTI
    • Voiding stones
    • Urological malignancy
    • Nephritic Syndrome - recent streptococcal pharyngitis
    • Recent ingestion of beets
  • Characteristics
    • Timing:
      • Initial: urethra
      • Total: bladder or upper urinary tract
      • Terminal: bladder neck or prostatic urethra
    • Clots:
      • Presence
      • Shape: vermiform (upper urinary tract)
    • Pain:
      • Severe, colicky flank pain (clots, stones)
      • Obstruction of ureters with clots
      • UTI
  • Red Flags:
    • Gross hematuria
    • Persistent microscopic hematuria
    • Age > 50 years
    • Hypertension
    • Edema

Urinary Incontinence

  • Stress Incontinence
    • Sudden leakage of urine with coughing, laughing, sneezing, lifting
    • Most common in women after childbearing or menopause
  • Urge Incontinence
    • Involuntary leakage of urine preceded by a strong urge to void
    • Cystitis, neurogenic bladder, bladder outlet obstruction
  • Mixed Incontinence
    • Combination of urge and stress incontinence
  • Overflow Incontinence
    • Involuntary leakage of urine when bladder pressure exceeds urethral pressure
    • Bladder chronically distended and never empties completely
    • Dribbling throughout day and worse at night
    • Develops over a long period of time
  • Functional Incontinence
    • Inability to hold urine due to reasons other than neurologic and lower urinary tract dysfunction
    • Patient mobility, alertness, ability to access toilet
  • Continuous Incontinence
    • Urinary tract fistula
    • Ectopic ureter
  • Enuresis
    • Urinary incontinence that occurs during sleep
    • Normal in children < 3 year old, but may persits up to 5 years old

Urinary Symptoms

  • Irritative Symptoms
    • Frequency
    • Urgency
    • Nocturia
    • Dysuria
  • Obstructive Symptoms
    • Weak stream
    • Intermittency
    • Straining
    • Hesitancy
    • Incomplete emptying (sensation)
    • Post-void dribbling
    • Polyuria (> 3L urine/day)
    • Hematuria
    • Pneumaturia
      • Passage of gas in urine
      • Recent urinary tract instrumentation or catheterization
      • Fistula formation (diverticulitis, sigmoid cancer, Crohn's disease)
    • Perineal pain
    • Pertinent Positives
      • Fever
      • Chills
      • Nausea
      • Vomiting

Sexual Dysfunction

  • Preference and Satisfaction
    • Relationship status
    • Sexual preference (men, women, both)
    • Satisfaction of sexual ability
  • Loss of libido
  • Impotence
    • Ability to achieve and maintain erection sufficient for intercourse
    • Ability to achieve an erection in the mornings
    • Onset
      • Sudden-psychogenic cause
      • Gradual-organic cause
      • Situational
    • Nocturnal or early morning erections
  • Premature Ejaculation
    • Reach orgasm within < 1 minute of initiation of sexual intercourse
  • Failure to ejaculate
  • Absence of orgasm

Urethral Discharge

  • Most common symptoms of STI
  • Gonococcal urethritis: thick, profuse, yellow to gray in colour
  • Nonspecific urethritis: scant and watery
  • Urethra Carcinoma: bloody
  • Hematospermia: presence of blood in seminal fluid
  • Tenosynovitis, monoarticular arthritis, and rash occur in disseminated gonorrhea
  • Likelihood Ratios for Symptoms, Signs, and Findings

    Likelihood ratios for men with suspected UTI

    Symptom
    LR+
    LR-
    Hematuria
    29
    0.7
    Offensive urine
    28
    0.7
    Nausea
    9
    0.7
    Dysuria
    3
    0.4
    Symptoms ≤ 9 days
    2
    0.6
    Previous IVP
    2
    0.8
    Urgency
    1
    0.9
    Previous UTI
    1
    0.9
    Increased frequency
    1
    1.3
    Nocturia
    0
    2.2

    Likelihood ratios for women with suspected UTI

    Symptom
    LR+
    LR-
    Self-diagnosis
    4
    0.1
    No vaginal discharge
    3.1
    0.3
    No vaginal irritation
    2.7
    0.2
    Hematuria
    2.0
    0.9
    Frequency
    1.8
    0.6
    Costovertebral tenderness on exam
    1.7
    0.9
    Back pain
    1.6
    0.8
    Fever
    1.6
    0.9
    Dysuria
    1.5
    0.5
    Flank pain
    1.1
    0.9
    Lower abdominal pain
    1.1
    0.9
    No vaginal d/c on exam
    1.1
    0.7

    Past Medical History (PMHx)

    • Diseases of the urinary tract
    • Sexually transmitted infections
    • Benign prostatic hyperplasia
    • Diabetes Mellitus
    • Hypertension
    • Neurologic diseases
    • Past Surgical History
      • Scopes (uretero-, cysto-)
      • TURP
      • TVT-O
      • Resections or procedures involving kidneys, adrenals, ureters, bladder and/or urethra
      • Hysterectomy
    • Any history of HIV testing?
    • Previous cyclophosphamide use (increased bladder cancer risk)

