Physical Examination

Physical examination is limited with urinary tract disorders, but special techniques are available. Many physical findings are helpful, if present, although their absence does not imply normalcy. For example, a renal bruit may indicate arterial stenosis, but its absence does not rule out the condition. Variations in examiner skill and patient factors also limit the accuracy and reliability of physical findings.

The kidneys are retroperitoneal organs and are difficult to palpate, except in very thin persons and children. The right kidney sits more inferiorly than the left because of the liver. The ureters are nonpalpable but, as with the kidneys, may radiate pain to the flank area. The bladder is typically nonpalpable unless distended with at least 150 mL of urine, and percussion is preferred over palpation for diagnosing disten-tion (Gerber and Brendler, 2007). In women an enlarged bladder may also be noted on bimanual examination.

Pelvic examination is useful for diagnosing cystocele in women. Two fingers can be placed in the introitus and opened to visualize the vaginal cavity. The patient then performs the Valsalva maneuver. The anterior wall dipping down into the vaginal cavity may signify a cystocele. More subtle cystoceles can be detected by placing a lubricated cotton swab in the urethral meatus and having the patient perform the Valsalva maneuver. If the swab moves upward (anteriorly), it may indicate movement of the bladder neck with straining.

Examination of the external genitalia in men may reveal penile lesions, regional adenopathy, or disorders of the scrotum and testicles. Uncircumcised men should have the foreskin retracted to rule out phimosis and visualize the glans. Careful palpation of the testicular complex is needed to detect and differentiate masses and anatomic abnormalities. Digital rectal examination (DRE) can estimate prostate size and detect masses or inflammation. It is usually performed with the patient leaning forward on the examination table with his elbows bent. Prostate tenderness, warmth, or a boggy consistency suggests prostati-tis. Prostate enlargement consistent with benign prostatic hyperplasia is typical in older men. Masses or asymmetry may indicate a tumor.

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