Tuesday, August 12, 2008

Urologists have a unique and interesting position in medicine. Their patients encompass all age groups, including prenatal, pediatric, adolescent, adult, and geriatric. Because there is no medical subspecialist with similar interests, 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. Historically, the diagnostic armamentarium has included urinalysis, endoscopy, and intravenous pyelography. Recent advances in ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and endourology have expanded our diagnostic capabilities. Despite these advances, however, the basic approach to the patient is still dependent on taking a complete history, executing a thorough physical examination, and performing a urinalysis. These basics dictate and guide the subsequent diagnostic evaluation.

HISTORY Overview

The medical history is the cornerstone of the evaluation of the urologic patient, and a well-taken history will frequently elucidate the probable diagnosis. However, many pitfalls can inhibit the urologist from obtaining an accurate history. The patient may be unable to describe or communicate symptoms because of anxiety, language barrier, or educational background. Therefore, the urologist must be a detective and lead the patient through detailed and appropriate questioning to obtain accurate information. There are practical considerations in the art of history taking that can help to alleviate some of these difficulties. In the initial meeting, an attempt should be made to help the patient feel comfortable. During this time, the physician should project a calm, caring, and competent image that can help foster two-way communication. Impaired hearing, mental capacity, and facility with English can be assessed promptly. These difficulties are frequently overcome by having a family member present during the interview or, alternatively, by having an interpreter present.

Patients need to have sufficient time to express their problems and the reasons for seeking urologic care; the physician, however, should focus the discussion to make it as productive and informative as possible. Direct questioning can then proceed logically. The physician needs to listen carefully without distractions to obtain and interpret the clinical information provided by the patient. 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. Each segment can provide significant positive and negative findings that will contribute to the overall evaluation and treatment of the patient.

Chief Complaint and Present Illness

Most urologic patients identify their symptoms as arising from the urinary tract and frequently present to the urologist for the initial evaluation. For this reason, the urologist frequently has the opportunity to act as both the primary physician and the specialist. The chief complaint must be clearly defined because it provides the initial information and clues to begin formulating the differential diagnosis. Most importantly, the chief complaint is a constant reminder to the urologist as to why the patient initially sought care. This issue must be addressed even if subsequent evaluation reveals a more serious or significant condition that requires more urgent attention. In our personal experience, a young woman presented with a chief complaint of recurrent urinary tract infections (UTIs). In the course of her evaluation, she was found to have a right adrenal mass. We subsequently focused on this problem and performed a right adrenalectomy for a benign cortical adenoma. We forgot about the woman's original symptoms until she presented for her subsequent postoperative examination. She reminded us of her original symptoms at that time, and subsequent evaluation revealed that she had a nylon suture that had eroded into the anterior wall of her bladder from a previous abdominal vesicourethropexy performed 2 years earlier for stress urinary incontinence. Her UTIs resolved after surgical removal of the suture.

In obtaining the history of the present illness, the duration, severity, chronicity, periodicity, and degree of disability are important considerations. The patient's symptoms need to be clarified for details and quantified for severity. Listed next are a variety of typical initial complaints. Specific questions that focus the differential diagnosis are provided.


Pain arising from the GU tract may be quite severe and is usually associated with either urinary tract obstruction or inflammation. Urinary calculi cause severe pain when they obstruct the upper urinary tract. Conversely, large, nonobstructing stones may be totally asymptomatic. Thus, a 2-mm-diameter stone lodged at the ureterovesical junction may cause excruciating pain whereas a large staghorn calculus in the renal pelvis or a bladder stone may be totally asymptomatic. Urinary retention from prostatic obstruction is also quite painful, but the diagnosis is usually obvious to the patient.

Inflammation of the GU tract is most severe when it involves the parenchyma of a GU organ. This is due to edema and distention of the capsule surrounding the organ. Thus, pyelonephritis, prostatitis, and epididymitis are typically quite painful. Inflammation of the mucosa of a hollow viscus such as the bladder or urethra usually produces discomfort, but the pain is not nearly as severe.

Tumors in the GU tract usually do not cause pain unless they produce obstruction or extend beyond the primary organ to involve adjacent nerves. Thus, pain associated with GU malignancies is usually a late manifestation and a sign of advanced disease.

Renal Pain.

