If NVH persists after initial negative investigation, should the patient undergo repeat inv estigation? Where dipstick haematuria persists after initial renal imaging and cystos- copy reveal no cause, the diagnostic yield of repeat investigation is very low. Nephrologic and repeat urological investigation reveal no urological malignancies, IgA nephropathy in 12%, and UTI in 24%.11 The recommendation from these studies is that repeat urological inves- tigation is not nece ssary unless a patient become symptomatic or develops visible haematuria. References 1 Edwards TJ, Dickinson AJ, Natale S, et al. (2006) A prospective analysis of th e diagnostic yield resulting from the attendance of 4020 patients at a protocol-driven haem aturia clinic. BJU Int 97:301 \200\2235. 2 Sultana SR, Goodman CM, Byrne DJ, Baxby K (1996) Microscopic haematuria: urological investigation using a standard protocol. Br J Urol 78:691 \200\2238. 3 Topham PS, Harper SJ, Furness PN, et al. (1994) Glomerular disease as a cause of isolated microscopic haematuria. Q J Med 87:329 \200\22335. 4 Tomson C, Porter T (2002) Asymptomatic microscopic or dipstick haematuria on adults: whic h investigations for which patients? A review of the evidence. Br J Urol 90:185 \200\22398. 5 Khadra MH, Pickard RS, Charlton M et al. (2000) A prospective analysis of 1930 patients w ith hematuria to evaluate current diagnostic practice. J Urol 163:524 \200\2237. 6 Turney BW, Willatt JM, Nixon D, et al. (2006) Computed tomography urography for diagnosing bladder cancer. BJU Int 98:345 \200\2238. 7 Cowan NC, Turney BW, Taylor NJ, et al. (2007) Multidetector computed tomography urography for diagnosing upper urinary tract urothelial tumors. BJU Int 99:1363-70. 8 Sudakoff GS, D unn DP, Guralnick ML, et al. (2008) Multidetector computed tomography urography as the primary imaging modality for detecting urinary tract neoplasms in patients with asymptomatic hematuria. J Urol 179:862 \200\2237. 9 Grossfeld GD (2001) Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association Best Practice Policy-Part II: patient evaluation, cytology, voided markers, imaging, cystoscopy, nephrology evaluation and follow-up. Urology 57:604 \200\22310. 10 Khadra MH (2000) A prospective analysis of 1930 patients with hematuria to e valuate current diagnostic practice. J Urol 163:524 \200\2237. 11 Mishriki SF (2008) Diagnosis of urologic malignancies in patients with asymptomatic dips tick haematuria: prospective study with 13year \200\231s follow-up. Urology 71:13-163. 12 Howard RS (1991) Long-term follow-up of asymptomatic microhematuria. J Urol 145:335 \200 \2236. CHAPTER 2 Signi \201 cance & preliminary investigation 14 Haemospermia De \201 nition The presence of blood in the semen. Usually intermittent, benign, self-limi ting, and no cause identi \201 ed. Causes Age <40y: usually in \202 ammatory (e.g. prostatitis, epididymo-orchitis, ure- thri tis); infective, including sexually transmitted diseases (STDs) (e.g. gonococcus), non-STD infection (e.g. Enterococcus faecalis, Chlamydia tra- chomatis, Ureaplasma urealyticum), or viral infection (e.g. Herpes simplex), urethral warts or idiopathic (though to an extent, this re \202 ects the limited investigation that is usually carried out in this age group) . Rarely, testicular tumor; perineal or testicular trauma. Tumors are found in 2.4%. Age >40y: as for men aged <40 \200\224commonest cause is now post-transrec- tal ultrasound (TRUS) biopsy of prostate; prostate cancer; bladder cancer; testicular cancer; BPH; dilated veins in the prostatic urethra; prostatic or seminal vesicle calculi; hypertension; carcin oma of the seminal vesicles; post-external beam radiotherapy or brachytherapy for prostate cancer. Tumors are found in 3.5% (mostly prostatic, rarely testis, seminal vesicle, epididy mal). Rare causes at any age: bleeding diathesis (von Willebrand \200\231s disease, hemophilia, a cquired coagulation defects); utricular, M llerian or seminal vesicle cysts \200\224which may cause ductal obstruction, dilatation, distension, and rupture of blood vessels; TB; sch istosomiasis; amyloid of prostate or seminal vesicles; post-injection of hemorrhoids. Very rarely, haemosper- mia may be confused with melanospermia from urinary tract melanoma. NB. Abnormalities detected on TRUS or MRI may not necessarily be the cause of the haemospermia. Examination Examine the testes, epididymis, prostate, and seminal vesicles (DRE). Measure B P. Investigation Send urine for culture. If risk of exposure to STDs, refer to local STD clini c for STD screen. If the haemospermia resolves after a single episode, an argument can be m ade for doing nothing else. If it recurs or persists, then even in young men (2.4% risk of \201 nding cancer if <40y old), arrange tests for PSA, FBC, LFTs and clotting, TRUS, \202 exible cystoscopy (look for ure- thral polyps, urethritis, prostatic