Symptoms of Disorders of the Genitourinary Tract
these 2 structures (T11-12).
 It will be necessary to discuss here only those urologic
symptom that are apart to be brought to the physician’s
attention by the patient.
 It is important to know if the symptom is acute or chronic;
recurrent
 Recurring symptoms represent acute exacerbations of
chronic disease.
SYSTEMIC MANIFESTATIONS
Symptoms:
 Fever :
o symptoms of urinary tract infection
o Acute pyelonephritis or prostatitis - high
temperatures ( 40oC [104 oF] ), often
accompanied by violent chills.
o Infants and children suffering from acute
pyelonephritis may have high temperatures
without other localizing symptoms or signs.
o Unexplained attacks of fever occurring even
years before may be due to asymtomatic
pyelonephritis.
o Renal carcinoma causes fever 39oC (102.2
oF)
 Simple acute cystitis is essentially an afebrile disease.
 The absence of fever does not by any means rule out
renal infection, for it is the rule that chronic
pyelonephritis does not cause fever.
 Weight loss is to be expected in
o a) the advanced stages of cancer,
o b) renal insufficiency due to obstruction or
infection supervenes.
o In children who have “failure to thrive” (low
weight and less than average height for
age), chronic obstruction, urinary tract
infection, or both should be suspected.
 General malaise noted with tumors, chronic
pyelonephritis, or renal failure.
 Presence of these symptoms may be compatible with
acquire immunodeficiency syndrome (AIDS).
LOCAL & REFFERRED PAIN
 Local pains is felt in or near the involved organ.
 Thus, the pain from a diseased kidney (T10-12,LI)is felt
in the costovertebral angle and in the flank in the region
of and below the 12th rib. Pain from an inflamed testicle
is felt in the gonad itself.
 Referred pain originates in a diseased organ but is felt at
some distance from the organ.
 The ureteral colic caused by a stone in the upper ureter
may be associated with severe pain in the ipsilateral
testicles; this is explained by the common innervation of
 A stone in the lower ureter may cause pain referred to
the scrotal wall; in this instances, the testis itself is not
hyperesthetic.
 The burning pain with voiding that accompanies acute
cystitis is felt in the distal urethra in the female or in the
glandular urethra in the female (S2-3).
 Abnormalities of a urologic organ can also cause pain in
any other organ (eg. Gastrointestinal,gynecologic) that
has a sensory nerve supply common to both
KIDNEY PAIN
 Renal pain is usually felt as a dull and constant ache in
the costovertebral angle just lateral to the sacrospinalis
muscle and just below the 12th rib this pain often spread
along the subcostal area toward the umbilicus or lower
abdominal quadrant.
 Cause: sudden distention of the renal capsule.
 It should be pointed out, that many urologic renal
diseases are painless because their progression is so
slow that sudden capsular distention does not occur.
 Such diseases include cancer, chronic pyelonephritis,
staghorn calculus, tuberculosis, polycystic kidney, and
hydronephrosis due to chronic ureteral obstruction.
PSEUDORENAL PAIN
(Radiculitis)
 Mechanical derangements of the costovertebral or
costotransverse joints can cause irritation or pressure
on the costal nerves.
 Disorders of this sort are common in the cervical and
thoracic areas, but the most common sites are T10-12.
 Irritation of these nerves causes costovertebral pain,
often with radiation into the ipsilateral lower abdominal
quadrant.
 Radiculitis may mimic ureteral colic or renal pain.
 The renal pain is seldom affected by movements of the
spine.
URETERAL PAIN
 Ureteral pain is typically stimulated by acute obstruction
(passage of a stone or a blood clot)
 In this instance, there is back pain from renal capsular
distention combined with severe colicky pain ( due to
renal pelvic and ureteral muscle spasm) that radiates
from the costovertebral angle down toward the lower
anterior abdominal quadrant, along the course of the
ureter.
 In men, it may be felt in the bladder, scrotum, or
testicles.
 In women, it may radiate into the vulva.
 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.
 It should be remembered that radiculitis may mimic
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 lodge in the upper ureter, the pain radiates
to the testicles, since the nerve supply or this organ is
similar to that of the kidney and upper ureter (T11-12).
