Physical examination of the genitourinary tract: Introduction презентация

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The history will suggest whether a complete or partial examination is indicated.

Слайд 1
Physical Examination of the Genitourinary Tract:

Introduction

Слайд 2
The history will suggest whether a complete or partial examination is

indicated.


Слайд 3 Examination of the Kidneys Inspection

Слайд 4Examination of the Kidneys Inspection
The presence and persistence of indentations in the

skin from lying on wrinkled sheets suggest edema of the skin secondary to perinephric abscess.

Слайд 5Palpation
The kidneys lie rather high under the diaphragm and lower ribs

and are therefore well protected from injury.

Слайд 6Palpation
The kidney is lifted by one hand in the costovertebral angle.



Слайд 7Palpation
On deep inspiration, the kidney moves downward; when it is lowest,

the other hand is pushed firmly and deeply beneath the costal margin in an effort to trap the kidney below that point. If this is successful, the anterior hand can palpate the size, shape, and consistency of the organ as it slips back into its normal position.

Слайд 8Palpation
The kidney sometimes can be palpated best with the examiner standing

behind the seated patient.

Слайд 9Palpation
Anomalies were found in 0.5% of 11,000 newborns.

Слайд 10Palpation
An enlarged renal mass suggests compensatory hypertrophy (if the other kidney

is absent or atrophic), hydronephrosis, tumor, cyst, or polycystic disease.

Слайд 11Palpation
Tumors may have the consistency of normal tissue; they may also

be nodular.

Слайд 12Palpation

This may be elicited by palpation or, more sharply, by percussion

over that area.

Слайд 13Percussion
At times, a greatly enlarged kidney cannot be felt on palpation,

particularly if it is soft. This can be true of hydronephrosis.

Слайд 14Transillumination
Transillumination may prove quite helpful in children under age 1 year

who present with a suprapubic or flank mass.

Слайд 15Transillumination
The fiberoptic light cord, used to illuminate various optical instruments, is

an excellent source of cold light.

Слайд 16Differentiation of Renal & Radicular Pain

Radicular pain is commonly felt in

the costovertebral and subcostal areas.

Слайд 17Differentiation of Renal & Radicular Pain
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.

Слайд 18Differentiation of Renal & Radicular Pain
Radicular pain may be noted as

an aftermath of a flank incision wherein a rib may become dislocated, causing the costal nerve to impinge on the edge of a ligament.

Слайд 19Differentiation of Renal & Radicular Pain
Radiculitis usually causes hyperesthesia of the

area of skin served by the irritated peripheral nerve.

Слайд 20Auscultation
Bruits over the femoral arteries may be found in association with

Leriche syndrome, which may be a cause of impotence.

Слайд 21Examination of the Bladder
The bladder cannot be felt unless it is

moderately distended. In adults, if it is percussible, it contains at least 150 mL of urine.

Слайд 22Examination of the Bladder
A sliding inguinal hernia containing some bladder wall

can be diagnosed (when the bladder is full) by compression of the scrotal mass. The bladder will be found to distend additionally.

Слайд 23Examination of the Bladder
Bimanual (abdominorectal or abdominovaginal) palpation may reveal the

extent of a vesical tumor.
To be successful, it must be done under anesthesia.

Слайд 24
Examination of the External Male Genitalia
Penis
Inspection

Слайд 25
If the patient has not been circumcised, the foreskin should be

retracted. This may reveal tumor or balanitis as the cause of a foul discharge.

Слайд 26
The scars of healed syphilis may be an important clue. An

active ulcer requires bacteriologic or pathologic study (eg, syphilitic chancre, epithelioma).

Слайд 27
Meatal stenosis is a common cause of bloody spotting in male

infants.

Слайд 28
The position of the meatus should be noted. It may be

located proximal to the tip of the glans on either the dorsum (epispadias) or the ventral surface (hypospadias).

Слайд 29Palpation
Palpation of the dorsal surface of the shaft may reveal a

fibrous plaque involving the fascial covering of the corpora cavernosa.

Слайд 30Urethral 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.

Слайд 31Urethral Discharge
Although gonorrhea must be ruled out as the cause of

a urethral discharge, a significant percentage of such cases are found to be caused by chlamydiae.