Pain of renal origin is usually located in the ipsilateral costovertebral 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. The pain may radiate across the flank anteriorly toward the upper abdomen and umbilicus and may be referred to the testis or labium. A corollary to this observation is that renal or retroperitoneal disease should be considered in the differential diagnosis of any man who complains of testicular discomfort but has a normal scrotal examination. Pain due to inflammation is usually steady, whereas pain due to obstruction fluctuates in intensity. Thus, the pain produced by ureteral obstruction is typically colicky in nature and intensifies with ureteral peristalsis, at which time the pressure in the renal pelvis rises as the ureter contracts in an attempt to force urine past the point of 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). Thus, renal pain may be confused with pain of intraperitoneal origin; it can usually be distinguished, however, by a careful history and physical examination. Pain that is due to a perforated duodenal ulcer or pancreatitis may radiate into the back, but the site of greatest pain and tenderness is in the epigastrium. Pain of intraperitoneal origin is seldom colicky, as with obstructive renal pain. Furthermore, pain of intraperitoneal origin frequently radiates into the shoulder because of irritation of the diaphragm and phrenic nerve; this does not occur with renal pain. Typically, patients with intraperitoneal pathology prefer to lie motionless to minimize pain, whereas patients with renal pain usually are more comfortable moving around and holding the flank.

Renal pain may also be confused with pain resulting from irritation of the costal nerves, most commonly T10-T12. Such pain has a similar distribution from the costovertebral angle across the flank toward the umbilicus. However, the pain is not colicky in nature. Furthermore, the intensity of radicular pain may be altered by changing position; this is not the case with renal pain.

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. The site of ureteral obstruction can often be determined by the location of the referred pain. With obstruction of the midureter, pain on the right side is referred to the right lower quadrant of the abdomen (McBurney's point) and thus may simulate appendicitis; pain on the left side is referred over the left lower quadrant and resembles diverticulitis. Also, the pain may be referred to the scrotum in the male or the labium in the female. Lower ureteral obstruction frequently produces symptoms of vesical irritability, including frequency, urgency, and suprapubic discomfort that may radiate along the urethra in men to the tip of the penis. Often, by taking a careful history, the astute clinician can predict the location of the obstruction. Ureteral pathology that arises slowly or produces only mild obstruction rarely causes pain. Therefore, ureteral tumors and stones that cause minimal obstruction are seldom painful.

Vesical Pain.

Vesical pain is usually produced either by overdistention 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. Furthermore, patients with slowly progressive urinary obstruction and bladder distention (e.g., diabetics with a flaccid neurogenic bladder) frequently have no pain at all despite residual urine volumes over I L.

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 micturition, and this is termed strangury. Furthermore, patients with cystitis frequently experience pain referred to the distal urethra that is associated with irritative voiding symptoms such as urinary frequency and dysuria.

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.

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. Alternatively, penile pain may be produced by paraphimosis, a condition in which the uncircumcised penile foreskin is trapped behind the glans penis, resulting in venous obstruction and painful engorgement of the glans penis (see later). Pain in the erect penis is usually due to Peyronie's disease or priapism (see later).

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. Because of the edema and pain associated with both acute epididymitis and testicular torsion, it is frequently difficult to distinguish these two conditions. Alternatively, scrotal pain may result from inflammation of the scrotal wall itself. This may result from a simple infected hair follicle or sebaceous cyst, but it may also be secondary to Fournier's gangrene, a severe, necrotizing infection arising in the scrotum that can rapidly progress and be fatal unless promptly recognized and treated.

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. Similarly, the dull pain associated with an inguinal hernia may be referred to the scrotum.


Hematuria is the presence of blood in the urine; greater than three red blood cells per high-power microscopic field (HPF) is significant. 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. In evaluating hematuria, several questions should always be asked, and the answers will enable the urologist to target the subsequent diagnostic evaluation efficiently:

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?

Gross versus Microscopic Hematuria.

The significance of gross versus microscopic hematuria is simply that the chances of identifying significant pathology increase with the degree of hematuria. Thus, it is uncommon for patients with gross hematuria not to have identifiable underlying pathology whereas it is quite common for patients with minimal degrees of microscopic hematuria to have a negative urologic evaluation.

Timing of Hematuria.

The timing of hematuria during urination frequently indicates the site of origin. Initial hematuria usually arises from the urethra; it occurs least commonly and is 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. It occurs at the end of micturition as the bladder neck contracts, squeezing out the last amount of urine.

Association with Pain.