cysts, urethral f oreign bodies, stones, and vascular abnormalities) and renal ultrasound, pelvic MRI (MRI an giography can identify rare vascular abnormalities). The author has a low threshold for \202 exible cystoscopy given the simplicity of doing this test. If haematuria coexists, inv estigate this as described. HAEMOSPERMIA 15 Treatment This is directed at the underlying abnormality, if found. If no cause is found, r eassure the patient that most cases are self-limiting. Further reading Ganabathi K, Chadwick D, Feneley RCL, Gingell JC (1992) Haemospermia. Br J Urol 69:225 \200\22330. Jones DJ (1991) Haemospermia: a prospective study. Br J Urol 67:88 \200\22390. Ahmad I, Krishna NS (2007) Hemospermia. J Urol 177:1613 \200\2238 CHAPTER 2 Signi \201 cance & preliminary investigation 16 Lower urinary tract symptoms (LUTS) A plethora of terms have been coined to describe the sy mptom complex traditionally associated with prostatic obstruction due to BPH. The \200\230 clas- sic \200\231 prostatic symptoms of hesitancy, poor \202 ow, frequency, urgency, noc turia, and terminal dribbling have, in the past, been termed \200\230pros- tatism \200\231 or simply \200\230BPH symptoms \200\231. One sometimes hears these symp- toms being descr ibed as due to \200\230BPO \200\231 (benign prostatic obstruction) or benign prostatic enl argement ( \200\230BPE \200\231; benign prostatic enlargement) or, more recently, \200\230 LUTS/BPH \200\231. However, these \200\230classic \200\231 symptoms of pro- static disease bear little relationship to prostate size, urinary \202 ow rate, residual urine volume o r indeed, urodynamic evidence of bladder outlet obstruction.1,2 Furthermore, age-matched me n and women have similar \200\230prostate \200\231 symptom scores,3,4 but women obviously have no prostate. We, therefore, no longer use the expression \200\230prostatism \200\231 to describe the symp- tom complex of hesitancy, poor \202 ow, etc. Instead, we call such symp- toms \200\230lower urinary tract symptoms \200\231 (LUTS), which is purely a descrip tive term avoiding any implication about the possible underlying cause of these symptoms.5 The new terminology \200\230LUTS \200\231 is useful because it reminds the urolo- gist to consider possible alternative causes of symptoms which may have absolutely nothing to do wi th prostatic obstruction and it reminds us to avoid operating on an organ, such as the pros tate, when the cause of the symptoms may lie elsewhere. Baseline symptoms can be \200\230measured \200\231 using a symptom index. The most widely used is the International Prostate Symptom Score (IPSS) which, in addition to the seven sym ptoms of the American Urological Association- Symptom Index (AUA-SI), includes a question f or the patient to assess the \200\230bothersomeness \200\231 of their LUTS6, the AUA-SI. Other causes of LUTS In broad terms, LUTS can be due to pathology in the prostate, the blad der, the urethra, other pelvic organs (uterus, rectum), or due to neurological disease affe cting the nerves that innervate the bladder. These pathologies can include BPE causing blad der out \202 ow obstruction (BOO), and infec- tive, in \202 ammatory, and neoplastic cond itions of the bladder, prostate, or urethra. While LUTS are, in general, relatively non-spe ci \201 c for particular pathologies, the context in which they occur (i.e. associated sym ptoms) can indicate their cause. For example: \200 LUTS in association with macroscopic haematuria or with dipstick or microscopic haematuria suggests a possibility of bladder cancer. This is more likely if urinary frequency, urgency , and \200\230bladder \200\231 pain (suprapubic pain) are prominent. Carcinoma in situ of the bladder \200\224a non-invasive, but potentially very aggressive, form of bladder cancer which very often progresses to muscle-invasive or metastatic cancer \200\224classically pr esents in this way. Recent onset of bedwetting in an elderly man is often due to high- pres sure chronic retention. Visual inspection of the abdomen may show marked distension due to a grossly enlarged bladder. The diagnosis of chronic retention is con \201 rmed by palpati ng the enlarged, LOWER URINARY TRACT SYMPTOMS (LUTS) 17 tense bladder which is dull to percussion and by drainage of a large volume (often well in excess of 2L) following catheterization Rarely, LUTS can be due to neurological disease cau sing spinal cord or cauda equina compression or to pelvic or sacral tumors. Associated symp toms include back pain, sciatica, ejaculatory disturbances, and sensory disturbances in the legs, feet, and perineum. In these rare cases, loss of pericoccygeal or perineal sensation (sacral nerve roots 2 \200\2234) indicates an interruption to the sensory innervation of t he bladder and an MRI scan will con \201 rm the clinical suspicion that there is a neurolo gical problem. 