 With stones in the mid portion of the ureter ion the right
side, the pain is referred to McBurney’s point and may
therefore simulate appendicitis on the left side, ot may
resemble diverticulitis or other diseases of the
descending or sigmoid colon (T12, LI).
 As the stone approaches the bladder, inflammation and
edema of the ureteral orifice ensue, and symptoms of
vesical irritability such as urinary frequency and urgency
may occur.
 It is important to realize, however, that in mild ureteral
obstruction, as seen in the congenital stenosis, there is
usually no pain, either renal or ureteral.
VESICAL PAIN
 The over distended bladder of the patient in acute
urinary retention will cause agonizing pain in the
suprapubic area.
 The patient in chronic urinary retention due to bladder
neck obstruction or neurogenic bladder may experience
little or no suprapubic discomfort even though the
bladder reaches the level of the umbilicus.
 The most common cause of bladder pain is infection; the
pain is usually not felt over the bladder but is referred to
the distal urethra and is to related to the act of urination.
 Terminal dysuria may be a major complaint in severe
cystitis.
PROSTATIC PAIN
 Direct pain from the prostate gland is not common.
 Occasionally, when the prostate is acutely inflamed, the
patient may feel a vague discomfort or fullness in the
perineal or rectal area (S2-4).
 Lumbosacral backache is occasionally experienced as
referred pain from the prostate but is not a common
symptom of prostatitis.
 Inflammation of the gland may cause dysuria,
frequency, and urgency.
TESTICULAR PAIN
 Testicular pain due to trauma, infection, or torsion of the
spermatic cord is very severe and is felt locally, although
there may be some radiation of the discomfort along the
spermatic cord into the lower abdomen.
 Uninfected hydrocele, spermatocele, and tumor of the
testis do not commonly cause pain.
 A varicocele may cause a dull ache in the testicle that is
increased after heavy exercise.
 At times, the first symptom of an early indirect inguinal
hernia may be testicular pain (referred).
 Pain from a stone in the upper ureter may be referred to
the testicles.
EPIDIDYMAL PAIN
 Acute infection of the epididymis is the only painful
disease of this organ and its quite common.
 The pain begins in the scrotum, and some degree of
neighborhood inflammatory reaction involves the
adjacent testis as well, further aggravating the
discomfort.
 In the early stage of epididymitis, pain may first be felt in
the groin or lower abdominal quadrant.
 (If on the right side, it may simulate appendicitis).
 This may be referred type of pain but can be secondary
to associated inflammatory of the vas deferens.
 The discomfort associated with epidymitis may be reach
the costal angle and mimic ureteral stone on rare
occasions.
BACK & LEG PAIN
 Pain low in the back and radiating down one or both
legs, when associated with symptoms of vesical neck
obstruction in an older man, suggests metastasis to the
pelvic from cancer of the prostate.
GASTROINTESTINAL SYMPTOM OF UROLOGIC
DISEASES
 Whether renal or ureteral disease is painful or not,
gastrointestinal symptoms are often present.
 The patient with acute pyelonephritis will suffer not only
from localized back pain, symptoms of vesical irritability,
chills, and fever also from generalized abdominal pain
and distention.
 The patient who is passing a stone down the ureter will
have typical renal and ureteral colic and, usually,
hematuria and may experience severe nausea and
vomiting as well as abdominal distention.
 However, the urinary symptoms so far overshadow the
gastrointestinal symptoms that the latter are usually
ignored.
 Inadvertent over distention of the renal pelvis (eg. With
opaque material in order obtain adequate retrograde
urograms) may cause the patient to become nauseated,
to vomit, and to complain of cramplike pain in the
abdomen.
 This clinical experiment demonstrates the renointestinal
reflex,which may lead to confusing symptoms.
 In the vary common “silent” urologic deseases, some
degree of gastrointestinal symptomatology may be
 present that could mislead the clinician into seeking the
diagnosis in the intraperitoneal zone.
SYMTOMS RELATED TO THE ACT OF URINATION
FREQUENCY, NOCTURIA, & URGENCY
Normal capacity of the bladder is about 400ml.