Hematuria, although frightening, is usually not painful unless it is associated with inflammation or obstruction. Thus, patients with cystitis and secondary hematuria may experience painful urinary irritative symptoms but the pain is usually not worsened with passage of clots. More commonly, pain in association with hematuria usually results from upper urinary tract hematuria with obstruction of the ureters with clots. Passage of these clots may be associated with severe, colicky flank pain similar to that produced by a ureteral calculus, and this helps identify the source of the hematuria.

Presence of Clots.

The presence of clots usually indicates a more significant degree of hematuria, and, accordingly, the probability of identifying significant urologic pathology increases.

Shape of Clots.

Usually, if the patient is passing clots, they are amorphous and of bladder or prostatic urethral origin. However, the presence of vermiform (wormlike) clots, particularly if associated with flank pain, identifies the hematuria as coming from the upper urinary tract with formation of vermiform clots within the ureter.

It cannot be emphasized strongly enough that hematuria, particularly in the adult, should be regarded as a symptom of malignancy until proved otherwise and demands immediate urologic examination. In a patient who presents with gross hematuria, cystoscopy should be performed as soon as possible, because frequently the source of bleeding can be readily identified. Cystoscopy will determine whether the hematuria is coming from the urethra, bladder, or upper urinary tract. In patients with gross hematuria secondary to an upper tract source, it is very easy to see the jet of red urine pulsing from the involved ureteral orifice.

Although inflammatory conditions may result in hematuria, all patients with hematuria, except perhaps young women with acute bacterial hemorrhagic cystitis, should undergo urologic evaluation. Older women and men who present with hematuria and irritative voiding symptoms may have cystitis secondary to infection arising in a necrotic bladder tumor or, more commonly, flat carcinoma in situ of the bladder. The most common cause of gross hematuria in a patient older than age 50 years is bladder cancer.

Lower Urinary Tract Symptoms Irritative Symptoms.

Frequency is one of the most common urologic symptoms. The normal adult voids five or six times per day, with a volume of approximately 300 mL with each void. Urinary frequency is due either to increased urinary output (polyuria) or to decreased bladder capacity. If voiding is noted to occur in large amounts frequently, the patient has polyuria and should be evaluated for diabetes mellitus, diabetes insipidus, or excessive fluid ingestion. Causes of decreased bladder capacity include bladder outlet obstruction with decreased compliance, increased residual urine, and/or decreased functional capacity due to irritation; neurogenic bladder with increased sensitivity and decreased compliance; pressure from extrinsic sources; or anxiety. By separating irritative from obstructive symptoms, the astute clinician should be able to arrive at a proper differential diagnosis.

Nocturia is nocturnal frequency. Normally, adults arise no more than twice at night to void. As with frequency, nocturia may be secondary to increased urine output or decreased bladder capacity. Frequency during the day without nocturia is usually of psychogenic origin and related to anxiety. Nocturia without frequency may occur in the patient with congestive heart failure and peripheral edema in whom the intravascular volume and urine output increase when the patient is supine. Renal concentrating ability decreases with age; therefore, urine production in the geriatric patient is increased at night, when renal blood flow is increased as a result of recumbency. In general, nocturia may be attributed to nocturnal polyuria (nocturnal urine overproduction) and/or diminished nocturnal bladder capacity ( Weiss and Blaivas, 2000 ). Nocturia may also occur in people who drink large amounts of liquid in the evening, particularly caffeinated and alcoholic beverages, which have strong diuretic effects. In the absence of these factors, nocturia signifies a problem with bladder function secondary to urinary outlet obstruction and/or decreased bladder compliance.

Dysuria is painful urination that is usually caused by inflammation. This pain is usually not felt over the bladder but is commonly referred to the urethral meatus. Pain occurring at the start of urination may indicate urethral pathology, whereas pain occurring at the end of micturition (strangury) is usually of bladder origin. Dysuria is frequently accompanied by frequency and urgency.

Obstructive Symptoms.

Decreased force of urination is usually secondary to bladder outlet obstruction and commonly results from benign prostatic hyperplasia (BPH) or a urethral stricture. In fact, except for severe degrees of obstruction, most patients are unaware of a change in the force and caliber of their urinary stream. These changes usually occur gradually and go generally unrecognized by most patients. The other obstructive symptoms noted later are more commonly recognized and are usually secondary to bladder outlet obstruction in men due to either BPH or a urethral stricture.