1 Ganabathi K, Chadwick D, Feneley RCL, Gingell JC (1992) Haemospermia. Br J Urol 69:225 \200\22330. 2 Jones DJ (1991) Haemospermia: a prospective study. Br J Urol 67:88 \200\22390. 3 Reynard JM, yang Q, Donovan JL, et al. (1998) The ICS- \200\231BPH \200\231 study: uro \202 owmetry, lower urinary tract symptoms and bladder outlet obstruction. Br J Urol 82:619 \200\22323. 4 Lepor H, Machi G (1993) Comparison of AUA symptom index in unselected males and females b etween \201 fty- \201 ve and seventy-niney of age. Urology 42:36 \200\22341. 5 Abrams P (1994) New words for old \200\224lower urinary tracy symptoms for \200\230prost atism \200\231. Br Med J 308:929 \200\22330. 6 Barry MJ, Fowler FJ Jr, O \200\231Leary MP, et al. (1992) The American Urological Associa tion symptom index for benign prostatic hyperplasia. J Urol 148:1549 \200\22357. CHAPTER 2 Signi \201 cance & preliminary investigation 18 Nocturia and nocturnal polyuria \200 \200 Nocturia Prevalence of nocturia women \200\22410% aged 20 \200\22340y, 50% aged >80y. Noctu ria in the ambulant elderly. Men who void more than twice at night have a 2-fold increased risk of death (possibly due to the associations of nocturia with endocrine and cardiovascul ar disease).3 (cid:116)2 is common and bothersome (sleep disturbance). (cid:116)2:1,2 men \200\22440% aged 60 \200\22370y, 55% aged >70y; (cid:116)2 is associated with a 2-fold increased risk of falls and injury The diagnostic approach to the patient with nocturia Nocturia can be due to urological dise ase, but more often than not, is non-urological in origin. Therefore, \200\230approach the lower urinary tract last \200\231 (Neil Resnick, Professor of Gerontology, Pittsburgh4). Causes of nocturia - - Urological: Non-urological: mellitus, central diabetes insipidus (DI), nephrogenic DI, prim ary polydipsia, hypercalcaemia, drugs, autonomic failure, obstructive sleep apnoea. BPO, overactive bladder, incomplete bladder emptying. renal failure, idiopathic nocturnal p olyuria, diabetes Assessment of the nocturic patient Ask the patient to complete a frequency volume chart (FV C) \200\224a voiding diary that records time and volume of each void over a 24h period for 7 days. This establishes: - - If the patient is polyuric or non-polyuric? If polyuric, is the polyuria present throughout 24h or is it con \201 ned to night time (nocturnal polyuria)? Polyuria is de \201 ned empirically as >3L of urine output per 24h (Stand- ardization Comm ittee of the International Continence Society (ICS), 2002). Nocturnal polyuria is empirically de \201 ned as the production of more than one-third of 24h urine output between midnight and 8 a.m. (It is a normal physiological mechanism to red uce urine output at night. Urine output between midnight and 8 a.m. \200\224one-third of th e 24h clock \200\224should certainly be no more than one-third of 24h total urine output an d in most people, will be considerably less than one-third.) Polyuria (urine output of >3L per 24h) is due either to a solute diuresis or a water diures is. Measure urine osmolality: <250mOsm/kg = water diuresis, >300mOsm/kg = solute diuresis. Excess levels of various solutes in the urine, such as glucose in the poorly controlled dia betic, lead to a solute diuresis. A water diuresis occurs in patients with primary polydip- sia (an appropriate physiological response to high water intake) and DI (antidiuretic horm one (ADH) de \201 ciency or resistance). Patients on lithium have renal resistance to ADH (nephrogenic DI). NOCTURIA AND NOCTURNAL POLYURIA 19 Further reading Guite HF, Bliss MR, Mainwaring-Burton RW, et al. (1988) Hypothesis: posture is one of the d eter- minants of the circadian rhythm of urine \202 ow and electrolyte excretion in elder ly female patients. Age Ageing 17:241 \200\2238. Matthiesen TB, Rittig S, Norgaard JP, Pedersen EB, Djurhuus JC (1996) Nocturnal polyuria an d natriuresis in male patients with nocturia and lower urinary tract symptoms. J Urol 156:1 292 \200\2239. 1 Coyne KS, Zhou Z, Bhattacharyya SK, et al. (2003) The prevalence of nocturia and its effe ct on health-related quality of life and sleep in a community sample in the USA. BJU Int 92 :948 \200\22354. 2 and diagnosis. BJU Int 84:5 \200\2238. Jackson S (1999) Lower urinary tract symptoms and nocturia in women: prevalence, etiology 3 McKeigue P, Reynard J (2000) Relation of nocturnal polyuria of the elderly to essential h yper- tension. Lancet 355:486 \200\2238. 