History taking

1. History taking

3. The urologist has the ability to make the initial evaluation and diagnosis and to provide medical and surgical therapy for all diseases of the genitourinary (GU) system

4. A complete history can be divided into the chief complaint and history of the present illness, the patient's past medical history, and a family history

5. Chief Complaint and Present Illness • The chief complaint is a constant reminder to the urologist as to why the patient initially sought care • In obtaining the history of the present illness, the duration, severity, chronicity, periodicity, and degree of disability are important considerations

6. Pain • Pain arising from the GU tract may be quite severe and is usually associated with either urinary tract obstruction or inflammation • Inflammation of the GU tract is most severe when it involves the parenchyma of a GU organ • Tumors in the GU tract usually do not cause pain unless they produce obstruction or extend beyond the primary organ to involve adjacent nerves.

7. Renal Pain • Pain of renal origin is usually located in the ipsilateralcostovertebral angle just lateral to the sacrospinalis muscle and beneath the 12th rib. • Pain is usually caused by acute distention of the renal capsule, generally from inflammation or obstruction • Pain of renal origin may be associated with gastrointestinal symptoms because of reflex stimulation of the celiac ganglion and because of the proximity of adjacent organs (liver, pancreas, duodenum, gallbladder, and colon). • Renal pain may also be confused with pain resulting from irritation of the costal nerves, most commonly T10-T12.

8. Ureteral Pain • Ureteral pain is usually acute and secondary to obstruction. • The pain results from acute distention of the ureter and by hyperperistalsis and spasm of the smooth muscle of the ureter as it attempts to relieve the obstruction, usually produced by a stone or blood clot.

9. Vesical Pain • Vesical pain is usually produced either by over distention of the bladder as a result of acute urinary retention or by inflammation. • Constant suprapubic pain that is unrelated to urinary retention is seldom of urologic origin. • Inflammatory conditions of the bladder usually produce intermittent suprapubic discomfort. • Thus, the pain in conditions such as bacterial cystitis or interstitial cystitis is usually most severe when the bladder is full and is relieved at least partially by voiding. • Patients with cystitis sometimes experience sharp, stabbing suprapubic pain at the end of micturation, and this is termed strangury

10. Prostatic Pain • Prostatic pain is usually secondary to inflammation with secondary edema and distention of the prostatic capsule. • Pain of prostatic origin is poorly localized, and the patient may complain of lower abdominal, inguinal, perineal, lumbosacral, and/or rectal pain • Prostatic pain is frequently associated with irritative urinary symptoms such as frequency and dysuria, and, in severe cases, marked prostatic edema may produce acute urinary retention

11. Penile Pain • Pain in the flaccid penis is usually secondary to inflammation in the bladder or urethra, with referred pain that is experienced maximally at the urethral meatus

12. Testicular Pain • Scrotal pain may be either primary or referred. • Primary pain arises from within the scrotum and is usually secondary to acute epididymitis or torsion of the testis or testicular appendices. • Chronic scrotal pain is usually related to noninflammatory conditions such as a hydrocele or a varicocele, and the pain is generally characterized as a dull, heavy sensation that does not radiate. • Because the testes arise embryologically in close proximity to the kidneys, pain arising in the kidneys or retroperitoneum may be referred to the testes.

13. Hematuria • Hematuria is the presence of blood in the urine; greater than three red blood cells per high-power microscopic field (HPF) is significant • Is the hematuria gross or microscopic?    • At what time during urination does the hematuria occur (beginning or end of stream or during entire stream)? • Is the hematuria associated with pain?    • Is the patient passing clots?    If the patient is passing clots, do the clots have a specific shape?

14. Timing of Hematuria • Initial hematuria usually arises from the urethra (usually secondary to inflammation) • Total hematuria is most common and indicates that the bleeding is most likely coming from the bladder or upper urinary tracts • Terminal hematuria occurs at the end of micturition and is usually secondary to inflammation in the area of the bladder neck or prostatic urethra.

15. Gross versus Microscopic Hematuria • The chances of identifying significant pathology increase with the degree of hematuria.

16. Lower Urinary Tract Symptoms • Irritative Symptoms-frequency,dysuria,nocturia, • Obstructive Symptoms-Decreased force of urination, hesitancy, Intermittency, Postvoid dribbling, Straining

17. Incontinence • Urinary incontinence is the involuntary loss of urine • Continuous Incontinence. • Stress Incontinence. • Urgency Incontinence • Overflow Urinary Incontinence

18. Enuresis • Enuresis refers to urinary incontinence that occurs during sleep. • It occurs normally in children up to 3 years of age but persists in about 15% of children at age 5 and about 1% of children at age 15

19. Sexual Dysfunction • Loss of Libido. • Impotence. • Failure to Ejaculate. • Absence of Orgasm. • Premature Ejaculation.

20. Hematospermia • Hematospermia refers to the presence of blood in the seminal fluid. • It almost always results from nonspecific inflammation of the prostate and/or seminal vesicles and resolves spontaneously, usually within several weeks.

21. Pneumaturia • Pneumaturia is the passage of gas in the urine • Instrumentation • Fistula between the intestine and the bladder • Diverticulitis • Carcinoma of the sigmoid colon, and regional enteritis (Crohn's disease)

22. Urethral Discharge • Urethral discharge is the most common symptom of venereal infection.

23. Fever and Chills • Fever and chills may occur with infection anywhere in the GU tract but are most commonly observed in patients with pyelonephritis, prostatitis, or epididymitis

24. Medical History • Patients with diabetes mellitus frequently develop autonomic dysfunction that may result in impaired urinary and sexual function • Patients with hypertension have an increased risk of sexual dysfunction because they are more likely to have peripheral vascular disease and because many of the medications that are used to treat hypertension frequently cause impotence • Multiple sclerosis

25. Family History • Adult polycystic kidney disease, • Tuberous sclerosis, • Von Hippel-Lindau disease, • Renal tubular acidosis, and • Cystinuria • It has been recognized that 8% to 10% of men with prostate cancer have a familial form of the disease that tends to develop about a decade earlier than the more common type of prostate cancer

26. Medications • Most of the antihypertensive medications interfere with erectile function, and changing antihypertensive medications can sometimes improve sexual function

27. Previous Surgical Procedures • Surprises that occur in the operating room are unhappy ones.

28. Smoking and Alcohol Use • Allergies