- Genitourinary System Physical Exam
Kidneys
Inspection
- Flank masses
- Peripheral edema
- Periorbital edema
Auscultation
- Bruits (renal arteries-10 cm lateral to umbilicus)
Palpation
- CVA Tenderness
- Percuss with ball of hand
- Pain suggests pyelonephritis or MSK injury
- Capture the Kidneys
- Place the patient supine
- Stand on the patients' right side
- Reach over and behind patient to pull up behind left posterior, costospinal angle
- Ask the patient to take a deep breath
- Press right hand firmly into LUQ just below costal margin to capture kidney
- Ask patient to breathe out and briefly stop breathing
- Slowly reduce pressure of right hand to release kidney. If palpable, note: size, contour, tenderness.
- Repeat with right kidney using left hand to lift patient’s right CVA and right hand to capture kidney in RUQ
Anus and Rectum
Inspection
- Position the patient lying on their left side, buttocks close to edge of table, hips and knees flexed and put on gloves
- Sacrococcygeal and perianal areas
- Lumps, ulcers, inflammation, rashes or excoriations
- Anal and perianal lesions: haemorrhoids, venereal warts, herpes, syphilitic chancre, and carcinoma
- Anal fissure from large, hard stools, IBD, or STIs
- Pruritus ani: swollen, thickened, fissured perianal skin with excoriations
- Anus
- Ask the patient to strain down
- Anal abscess: tender, purulent, reddened mass with fever/chills
- Fistulas may ooze blood, pus, or feculent mucus
- Rectal prolapse, haemorrhoids, fissures
- Anoscopy or sigmoidoscopy for better visualization
Palpation
- Conduct a digital rectal exam.
- Sensitivity for detecting prostate cancer of 59% and a specificity of 94%
Bladder
Inspection
- Acute or chronic urinary retention: bladder outline may be visible at or above the umbilicus
Percussion
- Percuss the bladder to assess for dullness
- Percuss to asses bladder level above the symphysis pubis. Percussable dullness occurs when bladder volume is 400-600ml
- Can be percussed if containing >150 cc urine
- Useful in chronic retention as bladder wall can be flabby and difficult to palpate
Palpation
- Top dome of bladder should feel smooth and round when distended
- Palpate for bladder tenderness
- Cannot be felt unless moderately distended
- Acute or chronic urinary retention
- Male infants/boys: hypertrophied bladder secondary to obstruction by posterior urethral valves
Male Genitalia
Penis
Inspection
- Ulcers
- Scars
- Nodules
- Signs of inflammation
- Prepuce (foreskin): retract or ask patient to retract
- Phimosis: tight prepuce that cannot be retracted over the glans
- Paraphimosis: tight prepuce that, once retracted, cannot be returned (leads to edema)
- Balanitis: inflammation of glans
- Balanoposthitis: inflammation of glans and prepuce
- Hypospadias: congenital, ventral displacement of the meatus
- Shaft and base of penis
- Nits or lice at the bases of the pubic hairs
Palpation
- Palpate any abnormalities
- Glans: Compress the glans gently between index finger and thumb
- Inspect urethral meatus for discharge
- If discharge not visible at time of inspection, milk shaft of the penis from base to the glans
- Shaft: between first two fingers and thumb (omit in young, asymptomatic males)
- Note any tenderness or induration
- Induration along ventral surface of penis suggests urethral stricture or carcinoma
- Tenderness of indurated area suggests periurethral inflammation (secondary to urethral stricture)
Scrotum
Inspection
- Rashes, lumps, swelling, veins, erythema, scrotal contours
- Make sure to include posterior surface of scrotum
- Poorly developed scrotum on either side (cryptorchidism)
- Epidermoid cysts: dome-shaped white/yellow papules/nodules formed by occluded follicles filled with keratin; common and benign
Palpation
- Testes and each epididymis (superior surface of testicle, should feel cordlike and nodular) between thumb and first two fingers
- Note size, shape, consistency, tenderness, and nodules
- Normal testis size: 3.5-5.5 cm
- Left testis usually hangs lower than right
- Epididymis is usually nodular and cordlike
- Spermatic cord from the epididymis to the inguinal ring noting nodules or swellings
- Check for hernias (instructions below)
Inguinal, Femoral, Scrotal Hernias
Inspection
- Positioning
- Patient: standing with inguinal/femoral/genital area exposed
- Examiner: sitting on stool in front of patient, using oblique lighting if possible
- Inspect inguinal/femoral/scrotal areas when patient relaxed and actively coughing
- Location of bulge
- Above (inguinal) or below (femoral) inguinal ligament crease
Palpation
- Examiner: Stand to side of patient, place fingers of right hand over patient’s right femoral region, the external inguinal ring, and the internal ring; vice versa on patient’s left side
- Ask patient to cough, note any bulging/impulse on fingers
Males
- Examiner: return to the sitting position, in front of patient
- Place tip of right index finger close to inferior margin of scrotal sac; locate right spermatic cord
- Course cord structures to right external inguinal ring, just lateral to right pubic tubercle
- Ask patient to cough or strain down; note bulging/impulses
- Direct hernia, bulge felt on side of finger
- Indirect hernia: bulge felt at tip of finger (coming from internal inguinal ring)
- Indirect hernia may extend into scrotum
- Differentiate from hydrocele: hernia will not transilluminate, will not have a superior border, and may have bowel sounds to auscultation
- If findings suggest hernia, try to reduce it by sustained pressure with your fingers
- Incarcerated: contents cannot be returned to the abdominal cavity
- Strangulated: blood supply to entrapped contents is compromised
- Suspected if tender and patient experiencing nausea, and vomiting
- Consider surgery
References
- Bickley, S. L. The Abdomen: The Kidneys. In: Bates’ Guide to Physical Examination. 10th ed. Philadelphia PA: Lippincott Williams & Wilkins; 2009: 445.
- Bickley, S. L. Male Genitalia and Hernias. In: Bates’ Guide to Physical Examination. 10th ed. Philadelphia PA: Lippincott Williams & Wilkins; 2009: 501-512.
- Bickley, S. L. The Anus, Rectum, and Prostate. In: Bates’ Guide to Physical Examination. 10th ed. Philadelphia PA: Lippincott Williams & Wilkins; 2009: 555-564.
- Hoogendam, A., Buntinx, F., CW de Vet, H. (1999). The diagnositic value of digital rectal examination in primary care screening for prostate cancer: a meta-analysis. Family Practice, 16(6), 621-626.
- Tanagho A. E., McAninch W. J. Access Medicine: Smith’s General Urology: Physical Examination of the Genitourinary Tract. http://www.accessmedicine.com.normedproxy.lakeheadu.ca/content.aspx?aid=3126305. Published 2008. Accessed February 14, 2011.
- Amerson JR. Inguinal canal and hernia examination. In: Walker HK, Hall WD, Hurst JW. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Boston, MA; 1990: 484-485.
- Bickley, S., Szilagyi, P. Bates’ Guide to Physical Examination and History Taking. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.