4 Resnick NM (2002) Geriatric incontinence and voiding dysfunction. In Walsh PC, Retik AB, Vaughan ED, and Wein AJ (eds)Campbell \200\231s Urology 8th edn. Philadelphia: WB Saunders. CHAPTER 2 Signi \201 cance & preliminary investigation 20 Loin ( \202 ank) pain This can present suddenly as severe pain in the \202 ank reaching a peak within minutes or hours (acute loin pain). Alternatively, it may have a slower cours e of onset (chronic loin pain), developing over weeks or months. Loin pain is frequently pr esumed to be urological in origin on the simplistic basis that the kidneys are located in t he loins. However, other organs are located in this region, pathology within which may be t he source of the pain and pain arising from extra-abdominal organs may radiate to the loins ( \200\230referred \200\231 pain). So when faced with a patient with loin pain, think late rally \200\224the list of differential diagnoses is long! The speed of onset of loin pain gives some, although not an absolute, indication of the cau se of urological loin pain. Acute loin pain is more likely to be due to something obstructi ng the ureter, such as a stone. Loin pain of more chronic onset suggests disease within the kidney or renal pelvis. Acute loin pain The most common cause of sudden onset of severe pain in the \202 ank is t he passage of a stone formed in the kidney down through the ureter. Ureteric stone pain cha racteristically starts very suddenly (within minutes), is col- icky in nature (waves of inc reasing severity are followed by a reduction in severity, although seldom going away comple tely), and it radiates to the groin as the stone passes into the lower ureter. The pain may change in location, from \202 ank to groin, but its location does not provide a good ind ication of the position of the stone, except where the patient has pain or discomfort in th e penis and a strong desire to void which suggests that the stone has moved into the intram ural part of the ureter (the segment within the bladder). The patient cannot get comfortabl e. They often roll around in agony. Fifty percent of patients with these classic symptoms of ureteric colic do not have a stone con \201 rmed on subsequent imaging studies nor do they physically ever pass a stone.1,2 They have some other cause for their pain (see b pp. 20 \200\22322). A ureteric stone is on ly very rarely life-threatening, but many of these differential diagnoses may be life-threa tening. Acute loin pain is less likely to be due to a ureteric stone in women and in patien ts at the extremes of age. It tends to be a disease of men (and to a lesser extent, women) between the ages of 720 and 60y, although it can occur in younger and older individuals. Acute loin pain \200\224non-stone, urological causes - Clot or tumor colic: a clot may form from a bleeding source within the kidney (e.g. renal c ell cancer or transitional cell cancer of the renal pelvis). Similarly, a ureteric TCC may cause ureteric obstruction and acute loin pain. Loin pain and haematuria are often assumed to be due to a stone, but it is important to approach investigation of such patients from t he perspective of haematuria (i.e. look to exclude cancer). Pelviureteric junction obstruct ion (PUJO), also known as uretero- pelvic junction obstruction (UPJO): may present acutely with \202 ank pain severe enough to mimic a ureteric stone. A CT scan will LOIN (FLANK) PAIN 21 demonstrate hydronephrosis, with a normal caliber ureter below the PUJ and no stone. MAG3 r enography con \201 rms the diagnosis. Infection: e.g. acute pyelonephritis, pyonephrosis, emphysematous pyelonephritis, xanthogranulomatous pyelonephritis. These patients have a hig h fever (>38 C) whereas ureteric stone patients do not (unless there is infection \200 \230behind \200\231 the obstructing stone) and are often systemically very unwell. Imaging studies may or may not show a stone and there will be radiological evidence of infection wi thin the kidney and perirenal tissues (oedema). Acute loin pain \200\224non-urological causes - Vascular. \200 Leaking abdominal aortic aneurysm (AAA). \200\230Medical \200\231. \200 Pneumonia. \200 Myocardial infarction. \200 Malaria presenting as bilateral loin pain and dark haematuria \200\224black water fever. Gynecological and obstetric. \200 Ovarian pathology (e.g. twisted ovarian cyst). \200 Ectopic pregnancy. Gastrointestinal. \200 A cute appendicitis. \200 In \202 ammatory bowel disease (Crohn \200\231s, ulcerative coli tis). \200 Diverticulitis. \200 Burst peptic ulcer. \200 Bowel obstruction. Testicula r torsion. Spinal cord disease. \200 Prolapsed intervertebral disc. Distinguishing urological from non-urological loin pain History and examination are clearly important. Patients with ureteric colic often move around the bed in agony. Those with per itonitis lie still. Palpate the abdomen for signs of peritonitis (abdominal tenderness and/ or guarding) and examine for abdominal masses (pulsatile and expansile = leaking AAA). Exa mine the patient \200\231s back, chest, and testicles. In women, do a pregnancy test. Chronic loin pain \200\224urological causes - Renal or ureteric cancer. \200 Renal cell carcinoma. \200 TCC of the renal pelvis or ur eter. Renal stones. \200 Staghorn calculi. \200 Non-staghorn calculi. Renal infection. \200 TB. PUJO. CHAPTER 2 Signi \201 cance & preliminary investigation 22 Testicular pathology (referred pain). \200 Testicular neoplasms. Ureteric pathology. \200 Ureteric re \202 ux. \200 Ureteric stone (may drop into the ureter, causing severe pain which then subsides to a lower level of chronic pain). Chronic loin pain \200\224non-urological causes - Gastrointestinal. \200 Bowel neoplasms. \200 Liver disease. Spinal disease. \200 Prol apsed intervertebral disc. \200 Degenerative disease. \200 Spinal metastases. 