1-Evaluation of the UrologicPatient : History, Physical Examination , and Urinalysis

1. 1-Evaluation of the UrologicPatient: History, PhysicalExamination, and Urinalysis HISTORY The medical history is the cornerstone of the evaluation of the urologic patient, and a well-taken history will frequently elucidate the probable diagnosis

2. 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. 1-Chief Complaint and Present Illness the chief complaint is a constant reminder to the urologist as to why the patient initially sought care.

3. Pain Pain arising from the GU tract may be quite severe and is usually associated with either urinary tract obstruction or inflammation Pain of renal origin may be associated with gastrointestinal symptoms.

4. 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. Hematuria Hematuria is the presence of blood in the urine; greater than three red blood cells per high-power microscopic field (HPF) is significant.

5. Patients with gross hematuria are usually frightened by the sudden onset of blood in the urine and frequently present to the emergency department for evaluation, fearing that they may be bleeding excessively. Hematuria of any degree should never be ignored and, in adults, should be regarded as a symptom of urologic malignancy until proved otherwise.

6. Nocturia is nocturnal frequency. Normally,adults arise no more than twice at night to void. Dysuria is painful urination that is usually caused by inflammation. Incontinence. Urinary incontinence is the involuntary loss of urine Enuresis. Enuresis refers to urinary incontinence that occurs during sleep.

7. urinary retention and high residual urine volumes URINALYSIS Proteinuria

8. 2-Urinary Tract Imaging:Basic Principles Imaging plays an indispensable role in the diagnosis and management of urologic diseases. Because many urologic conditions are unable to be assessed by physical examination, conventional radiography has long been critical to the diagnosis of conditions of the kidneys, ureters, and bladder.

9. Radiation protection for medical personnel includes (1) limiting time of exposure, (2) maximizing distance from radiation source, and (3) shielding.

10. PLAIN ABDOMINAL RADIOGRAPHY The plain abdominal radiograph is a conventional radiography study, which, in urology, is intended to display the kidneys, ureters and bladder. The plain abdominal radiograph may be employed • as a primary study or (2) as a scout film in anticipation of contrast media. • Plain films are widely used in the management of renal calculus disease.

13. Intravascular Iodinated Contrast Media Approximately 90% will be eliminated by the kidneys within 12 hours of administration Approximately 85% of IA reactions occur during or immediately after injection of IRCM and are more common in patients with a prior ADR to contrast media, asthmatics, diabetics, patients with impaired renal function or diminished cardiac function, and those who are taking β-adrenergic blockers.

14. IA reactions are most concerning because they are potentially fatal and can occur without any predictable or predisposing factors. Contrast-induced nephropathy (CIN) is defined as a rise in serum creatinine 25% above baseline, or more than 0.5 mg/dL within 3 days following exposure to contrast media, in the absence of an alternative cause. High doses of IRCM can impair renal function in some patients for 3 to 5 days. CIN in patients with normal kidney function is rare

15. INTRAVENOUS UROGRAPHY Once the mainstay of urologic imaging, the intravenous excretory urographic (IVU) study has essentially been replaced by CT and MRI.

16. Magnetic Resonance Imaging Contrast Agents Because magnetic resonance imaging (MRI) offers previously unseen detailed soft tissue imaging compared with CT, it was initially believed that MRI would not require contrast enhancement. However, by 2005, almost 50% of MRI studies were being performed with contrast media.

17. RETROGRADE PYELOGRAPHY Retrograde pyelograms are performed to opacify the ureters and intrarenal collecting system by the retrograde injection of contrast media. Any contrast media that can be used for excretory urography is also acceptable for retrograde pyelography. Attempts should be made to sterilize the urine before retrograde pyelography because there is a risk of introducing bacteria into the upper urinary tracts or into the bloodstream.

19. RETROGRADE URETHROGRAPHY A retrograde urethrogram is a study meant to evaluate the anterior and posterior urethra. Retrograde urethrography may be particularly beneficial in demonstrating the total length of a urethral stricture, which cannot be negotiated by cystoscopy. Retrograde urethrography also demonstrates the anatomy of the urethra distal to a stricture, which may not be assessable by voiding

21. STATIC CYSTOGRAPHY Static cystography is employed primarily to evaluate the structural integrity of the bladder.

23. VOIDING CYSTOURETHROGRAM A voiding cystourethrogram (VCUG) is performed to evaluate the anatomy and physiology of the bladder and urethra.

25. ULTRASONOGRAPHY The use of ultrasonography is fundamental to the practice of urology. Ultrasonography is a versatile and relatively inexpensive imaging modality that has the unique feature of being the only imaging modality to provide real-time evaluation of urologic organs and structure without the need for ionizing radiation.

27. Indications 1. Assessment of renal and perirenal masses 2. Assessment of the dilated upper urinary tract 3. Assessment of flank pain during pregnancy 4. Evaluation of hematuria in patients who are not candidates for intravenous pyelography (IVP), CT, or MRI because of renal insufficiency, contrast allergy, or physical impediment 5. Assessment of the effects of voiding on the upper urinary tract 6. Evaluation for and monitoring of urolithiasis 7. Intraoperative renal parenchyma and vascular imaging for ablation of renal masses 8. Percutaneous access to the renal collecting system 9. Guidance for transcutaneous renal biopsies, cyst aspiration, or ablation of renal masses 10. Postoperative evaluation of patients after renal and ureteral surgery 11. Postoperative evaluation of renal transplant patients

28. NUCLEAR SCINTIGRAPHY

29. COMPUTED TOMOGRAPHY

33. MAGNETIC RESONANCE IMAGING CT imaging remains the mainstay of urologic cross-sectional body imaging; however, MRI is increasingly being applied to the genitourinary system. With constant improvements in technology MRI is gradually narrowing the overall resolution quality gap between it and CT. A significant advantage of MRI is the excellent contrast resolution of soft tissue, without the need for contrast in many situations. Currently MRI is used when patients cannot be given iodinated contrast and when tissue findings in the urinary system cannot be resolved using CT or ultrasonography

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40. Core Principles of3-Perioperative Care PREOPERATIVE EVALUATION the urologic surgeon is responsible for assuring that the patient has been thoroughly evaluated by the other physicians in the health care team and presents to the operating room in the most optimized medical condition. The preoperative use of appropriate medical specialist consults will result in improved patient safety and obviate the need for unnecessary cancelled surgeries due to the inadequacy of medical optimization.

41. PRESURGICAL TESTING Often overlooked but extremely important is the requirement for a urine pregnancy test on the morning of surgery in any woman of childbearing age unless the ovaries or uterus have been previously surgically removed

42. Selection of Mode of Anesthesia An important role of the urologist in the anesthetic evaluation is to determine what mode of anesthesia is best for the particular patient and surgical procedure. The choice depends on patient related factors including comorbidities, airway, and patient preference and procedural factors including complexity, duration, anatomic location, and expected fluid/blood loss. A basic understanding of each method of anesthesia and the pharmacologic principles will aid the urologist in making recommendations to the anesthesiologist