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Assessment of the urological patient: History and examination

Assessment of the urological patient involves taking a complete and detailed history, a thorough physical examination and analysis of a urine sample. As with all history taking the enquiry should include details of the presenting complaint and its history, the relevant past medical history and a family and drug history. The examination should include the abdomen, external genitals and a digital rectal examination in men and a vaginal examination in women, if clinically indicated. The urinalysis is most readily performed by dipstick testing; a formal microscopic analysis may be required to investigate any abnormality.

History

Communication skills

It is perhaps even more important with urology than with other specialities, because of the personal nature of some of the symptom complexes, for the clinician to create a personal rapport and a warm environment to facilitate enquiry into sometimes intimate problems. Stand up to greet the patient and welcome him/her warmly. Introduce yourself and make an initial assessment of the patient's age, built, demeanour, intelligence and socio-economic group and adapt your consultation style accordingly, based on your experience, in an attempt to make the patient feel comfortable. An icebreaker such as 'I hope you haven't been waiting too long' or 'Did you manage to park easily?' can help the patient to relax. Aim to project a caring, experienced and open but professional image that will put the patient at ease and facilitate communication.

Then begin with, 'How old is your patient and what is his/her occupation? How can I help', or 'Your GP has written to us saying you have a problem with.please tell me about it', which are good open questions to start the consultation. Look out for signs that the patient may not be able to describe the problem due to anxiety or embarrassment or a language barrier. Then listen. Listen until you are clear on the nature of the problem, or the patient has gone off on a tangent and you feel you have to gently redirect him/her. Once you are clear on the presenting complaint, obtain a history of it and ask more specific questions aimed at eliciting the important diagnostic points. The following are common complaints initiating a consultation.

Basic symptoms

Haematuria

The presence of blood in the urine is termed haematuria. Haematuria has many causes ranging from the insignificant to life-threatening cancers and is often a result of urinary tract infection (UTI). The patient should therefore be asked whether the blood was accompanied by symptoms of urinary tract inflammation such as dysuria, pain, urinary frequency or whether the urine smelled offensive. In all patients with a history of haematuria, the urine should be examined by dipstick and cultured if this suggests infection (see later). The extent of investigation required for a confirmed infection is guided by patient characteristics; however, all patients with symptomatic infections should be treated with appropriate antibiotics and the urine retested for blood once the infection has resolved. It is important to remember that UTI itself can be the first sign of serious urinary tract pathology. Uncommonly, urine discolouration that is reported as haematuria may be caused by myoglobinuria, beetroot intake and drugs such as rifampicin. It is generally advisable to investigate for haematuria anyway. Haematuria may be visible or non-visible and associated with other LUTS or asymptomatic, and this is the starting point for subsequent enquiry.

Visible haematuria

Visible haematuria is arguably the most important symptom in urology as it implies urological cancer until proven otherwise, and all patients including those with demonstrated infection should undergo investigation. The patient may notice the blood at the beginning, throughout or at the end of the urinary stream, and this sign may give an indication of its origin and cause. Initial haematuria often originates from the prostate or urethra and as such is less likely to reflect bladder or upper urinary tract pathology, whereas haematuria throughout the stream implies the blood emanates from the bladder or above. Terminal haematuria may indicate upper tract bleeding. This differentiation is unreliable, however, and all patients require the same investigation with upper urinary tract cross-sectional imaging by computerised tomography including a urographic phase and cystoscopy as a minimum.

Non-visible haematuria

Non-visible or microscopic haematuria is defined by the presence of more than three erythrocytes per high-power field on microscopy or at least 1+ on dipstick of a fresh midstream urine sample. It is usually detected in the community on routine urine testing or during the investigation of symptoms. A few erythrocytes in the urine are common and often found after heavy exercise. After exclusion of infection as a cause, a single episode of non-visible haematuria accompanied by LUTS or persistent asymptomatic haematuria is clinically significant and should be investigated.

Asymptomatic non-visible haematuria commonly represents early chronic kidney disease, and patients under the age of 40 with no other risk factors for urothelial malignancy should be investigated with urine protein/creatinine ratio and first referred for nephrological rather than urological opinion if evidence of deteriorating glomerular filtration rate, significant proteinuria or hypertension is present. The patient should be asked if there has been a recent upper respiratory tract infection as this may be associated with glomerulonephritis.

Urological investigation with urinary tract ultrasound and cystoscopy of all other patients is recommended, and in some centres computerised tomography is also performed. The incidence of finding a significant urological abnormality in patients with asymptomatic non-visible haematuria is less than 10%.

KEYPOINTS

• Haematuria has many causes ranging from the insignificant to a range of malignancies. Infection should always be excluded; however, it may also be the first sign of serious pathology.
• Asymptomatic non-visible haematuria is commonly nephrological, not urological.
• Visible haematuria is caused by malignancy until proven otherwise.

Lower urinary tract symptoms

LUTS are a common reason for someone to seek a urological opinion with over a half of the population likely to experience them at some point in their lifetime; the incidence, as might be expected, increases with age. LUTS occur in both sexes, reminding us that these symptoms are not specific to the enlarged prostate and are currently classified as either voiding or storage symptoms.

Voiding symptoms

• Hesitancy - This is a delay in the start of micturition. Normally it takes a second or so to start passing urine.
• Intermittency - This is a stop/start pattern that happens involuntarily during micturition and is generally due to prostatic obstruction.
• Poor flow - This is a decreased flow of urine and can be due to prostatic obstruction or urethral stricture. This happens over a long period of time.
• Straining - This is due to the use of abdominal muscles to empty the bladder.
• Terminal dribble - This is passing drops of urine at the end of micturition and is generally an early sign of obstruction secondary to prostatic enlargement.
• Feelings of incomplete bladder emptying - This is the feeling of needing to void again soon after voiding.

Storage symptoms

• Frequency - A normal adult will pass urine 3-7 times during the day with volumes of around 200-400?mL per void. Urinary frequency is either due to increased urinary output (polyuria) or decreased bladder capacity.
• Nocturia - This is getting up at night more than once. It can be due to either increased urine production or decreased bladder capacity. Frequency without nocturia is usually psychological. On the other hand, nocturia without frequency can be related to heart failure or diabetes insipidus.
• Urgency - The International Continence Society defines urgency as 'a complaint of a sudden compelling desire to pass urine, which is difficult to defer'.
• Dysuria - This is a painful micturition and is generally felt both suprapubically and over the urethral meatus. It is usually a sign of inflammation in the urinary tract.

While often attributed to bladder outflow obstruction and functional bladder problems, LUTS are not disease or organ specific. Storage symptoms in particular may reflect a wide range of pathologies from impaired fluid and solute handling problems to non-specific inflammation of the urinary tract and can also be a sign of underlying malignant processes. Identical storage and voiding symptoms may be caused by either bladder muscle dysfunction or outflow tract obstruction due to benign or malignant prostatic enlargement. It is therefore important to determine the presence of individual voiding and storage symptoms, to quantify their severity and to elucidate other symptoms and signs that may indicate their...