1 Smith RC (1996) Diagnosis of acute \202 ank pain: value of unenhanced helical CT. Am J Roentgen 166:97 \200\223100. 2 Thomson JM (2001) Computed tomography versus intravenous urography in diagnosis of acute \202 ank pain from urolithiasis: a randomized study comparing imaging costs and radiation dose. Australas Radiol 45:291 \200\2237. This page intentionally left blank CHAPTER 2 Signi \201 cance & preliminary investigation 24 Urinary incontinence De \201 nitions Urinary incontinence (UI): the complaint of any invol untary leakage of urine. Stress urinary incontinence (SUI): the complaint of involuntary leakage of urine on effort or exertion or sneezing or coughing. SUI can also be a sign, the observation of involuntary leakage of urine from the urethra that occurs synchronously with exertion, coughing, etc. A diagnosis of urody- namic SUI is made during \201 lling cystometry when there is involu ntary leak- age of urine during a rise in abdominal pressure (induced by coughing) in the a bsence of a detrusor contraction. Urge urinary incontinence (UUI): the complaint of any involuntary leakage of urine accompan ied by or immediately preceded by urgency. Mixed urinary incontinence (MUI): a combination of SUI and UUI. - Both UUI and MUI cannot be a sign as they both require a perception of urgency by the patie nt. 25% of women aged >20y have UI, of whom 50% have SUI, 10 \200\22320% pure UUI, and 30 \200\22340% MUI. UI impacts on psychological health, social functioning, and quality of lif e. Signi \201 cance of SUI and UUI SUI occurs as a result of bladder neck/urethral hypermobil ity and/or neuromuscular defects causing intrinsic sphincter de \201 ciency (sphincter wea kness incontinence). As a consequence, urine leaks whenever urethral resistance is exceeded by an increased abdominal pressure occurring dur- ing exercise or coughing, for example. UUI may be due to bladder overactivity (formerly known as detrusor instability) or less com monly due to pathology that irritates the bladder (infection, tumor, stone). The correlatio n between urodynamic evidence of bladder overactivity and the sensation of urgency is poor, particularly in patients with MUI. Symptoms resulting from involuntary detrusor contrac- t ions may be dif \201 cult to distinguish from those due to sphincter weakness. Furthermore , in some patients, detrusor contractions can be provoked by coughing and, therefore, disti nguishing leakage due to SUI from that due to bladder overactivity can be very dif \201 cu lt. Other types of incontinence While SUI and especially UUI do not speci \201 cally allow ide nti \201 cation of the underlying cause, some types of incontinence allow a speci \201 c diagnosis to be made. - Bedwetting retention (HPCR). in an elderly man usually indicates high-pressure chronic URINARY INCONTINENCE 25 A constant leak of urine suggests a \201 stulous communication between the bladder (usual ly) and vagina (e.g. due to surgical injury at the time of hysterectomy or Caesarian sectio n) or, rarely, the presence of an ectopic ureter draining into the vagina (in which case th e urine leak is usually low in volume, but lifelong). Further reading Hannestady S, Rortveit G, Sandvik H, Hunskaar S (2000) A community-based ep idemiological survey of female urinary incontinence. The Norwegian EPINCONT study. J Clin E pidemiol 53:1150 \200\2237. CHAPTER 2 Signi \201 cance & preliminary investigation 26 Genital symptoms Scrotal pain - Pathology within the scrotum. \200 Torsion of the testicles. \200 Torsion of testicular appendages. \200 Epididymo-orchitis. \200 Testicular tumor. Referred pain. \200 Ureteric colic. Testicular torsion: ischaemic pain is severe (e.g. myocardial infarction, ischaemic leg, is chaemic testis). Torsion presents with sudden onset of pain in the hemiscrotum, sometimes w aking the patient from sleep. May radiate to the groin and/or loin. Five to ten percent of boys report a history of scrotal trauma in the period prior to the acute presentation of te sticular torsion.1,2 Similar episodes may have occurred in the past, with spontaneous resol ution of the pain (suggesting torsion/spontaneous detorsion). The testis is very tender. It may be high-riding (lying at a higher than normal position in the testis) and may lie hori zontally due to twisting of the cord. There may be scrotal erythema. Epididymo-orchitis: similar presenting symptoms as testicular torsion. Tenderness