PHYSICAL EXAMINATION

The physical examination often simplifies the process and allows the urologist to select the most
appropriate diagnostic studies. Along with the history, the physical examination remains a key
component of the diagnostic evaluation and should be performed conscientiously.
General Observations
The visual inspection of the patient provides a general overview. The skin should be inspected for
evidence of jaundice or pallor. The nutritional status of the patient should be noted. Cachexia is a
frequent sign of malignancy, and obesity may be a sign of underlying endocrinologic
abnormalities. Gynecomastia may be a sign of endocrinologic disease as well as a possible
indicator of alcoholism or previous hormonal therapy for prostate cancer. Edema of the genitalia
and lower extremities may be associated with cardiac decompensation, renal failure, nephrotic
syndrome, or pelvic and/or retroperitoneal lymphatic obstruction. Supraclavicular lymphadenopathy may
be seen with any GU neoplasm, most commonly prostate and testis cancer; inguinal lymphadenopathy
may occur secondary to carcinoma of the penis or urethra.
Kidneys
The are normally difficult to palpate because of their position under the diaphragm and ribs with
abundant musculature both anteriorly and posteriorly. Because of the position of the liver, the right
kidney is somewhat lower than the left. In children and thin women, it may be possible to palpate
the lower pole of the right kidney with deep inspiration.
The best way to palpate the kidneys is with the patient in the supine position. The kidney is lifted from
behind with one hand in the costovertebral angle. On deep inspiration, the examiner's hand is
advanced firmly into the anterior abdomen just below the costal margin In neonates, the kidneys can
be felt quite easily by palpating the flank between the thumb anteriorly and the fingers over the
costovertebral angle posteriorly.
Transillumination of the kidneys may be helpful in children younger than 1 year with a palpable
flank mass
Other diagnostic maneuvers that may be helpful in examining the kidneys are percussion and
auscultation. Although renal inflammation may cause pain that is poorly localized, percussion of the
costovertebral angle posteriorly more often localizes the pain and tenderness more accurately.
Abnormal Physical Examination FindingsKidneys
The most common abnormality detected on examination of the kidneys is a mass. Palpable renal
masses are either benign cysts or malignant renal tumors, and this distinction generally cannot be made
based on physical examination. In children, renal masses are frequently easier to palpate than in adults
Bladder
A normal bladder in the adult cannot be palpated or percussed until there is at least 150 mL of
urine in it. At a volume of about 500 mL, the distended bladder becomes visible in thin patients as a
lower midline abdominal mass.
Percussion is better than palpation for diagnosing a distended bladder. Alternatively, it may be
possible in thin patients and in children to palpate the bladder by lifting the lumbar spine with one hand
and pressing the other hand into the midline of the lower abdomen.
A careful bimanual examination, best done with the patient under anesthesia, is valuable in
assessing the regional extent of a bladder tumor or other pelvic mass. the bimanual examination
allows the examiner to assess the mobility of the bladder; such information cannot be obtained by
radiologic techniques such as CT and MRI, which convey static images.
Abnormal Physical Examination FindingsBladder

The most common palpable abnormality involving the urinary bladder is a full bladder, resulting from
overdistention. This may occur in men with bladder outlet or urethral obstruction due to BPH or urethral
stricture disease. In addition, a variety of neurologic conditions may lead to poor bladder emptying in
men or women. Large bladder tumors or calculi may also be palpable in some patients, particularly on
bimanual examination under anesthesia. Tenderness over the suprapubic area may indicate cystitis.
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). Most penile cancers occur in
uncircumcised men and arise on the prepuce or glans penis. Therefore, in a patient with a bloody
penile discharge in whom the foreskin cannot be withdrawn, a dorsal slit or circumcision must be
performed to adequately evaluate the glans penis and urethra.
The position of the urethral meatus should be noted. It may be located proximal to the tip of the glans on
the ventral surface (hypospadias) or, much less commonly, on the dorsal surface (epispadias). The
penile skin should be examined for the presence of superficial vesicles compatible with herpes simplex
and for ulcers that may indicate either venereal infection or tumor. The presence of venereal warts
(condylomata acuminata), which appear as irregular, papillary, velvety lesions on the male genitalia,
should also be noted.
The urethral meatus should be separated between the thumb and the forefinger to inspect for neoplastic
or inflammatory lesions within the fossa navicularis. The dorsal shaft of the penis should be palpated for
the presence of fibrotic plaques or ridges typical of Peyronie's disease. Tenderness along the ventral
aspect of the penis is suggestive of periurethritis, often secondary to a urethral stricture.
