Chapter 4. Physical Examination of the Genitourinary Tract

A careful history and assessment of symptoms will suggest whether a complete or limited examination is indicated, and also help direct the appropriate selection of subsequent diagnostic studies.

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 may be consistent with cancer or perinephric infection. The presence and persistence of indentations in the skin from lying on wrinkled sheets suggest edema of the skin secondary to perinephric abscess.

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. 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. The lower part of the right kidney can sometimes be felt, particularly in thin patients, but the left kidney usually cannot be felt unless it is enlarged or displaced.

The most successful method of renal palpation is carried out with the patient lying in the supine position on a hard surface (Figure 4–1). The kidney is lifted by one hand in the costovertebral angle (CVA). On deep inspiration, the kidney moves downward; the other hand is pushed firmly and deeply beneath the costal margin in an effort to trap the kidney. When successful, the anterior hand can palpate the size, shape, and consistency of the organ as it slips back into its normal position.

Alternatively, the kidney may be palpated with the examiner standing behind the seated patient. At other times, if the patient is lying on one side, the uppermost kidney drops downward and medially, making it more accessible to palpation. Perlman and Williams (1976) described an effective method of identifying renal anomalies in newborns. The fingers are placed in the costovertebral angle, with the thumb anterior and performing the palpation.

An enlarged renal mass suggests compensatory hypertrophy (if the other kidney is absent or atrophic), hydronephrosis, tumor, cyst, or polycystic disease. However, a mass in this area may also represent a retroperitoneal tumor, spleen, lesion of the bowel (eg, tumor, abscess), lesion of the gallbladder, or pancreatic cyst. Tumors may have the consistency of normal tissue or be nodular, while hydronephrosis may be either firm or soft. Polycystic kidneys are usually nodular and firm.

An acutely infected kidney is tender, but the presence of marked muscle spasm may make this difficult to elicit. In addition, this sign may not always be helpful since the normal kidney is also often tender.

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). Symptoms may be elicited by palpation or sharp percussion over the 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 and this part of the examination should not be omitted.

Percussion is of particular value in outlining an enlarging mass (progressive hemorrhage) in the flank following renal trauma, when tenderness and muscle spasm prevent palpation.

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 right angles to the abdomen. 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.

Differentiation of Renal and Radicular Pain

Radicular pain is commonly felt in the costovertebral and subcostal areas. It may also spread along the course of the ureter and is the most common cause of so-called “kidney pain.” Every patient who complains of flank pain should be examined for evidence of nerve root irritation. Frequent causes are poor posture (scoliosis, kyphosis), arthritic changes in the costovertebral or costotransverse joints, impingement of a rib spur on a subcostal nerve, hypertrophy of costovertebral ligaments pressing on a nerve, and intervertebral disk disease (Smith and Raney, 1976). Radicular pain may be noted as an aftermath of a flank incision where a rib is dislocated, causing impingement of costal nerve on the edge of a ligament. Pain experienced during the preeruptive phase of herpes zoster involving any of the segments between T11 and L2 may simulate pain of renal origin.

Radiculitis usually causes hyperesthesia of the area of skin served by the irritated peripheral nerve. This hypersensitivity can be elicited by means of the pinwheel or grasping and pinching both skin and fat of the abdomen and flanks. Pressure exerted by the thumb over the costovertebral joints reveals local tenderness at the point of emergence of the involved nerve.

Auscultation

Auscultation of the costovertebral areas and upper abdominal quadrants may reveal a systolic bruit, often associated with stenosis or aneurysm of the renal artery. Bruits over the femoral arteries may be found in association with Leriche syndrome, which may be a cause of impotence.

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. In chronic retention, the bladder may be difficult to palpate due to the flabby bladder wall, in which case percussion is of value.

In male infants or young boys, 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 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. Bimanual (abdominorectal or abdominovaginal) palpation may reveal the extent of a vesical tumor; to be successful, it should be done under anesthesia.

Penis

Inspection

If the patient has not been circumcised, the foreskin should be retracted. This may reveal tumor or balanitis as the cause of foul discharge. If retraction is not possible due to phimosis, surgical correction (dorsal slit or circumcision) is indicated.

The observation of a poor urinary stream is significant: in newborns, neurogenic bladder or the presence of posterior urethral valves should be considered, whereas in men such a finding suggests urethral stricture or prostatic obstruction.

The scars of healed syphilis may be an important clue. An active ulcer requires bacteriologic or pathologic study (eg, syphilitic chancre, epithelioma). Superficial ulcers or vesicles are compatible with herpes simplex and often interpreted by the patient as a serious sexually transmitted disease (eg, syphilis). Venereal warts may be observed.

