History and Physical

Exam of the
Genitourinary System

Vince Edward C. Araneta, MD, FPAFP,

CSPSH
Anatomy of the Kidneys
• The kidneys lie along the borders of the
psoas muscles and are therefore obliquely
placed. The position of the liver causes the
right kidney to be lower than the left.

• The adult kidney weighs between 125 and

170 g in men and 115 and 155 g in women.
It is about 10–12 cm long, 5–7 cm wide, and
3–5 cm thick.
Anatomy of the Kidneys
• The kidneys are supported by the perirenal
fat (which is enclosed in the perirenal fascia),
the renal vascular pedicle, abdominal muscle
tone, and the general bulk of the abdominal
viscera,

• Variations in these factors permit variations in

the degree of renal mobility. The average
descent on inspiration or on assuming the
upright position is 4–5 cm.
 Anatomy of the
Kidneys
• On longitudinal section, the kidney is
seen to be made up of an outer cortex, a
central medulla, and the internal calices
and pelvis.

• The cortex is homogeneous in

appearance. Portions of it project toward
the pelvis between the papillae and
fornices and are called the columns of
Bertin.
 Histology
• Nephron - The functioning unit of the
kidney is the nephron, which is composed
of a tubule that has both secretory and
excretory functions.

• Supporting tissue - The renal stroma is

composed of loose connective tissue and
contains blood vessels, capillaries, nerves,
and lymphatics.
 Blood Supply (Arterial)
• Usually there is one renal artery, a branch of the
aorta that enters the hilum of the kidney between
the pelvis, which normally lies posteriorly, and
the renal vein.

• The renal artery divides into anterior and

posterior branches.

• The posterior branch supplies the midsegment of

the posterior surface. The anterior branch
supplies both upper and lower poles as well as
the entire anterior surface. The renal arteries are
all end arteries.
 Blood Supply (Venous)
• The renal veins are paired with the
arteries, but any of them will drain the
entire kidney if the others are tied off.

• Although the renal artery and vein are

usually the sole blood vessels of the
kidney, accessory renal vessels are
common and may be of clinical
importance if they are so placed so as to
compress the ureter, in which case
hydronephrosis may result.
 Nerve Supply and
Lymphatics
• The renal nerves derived from the renal
plexus accompany the renal vessels
throughout the renal parenchyma.

• The lymphatics of the kidney drain into

the lumbar lymph nodes.
 Anatomy of the Bladder
• The bladder is a hollow muscular organ that
serves as a reservoir for urine.

• In women, its posterior wall and dome are

invaginated by the uterus.

• The adult bladder normally has a capacity

of 400–500 mL.
 Anatomy of the Bladder
• In males, the bladder is related posteriorly
to the seminal vesicles, vasa deferentia,
ureters, and rectum.

• In females, the uterus and vagina are

interposed between the bladder and
rectum.
 Blood Supply
• The bladder is supplied by the superior,
middle, and inferior vesical arteries, which
arise from the anterior trunk of the internal
iliac (hypogastric) artery, and by smaller
branches from the obturator and inferior
gluteal arteries.

• Surrounding the bladder is a rich plexus of

veins that ultimately empties into the
internal iliac (hypogastric) veins.
 Nerve Supply and
Lymphatics
• The bladder receives innervation from
sympathetic and parasympathetic nervous
systems.

• The lymphatics of the bladder drain into the

vesical, external miliac, internal iliac
(hypogastric), and common iliac lymph
nodes.
Symptoms of the Genitourinary
Tract
• In the workup of any patient, the history is of
paramount importance;

• It is important to know not only whether the

disease is acute or chronic but also whether it is
recurrent, since recurring symptoms may
represent acute exacerbations of chronic
disease.

• Obtaining the history is an art that depends on

the skill and methods used to elicit information.
The history is only as accurate as the patient’s
ability to describe the symptoms.
 Systemic Manifestations

• Symptoms of fever and weight loss should

be sought.

• The presence of fever associated with other

symptoms of urinary tract infection may be
helpful in evaluating the site of the infection.

• Simple acute cystitis is essentially an afebrile

disease. Acute pyelonephritis or prostatitis is
apt to cause high temperatures.
 Systemic Manifestations

• Weight loss is to be expected in the

advanced stages of cancer.

• In children who have “failure to thrive” (low

weight and less than average height for their
age), chronic obstruction, urinary tract
infection, or both should be suspected.