    Family History (FmHx)

    • Nephro/urolithiasis
    • Polycystic Kidney Disease
    • Tuberous Sclerosis
    • Renal Tubular Acidosis
    • Cystinuria
    • Cancer - prostate, bladder, renal
    • Inflammatory bowel disease
    • Colorectal cancer and polyps

    Social History (SocHx)

    • Travel history
    • Exercise
    • Diet
    • Alternative healthcare practices
    • Type of intercourse: anal, oral, vaginal
    • Bladder cancer risk factors: smokers, dye industry workers, textile workers and painters, hairdressers

    Substance Use History (SubHx)

    Medications

    • Antihypertensives (interfere with erectile function)
    • Psychotropics interfere with emission and orgasm
      • Sedatives
      • Tranquilizers
      • Benzodiazepines
      • Antidepressants
    • Anticholinergics
    • Sympathetic blockers
    • Diuretics
    • Antimicrobials
      • Aminoglycosides
      • Penicillins
      • Cephalosporins
      • Amphotericin
    • Chemotherapy
    • NSAIDs
    • Nitroglycerin (contraindicated to Rx Nitro and PDE5’s)

    Allergies

    Note allergies and ensure they concord with those listed in the EMR

    Immunizations

    • Note immunization history as described in the immunization history section. Especially relevant to the Genitourinary History is the HPV vaccine.
    • Especially relevant to GU section:
      • HPV vaccine
      • Mumps vaccine (Mumps infection can lead to sterility)

    Review of Systems

    Conduct a review of systems, keeping other etiologies from your differential in mind.

    References

    1. Bickley S. L. The Abdomen: The Kidneys. In: Bates’ Guide to Physical Examination. 10th ed. Philadelphia PA: Lippincott Williams & Wilkins; 2009: 445.
    2. Bickley S. L. Male Genitalia and Hernias. In: Bates’ Guide to Physical Examination. 10th ed. Philadelphia PA: Lippincott Williams & Wilkins; 2009: 501-512.
    3. Bickley S. L. The Anus, Rectum, and Prostate. In: Bates’ Guide to Physical Examination. 10th ed. Philadelphia PA: Lippincott Williams & Wilkins; 2009: 555-564.
    4. Miller E. M. STDs (gonococcal infections). Essential Evidence Plus. http://www.essentialevidenceplus.com.normedproxy.lakeheadu.ca/content/eee/342. Published 2009. Accessed February 11, 2011.
    5. Preminger, G.M. Urinary Calculi. The Merck Manual Online Medical Library: The Merck Manual for Health Care Professionals. http://www.merckmanuals.com/professional/genitourinary_disorders/urinary_calculi/urinary_calculi.html?qt=nephrolithiasis&alt=sh#v1052661. Published 2012. Accessed November 2, 2013.
    6. Shankel S. Bacterial Urinary Tract Infections. The Merck Manual Online Medical Library: The Merck Manual for Health Care Professionals. http://www.merckmanuals.com/professional/genitourinary_disorders/urinary_tract_infections_uti/bacterial_urinary_tract_infections.html?qt=pyelonephritis&alt=sh#v1052851. Published 2012. Accessed November 2, 2013.
    7. Shenot, P. J.. Epididymitis. The Merck Manual Online Medical Library: The Merck Manual for Health Care Professionals. http://www.merckmanuals.com/professional/genitourinary_disorders/penile_and_scrotal_disorders/epididymitis.html?qt=epididymitis&alt=sh#v1058894. Published 2013. Accessed November 2, 2013.
    8. Shenot, P. J. Testicular Torsion. The Merck Manual Online Medical Library: The Merck Manual for Health Care Professionals. http://www.merckmanuals.com/professional/genitourinary_disorders/penile_and_scrotal_disorders/testicular_torsion.html?qt=testicular%20torsion&alt=sh#v1059012. Published 2013. Accessed November 2, 2013.
    9. Sidani A. M., Zoorob, J. R. Urinary tract infection (adult). Essential Evidence Plus. http://www.essentialevidenceplus.com.normedproxy.lakeheadu.ca/content/eee/654. Published 2009. Accessed February 11, 2011.
    10. Flannery T. M. Benign prostatic hyperplasia. Essential Evidence Plus. http://www.essentialevidenceplus.com.normedproxy.lakeheadu.ca/content/eee/358. Published 2010. Accessed February 11, 2011.
    11. Sadjadi S. Isolated Hematuria. The Merck Manual Online Medical Library: The Merck Manual for Health Care Professionals. http://www.merckmanuals.com/professional/sec17/ch226/ch226h.html. Published 2009. Accessed February 11, 2011.
    12. Tanagho A. E., McAninch W. J. Access Medicine: Smith’s General Urology: Symptoms of Disorder of the Genitourinary Tract. http://www.accessmedicine.com.normedproxy.lakeheadu.ca/content.aspx?aid=3126305. Published 2008. Accessed February 14, 2011.