is usuall y localized to the epididymis (absence of testicular tenderness may help to distinguish epi didymo-orchitis from testicular tor- sion, but in many cases, it is dif \201 cult to disti nguish between the two). See b p. 522 for advice on attempting to distinguish torsion from epididymo-orchitis. Testicular tumor: 20% present with testicular pain. Acute presentations of testicular tumors - Testicular swelling may occur rapidly (over days or weeks). An associated (secondary) hydro cele is common. A hydrocele in a young person should always be investigated with an ultraso und to determine whether the underlying testis is normal. Rapid onset (days) of testicular swelling can occur. Very rarely present with advanced metastatic disease (high-volume disea se in the retroperitoneum, chest, and neck causing chest, back, or abdominal pain or shortn ess of breath). Approximately 10 \200\22315% of testis tumors present with signs suggesting in \202 ammation (i.e. signs suggesting a diagnosis of epididymo-orchitis \200\224a tende r, swollen testis, with redness in the overlying scrotal skin and a fever). Chronic scrotal pain Includes: - Testicular pain syndrome (a cause can be identi \201 ed in as many as 75% of cases). \200 Testicular tumor. \200 Previous trauma or surgery, e.g. hernia repair, hydrocele repair , epididymal cyst removal, varicocele repair. Post-infection. GENITAL SYMPTOMS 27 \200 \200 Diabetic neuropathy. Polyarteritis nodosa. If there is radiation of the pain, consider a pr imary source in the vertebrae (e.g. prolapsed disc, tumor), ureter (ureteric stone), or a r etroperitoneal tumor. Post-vasectomy pain syndrome (1 \200\22315% of men post-vasectomy; in some men, caused by o bstruction to the vas, sperm granuloma, chronic epididymitis). Epididymal pain syndrome. \200 \200 \200 Chronic bacterial infection. STDs. Trauma. Other causes of chronic scrotal pain include post-laparoscopic nephrec- tomy (55% of men) a nd radical nephrectomy (20%) \200\22450% of men expe- riencing resolution of the pain by on e month post-surgery (possibly due to ligation of gonadal vein); chronic prostatitis (tende r prostate on DRE); pudendal neuralgia. Management - - - examine scrotum for any of the above pathologies; DRE. midstream urine (MSU), scrotal ultra sound scan. Examination: Investigation: Treatment: if chronic epididymitis is suspected; pelvic \202 oor physiotherapy; pain clinic referral; surgery \200\224last resort, partial or total epid idymectomy, inguinal orchidectomy, vasectomy reversal, spermatid cord denervation. having excluded the above causes, antibiotics may be used Priapism Painful, persistent, prolonged erection of the penis not related to sexual stimula tion (causes summarized in Chapter 13). Two broad categories \200\224 low- \202 ow (most c ommon) and high- \202 ow. Low- \202 ow priapism \200\224due to hae- matological disease, malignant in \201 ltration of the corpora cavernosa with malignant disease, or drugs; pain ful because the corpora are ischaemic. High- \202 ow priapism \200\224due to perineal trau ma which creates an arteriov- enous \201 stula; painless. Diagnosis is usually obvious from the history and examination of the erect, tender penis (i n low- \202 ow priapism). Characteristically, the corpora cavernosa are rigid and the glan s is \202 accid. Examine the abdomen for evi- dence of malignant disease and perform a DR E to examine the prostate and check anal tone. Further reading Keoghane SR, Sullivan ME (2010) Investigating and managing chronic scrotal pain. BMJ 341:1263 \200\2236. 1 scrotum: a 9year experience at a single institution. J Urol 158:1198 \200\223200. Jefferson RH, Perez LM, Joseph DB (1997) Critical analysis of the clinical presentation of acute 2 Lrhor \201 H, Manunta A, Rodriguez A, Lobel B (2002) Trauma induced testicular torsion. J Urol 168:2548. CHAPTER 2 Signi \201 cance & preliminary investigation 28 Abdominal examination in urological disease Because of their retroperitoneal (kidneys, uret ers) or pelvic location (bladder and prostate), \200\230urological \200\231 organs are rel atively inaccessible to the examining hand when compared with, for example, the spleen, liv er, or bowel. For the same reason, for the kidneys and bladder to be palpable implies a fai rly advanced disease state. 