Abnormal Physical Examination FindingsPenis
Phimosis
Phimosis is a condition in which the foreskin cannot be retracted behind the glans penis. In males
younger than 4 years, it is normal for the foreskin to be unretractable;
Paraphimosis
Paraphimosis is a condition in which the foreskin has been retracted and left behind the glans penis,
constricting the glans and causing painful vascular engorgement and edema. Paraphimosis is often
iatrogenic and frequently occurs after a well-meaning health professional has examined the
penis or inserted a urethral catheter and forgotten to replace the foreskin in its natural position
Peyronie's Disease
Peyronie's disease is a common condition that results in fibrosis of the tunica albuginea, the elastic
membrane that surrounds each corpus cavernosum, producing curvature of the penis during
erection.
Priapism
Priapism is a prolonged painful erection that is not related to sexual activity. It occurs most commonly
in patients with sickle cell disease but can also occur in those with advanced malignancy,
coagulation disorders, pulmonary disease, and in many patients without an obvious etiology.
Physical examination reveals the penis to be rigid and mildly tender; the glans penis, however, is usually
flaccid.
Hypospadias
Hypospadias is a congenital abnormality in which the urethral meatus is positioned either along the
ventral shaft of the penis or on the scrotum or perineum instead of being located at the tip of the penis.
Such cases are best corrected early in childhood to avoid social embarrassment and psychological
trauma.
Carcinoma
Carcinoma of the penis usually presents as a velvety, raised lesion arising on the glans penis or inner
surface of the prepuce. Alternatively, it may present as an ulcerative lesion. Carcinoma of the penis
occurs almost exclusively in uncircumcised men.
Scrotum and Contents

The scrotum is a loose sac containing the testes and spermatic cord structures. The scrotal wall is made
up of skin and an underlying thin muscular layer. The testes are normally oval, firm, and smooth; in
adults, they measure about 6 cm in length and 4 cm in width. They are suspended in the scrotum, with
the right testis normally anterior to the left. The epididymis lies posterior to the testis and is palpable as a
distinct ridge of tissue. The vas deferens can be palpated above each testicle and feels like a piece of
heavy twine.
The scrotum should be examined for dermatologic abnormalities. Because the scrotum, unlike the
penis, contains both hair and sweat glands, it is a frequent site of local infection and sebaceous
cysts. Hair follicles can become infected and may present as small pustules on the surface of the
scrotum. These usually resolve spontaneously, but they can give rise to more significant infection,
particularly in patients with reduced immunity and in those with diabetes. Patients often become
concerned about these lesions, mistaking them for testicular tumors.
The testes should be palpated gently between the finger tips of both hands. The testes normally have a
firm, rubbery consistency with a smooth surface.. A firm or hard area within the testis should be
considered a malignant tumor until proved otherwise. The epididymis should be palpable as a ridge
posterior to each testicle. Masses in the epididymis (spermatocele, cyst, epididymitis) are almost
always benign.
To examine for a hernia, the physician's index finger should be inserted gently into the scrotum
and invaginated into the external inguinal ring The scrotum should be invaginated in front of the
testicle, and care should be taken not to elevate the testicle itself, which is quite painful. Once the
external ring has been located, the physician should place the finger tips of his or her other hand over
the internal inguinal ring and ask the patient to bear down (Valsalva's maneuver). A hernia will be felt as
a distinct bulge that descends against the tip of the index finger in the external inguinal ring as the
patient bears down. Although it may be possible to distinguish a direct inguinal hernia arising through the
floor of the inguinal canal from an indirect inguinal hernia prolapsing through the internal inguinal ring,
this is seldom possible and of little clinical significance because the surgical approach is essentially
identical for both conditions.
The spermatic cord is also examined with the patient in the standing position. A varicocele is a dilated,
tortuous spermatic vein that becomes more obvious as the patient performs a Valsalva maneuver. The
epididymis can again be palpated as a ridge of tissue running longitudinally, posterior to each testis. The
testis should be palpated again between the fingers of both hands, once again taking care not to exert
any pressure on the testicle itself so as to avoid pain.
Transillumination is helpful in determining whether scrotal masses are solid (tumor) or cystic
(hydrocele, spermatocele). A small flashlight or fiberoptic light cord is placed behind the mass. A cystic
mass transilluminates easily, whereas light is not transmitted through a solid tumor.