Frequency
- caused by residual urine which decreases
the functional capacity of the organ.
- When the mucosae, submucosa, and
even the muscularis become a inflamed
(eg. Infection, foreign body, stones tumor),
the capacity of the bladder decreases
sharply.
- Decrease is due to 2 factors:
- the pain resulting from even mild
stretching of the bladder
- the loss of bladder compliance resulting
from inflammatory edema.
Nocturia
- may be symptom of renal disease related
to a decrease in the functioning renal
parenchyma with loss of concentrating
power.
- Nocturia can occur in the absence of
disease in person who drink excessive
amount of fluids in the late evening.
- Coffee and alcoholic beverages, because
of their specific diuretic effect
DYSURIA
- Painful urination is usually related to acute
inflammatory of the bladder, urethra, or
prostate.
- Described as “burning” on urination,
located in the distal urethra in men.
- Women usually localize the pain in the
urethra.
- The pain is present only with voiding and
disappears soon after micturition is
completed.
- Pain is also may be more marked at the
beginning of or throughout the act of
urination.
- 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 to 3
years of life but becomes troublesome,
particularly to parents after that age.
- It may be functional or secondary to
delayed neuromuscular maturation of the
urethrovesical component, but it may be
present as a symptom of organic disease
(eg., infection, distal urethra stenosis in
girls, posterior urethra valves in boys,
neurologic bladder)
- If however, wetting occurs also during the
daytime or if there are other urinary
symptoms--- or if the enuresis persists
beyond age 5 to 6 --- urologic
investigation is essential.
- In adult life, enuresis may be replaced by
nocturia for which no organic basis can be
found.
SYMPTOMS OF BLADDER OUTLET OBSTRUCTION
A. Hesitancy:
- Hesitancy in initiating the urinary stream is
of the early symptoms of bladder outlet
obstruction.
- Prostate obstruction and urethral stricture
are common causes of this symptom.
B. Loss of Force and decrease of caliber of the
Stream:
- Progressive loss of force and caliber of
the urinary stream is noted as urethral
resistance increases despite the
generation of increased intravesical
pressure.
- This can be evaluate by measuring
urinary flow rates, which in normal
circumstances with a full bladder should
approximate 20 ml/sec.
C. Terminal Dribbing:
- This becomes more and more noticeable
as obstruction progresses and is a most
distressing symptom.
D. Urgency:
- A strong, sudden desire to urinate is
caused by hyperactivity and irritability of
the bladder resulting from obstruction,
inflammation, or neuropathic disease.
- In most circumstances, the patient is able
to temporarily control the sudden need to
void, but loss of small amounts of urine
may occur (urgency incontenence).
E. Acute Urinary Retention:
- Sudden inability to urine may supervene
- The patient experiences increasingly
agonizing suprapubic pain associated with
severe urgency and may dribble only
small amount of urine.
F. Chronic Urinary Retention:
- This may cause little discomfort to the
patient even though there is great
hesitancy in starting the stream and
 marked reduction of its force and caliber. Chyluria
Constant dribbing of urine (paradoxic The passage of lymphatic fluid or chyle is
incontinence) may be experienced. noted by the patient as passage of milky white urine.
- It may likened to water pouring over a This represents a lymphatic urinary system fistula.
dam. Filiariasis, trauma, tuberculosis, and Retroperitoneal
G. Interruption of the Urinary Stream: tumors have caused the problem .
- Interruption may be abrupt and
accompanied by severe pain radiating Bloody Urine
down the urethra. Hematuria is a danger signal that cannot be
- This type of reaction strongly suggests the ignored. It is important to whether the hematuria is
complication of vesical calculus. associated with symptom of vesical irritability ,and
H. Sense of Residual Urine: pass red urine after eating beets or taking laxatives
- The patient often feels that urine is still in containing phenolphthalein. The hemoglobinuria that
the bladder even after urination has been occurs as a feature of the hemolytic may also cause
completed. the urine to be red.
I. Cystitis:
- Recurring episodes of acute cystitis A. Bloody Urine in Relation to Symptoms
suggest the presence of the residual and Diseases:
urine.