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 \200\230urologic al \200\231 organs. Characteristics and causes of an enlarged kidney The mass lies in a paracolic gutter, it mo ves with respiration, is dull to percussion, and can be felt bimanually. It can also be bal loted (i.e. bounced like a ball (balla = ball (Italian)) between your hands, one placed on the anterior abdominal wall and one on the posterior abdominal wall. Causes of an enlarged kidney: renal carcinoma, hydronephrosis, pyoneph- rosis, perinephric abscess, polycystic disease, nephroblastoma. Characteristics and causes of an enlarged liver The mass descends from underneath the right costal margin, you cannot get above it, it moves with respiration, it is dull to percussio n, and has a sharp or rounded edge. The surface may be smooth or irregular. Causes of an enlarged liver: infection, congestion (heart failure, hepatic vein obstruction \200\224Budd \200\223Chiari syndrome), cellular in \201 ltration (amyloid), cellular prol iferation, space-occupying lesion (polycystic disease, meta- static in \201 ltration, prim ary hepatic cancer, hydatid cyst, abscess), cirrhosis. Characteristics and causes of an enlarged spleen The mass appears from underneath the costa l margin, enlarges towards the right iliac fossa, is \201 rm and smooth, and may have a p alpable notch. It is not possible to get above the spleen, it moves with respiration, is du ll to percussion, and it cannot be felt bimanually. Causes of an enlarged spleen: bacterial infection (typhoid, typhus TB, septicaemia); viral infection (glandular fever); protozoal infection (malaria, kala-azar); spirochaete infectio n (syphilis, Leptospirosis \200\224Weil \200\231s disease); cellular proliferation (myeloid and lymphatic leukemia, myelosclerosis, spherocystosis, thrombocytopenic purpura, pernicio us anemia); con- gestion (portal hypertension \200\224cirrhosis, portal vein thrombosis, he patic vein obstruction, congestive heart failure); cellular in \201 ltration (amyloid, Gau cher \200\231s disease); space-occupying lesions (solitary cysts, hydatid cysts, lymphoma, polycystic disease). ABDOMINAL EXAMINATION IN UROLOGICAL DISEASE 29 Characteristics of an enlarged bladder Arises out of the pelvis, dull to percussion, pressu re of examining hand may cause a desire to void. Abdominal distension: causes and characteristics - Fetus \200\224smooth, \201 rm mass, dull to percussion, arising out of the pelvis. Flatus \200\224hyperresonant (there may be visible peristalsis if the accumulation of \202 atus is due to bowel obstruction). Feces \200\224palpable in the \202 anks and across the epi gastrium, \201 rm, and may be indentable; there may be multiple separate masses in the li ne of the colon. Fat. Fluid (ascites) \200\224 \202 uid thrill, shifting dullness. Large a bdominal masses (massive hepatomegaly or splenomegaly, \201 broids, polycystic kidneys, r etroperitoneal sarcoma). - The umbilicus and signs and symptoms of associated pathology The umbilicus represents the l ocation of four fetal structures \200\224the umbili- cal vein, two umbilical arteries, and the urachus which is a tube extending from the superior aspect of the bladder towards the u mbilicus (it repre- sents the obliterated vesicourethral canal). The urachus may remain open at various points, leading to the following abnormalities. - Completely patent urachus: urine through the umbilicus; usually doesn \200\231t present unt il adulthood (strong contractions of bladder of a child closes the mouth of the \201 stul a). Vesicourachal diverticulum: bladder; usually symptomless. can become infected, forming an abscess Umbilical cyst or sinus: or may chronically discharge infected material from the umbilicus. A cyst can present as an immobile, midline swelling between the umbilicus and b ladder, deep to the rectus sheath. It may have a small communication with the bladder and, therefore, its size can \202 uctuate as it can becomes swollen with urine. communicates with the bladder and leaks a diverticulum in the dome of the Other causes of umbilical masses Metastatic deposit (from abdominal cancer, metastatic spre ad occurring via lymphatics in the edge of the falciform ligament, running alongside the ob literated umbilical vein); \200\230deposit \200\231 of endometriosis (becomes painful and discharges blood at the same time as menstruation). CHAPTER 2 Signi \201 cance & preliminary investigation 30 Digital rectal examination (DRE) The immediate anterior relationship of the rectum in the m ale is the pros- tate. The DRE is the mainstay of examination of the prostate. Explain the need for the examination. Ensure the examination is done in privacy. In the UK, DRE is usually done in the left lateral position \200\224with the patient lying on their l eft side, and with the hips and knees \202 exed to 90 or more. Examine the anal region for \201 stulae and \201 ssures. Apply plenty of lubricating gel to the gloved \201 n ger. Lift the tight buttock upwards with your other hand to expose the anus and gently and slowly insert your index \201 nger into the anal canal, then into the rectum. Palpate anteriorly with the pulp of your \201 nger and feel the surface of the prostate. Note its consistency (normal or \201 rm), its surface (smooth or irregular), and estimate its size. (It can be helpful to relate its size to com- mon objects (e.g. fruit or nuts!) A normal prostate is the size of a walnut, a moderately enlarged prostate that