• General malaise may be noted with tumors,

chronic pyelonephritis, or renal failure.
 Kidney Pain
• Typical renal pain is felt as a dull and
constant ache in the costovertebral angle
just lateral to the sacrospinalis muscle and
just below the 12th rib.

• Acute pyelonephritis (with its sudden

edema) and acute ureteral obstruction (with
its sudden renal back pressure) both cause
this typical pain.
Kidney Pain
 Ureteral Pain
• This is typically stimulated by acute
obstruction (passage of a stone or a blood
clot).

• The severity and colicky nature of this pain

are caused by the hyperperistalsis and
spasm of this smooth-muscle organ as it
attempts to rid itself of a foreign body or to
overcome obstruction.
 Ureteral Pain
• The physician may be able to judge the
position of a ureteral stone by the history of
pain and the site of referral.

• If the stone is lodged in the upper ureter,

the pain radiates to the testicle, since the
nerve supply of this organ is similar to those
of the kidney and upper ureter (T11–T12).
 Vesical Pain
• The overdistended bladder of the patient in
acute urinary retention causes agonizing
pain in the suprapubic area.

• The most common cause of bladder pain is

infection; the pain is seldom felt over the
bladder but is referred to the distal urethra
and is related to the act of urination.
 Other Symptoms

• Prostatic Pain
• Testicular Pain
• Epididymal Pain
Symptoms Related to the
Act of Urination

• Frequency

• Dysuria

• Enuresis
 Frequency
• The normal capacity of the bladder is about 400
mL. Frequency may be caused by residual urine,
which decreases the functional capacity of the
organ.

• During very severe acute infections, the desire

to urinate may be constant, and each voiding
may produce only a few milliliters of urine.

• Diseases that cause fibrosis of the bladder are

accompanied by frequency of urination.
 Dysuria
• Painful urination is usually related to acute
inflammation of the bladder, urethra, or
prostate.

• More severe pain sometimes occurs in the

bladder just at the end of voiding, suggesting
that inflammation of the bladder is the likely
cause.

• Dysuria often is the first symptom suggesting

urinary infection and is often associated with
urinary frequency and urgency
 Enuresis
• Strictly speaking, enuresis means bedwetting at
night. It is physiologic during the first 2 or 3
years of life but becomes troublesome,
particularly to parents, after that age.

• In adult life, enuresis may be replaced by

nocturia for which no organic basis can be
found.
 Symptoms of Bladder
Outlet Obstruction
• Hesitancy
• Loss of Force and Decrease Caliber of the
Stream
• Terminal Dribbling
• Urgency
• Acute and Chronic Urinary Retention
• Intermittent Urinary Stream
• Sense of Incomplete Emptying
• Cystitis
 Incontinence
• Urge Incontinence - Urgency may be so
precipitate and severe that there is involuntary
loss of urine.

• Overflow Incontinence - Paradoxic incontinence

is loss of urine due to chronic urinary retention
or secondary to a flaccid bladder. The
intravesical pressure finally equals the urethral
resistance; urine then constantly dribbles forth.
Oliguria and Anuria
• Oliguria and anuria may be caused by
acute renal failure (due to shock or
dehydration), fluid ion imbalance, or
bilateral ureteral obstruction.
Pneumaturia
• The passage of gas in the urine strongly
suggests a fistula between the urinary tract
and the bowel.

• This occurs most commonly in the bladder

or urethra but may be seen also in the
ureter or renal pelvis.

• Carcinoma of the sigmoid colon,

diverticulitis with abscess formation,
regional enteritis, and trauma cause most
vesical fistulas.
Cloudy Urine
• Patients often complain of cloudy urine,
but it is most often cloudy merely
because it is alkaline; this causes
precipitation of phosphate.

• Infection can also cause urine to be

cloudy and malodorous. A properly
performed urinalysis will reveal the
cause of cloudiness.
Chyluria
• The passage of lymphatic fluid or chyle is
noted by the patient as passage of milky
white urine.

• This represents a lymphatic–urinary system

fistula. Most often, the cause is obstruction
of the renal lymphatics, which results in
forniceal rupture and leakage.

• Filariasis, trauma, tuberculosis, and

retroperitoneal tumors have caused this
problem.
Bloody Urine
• Hematuria is a danger signal that
cannot be ignored.