Urinary hesitancy refers to a delay in the start of micturition. Normally, urination begins within a second after relaxing the urinary sphincter, but it may be delayed in men with bladder outlet obstruction.

Intermittency refers to involuntary start-stopping of the urinary stream. It most commonly results from prostatic obstruction with intermittent occlusion of the urinary stream by the lateral prostatic lobes.

Postvoid dribbling refers to the terminal release of drops of urine at the end of micturition. This is secondary to a small amount of residual urine in either the bulbar or the prostatic urethra that is normally “milked back” into the bladder at the end of micturition ( Stephenson and Farrar, 1977 ). In men with bladder outlet obstruction, this urine escapes into the bulbar urethra and leaks out at the end of micturition. Men frequently will attempt to avoid wetting their clothing by shaking the penis at the end of micturition. In fact, this is ineffective, and the problem is more readily solved by manual compression of the bulbar urethra in the perineum and blotting the urethral meatus with a tissue. Postvoid dribbling is often an early symptom of urethral obstruction related to BPH, but, in itself, seldom necessitates any further treatment.

Straining refers to the use of abdominal musculature to urinate. Normally, it is unnecessary for a man to perform a Valsalva maneuver except at the end of urination. Increased straining during micturition is a symptom of bladder outlet obstruction.

It is important for the urologist to distinguish irritative from obstructive lower urinary tract symptoms. This most frequently occurs in evaluating men with BPH. Although BPH is primarily obstructive, it produces changes in bladder compliance that result in increased irritative symptoms. In fact, men with BPH more commonly present with irritative than obstructive symptoms, and the most common presenting symptom is nocturia. The urologist must be careful not to attribute irritative symptoms to BPH unless there is documented evidence of obstruction. In general, lower urinary tract symptoms are nonspecific and may occur secondary to a wide variety of neurologic conditions as well as to prostatic enlargement ( Lepor and Machi, 1993 ). In this regard, two important examples are mentioned. Patients with high-grade flat carcinoma in situ of the bladder may present with urinary irritative symptoms. The urologist should be particularly aware of the diagnosis of carcinoma in situ in men who present with irritative symptoms, a history of cigarette smoking, and microscopic hematuria. In our personal experience, we cared for a 54-year-old man who presented with this history and was treated for BPH for 2 years before the diagnosis of bladder cancer was established. Once the correct diagnosis was made, the patient had developed muscle-invasive disease and required a cystectomy for cure.

The second important example is irritative symptoms resulting from neurologic disease, such as cerebrovascular accidents, diabetes mellitus, and Parkinson's disease. Most neurologic diseases encountered by the urologist are upper motor neuron in etiology and result in a loss of cortical inhibition of voiding with resultant decreased bladder compliance and irritative voiding symptoms. The urologist must be extremely careful to rule out underlying neurologic disease before performing surgery to relieve bladder outlet obstruction. Such surgery not only may fail to relieve the patient's irritative symptoms but also may result in permanent urinary incontinence.

Since its introduction in 1992, the American Urological Association (AUA) symptom index has been widely used and validated as an important means of assessing men with lower urinary tract symptoms ( Barry et al, 1992 ). The original AUA symptom score is based on the answers to seven questions concerning frequency, nocturia, weak urinary stream, hesitancy, intermittency, incomplete bladder emptying, and urgency. The International Prostate Symptom Score (I-PSS) includes these seven questions, as well as a global quality of life question ( Table 3-1 ). The total symptom score ranges from 0 to 35 with scores of 0 to 7, 8 to 19, and 20 to 35 indicating mild, moderate, and severe lower urinary tract symptoms, respectively. The I-PSS is a helpful tool both in the clinical management of men with lower urinary tract symptoms and in research studies regarding the medical and surgical treatment of men with voiding dysfunction.