Слайд 32Urethral Discharge
Bloody discharge should suggest the possibility of a foreign body

in the urethra (male or female), urethral stricture, or tumor.
Urethral discharge must always be sought before the patient is asked to void.

Слайд 33Scrotum
Angioneurotic edema and infections and inflammations of the skin of the

scrotum are not common.

Слайд 34
Elephantiasis of the scrotum is caused by obstruction to lymphatic drainage.

It is endemic in the tropics and is due to filariasis.

Слайд 35Testis
The testes should be carefully palpated with the fingers of both

hands.

Слайд 36Testis
A hydrocele will cause the intrascrotal mass to glow red.

Слайд 37Testis
About 10% of tumors are associated with a secondary hydrocele that

may have to be aspirated before definitive palpation can be done.

Слайд 38Testis
The atrophic testis (following postoperative orchiopexy, mumps orchitis, or torsion of

the spermatic cord) may be flabby and at times hypersensitive but is usually firm and hyposensitive.

Слайд 39Epididymis
The epididymis is sometimes rather closely attached to the posterior surface

of the testis, and at other times it is quite free of it.

Слайд 40Epididymis
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 quite red.

Слайд 41Epididymis
Chronic painless induration should suggest tuberculosis or schistosomiasis, although nonspecific chronic

epididymitis is also a possibility.

Слайд 42Spermatic Cord & Vas Deferens
A swelling in the spermatic cord may

be cystic (e.g., hydrocele or hernia) or solid (e.g., connective tissue tumor).

Слайд 43Spermatic Cord & Vas Deferens
Careful palpation of the vas deferens may

reveal thickening (e.g., chronic infection), fusiform enlargements (the "beading" caused by tuberculosis), or even absence of the vas.

Слайд 44Spermatic Cord & Vas Deferens
When a male patient stands, a mass

of dilated veins (varicocele) may be noted behind and above the testis.

Слайд 45Testicular Tunics & Adnexa
Hydroceles are usually cystic but on occasion are

so tense that they simulate solid tumors. Transillumination makes the differential diagnosis. They may develop secondary to nonspecific acute or tuberculous epididymitis, trauma, or tumor of the testis.
The latter is a distinct possibility if hydrocele appears spontaneously between the ages of 18 and 35. It should be aspirated to permit careful palpation of underlying structures.

Слайд 46Testicular Tunics & Adnexa
Hydrocele usually surrounds the testis completely.

Слайд 47Examination of the Female Genitalia
Vaginal Examination
Diseases of the female genital tract

may involve the urinary organs secondarily, thereby making a thorough gynecologic examination essential.

Слайд 48Inspection
In newborns and children especially, 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).

Слайд 49Inspection
Biopsy is indicated if a malignant tumor cannot be ruled out.


Слайд 50Inspection
The diagnosis of senile vaginitis (and urethritis) is established by staining

a smear of the vaginal epithelium with Lugol's solution.

Слайд 51Inspection
Multiple painful small ulcers or blisterlike lesions may be noted; these

probably represent herpes virus type 2 infection, which may have serious sequels.

Слайд 52Inspection
The presence of skenitis and bartholinitis may reveal the source of

persistent urethritis or cystitis.
The condition of the vaginal wall should be observed.
Bacteriologic study of the secretions may be helpful.
Urethrocele and cystocele may cause residual urine and lead to persistent infection of the bladder.

Слайд 53Inspection
They are often found in association with stress incontinence.

Слайд 54Palpation
A soft mass found in this area could be a urethral

diverticulum.
Pressure on such a lesion may cause pus to extrude from the urethra.

Слайд 55Palpation
A stone in the lower ureter may be palpable. Evidence of

enlargement of the uterus (e.g., pregnancy, myomas) or diseases or inflammations of the colon or adnexa may afford a clue to the cause of urinary symptoms (e.g., compression of a ureter by a malignant ovarian tumor, endometriosis, or diverticulitis of the sigmoid colon adherent to the bladder).

Слайд 56Palpation
Rectal examination may afford further information and is the obvious route

of examination in children and virgins.

Слайд 57Rectal Examination in Males
Sphincter & Lower Rectum

The estimation of sphincter tone

is of great importance.

Слайд 58

The same is true for a spastic anal sphincter.