Abnormal Physical Examination FindingsScrotum and Contents
Testicular Cancer
The most common physical finding in the testis is a mass. A useful guideline is that most masses
arising from the testis are malignant, whereas almost all masses arising from the spermatic cord
structures are benign. They are usually discovered incidentally by the patient when showering or
during self-examination.
Torsion
Torsion is the twisting of the testis on the spermatic cord, resulting in strangulation of the blood supply
and infarction of the testis. Torsion occurs most commonly between the ages of 12 and 20 years,
although it does occur less frequently during the first year of life. The patient usually presents with
the sudden onset of pain and swelling of the involved testis. The pain may radiate into the groin and
lower abdomen; thus, it may be confused with appendicitis unless the physician examines the genitalia
carefully. On physical examination, it is difficult to distinguish the testis from the epididymis because of
localized swelling. For this reason, the condition is frequently misdiagnosed as epididymitis
Hydrocele
A hydrocele is a collection of fluid between the tunica vaginalis and the testis. The patient presents with
progressive swelling and local discomfort on the involved side of the scrotum. Physical examination
reveals smooth, symmetrical enlargement of one side of the scrotum in which it is very difficult to feel the

testis. The diagnosis is made by transillumination of the scrotum. However, because about 10% of
testicular tumors present with an associated reactive hydrocele, it is important to be sure that the
hydrocele transilluminates completely and, if there is any doubt, to confirm the diagnosis with a
subsequent scrotal ultrasound.
Varicocele
A varicocele is an enlarged, tortuous spermatic vein above the testicle that almost always occurs on the
left side. The patient presents with a soft mass or swelling above the testicle noted when he stands or
strains. This has been described as a "bag of worms." Varicoceles typically decrease in size and may
disappear when the patient is supine. Patients with the sudden onset of a varicocele, a right-sided
varicocele, or a varicocele that does not reduce in size in the supine position should be
suspected of having a retroperitoneal neoplasm with obstruction of the spermatic vein where it
enters either the renal vein on the left or the inferior vena cava on the right. Such patients should
undergo a sonogram or CT scan to rule out malignancy before receiving treatment for the varicocele.
Rectal and Prostate Examination in the Male
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. Prostate cancer is the second most common
cause of male cancer deaths after age 55 years and the most common cause of cancer deaths in men
older than 70 years.
Before performing the DRE, the physician should place the palm of his other hand against the patient's
lower abdomen. This provides subtle reassurance to the patient by allowing the physician to make
gentle contact with the patient before touching the anus. It also allows the physician to steady the patient
and provide gentle counterpressure if the patient tries to move away as the DRE is being performed.
The DRE itself begins by separating the buttocks and inspecting the anus for pathology, usually
hemorrhoids, but, occasionally, an anal carcinoma or melanoma may be detected. The gloved,
lubricated index finger is then inserted gently into the anus. Only one phalanx should be inserted initially
to give the anus time to relax and to easily accommodate the finger. Estimation of anal sphincter tone is
of great importance; a flaccid or spastic anal sphincter suggests similar changes in the urinary sphincter
and may be a clue to the diagnosis of neurogenic disease. If the physician waits only a few seconds, the
anal sphincter will normally relax to the degree that the finger can be advanced to the knuckle without
causing pain. The index finger then sweeps over the prostate; the entire posterior surface of the gland
can usually be examined if the patient is in the proper position. 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).
The index finger is extended as far as possible into the rectum, and the entire circumference is
examined to detect an early rectal carcinoma. Adequate tissues, soap, and towels should be available
for the patient to cleanse himself after the examination. The physician should then leave the room and
allow the patient adequate time to wash and dress before concluding the consultation.
Abnormal Physical Examination FindingsProstate
Acute Prostatitis
Acute prostatitis most commonly occurs in sexually active men between the ages of 20 and 40
years. Symptoms include fever, malaise, perineal and rectal discomfort, urinary frequency, urgency,
dysuria, and sometimes urinary retention. When acute prostatitis is suspected, rectal examination
should be performed carefully. Examination reveals the prostate to be warm, tender, and sometimes
fluctuant or boggy in consistency. A localized fluctuant, tender region within the prostate may indicate a
prostatic abscess for which surgical drainage is required. The prostate should never be massaged for
secretions in men with acute prostatitis. Massage of the acutely infected prostate is not only
unnecessary but also extremely uncomfortable for the patient. In addition, massage may disseminate
bacteria through the vas deferens, causing secondary epididymitis or, more significantly, may
disseminate bacteria into the blood stream, producing gram-negative septicemia.