1. Hematuria associated with renal
Incontinence colic suggests ureteral stone
There are many reasons for incontinence. 2. Hematuria is not uncommonly
True Incontinence: The patient may lose urine without associated with non specific,
warning; this may be a constant periodic symptom. tuberculous, or schistosomal
The more obvious causes include extrophy of the infection of the bladder.
bladder, epispadias, vesicovaginal fistula, and ectopic 3. The bleeding is often terminal
ureteral orifice. Injury to the urethral smooth muscle (bladder neck or prostate),
sphincters may occur during prostatectomy or although it may be present
childbirth. Congenital or acquired neurogenic diseases throughout urination (vesical or
may lead to dysfunction of the bladder and upper tract).
incontinence. 4. Stone in the bladder often causes
A. Stress Incontinence: When slight weakness of hematuria, but infection is usually
the sphincteric mechanisms is present, urine may present, and there are symptoms
be lost in association with physical strain (eg. of bladder neck obstruction,
Coughing, laughing, rising from a chair) neurogenic bladder, or cystocele.
B. Urge Incontinence: This type of urgency may be 5. When a tumor of the bladder
so precipitate and severe that there is involuntary ulcerates
loss of urine.
C. Paradoxic (overflow or false) Incontence: This is Less common causes:
loss of urine due to chronic urinary retention or Silent Hematuria Painless Bleeding
secondary to a flaccid bladder. The intravesical staghorn calculus, Acute
pressure finally equals the urethral resistance; polycystic kidneys glomerulonephritis
urine then constantly dribbles forth. solitary renal cyst,
sickle cell disease
Oliguria & Anuria hydronephrosis

Oliguria and anuria may be caused by acute renal B. time of Hematuria:

failure ( due to shock or dehydration), fluid-ion
imbalance, or bilateral ureteral obstruction. Partial (initial Terminal) Total (present Terminal
throughout hematuria
Pneumaturia : urination)
The passage of gas in the urine almost anterior urethral lesion - arises from posterior
always means that there is a fistula between the (eg, the posterior urethritis
urinary tract and the bowel. urethritis,stricture,meatal urethra, and
stenosis in young boys) bladder neck, polyps
Cloudy Urine or trigone. and
Patients often complain of cloudy urine, but - source at or tumors of
it is most often cloudy merely because it is alkaline; above the the
this causes precipitation of phosphate. Infection can level of the vesical
also cause urine to be cloudy and malodorous. bladder neck.
- (eg,stone,
 tumor ,
tuberculosis,
nephritis).
OTHER OBJECTIVES MANIFESTATIONS
Urethral Discharge
Urethral discharge in men is one of the most common
complaints on urology. Causative organism - N gonorrhoeae or
C trachomatis.
The discharge is often accompanied by local burning
on urination or an itching sensation in the urethra.
Skin lesions of the external Genitalia
An ulceration of the glans penis or its shaft may
represent syphilitic chancre, chancoid herpes simplex,or
squamous cell carcinoma. Venereal warts of the penis are
common.
Visible or Palpable masses
Represent renal tumor, hydronephrosis, or polycystic
kidney.
Enlarged lymph nodes in the neck may contain
metastatic tumor from the prostate or testis.
Lumps in the groin may represent spread of tumor of
the penis or lymphadenitis from chancroid, syphilis, or
lymphogranuloma venereum.
Painless masses in the scrotal contents are common
and include hydroele, varicocele, spermatocele, chronic
epididymitis, hernia, and testicular tumor.
Edema
Edema of the legs may result from compression of the
iliac veins by lymphatic metastases from prostatic cancer.
Edema of the genitalia suggest filariasis or chronic
ascites.
Bloody Ejaculation
Inflammation of the prostate or seminal vesicles can
cause hematospermia.
Gynecomastia
Is often idiopathic; Common in elderly men.
Estrogens for control of prostate cancer.
Associated with choriocarcinoma and interstitial cell
and Sertoli cell tumors of the testis.
Endocrinologic diseases, eg, Klinefelter’s syndrome
Size of Penis in Infant or Child
Micropenis is probably due to fetal testosterone
deficiency.
Megalopenis is caused by over activity of the adrenal
cortex and in association with intertitial cell tumor of the testis.