Слайд 59Prostate
A specimen of urine for routine analysis should be collected before

the rectal examination is made.

Слайд 60Size
The average prostate is about 4 cm in length and width.

It is widest superiorly at the bladder neck.

Слайд 61Consistency
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).

Слайд 62Consistency
Generally speaking, nodules caused by infection are raised above the surface

of the gland.

Слайд 63Consistency
At their edges, the induration gradually fades to the normal softness

of surrounding tissue.

Слайд 64
The prostate-specific antigen (PSA) level can be helpful if elevated. Transrectal

ultrasound-guided biopsy can be diagnostic.

Слайд 65Mobility
The prostate should be routinely massaged in adults and its secretion

examined microscopically.

Слайд 66Mobility
It should not be massaged, however, 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.
Even without symptoms, massage is necessary, for prostatitis is commonly asymptomatic. Diagnosis and treatment of such silent disease is important in preventing cystitis and epididymitis.

Слайд 67Massage & Prostatic Smear
Copious amounts of secretion may be obtained from

some prostate glands and little or none from others.

Слайд 68Massage & Prostatic Smear
Microscopic examination of the secretion is done under

low-power magnification. Normal secretion contains numerous lecithin bodies, which are refractile, like red cells, but much smaller than red cells.

Слайд 69Massage & Prostatic Smear
The presence of large numbers of pus cells

is pathologic and suggests the diagnosis of prostatitis.

Слайд 70Massage & Prostatic Smear
On occasion, it may be necessary to obtain

cultures of prostatic secretion in order to demonstrate nonspecific organisms, tubercle bacilli, gonococci, or chlamydiae.

Слайд 71Seminal Vesicles
Palpation of the seminal vesicles should be attempted. The vesicles

are situated under the base of the bladder and diverge from below upward.

Слайд 72Seminal Vesicles
Stripping of the seminal vesicles should be done in association

with prostatic massage, for the vesicles are usually infected when prostatitis is present.

Слайд 73Lymph Nodes

It should be remembered that generalized lymphadenopathy usually occurs early

in human immunodeficiency syndrome (HIV).

Слайд 74Inguinal & Subinguinal Lymph Nodes
Such diseases include chancroid, syphilitic chancre, lymphogranuloma

venereum, and, on occasion, gonorrhea.

Слайд 75Inguinal & Subinguinal Lymph Nodes
Malignant tumors (squamous cell carcinoma) involving the

penis, glans, scrotal skin, or distal urethra in women metastasize to the inguinal and subinguinal nodes.

Слайд 76Other Lymph Nodes
Tumors of the testis and prostate may involve the

left supraclavicular nodes. Tumors of the bladder and prostate typically metastasize to the internal iliac, external iliac, and preaortic nodes, although only occasionally are they so large as to be palpable.

Слайд 77Neurologic Examination
A careful neurologic survey may uncover sensory or motor impairment

that will account for residual urine (neuropathic bladder) or incontinence.

Слайд 78Neurologic Examination

The bulbocavernosus reflex is elicited by placing a finger in

the patient's rectum and squeezing the glans penis or clitoris or by jerking on an indwelling Foley catheter.
The normal reflex is contraction of the anal sphincter and bulbocavernosus muscles in response to these maneuvers.

Слайд 79Neurologic Examination

It is wise, particularly in children, to seek a dimple

over the lumbosacral area.

Слайд 80NONSPECIFIC INFLAMMATORY DISEASES OF GENITOURINARY ORGANS

Слайд 81Nonspecific inflammatory diseases of genitourinary organs:
Acute pyelonephritis
Chronic pyelonephritis

Слайд 82Nonspecific inflammatory diseases of genitourinary organs:
Cystitis
Paracystitis
Urethritis

Слайд 83Nonspecific inflammatory diseases of genitourinary organs:
Prostatitis
Vesiculitis


Слайд 84Pyelonephritis
is nonspecific inflammatory infectious process, in which the parenchyma

and pelvis of the kidney simultaneously or sequentially are affected.

Слайд 85Pyelonephritis
Patients with acute pyelonephritis present with chills, fever, and costovertebral angle

tenderness.
They often have accompanying lower-tract symptoms such as dysuria, frequency, and urgency.

