SURG UROLOGY 1

IB CSL SURGERY

UROLOGY
Dr PC Tam

Surgery

Mon 07-10-02

Expose: umbilicus to mid-thigh (blanket/ towel to cover genitalia)
Avoid examining Pt in large group (2-3 students at most)
Do not routinely wear gloves for external genitalia examination (more clumsy); only if:

Suspect STD (urethral discharge, penile ulcer suggesting syphilis)
Poor hygiene
Incontinence: urinary + faecal incontinence
Raw areas
Wound in Dr's hand
DRE

Glove types

Commonly: PVC (rough)
Non-sterile latex gloves (also sterile latex gloves for OT); can cause allergies
Gloves on paper backing (1) Drug hands (2) R hand palm faces paper (3) Tear glove off with hand inside (4) Don't throw away paper (5) L hand palm faces plastic (6) Don't throw away paper

INSPECTION

Suprapubic area
Pubic hair: distribution, hypogonadism features?

FEMALE URETHRA

Dorsal position, with thigh abducted

Inspection

Appearance of urethral orifice
Escape of urine with coughing – stress incontinence

Palpation

Pass a finger into the vagina and feel the floor of urethra for any induration

PENIS

Inspection

Phimosis, paraphimosis
Site and appearance of external urinary meatus

Palpation

Uncircumcised: retract foreskin
Squeeze external meatus vertically - colour of mucosa
Urethra: palpate in Hx of urethral discharge
Palpate shaft of penis for fibrous nodules
Localised, painless induration of one/ both corpora cavernosa
Palpate floor of male urethra from glans to pelvic floor (anterior part along bottom of penis; posterior part between testis)

Palpation

Any localised, painless induration of one or both corpora cavernosa
Palpate the floor of male urethra from glans to the pelvic floor

SCROTUM & TESTICLES

Inspection

Lift up
Discharge or abnormality in posterior part (that may be hidden)
Anterior aspect: scrotal skin (abnormality)
Any obvious swelling – eg. one testis much larger, or a generalised swelling
Redness of the scrotal skin
Enlarged veins of the pampiniform plexus on standing, empty with patient in lying position

Palpation

Palpate testis: start with L (Dr on right side); lift up, stabilise with third finger and palpate with thumb and index finger
Feel for epididymis at posterior testicle (epididymitis: can feel testes in front (normal); induration over posterior aspect; may be accompanied by hydrocele)
Normally, testicle freely mobile in scrotum
Palpate vas deferens: esp. in Pt's with Hx of infertility
Then repeat R side testicle: use little finger of L hand to push away penis
Repeat: mobility within scrotum, palpate epididymis, stabilise testicle and use thumb and index to palpate testicle for nodules/ hard mass (eg. Testicular tumour), vas over right side
Mass: site (testis, epididymis), size, consistency, tenderness, feeling a bag of worms
Hernia: bowel into tunica vaginalis
Tumour in testicle: most dangerous

Transillumination

Fluid containing hydroceles and epididymal cysts will be translucent

Measure testicular size

Not in every Pt; measure if suspect hypogonadism (insufficient testosterone)
Eg. Male with infertility, erectile dysfunction, something wrong with hypothalamic-pituitary-testicular axis

Orchidometer: state volume in ml; measure both sides; more common method
Use Sieger (?) orchidometer: measure length + width

NOTE: MUST EXAMINE TESTIS in ab exam, enlarged LN (eg. Para-aortic), both medical and surgical Pt's (commonly excluded: forget, reduce embarrassment to Pt)

Varicocele

Varicocele: blood collecting in tortuous dilated spermatic vein

on standing, ¯ on lying down

Kneel so your eyes at level of testicles

Stand Pt up, wait 1-2 min, blood collects in pampiniform plexus, put finger gently on surface, nodularity under skin

Palpate area of spermatic cord on left gently with right hand for evidence of dilated vein

Can see bag of worms? Grade 3 varicocele

Grade 1: palpable only when Pt Valsalva manoeuvre
Grade 2: palpable not visible
Grade 3: varicocele visible even without palpation

Repeat on right (although varicocele more common on left side than right ® L testicular vein drains into left renal vein (has higher pressure than IVC); R testicular vein drains into IVC \ (1) Longer drainage course (2) Higher pressure

80-90% varicocele affect only left side; 10% affect both sides; < 10% only affect right side

Varicocele occur in 15% of normal male population (common)

Recent onset of varicocele: dangerous - small possibility of renal cell carcinoma with renal thrombus entering left renal vein, blocking left testicular vein

If long-standing: safer

Hydrocele

Smooth swelling over scrotum; transilluminates
To distinguish from hernia - hydrocele: can get above swelling
Large, tense hydrocele: cannot distinctly feel testis (hydrocele fluid under tension)
Small hydrocele: may be able to feel testis