Infertility
Many men are referred to the urologist for fertility
studies.
One should explore the patients sexual habits and
investigate diseases and disorders that have affected the scrotal
contents (ie,mumps, torsion of the spermatic cord, epididymitis)
and exposure to the testicular toxins (eg,x-ray radiation).
COMPLAINTS RELATED TO SEXUAL PROBLEMS
Sexual Difficulties in Men:
 Men may complain directly of sexual difficulty.
 Ashame of sexual dysfunction – consult for prostatic
problems
 Main sexual symptoms
o impaired quality of erection
o premature loss of erection
o absence of ejaculate or orgasm
o premature ejaculation
o loss of desire.
Sexual Difficulties in women:
 Women suffering from the psychosomatic cystitis
syndrome almost always admit to an unhappy sex life.
 Frequency or vaginal-urethral pain often occurs on the
day following the incomplete sexual act.
 Inadequancy of their sexual experiences
Sexual Difficulties of Suspected Psychosomatic Origin:
 In treating sexual difficulties of suspected psychosomatic
origin, the physician should explore pertinent facts
concerning childhood, adolescence ( sex education and
experiences), marriage problems, and relationship with
relatives, business associates, etc.
 Both psyche and soma may be involved, and the patient
must be assured that there is no serious organic
disease.
 Although sexual interest and activity decline with
advancing years, physically healthy men and women
may continue to be sexually active into their eight or
ninth decades.
EXAMINATION OF THE BLADDER
 The bladder cannot be felt unless it is moderately
distended.
 In the adult, if it is percussible, it contains at least 150
mL of urine.
 In acute or (more commonly) in chronic urinary retention,
the bladder may reach or even rise above the umbilicus,
in which case its outline may be seen and usually felt.
 (In chronic retention,where the bladder wall is flabby, the
bladder may be difficult to palpate. In this instance,
percussion is of great value).
 In the male infant or little boy, palpation of a hard mass
deep in the center of the pelvis is compatible with a
thickened hypertrophied bladder secondary to
obstruction caused by posterior urethral valves.
  A sliding inguinal hernia containing some bladder wall
can be diagnosed (when the bladder is full) by
compressing the scrotal mass.
 The bladder will be found to further distend.
 A few instances have been reported wherein marked
edema of the legs has developed secondary to
compression of the iliac vessels by a distended bladder.
 Bimanual (abdominorectal or abdominovaginal)
palpation may reveal the extend of a vesical tumor. To be
successful, it must be done under anesthesia.
EXAMINATION OF THE EXTERNAL OF THE EXTERNAL
MALE GENITALIA
PENIS
Inspection
 Uncircumcised, the foreskin should be retracted
 (Phimosis),surgical correction (dorsal slit or
circumcision) is indicated.
 scars of healed syphilis is an important clue.
 active ulcer requires bacteriologic or pathologic study
(eg. Sysphilitic chancre, epithelionma).
 Superficial ulcers or vesicle are compatible with
herpes simplex
 Venereal warts may be observed.
 Meatal stenosis is a common cause of bloody spotting
in the male infant.
 Micropenis or macropenis may be observed.
Palpation
 Palpation of the dorsal surface of the shaft may reveal
a fibrous plaque involving the fascial covering of the
corpura cavernosa.
 Tender areas of induration felt along the urethra may
be signify periurethritis secondary to urethral stricture.
Urethral Discharge
 Urethral discharge is the most common complaint
referable to the male sex organ.
 Gonoccocal pus is usually profuse, thick, and yellow
or gray-brown.
 Non-gonorrheal discharges is thin, mucoid, and
scanty.
 Bloody discharge suggest the possibility of a foreign
body in the urethra (male or female), urethral stricture,
or tumor.
SCROTUM
 Infections and inflammations of the skin of the scrotum
are not common.
 Small sebaceous cysts are occasionally seen.
 Malignant tumors - rare.
 Scrotum is bifid when mid-scrotal or perineal
hypospadias is present.
 Elephantiasis of the scrotum - obstruction to lymphatic
drainage, due to filariasis.
TESTIS
 A hard area in the testis proper must be regarded as a
malignant tumor until proved otherwise.