Слайд 86Pyelonephritis
Sepsis may occur, with 20–30% of all systemic sepsis resulting from

a urine infection.

Слайд 87Pyelonephritis
Bacteria are cultured from the urine when the culture is obtained

before antibiotic treatment is instituted.

Слайд 88Pyelonephritis
The infection penetrates into the kidney by two routes:

Hematogenous

Слайд 89Pyelonephritis
Of the local factors contributing to origination pyelonephritis most

often is the disturbance of outflow of urine (reason – different anomalies of the kidneys and urinary paths)

Слайд 90Factors, which promote development of acute pyelonephritis
Stones of the kidney
Ureter and

urethra

Слайд 91The triad of symptoms of acute pyelonephritis
High body temperature
Pain in

the lumbar area

Слайд 92Acute Pyelonephritis

Of great value for diagnostics are the laboratory methods of

investigations

Слайд 93Acute Pyelonephritis
Radiological researches in patients with AP are necessary

to exclude accompanying diseases, which promote development of infectious process, and to specify the character of pathological changes in serious cases

Слайд 94Acute Pyelonephritis
Treatment of primary AP in most cases is conservative

Слайд 95Acute Pyelonephritis treatment
The management of acute pyelonephritis depends on the severity of

the infection.

Слайд 96Acute Pyelonephritis treatment
Empiric therapy with intravenous ampicillin and aminoglycosides is effective against

a broad range of uropathogens, including enterococci and Pseudomonas species. Alternatively, amoxicillin with clavulanic acid or a third-generation cephalosporin can be used.

Слайд 97Acute Pyelonephritis treatment
Fever from acute pyelonephritis may persist for several days despite

appropriate therapy.

Слайд 98Acute Pyelonephritis treatment
In patients who are not severely ill, outpatient treatment with

oral antibiotics is appropriate. For adults, treatment with fluoroquinolones or TMP-SMX is well tolerated and effective.

Слайд 99Vesicoureteral Reflux
Approximately 50% of patients with the infection of

urinary paths have
Vesicoureteral Reflux – is a backflow of urine from the bladder to the ureter and kidney

Слайд 100Classification of Vesicoureteral Reflux according to its grades:
Grade I: a contrast

drug fills the ureter, but does not get into the renal pelvis.

Слайд 101Classification of Vesicoureteral Reflux according to its grades:
Grade IV: moderate dilatation

and/or tortuousity of the ureter with moderate dilatation of the renal pelvis and calyces


Слайд 102Treatment of Vesicoureteral Reflux
Antibacterial treatment is directed to prevention of

development infection of the urinary paths. Routinely Sulphonamides and Nitrofurans are prescribed.

Слайд 103Treatment of Vesicoureteral Reflux
Indications for operative treatment:
Inefficient conservative treatment

Слайд 104Secondary Acute Pyelonephritis
Differs from primary in a clinical picture by

its greater expressivness of sings of local nature that allows faster and easier to recognize acute pyelonephritis

Слайд 105Cause of Secondary Acute Pyelonephritis
Stones of the kidney and ureter

Слайд 106Chronic Pyelonephritis
The diagnosis is made by radiologic or pathologic examination rather

than from clinical presentation.

Слайд 107Chronic Pyelonephritis
Many individuals with chronic pyelonephritis have no symptoms, but they

may have a history of frequent UTIs.

Слайд 108Chronic Pyelonephritis
Main X-ray signs are:

Deformations of the pyelocaliceal system

Слайд 109Chronic Pyelonephritis
Main X-ray signs are:
Changes of dimensions and contours of the

kidneys


Слайд 110Chronic Pyelonephritis
Renal scarring induced by UTIs is rarely seen in adult

kidneys.

Слайд 111Chronic Pyelonephritis
In these patients, urinalysis may show leukocytes or proteinuria but

is likely to be normal.

Слайд 112Treatment of Chronic Pyelonephritis
Removal of causes produsing the disturbance of urine

passage of renal circuation, venous in particular

Слайд 113Chronic Pyelonephritis management
The management of chronic pyelonephritis is somewhat limited because renal

damage incurred by chronic pyelonephritis is not reversible.