Meatal stenosis is a common cause of bloody spotting in male infants. On occasion, it may be of such degree as to cause advanced bilateral hydronephrosis.

The position of the meatus should be noted. It may be located proximal to the tip of the glans on either the dorsal (epispadias) or the ventral surface (hypospadias). In either instance, there is apt to be abnormal curvature (chordee) of the penis in the direction of the displaced meatus.

Micropenis or macropenis may be noted during examination of the penis. In the neonate, the presence of hypospadias and bilateral undescended testes should raise the possibility of an intersex condition.

Palpation

Palpation of the dorsal surface of the shaft may reveal a fibrous plaque involving the tunica albuginea covering of the corpora cavernosa, typical of Peyronie's disease. Tender areas of induration felt along the urethra may signify periurethritis secondary to urethral stricture.

Urethral Discharge

Urethral discharge is the most common complaint referable to the male sex organ. Gonococcal pus is usually profuse, thick, and yellow or gray–brown. Nongonorrheal discharges may be similar in appearance but are often thin, mucoid, and scant. Although gonorrhea must be ruled out as the cause of urethral discharge, a significant percentage of cases is found to be caused by chlamydiae. Patients with urethral discharge should also be examined for other sexually transmitted diseases since multiple infection is not uncommon.

Bloody discharge suggests the possibility of a foreign body in the urethra, urethral stricture, or tumor.

Urethral discharge must always be sought before the patient is asked to void.

Scrotum

Angioneurotic edema and infections and inflammation of the skin of the scrotum are not common. Small sebaceous cysts are occasionally seen while malignant tumors are rare. The scrotum is bifid when midscrotal or perineal hypospadias is present.

Elephantiasis of the scrotum is caused by obstruction to lymphatic drainage and endemic in the tropics due to filariasis. Genital lymphedema may also result from radical resection of the lymph nodes of the inguinal and femoral areas, in which case the skin of the penis is involved. Small hemangiomas of the skin are common and may bleed spontaneously.

Scrotal ultrasound is a helpful adjunct in evaluating the scrotal contents.

Testis

The testes should be carefully palpated with the fingers of both hands. A hard area in the testis proper must be regarded as a malignant tumor until proven otherwise. Transillumination of scrotal masses should be done routinely. With the patient in a dark room, a flashlight or fiberoptic light is placed against the scrotal sac posteriorly. A hydrocele will cause the intrascrotal mass to glow red; conversely light is not transmitted through a solid tumor. Tumors are often smooth but may be nodular and the testes may seem abnormally heavy. A testis replaced by tumor or damaged by gumma is insensitive to pressure, and the usual sickening sensation is absent. About 10% of tumors are associated with a secondary hydrocele that may require aspiration before definitive palpation can be performed.

The testis may be absent from the scrotum, and this may be transient (physiologic retractile testis) or true cryptorchidism. Palpation of the groins may reveal the presence of the organ.

The atrophic testis (postoperative orchiopexy, mumps orchitis, or torsion of the spermatic cord) may be flabby and at times hypersensitive but is usually firm and hyposensitive. Although spermatogenesis may be absent, androgen function is occasionally maintained.

Epididymis

The epididymis is sometimes rather closely attached to the posterior surface of the testis, and at other times, it is quite free of it. The epididymis should be carefully palpated for size and induration, which implies infection since primary tumors are exceedingly rare.

In the acute stage of epididymitis, the testis and epididymis are indistinguishable by palpation; the testicle and epididymis may be adherent to the scrotum, which is usually red and exquisitely tender. With few exceptions, the infecting organism is Neisseria gonorrhoeae, Chlamydia trachomatis, or Escherichia coli.

Chronic painless induration suggests tuberculosis or schistosomiasis, although nonspecific chronic epididymitis is also possible. Other signs of genitourinary tuberculosis include sterile pyuria, thickened seminal vesicle, nodular prostate, and “beading” of the vas deferens.

Spermatic Cord and Vas Deferens

A swelling in the spermatic cord may be cystic (eg, hydrocele or hernia) or solid (eg, connective tissue tumor) although the latter is rare. Lipoma in the investing fascia of the cord may simulate a hernia. Diffuse swelling and induration of the cord are seen with filarial funiculitis.

Careful palpation of the vas deferens may reveal thickening (eg, chronic infection), fusiform enlargements (“beading” caused by tuberculosis), or even absence of the vas. The latter finding is of importance in infertile males and may be associated with cystic fibrosis or ipsilateral Wolffian duct abnormality (eg, renal agenesis).

When a male patient stands, a mass of dilated veins (varicocele) may be noted behind and above the testis. The degree of dilatation decreases with recumbency and can be increased by the Valsalva maneuver. The major potential sequela of varicocele is infertility (see Chapter 42).