Table 3-1 -- International Prostate Symptom Score
Patient's Name Not At All Less Than 1 Time in 5 Less Than Half the Time About Half the Time More Than Half the Time Almost Always Your Score
Date of Birth Date Completed
1. Incomplete emptying
Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 0 1 2 3 4 5
2. Frequency
Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 0 1 2 3 4 5
3. Intermittency
Over the past month, how often have you found you stopped and started again several times when you urinated? 0 1 2 3 4 5
4. Urgency
Over the past month, how often have you found it difficult to postpone urination? 0 1 2 3 4 5
5. Weak stream
Over the past month, how often have you had a weak urinary stream? 0 1 2 3 4 5
6. Straining
Over the past month, how often have you had to push or strain to begin urination? 0 1 2 3 4 5
None 1 Time 2 Times 3 Times 4 Times 5 Times or More
7. Nocturia
Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? 0 1 2 3 4 5
Total I-PSS Score
Quality of Life Due to Urinary Symptoms Delighted Pleased Mostly Satisfied Mixed—About Equally Satisfied and Dissatisfied Mostly Dissatisfied Unhappy Terrible
If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? 0 1 2 3 4 5 6
From Cockett ATK, Aso Y, Denis L, et al: The Second International Consultation on Benign Prostatic Hyperplasia (BPH). In Cockett ATK, Aso Y, Chatelain C, et al (eds): The Second International Consultation on Benign Prostatic Hyperplasia (BPH). Pairs, Scientific Communication International, 1994, p 553.

There are limitations to the use of symptom indices, and it is important for the physician to discuss the patient's responses with him. It has been demonstrated that a grade 6 reading level is necessary to understand the I-PSS, and some patients with neurologic disorders and dementia may also have difficulty completing the symptom score ( MacDiarmid et al, 1998 ). In addition, the symptom score, as well as the obstructive and irritative voiding symptoms, is nonspecific, and the symptoms may be caused by a variety of conditions other than BPH. Similar symptom scores have been demonstrated to be present in age-matched men and women between 55 and 79 years of age ( Lepor and Machi, 1993 ). Despite these limitations, the I-PSS is a simple adjunct in assessing men with lower urinary tract symptoms and may be used in the initial evaluation of men with lower urinary tract symptoms as well as in the assessment of treatment response.


Urinary incontinence is the involuntary loss of urine. A careful history of the incontinent patient will often determine the etiology. Urinary incontinence can be subdivided into four categories.

Continuous Incontinence.

Continuous incontinence is most commonly due to a urinary tract fistula that bypasses the urethral sphincter. The most common type of fistula that results in urinary incontinence is a vesicovaginal fistula usually secondary to gynecologic surgery, radiation, or obstetric trauma. Less commonly, ureterovaginal fistulas may occur from similar causes.

A second major cause of continuous incontinence is an ectopic ureter that enters either the urethra or the female genital tract. An ectopic ureter usually drains a small, dysplastic upper pole segment of kidney, and the amount of urinary leakage may be quite small. Such patients may void most of their urine normally but have a continuous amount of small urinary leakage that may be misdiagnosed for many years as a chronic vaginal discharge. In our experience, we cared for a 30-year-old woman—who had been misdiagnosed with enuresis in childhood and as having a chronic vaginal discharge in adult life—whose urinary leakage was totally corrected by surgical removal of the dysplastic, upper pole segment of her right kidney. Ectopic ureters never produce urinary incontinence in males because they always enter the bladder neck or prostatic urethra proximal to the external urethral sphincter.

Stress Incontinence.

Stress incontinence refers to the sudden leakage of urine with coughing, sneezing, exercise, or other activities that increase intra-abdominal pressure. During these activities, intra-abdominal pressure rises transiently above urethral resistance, resulting in a sudden, usually small amount of urinary leakage. Stress incontinence is most common in women after childbearing or menopause and is related to a loss of anterior vaginal support and weakening of pelvic tissues. Stress incontinence is also observed in men after prostatic surgery, most commonly radical prostatectomy, in which there may be injury to the external urethral sphincter. Stress urinary incontinence is difficult to manage pharmacologically, and patients with significant stress incontinence are usually best treated surgically.

Urgency Incontinence.

Urgency incontinence is the precipitous loss of urine preceded by a strong urge to void. This symptom is commonly observed in patients with cystitis, neurogenic bladder, and advanced bladder outlet obstruction with secondary loss of bladder compliance. It is important to distinguish urgency incontinence from stress incontinence for two reasons. First, urgency incontinence may result from a secondary underlying pathologic process, which should be identified; treatment of this primary problem, such as infection or bladder outlet obstruction, may result in resolution of urgency incontinence. Second, patients with urgency incontinence usually are not amenable to surgical correction but, rather, are more appropriately treated with pharmacologic agents that increase bladder compliance and/or increase urethral resistance.

Overflow Urinary Incontinence.