 Trans-illumination of all scrotal masses - done
routinely.
o A hydrocele will cause the intrascoral mass
to glow red.
o Light will not be transmitted through a solid
tumor.
 Tumors are often smooth but may be nodular,
abnormally heavy.
 A testis replaced by tumor or damage by gamma is
insensitive to pressure, and the usual sickening
sensation is absent.
 10% of tumors - associated with secondary hydrocele
 The testis may be absent from the scrotum.
o represents transient (physiologic retractile
testis) or true cryptorchidism.
 Atropic testis
o following postoperative orchidopexy
o mumps orchitis,
o torsion of the spermatic cord
EPIDIDYMIS
 The epididymis is closely attached to the posterior
surface of the testis
 Induration means infection (primary tumors are
exceedingly rare).
 In the acute stage of epididymitis, the testis and
epidymis are indistinguishable by palpation; the
testicle and epididymis may be adherent to the
scrotum, which is usually quite red.
 Tenderness is exquisite.
 With few exeptions, the infecting organism is either
Neisseria gonorrhoeae, Chamydia trachomatis, or
Escherichia coli.
 Chronic painless induration should suggest
tuberculosis or schistosomiasis, although nonspecific
chronic epididymitis is also a possibility.
 Other sighns of tuberculosis of the genitourinary tract
usually present include “sterile” pyuria, a thickened
seminal vesicle , a nodular prostate, and “breading “ of
the vas deferens.
SPERMATIC CORD & VAS DEFERENS
 A swelling in the spermatic cord may be cystic
(eg,hydrocele or hernia) or solid (eg, connective tissue
tumor).
  Lipoma in the investing fascia of the cord - simulates
hernia.
 Diffuse swelling and induration of the cord are seen
with filarial funiculitis.
TESTICULAR TUNICS & ADNEXA
 Hydrocele are usually cystic but on occasion are so
tense that they simulate solid tumors.
 Trans-illumination makes the differential diagnosis.
 develop secondary to nonspecific acute or tuberculous
epididymitis, trauma, or tumor of the testis.
o The latter is a distinct possibility if hydrocele
appears “spontaneously” between the ages
of 18 and 35.
 It should be aspirated to perfect careful palpation of
underlying structures.
 Cystic masses that are separate from but in the region
of the upper pole of the testis are probably
spermatoceles.
o Aspiration reveals the typical thin, milky
fluid, which contains sperms.
VAGINAL EXAMINATION
 Disease of the female genital tract may secondarily
involved the urinary organs
 Associated with urethrocystitis secondary to urethral
diverticulitis or cervicitis, pyelonephritis during
pregnanacy, and urethral obstruction from metastatic
nodes or direct extension in cancer of the cervix.
Inspection
 The urinary meatus may reveal a reddened, tender ,
friable lesion ( urethral carbuncle) or reddened,
everted posterior lip, often seen with senile urethritis
and vaginitis.
 Biopsy is indicated if a malignant tumor cannot be
ruled out.
 Diagnosis of senile vaginitis (and urethritis) is
established by staining a smear of the vaginal
epithelium with Lugol’ solution.
o Cells lacking glycogen (hypoestrogennism)
do not take up the stain , whereas normal
cells do.
 Multiple painful small ulcers or blisterlike lesions
maybe noted; these represent herpesvirus type 2
infection, which may have serious sequels.
 Smears and cultures of urethral or vaginal discharge
should be made.
 Gonoccocci are relatively easy to identitiy; culture of
chlamydiae requires techniques seldom available to
the physicial.
 Evidence of Skenitis and bartholinitis may reveal the
source of persistent urethritis or cystitis.
 Urethrocele and cystocele may cause residual urine
and lead to persistent infection of the bladder.
 The cervix should be inspected to detect cancer or
infection.
o Taking biopsy specimens or making
Palpanicolaou smears may be indicated.
PALPATION
 At times, the urethra, the base of the bladder, and the
lower ureters may be tender on palpation
 Induration of the urethra or trigonal area or a mass
involving either may be a clue to an existing tumor.
 A soft mass found in this area could be a urethral
diverticulum.
 A stone in the lower ureter may be palpable.