Слайд 114Chronic Pyelonephritis management
Long-term use of continuous prophylactic antibiotic therapy may be required

to limit recurrent UTIs and renal scarring.

Слайд 115Chronic Pyelonephritis management
Rarely, removal of the affected kidney may be necessary due

to hypertension or having a large stone burden in a nonfunctioning kidney.

Слайд 116Necrosis of Renal Papillae

Слайд 117Bacteriemic Shock

Слайд 118Pyonephrosis
means the final stage of specific or nonspecific purulent-destructive

inflammatory lesion of the kidney. The pyonephrotic kidney represents the organ, exposed to purulent destruction, consisting of separate cavities, filled with pus, urine and products of nephrolysis.

Слайд 119Apostematous Pyelonephritis
represents a purulent-inflammatory process with the formation of

numerous, small-sized pustules (apostemas) predominantly in the renal cortex.

Слайд 120Renal Abscesses
Renal abscesses result from a severe infection that leads to

liquefaction of renal tissue; this area is subsequently sequestered, forming an abscess.
They can rupture out into the perinephric space, forming perinephric abscesses.

Слайд 121Renal Abscesses
When the abscesses extend beyond the Gerota's fascia, paranephric abscesses

develop.

Слайд 122Renal Abscesses
With the development of effective antibiotics and better management of

diseases such as diabetes and renal failure, renal/perinephric abscesses due to gram-positive bacteria are less prevalent; those caused by E coli or Proteus species are becoming more common.

Слайд 123Renal Abscesses
Abscesses that form in the renal cortex are likely to

arise from hematogenous spread, whereas those in the corticomedullary junction are caused from gram-negative bacteria in conjunction with some other underlying urinary tract abnormalities, such as stones or obstruction.

Слайд 124Renal Abscesses management
The appropriate management of renal abscess first must include appropriate

antibiotic therapy.

Слайд 125Renal Abscesses management
The drained fluid should be cultured for the causative organisms.


Слайд 126Renal Abscesses management
If the abscess still does not resolve, then open surgical

drainage or nephrectomy may be necessary.

Слайд 127Pyonephrosis
Pyonephrosis refers to bacterial infection of a hydronephrotic, obstructed kidney, which

leads to suppurative destruction of the renal parenchyma and potential loss of renal function. Because of the extent of the infection and the presence of urinary obstruction, sepsis may rapidly ensue, requiring rapid diagnosis and management.

Слайд 128Pyonephrosis
Patients with pyonephrosis are usually very ill, with high fever, chills,

and flank pain.

Слайд 129Pyonephrosis management
Management of pyonephrosis includes immediate institution of antibiotic therapy and drainage

of the infected collecting system.

Слайд 130Pyonephrosis management
Extensive manipulation may rapidly induce sepsis and toxemia.

Слайд 131Pyonephrosis management
In the ill patient, drainage of the collecting system with a

percutaneous nephrostomy tube is preferable.

Слайд 132Acute Cystitis
The most common causative agent of cystitis is E.Coli,

then Staphylococcus, Enterococcus, Proteus, Streptococcus, etc.

Слайд 133Acute Cystitis
Acute cystitis refers to urinary infection of the lower

urinary tract, principally the bladder.

Слайд 134Acute Cystitis
The diagnosis is made clinically. In children, the distinction

between upper and lower UTI is important.

Слайд 135Acute Cystitis
Patients with acute cystitis present with irritative voiding symptoms

such as dysuria, frequency, and urgency.

Слайд 136Acute Cystitis
Urine culture is required to confirm the diagnosis and

identify the causative organism.

Слайд 137Acute Cystitis
E coli causes most of the acute cystitis. Other

gram-negative (Klebsiella and Proteus spp.) and gram-positive (Staphylococcus saprophyticus and enterococci) bacteria are uncommon pathogens.

Слайд 138Acute Cystitis Management
Trimethoprim-sulfamethoxazole and nitrofurantoin are less expensive and thus

are recommended for the treatment of uncomplicated cystitis

Слайд 139Acute Cystitis Management
In adults and children, the duration of treatment

is usually limited to 3–5 days.
Longer therapy is not indicated.

Слайд 140Acute Cystitis Management
Resistance to penicillins and aminopenicillins is high and

thus they are not recommended for treatment.

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