Overflow urinary incontinence, often called paradoxical incontinence, is secondary to advanced urinary retention and high residual urine volumes. In these patients, the bladder is chronically distended and never empties completely. Urine may dribble out in small amounts as the bladder overflows. This is particularly likely to occur at night when the patient is less likely to inhibit urinary leakage. Overflow incontinence has been termed paradoxical incontinence because it can often be cured by relief of bladder outlet obstruction. It is, however, often difficult to make the diagnosis of overflow incontinence by history and physical examination alone, particularly in the obese patient, in whom percussion of the distended bladder may be difficult. Overflow incontinence usually develops over a considerable length of time, and patients may be totally unaware of incomplete bladder emptying. Thus, any patient with significant incontinence should undergo measurement of postvoid residual urine.


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 ( Forsythe and Redmond, 1974 ). Enuresis must be distinguished from continuous incontinence, which occurs in the day as well as night and which, in a young girl, usually indicates the presence of an ectopic ureter. All children older than age 6 years with enuresis should undergo a urologic evaluation, although the vast majority will be found to have no significant urologic abnormality.

Sexual Dysfunction

Male sexual dysfunction is frequently used synonymously with impotence or erectile dysfunction, although impotence refers specifically to the inability to achieve and maintain an erection adequate for intercourse. Patients presenting with “impotence” should be questioned carefully to rule out other male sexual disorders, including loss of libido, absence of emission, absence of orgasm, and, most commonly, premature ejaculation. Obviously, it is important to identify the precise problem before proceeding with further evaluation and treatment.

Loss of Libido.

Because androgens have a major influence on sexual desire, a decrease in libido may indicate androgen deficiency arising from either pituitary or testicular dysfunction. This can be evaluated directly by measurement of serum testosterone that, if abnormal, should be further evaluated by measurement of serum gonadotropins and prolactin. Because the amount of testosterone required to maintain libido is usually less than that required for full stimulation of the prostate and seminal vesicles, patients with hypogonadism may also note decreased or absent ejaculation. Conversely, if semen volume is normal, it is unlikely that endocrine factors are responsible for loss of libido. A decrease in libido may also result from depression and a variety of medical illnesses that affect general health and well-being.


Impotence refers specifically to the inability to achieve and maintain an erection sufficient for intercourse. A careful history will often determine whether the problem is primarily psychogenic or organic. In men with psychogenic impotence, the condition frequently develops rather quickly secondary to a precipitating event such as marital stress or change or loss of a sexual partner. In men with organic impotence, the condition usually develops more insidiously and frequently can be linked to advancing age or other underlying risk factors.

In evaluating men with impotence, it is important to determine whether the problem exists in all situations. Many men who report impotence may not be able to have intercourse with one partner but will with another. Similarly, it is important to determine whether men are able to achieve normal erections with alternative forms of sexual stimulation (e.g., masturbation, erotic videos). Finally, the patient should be asked whether he ever notes nocturnal or early morning erections. In general, patients who are able to achieve adequate erections in some situations but not others have primarily psychogenic rather than organic impotence.

Failure to Ejaculate.

Anejaculation may result from several causes: (1) androgen deficiency, (2) sympathetic denervation, (3) pharmacologic agents, and (4) bladder neck and prostatic surgery. Androgen deficiency results in decreased secretions from the prostate and seminal vesicles causing a reduction or loss of seminal volume. Sympathectomy or extensive retroperitoneal surgery, most notably retroperitoneal lymphadenectomy for testicular cancer, may interfere with autonomic innervation of the prostate and seminal vesicles, resulting in absence of smooth muscle contraction and absence of seminal emission at time of orgasm. Pharmacologic agents, particularly α-adrenergic antagonists, may interfere with bladder neck closure at time of orgasm and result in retrograde ejaculation. Similarly, previous bladder neck or prostatic urethral surgery, most commonly transurethral resection of the prostate, may interfere with bladder neck closure, resulting in retrograde ejaculation. Finally, retrograde ejaculation may develop spontaneously in diabetic men.

Patients who complain of absence of ejaculation should be questioned regarding loss of libido or other symptoms of androgen deficiency, present medications, diabetes, and previous surgery. A careful history will usually determine the cause of this problem.

Absence of Orgasm.

Anorgasmia is usually psychogenic or caused by certain medications used to treat psychiatric diseases. Sometimes, however, anorgasmia may be due to decreased penile sensation owing to impaired pudendal nerve function. Most commonly, this occurs in diabetics with peripheral neuropathy. Men who experience anorgasmia in association with decreased penile sensation should undergo vibratory testing of the penis and further neurologic evaluation as indicated.