DIGITAL RECTAL EXAMINATION

Positions

Left lateral position: less embarrassing for Pt, even very ill Pt's can assume this position; back + buttocks near edge of bed; flex R more than L leg [can have R lateral position; uncomfortable as Pt faces Dr but upon insertion can palpate prostate immediately] (used in HK)

Knee chest position: prostate and rectum pushed down when Pt flexes hip \ easier to palpate (esp. in large/ obese men); used more by urologists (esp. in USA)

Standing bent over table at waist: similar to knee-chest, but hips not flexed as much \ prostate not pushed down as much

Lithotomy

Sit beside bed
2 glove for right hand, 1 glove left hand OR 1 glove on each hand for examination, then transfer glove from left hand to right just before DRE
Wear 2 gloves on R hand (1) Extra security during DRE (2) After removing glove, still have one glove to help clean Pt up

Inspection

Perineal skin ® fistulae, scars, discharge

Anus + peri-anal area ® fissure, external piles etc

Haemorrhoidal tags, fissures, haemorrhoids, Valsalva manoeuvre

Palpation

Same area ® tenderness, induration

Perianal sensation: toothpick, end of tendon hammer (anocutaneous reflex - contraction of anal sphincter after 1 sec - indicates afferent + efferent parts of reflex arc are functioning through sacral part of SC) ® Cauda equina compression: absent reflex, retention of urine

Digital Rectal Examination

Prostate in front of rectum \ posterior part accessible by DRE

Anterior part (not accessible) - fibromuscular stroma \ rarely have pathology here

Transition zone (inner part of prostate) - not easily accessible - may have pathology

KY Jelly on right index finger

Put tip of finger on anus, bend distal IPJ slightly

Exert gentle pressure, feel relaxation of external sphincter + slowly insert finger (may have to turn body to face Pt's face)

Palpate posterior ® right lateral ® left lateral rectal wall (abnormalities in lining - tumour, ulcer, induration, irregularities, nodules)

Sit/ kneel - palpate anterior rectal wall + prostate (asymmetry, irregular hard area, nodule, etc)

Pt to bear down to press pathology against finger (most colonic neoplasms within reach)

Cancer: hard, easily detectable ® (1) Hard well-circumscribed nodule (2) Induration with normal consistency but asymmetrical (3) Nodularity (4) Beyond prostate capsule invading adjacent tissue

Prostate: normal size = walnut, firm and rubbery, median furrow separating lateral lobes; describe @ surface smooth/ nodular, elastic/ hard/ boggy/ soft/ fluctuant; mobile/ fixed

Seminal vesicles usu. not palpable

BPH: prostate normal consistency but may be as large as tennis ball

Poor correlation between prostate size and voiding symptoms

Pt should find examination uncomfortable but not painful

Withdraw finger: inspect glove for blood

Turn glove inside out, wrap in paper (from glove), dispose properly

Clean Pt: again, turn glove inside out and dispose in paper

If suspect ca

PSA
Transrectal US: quick, painless, size/ nature/ location of pathology
Prostate biopsy: if PSA and US abnormal

Prostatic Massage for Specimen Collection

Knee- elbow position

Eg. Acute prostatitis

Very tender; palpate if UTI, fever, chills

VB1 = 1st 10 m; urethral organisms

VB2 = MSU; UB organisms

Prostatic massage (from lateral margins to midline, along midline from apex to base) - collect any prostatic secretions ® Slow, firm strokes with the pressure applied evenly, after which the contents of the penile urethra are milked down

VB3 = 1st 10 cc after massage; prostatic org

Definitive Dx of bacterial prostatitis: VB3 > VB1 or VB2 (> 10-100x)

Microbiologists; need specific colony count; time consuming

Unpopular test, most accurate way of Dx prostatitis

If WBC increased in prostatic secretions: if +ve = inflammation/ infection (20-30%)
If -ve: chronic pelvic pain syndrome; prostatodynia (eg. Tension in pelvic floor) (most Pt's)
Of +ve WBC in PES (prostatic expression secretion), only small % have bacteria

Acute bacterial prostatitis: v tender, septic, high fever, retention of urine, no massage (causes septicaemia); < 10% have +ve bacterial growth

Chronic prostatitis: prostatodynia

Non-bacterial prostatitis: +ve WBC, -ve bacterial (may have unusual organism - eg. Chlamydia - cannot isolate in traditional bacterial culture; may have viral infection; un-ID bacteria; chemical prostatitis)

Chemical prostatitis (aetiology not know): don't know how to relax pelvis floor, urine forced against closed sphincter, from prostatic urethra in prostatic duct; chemicals in urine \ cause inflammation)

Proctoscopy

Visualise the ano-rectal lining

Finished

Make Pt comfortable
Cover up lower body with blanket
Ask Pt to turn supine