Testicular Tunics and Adnexa

Hydroceles are usually cystic but on occasion so tense that they simulate solid tumors; transillumination confirms the diagnosis. The fluid may accumulate secondary to nonspecific acute or tuberculous epididymitis, trauma, or tumor of the testis. The latter is a distinct possibility if the hydrocele appears spontaneously between the ages of 18 and 35. It should be aspirated to permit careful palpation of underlying structures or further characterized with ultrasonography.

Hydroceles usually surround the testis completely. Cystic masses that are separate from but in the region of the upper pole of the testis are typically spermatoceles. Aspiration reveals the typical thin, milky fluid, which contains sperm.

Vaginal Examination

Diseases of the female genital tract may secondarily involve the urinary organs, making a thorough gynecologic examination essential, which should be performed by the male physician in the presence of a female nurse or health professional. Commonly associated conditions include urethrocystitis secondary to urethral diverticulitis or cervicitis, pyelonephritis during pregnancy, and ureteral obstruction from metastatic nodes or direct extension from cervical cancer.

Inspection

In newborns and children, the vaginal vestibule should be inspected for a single opening (common urogenital sinus), labial fusion, split clitoris and lack of fusion of the anterior fourchette (epispadias), or hypertrophied clitoris and scrotalization of the labia majora (adrenogenital syndrome).

The urinary meatus may reveal a reddened, tender, friable lesion (urethral caruncle) or a reddened, everted posterior lip often seen with senile urethritis and vaginitis. Biopsy is indicated if a malignant tumor cannot be ruled out. The diagnosis of senile vaginitis and urethritis is established by staining a smear of the vaginal epithelium with Lugol's solution. Cells lacking glycogen (hypoestrogenism) do not take up the stain, whereas normal cells do.

Multiple painful small ulcers or blister-like lesions may be noted, usually representing herpes virus type 2 infection, which may have serious sequelae.

Smears and cultures of urethral or vaginal discharge should be made. Gonococci are relatively easy to identify; culture of chlamydiae requires techniques seldom available to the physician.

The presence of skenitis and bartholinitis may reveal the source of persistent urethritis or cystitis. The condition of the vaginal wall should be observed. Urethrocele and cystocele, often found with stress incontinence, may be associated with residual urine and lead to persistent infection of the bladder. A bulge in the anterior vaginal wall may represent a urethral diverticulum. The cervix should be inspected for cancer or infection. Taking biopsy specimens or making Papanicolaou smears may be indicated.

Palpation

At times, the urethra, base of the bladder, and lower ureters may be tender on palpation, but little can be deduced from this finding. Induration of the urethra or trigonal area, or a mass involving either, may be a clue to an existing tumor. A soft mass could be a urethral diverticulum, and pressure may cause pus to extrude from the urethra. A stone in the lower ureter may be palpable. Evidence of enlargement of the uterus (eg, pregnancy, myoma) or diseases or inflammations of the colon or adnexa may afford a clue to the cause of urinary symptoms (eg, compression of ureter by 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; metastases to iliac lymph nodes may compress the ureters.

Rectal examination may provide further information and is the obvious route of examination in children and virgins.

Sphincter and Lower Rectum

The estimation of sphincter tone is of importance. Laxity of the muscle suggests similar changes in the urinary sphincter and detrusor and the possibility of neurogenic disease; the same is true for a spastic anal sphincter. In addition to the digital prostatic examination, the examiner should palpate the entire lower rectum to rule out stenosis, internal hemorrhoids, cryptitis, rectal fistulae, mucosal polyps, and rectal cancer. Testing perianal sensation is mandatory.

Prostate

A specimen of urine for routine analysis should be collected before the rectal examination. This is of importance, since prostatic massage or even palpation at times forces prostatic secretion into the posterior urethra. If this secretion contains pus, a specimen of voided urine after the rectal examination will be contaminated.

Size

The average prostate is about 4 cm in both length and width. As the gland enlarges, the lateral sulci become relatively deeper and the median furrow becomes obliterated. The clinical importance of prostatic hyperplasia is measured by the severity of symptoms and the amount of residual urine rather than by the size of the gland on palpation. The prostate may be of normal size and consistency on examination in a patient with acute urinary retention or severe obstructive urinary complaints.

Consistency

Normally, the consistency of the gland is similar to that of the contracted thenar eminence of the thumb (with the thumb completely opposed to the little finger) and is rather rubbery. It may be mushy if congested (due to lack of intercourse or chronic infection with impaired drainage), indurated (due to chronic infection with or without calculi), or stony hard (due to advanced carcinoma).