Premature Ejaculation.

Men who complain of premature ejaculation should be questioned carefully because this is obviously a very subjective symptom. It is common for men to ejaculate within 2 minutes after initiation of intercourse, and many men who complain of premature ejaculation in actuality have normal sexual function with abnormal sexual expectations. However, there are men with true premature ejaculation who reach orgasm within less than 1 minute after initiation of intercourse. This problem is almost always psychogenic and best treated by a clinical psychologist or psychiatrist who specializes in treatment of this problem and other psychological aspects of male sexual dysfunction. With counseling and appropriate modifications in sexual technique, this problem can usually be overcome. Alternatively, treatment with serotonin reuptake inhibitors, such as sertraline and fluoxetine, have been demonstrated to be helpful in men with premature ejaculation ( Murat Basar et al, 1999 ).


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. It frequently occurs after a prolonged period of sexual abstinence, and we have observed it several times in men whose wives are in the final weeks of pregnancy. Patients with hematospermia that persists beyond several weeks should undergo further urologic evaluation, because, rarely, an underlying etiology will be identified. A genital and rectal examination should be done to exclude the presence of tuberculosis, a prostate-specific antigen (PSA) and a rectal examination done to exclude prostatic carcinoma, and a urinary cytology done to exclude the possibility of transitional cell carcinoma of the prostate. It should be emphasized, however, that hematospermia almost always resolves spontaneously and rarely is associated with any significant urologic pathology.


Pneumaturia is the passage of gas in the urine. In patients who have not recently had urinary tract instrumentation or a urethral catheter placed, this is almost always due to a fistula between the intestine and the bladder. Common causes include diverticulitis, carcinoma of the sigmoid colon, and regional enteritis (Crohn's disease). In rare instances, patients with diabetes mellitus may have gas-forming infections, with carbon dioxide formation from the fermentation of high concentrations of sugar in the urine.

Urethral Discharge

Urethral discharge is the most common symptom of venereal infection. A purulent discharge that is thick, profuse, and yellow to gray is typical of gonococcal urethritis; the discharge in patients with nonspecific urethritis is usually scant and watery. A bloody discharge is suggestive of carcinoma of the urethra.

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. When associated with urinary obstruction, fever and chills may portend septicemia and necessitate emergency treatment to relieve obstruction.

Medical History

The past medical history is extremely important because it frequently provides clues to the patient's current diagnosis. The past medical history should be obtained in an orderly and sequential manner.

Previous Medical Illnesses with Urologic Sequelae

There are obviously many diseases that may affect the GU system, and it is important to listen and record the patient's previous medical illnesses. Patients with diabetes mellitus frequently develop autonomic dysfunction that may result in impaired urinary and sexual function. A previous history of tuberculosis may be important in a patient presenting with impaired renal function, ureteral obstruction, or chronic, unexplained UTIs. 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. Patients with neurologic diseases such as multiple sclerosis are also more likely to develop urinary and sexual dysfunction. In fact, 5% of patients with previously undiagnosed multiple sclerosis present with urinary symptoms as the first manifestation of the disease ( Blaivas and Kaplan, 1988 ). As mentioned earlier, in men with bladder outlet obstruction, it is important to be aware of preexisting neurologic conditions. Surgical treatment of bladder outlet obstruction in the presence of detrusor hyperreflexia may result in increased urinary incontinence postoperatively. Finally, patients with sickle cell anemia are prone to a number of urologic conditions, including papillary necrosis and erectile dysfunction secondary to recurrent priapism. There are obviously many other diseases with urologic sequelae, and it is important for the urologist to take a careful history in this regard.

Family History

It is similarly important to obtain a detailed family history because many diseases are genetic and/or familial. Examples of genetic diseases include adult polycystic kidney disease, tuberous sclerosis, von Hippel-Lindau disease, renal tubular acidosis, and cystinuria; these are but a few common and well-recognized examples.

In addition to these diseases of known genetic predisposition, there are other conditions in which the precise pattern of inheritance has not been elucidated but that clearly have a familial tendency. It is well known that individuals with a family history of urolithiasis are at increased risk for stone formation. More recently, 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 ( Bratt, 2000 ). There are other familial conditions that are mentioned elsewhere in the text, but suffice it to state again that obtaining a careful history of previous illnesses and a family history of urologic disease can be extremely valuable in establishing the correct diagnosis.