 Evidence of enlargement of the ureters (eg,
pregnancy, myomas) or disease or inflammations of
the colon or adnexa may afford a clue to the cause of
urinary symptom (eg, compression of a ureter by a
malignant ovarian tumor, endometriosis, or
diverticulitis of the sigmoid colon adherent to the
bladder).
 Carcinoma of the cervix may invade the base of the
bladder, causing vesical irritability or hematuria ; or its
metastases to iliac lymph nodes may compress the
ureters.
 Rectal examination may afford further information and
is the obvious route of examination in children and
virgins.
RECTAL EXAMINATION OF THE MALE
SPHINCTER & LOWER RECTUM
 the examiner should palpate the entire lower rectum to
rule out stenosis, internal hemorrhoids , cryptitis,
rectal fistulas, nucosal polyps, and rectal cancer
 Testing perianal sensation is mandatory.
PROSTATE
 A specimen of urine for routine analysis should be
collected before the rectal examination is made.
 This is of the utmost importance, since prostatic
massage(or even palpation at times) will force
prostatic secretion into the posterior urethra.
 If this secretion contains pus, a specimen of urine
voided after the rectal examination will be
contaminated by it.
SIZE
 Approximately about 4 cm in length and width.
 On rectal examination, the prostate maybe of normal
size and consistency in a patient with acute urinary
retention.
CONSISTENCY
 Normally, the consisitency of a gland is similar to that
of the contracted thenar eminence of the thumb
 completely opposed to the little finger) or rather
rubbery.
 Mushy if congestive. ( due to lack of intercourse or to
chronic infection with impaired drainage),
 Indurated (due to chronic infection with or without
calculi ) or stonyhard (due to advanced carcinoma.
 In cancer, conversely , the suspicious lesion is usually
not raised; it is hard and has a sharp edge, ie, there is
an abrupt change in consistency on the same plane.
 Serum acid phosphatase determination and radio
grams of bones are oif no help in diagnosing early
carcinoma of the prostate.
MOBILITY
 With advanced carcinoma, it is fixed because of local
extention through the capsule.
 The prostate should be routinely massaged in the
adult and its secretion examined microscopically.
 It should not be massaged,
o in the presence of an acute urethral
discharged, acute prostatitis or acute
prostatocystitis;
o in men near the stage of complete urinary
retention ( because it may precipitate
complete retention};
o in men suffering from obvious cancer of the
gland.
 Diagnosis and treatment of such silent disease is
important in preventing cystitis and epididymitis .
 Such diseases include chancroid, syphilitic chancre,
lymphogranuloma venereum, and, on occasion,
gonorrhea.
 Malignant tumors (squamous cell carcinoma )
involving the penis, glans, scrotal skin, or distal
urethra in women metastasize to the inguinal and
subinguinal nodes.
 Testicular tumors do not spread to these nodes
unless they have invaded the scrotal skin or the
patient has previously undergone orchidopexy.
OTHER LYMPH NODES
 Tumors of the testis and prostate may involved the left
supraclavicular nodes.
 Tumors of the bladder and prostate typically
metastasize to the internal iliac, external iliac, and pre-
aortic nodes, although only occasionally are they so
large as to be palpable.
 Upper abdominal masses near the midline in a young
man should suggest metastases from cancer of the
testis

SEMINAL VESICLES
 Normal seminal vesicles are usually not palpable, but
when they are overdistended they may feel quite
cystic.
 In the presence of chronic infection ( particularly
tuberculosis or schistosomiasis) or in association with
advanced carcinoma of the prostate, they may be
markedly indurated.
 Stripping of the seminal vesicles should be done in
association with prostatic massage, for the vesicles
should be done in association with the prostatic
massage, for the vesicles are usually infected when
prostatitis is present.
 Primary tumors of the vesicles are very rare..
LYMPH NODES
 It should be remembered that generalized lymph
ademnopathy usually occurs early in acquired
immunodeficiency syndrome (AIDS)

INGUINAL & SUBINGUINAL LYMPH NODES

 With inflammatory lesions of the skin of the penis and
scrotum or vulva, the inguinal and subinguinal lymph
nodes maybe involved.