OnExam

Kidneys

Inspection
  • Flank masses
  • Peripheral edema
  • Periorbital edema
Auscultation
  • Bruits (renal arteries-10 cm lateral to umbilicus)
Palpation
  • CVA Tenderness
    • Percuss with ball of hand
    • Pain suggests pyelonephritis or MSK injury
  • Capture the Kidneys
      1. Place the patient supine
      2. Stand on the patients' right side
      3. Reach over and behind patient to pull up behind left posterior, costospinal angle
      4. Ask the patient to take a deep breath
      5. Press right hand firmly into LUQ just below costal margin to capture kidney
      6. Ask patient to breathe out and briefly stop breathing
      7. Slowly reduce pressure of right hand to release kidney. If palpable, note: size, contour, tenderness.
      8. Repeat with right kidney using left hand to lift patient’s right CVA and right hand to capture kidney in RUQ

Anus and Rectum

Inspection
  • Position the patient lying on their left side, buttocks close to edge of table, hips and knees flexed and put on gloves
  • Sacrococcygeal and perianal areas
    • Lumps, ulcers, inflammation, rashes or excoriations
    • Anal and perianal lesions: haemorrhoids, venereal warts, herpes, syphilitic chancre, and carcinoma
    • Anal fissure from large, hard stools, IBD, or STIs
    • Pruritus ani: swollen, thickened, fissured perianal skin with excoriations
  • Anus
    • Ask the patient to strain down
    • Anal abscess: tender, purulent, reddened mass with fever/chills
    • Fistulas may ooze blood, pus, or feculent mucus
    • Rectal prolapse, haemorrhoids, fissures
    • Anoscopy or sigmoidoscopy for better visualization
Palpation
  • Conduct a digital rectal exam.
  • Sensitivity for detecting prostate cancer of 59% and a specificity of 94%

Bladder

Inspection
  • Acute or chronic urinary retention: bladder outline may be visible at or above the umbilicus
Percussion
  • Percuss the bladder to assess for dullness
  • Percuss to asses bladder level above the symphysis pubis. Percussable dullness occurs when bladder volume is 400-600ml
  • Can be percussed if containing >150 cc urine
  • Useful in chronic retention as bladder wall can be flabby and difficult to palpate
Palpation
  • Top dome of bladder should feel smooth and round when distended
  • Palpate for bladder tenderness
  • Cannot be felt unless moderately distended
  • Acute or chronic urinary retention
  • Male infants/boys: hypertrophied bladder secondary to obstruction by posterior urethral valves

Male Genitalia

Penis

Inspection
  • Ulcers
  • Scars
  • Nodules
  • Signs of inflammation
    • Prepuce (foreskin): retract or ask patient to retract
    • Phimosis: tight prepuce that cannot be retracted over the glans
    • Paraphimosis: tight prepuce that, once retracted, cannot be returned (leads to edema)
    • Balanitis: inflammation of glans
    • Balanoposthitis: inflammation of glans and prepuce
    • Hypospadias: congenital, ventral displacement of the meatus
    • Shaft and base of penis
    • Nits or lice at the bases of the pubic hairs
    Palpation
    • Palpate any abnormalities
    • Glans: Compress the glans gently between index finger and thumb
      • Inspect urethral meatus for discharge
      • If discharge not visible at time of inspection, milk shaft of the penis from base to the glans
    • Shaft: between first two fingers and thumb (omit in young, asymptomatic males)
    • Note any tenderness or induration
      • Induration along ventral surface of penis suggests urethral stricture or carcinoma
      • Tenderness of indurated area suggests periurethral inflammation (secondary to urethral stricture)

Scrotum

Inspection
  • Rashes, lumps, swelling, veins, erythema, scrotal contours
  • Make sure to include posterior surface of scrotum
  • Poorly developed scrotum on either side (cryptorchidism)
  • Epidermoid cysts: dome-shaped white/yellow papules/nodules formed by occluded follicles filled with keratin; common and benign
Palpation
  • Testes and each epididymis (superior surface of testicle, should feel cordlike and nodular) between thumb and first two fingers
  • Note size, shape, consistency, tenderness, and nodules
  • Normal testis size: 3.5-5.5 cm
  • Left testis usually hangs lower than right
  • Epididymis is usually nodular and cordlike
  • Spermatic cord from the epididymis to the inguinal ring noting nodules or swellings
  • Check for hernias (instructions below)

Female Genitalia

Find a complete female genitalia exam outlined in the Obstetrics and Gynecology Physical Exam section.

Inguinal, Femoral, Scrotal Hernias

    Inspection
  • Positioning
    • Patient: standing with inguinal/femoral/genital area exposed
    • Examiner: sitting on stool in front of patient, using oblique lighting if possible
  • Inspect inguinal/femoral/scrotal areas when patient relaxed and actively coughing
  • Location of bulge
    • Above (inguinal) or below (femoral) inguinal ligament crease
Palpation
  • Examiner: Stand to side of patient, place fingers of right hand over patient’s right femoral region, the external inguinal ring, and the internal ring; vice versa on patient’s left side
  • Ask patient to cough, note any bulging/impulse on fingers
Males
  • Examiner: return to the sitting position, in front of patient
  • Place tip of right index finger close to inferior margin of scrotal sac; locate right spermatic cord
  • Course cord structures to right external inguinal ring, just lateral to right pubic tubercle
  • Ask patient to cough or strain down; note bulging/impulses
    • Direct hernia, bulge felt on side of finger
    • Indirect hernia: bulge felt at tip of finger (coming from internal inguinal ring)
    • Indirect hernia may extend into scrotum
    • Differentiate from hydrocele: hernia will not transilluminate, will not have a superior border, and may have bowel sounds to auscultation
  • If findings suggest hernia, try to reduce it by sustained pressure with your fingers
    • Incarcerated: contents cannot be returned to the abdominal cavity
    • Strangulated: blood supply to entrapped contents is compromised
  • Suspected if tender and patient experiencing nausea, and vomiting
  • Consider surgery

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. Hoogendam, A., Buntinx, F., CW de Vet, H. (1999). The diagnositic value of digital rectal examination in primary care screening for prostate cancer: a meta-analysis. Family Practice, 16(6), 621-626.
  5. Tanagho A. E., McAninch W. J. Access Medicine: Smith’s General Urology: Physical Examination of the Genitourinary Tract. http://www.accessmedicine.com.normedproxy.lakeheadu.ca/content.aspx?aid=3126305. Published 2008. Accessed February 14, 2011.
  6. Amerson JR. Inguinal canal and hernia examination. In: Walker HK, Hall WD, Hurst JW. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Boston, MA; 1990: 484-485.
  7. Bickley, S., Szilagyi, P. Bates’ Guide to Physical Examination and History Taking. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.