• Carcinoma of the kidney or bladder,

calculi, and infection are a few of the
conditions in which hematuria is
typically demonstrable at the time of
presentation.
Bloody Urine in Relation to
Symptoms and Diseases
• Hematuria associated with renal colic
suggests a ureteral stone, although a clot
from a bleeding renal tumor can cause the
same type of pain.

• Hematuria is commonly associated with

nonspecific, tuberculous, or schistosomal
infection of the bladder.

• Dilated veins may develop at the bladder

neck secondary to enlargement of the
prostate.
Bloody Urine in Relation to
Symptoms and Diseases
• Hematuria without other symptoms
(silent hematuria) must be regarded as
a symptom of tumor of the bladder or
kidney until proved otherwise.

• Less common causes of silent

hematuria are staghorn calculus,
polycystic kidneys, benign prostatic
hyperplasia, solitary renal cyst, sickle
cell disease, and hydronephrosis.
Time of Hematuria

• Learning whether the hematuria is

partial (initial, terminal) or total (present
throughout urination) is often of help in
identifying the site of bleeding.

• Terminal hematuria usually arises from

the posterior urethra, bladder neck, or
trigone.
 Other Objective
Manifestations
• Urethral discharge
• Skin lesions of the external genitalia
• Visible or palpable masses
• Edema
• Bloody ejaculation
• Gynecomastia
 Physical
Examination of the
Kidneys
 Inspection
• A mass that is visible in the upper
abdominal area may be difficult to
palpate if soft, as with
hydronephrosis.

• Fullness in the costovertebral angle

(CVA) may be consistent with
cancer or perinephric infection.
 Palpation

• The kidneys lie rather high under the

diaphragm and lower ribs and are
therefore well protected from injury.

• Because of the position of the liver, the

right kidney is lower than the left.
 Palpation

• The kidneys are difficult to palpate in

men because of:
(1) resistance from abdominal muscle
tone and
(2) more fixed position than in women,
moving only slightly with change of
posture or respiration.
 Palpation

• The most successful method of renal

palpation is carried out with the patient
lying in the supine position on a hard
surface.

• The kidney is lifted by one hand in the

CVA. On deep inspiration, the kidney
moves downward; the other hand is
pushed firmly and deeply beneath the
costal margin so as to trap the kidney.
 Palpation

• Perlman and Williams (1976) described

an effective method of identifying renal
anomalies in newborns.

• The fingers are placed in the CVA, with

the thumb anterior and performing the
palpation.
 Palpation

• An acutely infected kidney is tender,

but the presence of marked muscle
spasm may make this difficult to elicit.

• Although renal pain may be diffusely

felt in the back, tenderness is usually
well localized, just lateral to the
sacrospinalis muscle and below the
12th rib (ie, CVA).
 Percussion

• At times, an enlarged kidney cannot be

felt, particularly if it is soft as in some
cases of hydronephrosis.

• However, such masses may be outlined by

both anterior and posterior percussion.
 Percussion

• If the kidneys are tender to palpation, assess

percussion tenderness over the CVAs.

• Pressure from your fingertips may be enough to

elicit tenderness; if not, use fist percussion.

• Place the ball of one hand in the CVA and strike it

with the ulnar surface of your fist.
 Transillumination

• Transillumination may prove helpful in

children younger than 1 year who
present with a suprapubic or flank
mass.

• A dark room is required along with a

flashlight with an opaque flange
protruding beyond the lens. The
flashlight is applied at a right angle to
the abdomen
 Transillumination

• The fiberoptic light cord, used to

illuminate various optical instruments, is
an excellent source of cold light.

• A distended bladder or cystic mass will

transilluminate; a solid mass will not.

• Flank masses may be assessed by

applying the light posteriorly.
 Physical
Examination of
the Bladder
Examination of the Bladder

• The bladder cannot be felt unless it is

moderately distended.

• In adults, it contains at least 150 mL of urine

if it can be percussed.

• In acute or chronic urinary retention, the

bladder may reach or even rise above the
umbilicus, when its outline may be seen and
usually felt.
 Examination of the
Bladder
• A sliding inguinal hernia containing some
bladder wall can be diagnosed by
compression of the scrotal mass when the
bladder is full, leading to additional
distension.

• A few instances have been reported where

marked edema of the legs has developed
secondary to compression of the iliac
vessels by a distended bladder.
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