The difficulty lies in differentiating firm areas in the prostate: fibrosis from nonspecific infection, granulomatous prostatitis, nodularity from tuberculosis, or firm areas due to prostatic calculi or early cancer. Generally, nodules caused by infection are raised above the surface of the gland. At their edges, the induration gradually fades to the normal softness of surrounding tissue. Conversely, the suspicious lesion in cases of prostate cancer is usually not raised; rather, it is hard and has a sharp edge (ie, there is an abrupt change in consistency on the same plane). It tends to arise in the lateral sulcus (Figure 4–2).

Even the most experienced clinician can have trouble differentiating cancer from other conditions. The serum prostate-specific antigen (PSA) level can be helpful if elevated and is currently the most common method of diagnosing prostate cancer (clinical stage T1c). Transrectal ultrasound-guided biopsy of the prostate can be diagnostic. Recent evidence suggests that rectal examination after radical prostatectomy is unnecessary when PSA is undetectable, since no case of locally recurrent cancer was identified in the absence of an elevated PSA.

Mobility

The mobility of the gland varies. Occasionally, it has great mobility while at other times, very little. With advanced carcinoma, it is fixed because of local extension through the capsule. In adults, the prostate should be routinely massaged and its secretion examined microscopically. However, prostatic massage should be avoided in the presence of an acute urethral discharge, acute prostatitis, or acute prostatocystitis; in men near the stage of complete urinary retention (because it may precipitate complete retention); or in men suffering from obvious cancer of the gland.

Massage and Prostatic Smear

Copious amounts of secretion may be obtained from some prostate glands and little or none from others. The amount obtained depends to some extent on the vigor with which the massage is carried out. If no secretion is obtained, the patient should be asked to void even a few drops of urine, as these will contain adequate secretion for examination. Microscopic examination of the secretion is done under low-power magnification. Normal secretion contains numerous lecithin bodies, which are refractile like red blood cells but much smaller. Only an occasional white cell is present. A few epithelial cells and, rarely, corpora amylacea are seen. Sperm may be present, but its absence is of no significance.

The presence of large numbers or clumps of leukocytes suggests prostatitis. Stained smears are usually impractical because it is difficult to fix the material on the slide; even when fixation and staining are successful, pyogenic bacteria are usually not found. Acid-fast organisms can often be found by appropriate staining methods.

On occasion, it may be necessary to obtain cultures of prostatic secretion in order to demonstrate nonspecific organisms, tubercle bacilli, gonococci, or chlamydiae. After thorough cleansing of the glans and emptying of the bladder to mechanically cleanse the urethra, the prostate is massaged. Drops of secretion are collected in a sterile tube of appropriate culture medium.

Seminal Vesicles

Palpation of the seminal vesicles should be attempted. The vesicles are situated under the base of the bladder and diverge from below upward (Figure 1–8). Normal seminal vesicles are usually impalpable, but may feel cystic when overdistended. In the presence of chronic infection (particularly tuberculosis or schistosomiasis) or in association with advanced carcinoma of the prostate, they may be indurated. Stripping of the seminal vesicles should be done in association with prostatic massage, for the vesicles are usually infected when prostatitis is present. Primary tumors of the vesicles are very rare. A cystic mass may rarely be felt over the prostate or just above it. This probably represents a cyst of the Müllerian duct or the utricle; the latter is occasionally associated with severe hypospadias.

Lymph Nodes

It should be remembered that generalized lymphadenopathy usually occurs early in human immunodeficiency syndrome (see Chapter 15).

Inguinal and Subinguinal Lymph Nodes

With inflammatory lesions of the skin of the penis and scrotum or vulva, the inguinal and subinguinal lymph nodes may be involved. 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 involve the left supraclavicular nodes (Virchow's or Troisier's node). Tumors of the bladder and prostate typically metastasize to the internal iliac, external iliac, and preaortic nodes, although rarely 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; the primary growth may be minute and hidden in the substance of what appears to be a normal testicle.

A careful neurologic survey may uncover sensory or motor impairment that account for residual urine or incontinence. Since the bladder and sphincter are innervated by the second to the fourth sacral segments, information can be gained by testing anal sphincter tone, evaluating sensation of the perianal skin, and testing Achilles tendon and bulbocavernosus reflexes. The bulbocavernosus reflex is elicited by placing a finger in the rectum and squeezing the glans penis or clitoris, or by jerking on an indwelling Foley catheter. The normal reflex involves contraction of the anal sphincter and bulbocavernosus muscles in response to these maneuvers.

It is wise, particularly in children, to seek a dimple over the lumbosacral area. One should palpate the sacrum to ensure it is present and normally formed. Sacral agenesis or partial development is compatible with deficits of S2–4. If findings seem abnormal, x-ray examination is indicated.

Examination of the Kidneys

External Genitalia in Males

External Genitalia in Females

Prostate

Neurologic Examination