of a tangeri ne, and a big prostate the size of an apple or orange.) The normal bilobed prostate has a g roove (the median sulcus) between the two lobes and in prostate cancer, this groove may be obscured. Many men \201 nd DRE uncomfortable or even painful and the inexpe- rienced doctor may equ ate this normal discomfort with prostatic ten- derness. Prostatic tenderness is best elicit ed by gentle pressure on the prostate with the examining \201 nger. If the prostate is re ally involved by some acute, in \202 ammatory condition such as acute, infective prostatit is or a prostatic abscess, it will be very tender. DRE should be avoided in the profoundly neutropenic patient (risk of septicaemia) and in pa tients with an anal \201 ssure where DRE would be very painful. Other features to elicit in the DRE The integrity of the sacral nerves that innervate the b ladder and of the sacral spinal cord can be established by eliciting the bulbocavernosus re \202 ex (the BCR) during a DRE. The sensory side of the re \202 ex is elicited by squeez ing the glans of the penis or the clitoris (or in catheterized patients, by gently pulling the balloon of the catheter onto the bladder neck). The motor side of the re \202 ex is te sted by feeling for contraction of the anus during this sensory stimulus. Contraction of th e anus represents a positive BCR and indicates that the afferent and efferent nerves of the sacral spinal cord (S2 \200\2234) and the sacral cord are intact. This page intentionally left blank CHAPTER 2 Signi \201 cance & preliminary investigation 32 Lumps in the groin Differential diagnosis Inguinal hernia, femoral hernia, enlarged lymph n odes, saphena varix, hydrocele of the cord (or of the canal of N ck in women), vaginal hyd rocele, undescended testis, lipoma of the cord, femoral aneurysm, psoas abscess. Determining the diagnosis Hernia A hernia (usually) has a cough impulse (i.e. it expands on coughing) and (usually) reduces with direct pressure or on lying down unless, uncom- monly , it is incarcerated (i.e. the contents of the hernia are \201 xed in the hernia sac by t heir size and by adhesions). Movement of the lump is not the same as expansion. Many groin lumps have a transmitted impulse on coughing (i.e. they move), but do not expand on coughin g. Since inguinal and femoral hernias arise from within the abdomen and descend into the gr oin, it is not possible to \200\230get above \200\231 them. For lumps that arise from with in the scrotum, the superior edge can be palpated (i.e. it is possible to \200\230get abov e \200\231 them). Once a hernia has protruded through the abdominal wall, it can expand in any direction in t he subcutaneous tissues and therefore, the position of the unreduced hernia cannot be used to establish whether it is inguinal or femoral. The point of reduction of the hernia establ ishes whether it is an inguinal or femoral hernia. Inguinal: the hernia reduces through the abdominal wall at a point above and medial to the pubic tubercle. An indirect inguinal hernia often descends into the scrotum; a direct ingui nal hernia rarely does. Femoral: the hernia reduces through the abdominal wall at a point below and lateral to the pubic tubercle. Enlarged inguinal lymph nodes A \201 rm, non-compressible, nodular lump in the groin. Loo k for pathology in the skin of the scrotum and penis, the perianal area and anus, and the s kin and super \201 cial tissues of the thigh and leg. Saphena varix A dilatation of the proximal end of the saphenous vein. Can be confused with an inguinal or femoral hernia because it has an expansile cough impulse (i.e. expands on co ughing) and disappears on lying down. It is easily compressible and has a \202 uid thrill when the distal saphenous vein is percussed. Hydrocele of the cord (or of the canal of N ck in women) A hydrocele is an abnormal quanti ty of peritoneal \202 uid between the parietal and visceral layers of the tunica vaginali s, the double layer of peri- toneum surrounding the testis, and which was the processus vag inalis in the fetus. Normally, the processus vaginalis becomes obliterated along its entire length, apart from where it surrounds the testis where a potential LUMPS IN THE GROIN 33 space remains between the parietal and visceral layers. If the central part of the processu s vaginalis remains patent, \202 uid secreted by the \200\230trapped \200\231 peritoneum accumulates and forms a hydrocele of the cord (the equiva- lent in females is known as the canal of N ck). A hydrocele of the cord may, therefore, be present in the groin. Undescended testis May be on the correct anatomical path, but may have failed to reach the scrotum (incompletely descended testis) or may have descended away from the normal anatomic al path (ectopic testis). The \200\230lump \200\231 is smooth, oval, tender to palpation, non-compressible, and there is no testis in the scrotum.