Benign Prostatic Hyperplasia
The physical findings in BPH are usually limited to the prostate. In BPH, the prostate remains rubbery in
consistency, but may be variably enlarged from normal chestnut size to the size of a lemon, or,
occasionally, even as large as an orange. There is only a general correlation between prostatic size and

degree of symptoms.
Since BPH affects almost all men older than age 50 years, the finding of an enlarged prostate on
physical examination is not a reason per se to initiate further urologic evaluation. The severity of
the disease and the need for treatment are best determined by the patient's symptoms as well as the
results of further urologic testing, such as measurement of a urinary flow rate and postvoid residual
urine.
Carcinoma of the Prostate
Prostate cancer usually arises in the posterior peripheral region of the prostate and, therefore, is
frequently palpable in its early stages on rectal examination. On physical examination, prostatic
carcinomas are palpable as firm, indurated nodules or regions within the prostate. These areas of
induration are characterized by having a woodlike consistency. As prostatic carcinomas progress, the
entire gland becomes firmer than usual. Eventually, these tumors may progress beyond the capsule of
the prostate, extending cephalad into the seminal vesicles and laterally toward the pelvic side wall.
It should be emphasized that men with early, localized carcinoma of the prostate are almost always
asymptomatic. Therefore, a patient should never be allowed to dissuade the urologist from performing
a rectal examination simply because he is asymptomatic. Urinary obstructive symptoms and skeletal
pain are symptoms of advanced, incurable disease.
Detection of early prostatic carcinoma on rectal examination takes practice, and has been greatly
facilitated by the discovery of PSA. An elevated PSA should raise the suspicion of prostatic carcinoma,
regardless of the findings on rectal examination. Conversely, a normal PSA does not exclude the
possibility of early prostate cancer, and, in fact, 30% of men with early prostate cancer will have a
normal serum PSA
A prostatic biopsy should be performed for any palpable lesion within the prostate Other causes of
prostatic induration besides cancer include calculi (which are typically harder than tumors), inflammation,
fibrous BPH, and infarction. Biopsies are now done easily using topical anesthesia under transrectal
ultrasound guidance. There is no excuse for delaying a prostatic biopsy in an otherwise healthy
younger man with either an abnormal DRE or an elevated PSA. It serves no purpose to have the
patient return in 6 months for a repeat examination to see whether the nodule has changed, because
prostate cancers usually grow very slowly; the fact that a nodule does not change appreciably with time
is of no clinical significance.
Pelvic Examination in the Female
Male urologists should always perform the female pelvic examination with a female nurse or
other health professional present. The patient should be allowed to undress in privacy and be fully
draped for the procedure before the physician enters the room. The examination itself should be
performed in standard lithotomy position with the patient's leg abducted. Initially, the external genitalia
and introitus should be examined, with particular attention paid to atrophic changes, erosions, ulcers,
discharge, or warts, all of which may cause dysuria and pelvic discomfort. The urethral meatus should
be inspected for caruncles, mucosal hyperplasia, cysts, and mucosal prolapse. The patient is then asked
to perform a Valsalva maneuver, and is carefully examined for a cystocele (prolapse of the bladder) or
rectocele (prolapse of the rectum). The patient is then asked to cough, which may precipitate stress
urinary incontinence. Palpation of the urethra is done to detect induration, which may be a sign of
chronic inflammation or malignancy. Palpation may also disclose a urethral diverticulum, and palpation
of a diverticulum may cause a purulent discharge from the urethra. Bimanual examination of the bladder,
uterus, and adnexa should then be performed with two fingers in the vagina and the other hand on the
lower. Any abnormality of the pelvic organs should be evaluated further with a pelvic ultrasound or CT
scan.
Abnormal Physical Examination FindingsFemale Pelvic Examination
A careful bimanual examination of the female pelvis may reveal a variety of abnormalities of the uterus,
ovaries, and cervix, including benign and malignant masses and inflammatory lesions. Various forms of
pelvic prolapse, such as cystocele, rectocele, and enterocele, may also be detected. Inspection of the
urethral meatus and vaginal introitus may also be helpful in identifying condylomata, urethral lesions,
and other abnormalities.