It is similarly important to obtain an accurate and complete list of present medications because many drugs interfere with urinary and sexual function. For example, most of the antihypertensive medications interfere with erectile function, and changing antihypertensive medications can sometimes improve sexual function. Similarly, many of the psychotropic agents interfere with emission and orgasm. In our own recent experience, we cared for a man who presented with anorgasmia. He had been to several physicians without improvement in this problem. When we obtained his past medical history, he mentioned that he had been taking a psychotropic agent for transient depression for several years, and his anorgasmia resolved when this no longer needed medication was discontinued. The list of medications affecting urinary and sexual function is exhaustive, but, once again, each medication should be recorded and its side effects investigated to be sure that the patient's problem is not drug related. A listing of common medications that may cause urologic side effects is presented in Table 3-2 .

Table 3-2 -- Drugs Associated with Urologic Side Effects
Urologic Side Effects Class of Drugs Specific Examples
Decreased libido Antihypertensives Hydrochlorothiazide
Erectile dysfunction Propranolol
Psychotropic drugs Benzodiazepines
Ejaculatory dysfunction

α-Adrenergic antagonists

Psychotropic drugs












Decreased spermatogenesis

Chemotherapeutic agents

Drugs with abuse potential

Drugs affecting endocrine function

Alkylating agents





Incontinence or impaired voiding

Direct smooth muscle stimulants


Smooth muscle relaxants

Striated muscle relaxants




Valproic acid



Urinary retention or obstructive voiding symptoms

Anticholinergic agents or musculotropic relaxants

Calcium channel blockers

Antiparkinsonian drugs

α-Adrenergic agonists












Acute renal failure


Chemotherapeutic drugs







Nonsteroidal anti-inflammatory drugs



Cardiac drugs

Gastrointestinal drugs

Psychotropic drugs

Tricyclic antidepressants








Previous Surgical Procedures

It is important to be aware of previous operations, particularly in a patient in whom surgery is intended. Obviously, previous operations may make subsequent ones more difficult. If the previous surgery was in a similar anatomic region, it is worthwhile to try to obtain the previous operative report. In our own experience, this small additional effort has been rewarded on numerous occasions by providing a clear explanation of the patient's previous surgery that greatly simplified the subsequent operation. In general, it is worthwhile obtaining as much information as possible before any intended surgery because most surprises that occur in the operating room are unhappy ones.

Smoking and Alcohol Use

Cigarette smoking and consumption of alcohol are clearly linked to a number of urologic conditions. Cigarette smoking is associated with an increased risk of urothelial carcinoma, most notably bladder cancer, and it is also associated with increased peripheral vascular disease and erectile dysfunction. Chronic alcoholism may result in autonomic and peripheral neuropathy with resultant impaired urinary and sexual function. Chronic alcoholism may also impair hepatic metabolism of estrogens, resulting in decreased serum testosterone, testicular atrophy, and decreased libido.

In addition to the direct urologic effects of cigarette smoking and alcohol consumption, patients who are actively smoking or drinking at the time of surgery are at increased risk for perioperative complications. Smokers are at increased risk for both pulmonary and cardiac complications. If possible, they should discontinue smoking at least 8 weeks before surgery to optimize their pulmonary function ( Warner et al, 1989 ). If they are unable to do this, they should at least quit smoking for 48 hours before surgery, because this will result in a significant improvement in cardiovascular function. Similarly, chronic alcoholics are at increased risk for hepatic toxicity and subsequent coagulation problems postoperatively. Furthermore, alcoholics who continue drinking up to the time of surgery may experience acute alcohol withdrawal during the postoperative period that can be life threatening. Prophylactic administration of lorazepam (Ativan) greatly reduces the potential risk of this significant complication.


Finally, medicinal allergies should be questioned because, obviously, these medications should be avoided in future treatment of the patient. All medicinal allergies should be marked boldly on the front of the patient's chart to avoid potential complications from inadvertent exposure to the same medications.

In summary, a careful and thorough medical history, including the chief complaint and history of present illness, past medical history, and family history, should be obtained in every patient. Unfortunately, time constraints often make it difficult for the physician to spend the necessary time to obtain a full history. A reasonable substitute is to have a trained nurse or other health professional see the patient first. By using a standard history form, much of the information discussed previously can be obtained in a preliminary interview. It then remains for the urologist to only fill in the blanks, have the patient elaborate on potentially relevant aspects of the past medical history, and then perform a complete physical examination.

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