CLINICAL DECISION-MAKING - PHYSICAL EXAMINATION

PHYSICAL EXAMINATION

KEY POINTS: EVALUATION OF THE UROLOGIC PATIENT

▪ The urologist can undertake the initial evaluation and establish a diagnosis for almost all patients with diseases of the GU system. ▪ A complete history and appropriate physical examination is critical in the assessment of urologic patients. ▪ A complete urinalysis including chemical and microscopic analyses should be performed because this may provide important information critical to the diagnosis and treatment of urologic patients.

A complete and thorough physical examination is an essential component of the evaluation of patients who present with urologic disease. Although it is tempting to become dependent on results of laboratory and radiologic tests, the physical examination often simplifies the process and allows the urologist to select the most appropriate diagnostic studies. Along with the history, the physical examination remains a key component of the diagnostic evaluation and should be performed conscientiously.

General Observations

The visual inspection of the patient provides a general overview. The skin should be inspected for evidence of jaundice or pallor. The nutritional status of the patient should be noted. Cachexia is a frequent sign of malignancy, and obesity may be a sign of underlying endocrinologic abnormalities. In this instance, one should search for the presence of truncal obesity, a “buffalo hump,” and abdominal skin striae, which are stigmata of hyperadrenocorticism. In contrast, debility and hyperpigmentation may be signs of hypoadrenocorticism. Gynecomastia may be a sign of endocrinologic disease as well as a possible indicator of alcoholism or previous hormonal therapy for prostate cancer. Edema of the genitalia and lower extremities may be associated with cardiac decompensation, renal failure, nephrotic syndrome, or pelvic and/or retroperitoneal lymphatic obstruction. Supraclavicular lymphadenopathy may be seen with any GU neoplasm, most commonly prostate and testis cancer; inguinal lymphadenopathy may occur secondary to carcinoma of the penis or urethra.

Kidneys

The kidneys are fist-sized organs located high in the retroperitoneum bilaterally. In the adult, the kidneys are normally difficult to palpate because of their position under the diaphragm and ribs with abundant musculature both anteriorly and posteriorly. Because of the position of the liver, the right kidney is somewhat lower than the left. In children and thin women, it may be possible to palpate the lower pole of the right kidney with deep inspiration. However, it is usually not possible to palpate either kidney in men, and the left kidney is almost always impalpable unless it is abnormally enlarged.

The best way to palpate the kidneys is with the patient in the supine position. The kidney is lifted from behind with one hand in the costovertebral angle ( Fig. 3-1 ). On deep inspiration, the examiner's hand is advanced firmly into the anterior abdomen just below the costal margin. At the point of maximal inspiration, the kidney may be felt as it moves downward with the diaphragm. With each inspiration, the examiner's hand may be advanced deeper into the abdomen. Once again, it is more difficult to palpate kidneys in men because the kidneys tend to move downward less with inspiration and because they are surrounded with thicker muscular layers. In children, it is easier to palpate the kidneys because of decreased body thickness. In neonates, the kidneys can be felt quite easily by palpating the flank between the thumb anteriorly and the fingers over the costovertebral angle posteriorly.

Figure 3-1 Bimanual examination of the kidney. (From Judge RD, Zuidema GD, Fitzgerald FT [eds]: Clinical Diagnosis, 5th ed. Boston, Little, Brown, 1989, p 370.)

Transillumination of the kidneys may be helpful in children younger than 1 year of age with a palpable flank mass. Such masses frequently are of renal origin. A flashlight or fiberoptic light source is positioned posteriorly against the costovertebral angle. Fluid-filled masses such as cysts or hydronephrosis produce a dull reddish glow in the anterior abdomen. Solid masses such as tumors do not transilluminate. Other diagnostic maneuvers that may be helpful in examining the kidneys are percussion and auscultation. Although renal inflammation may cause pain that is poorly localized, percussion of the costovertebral angle posteriorly more often localizes the pain and tenderness more accurately. Percussion should be done gently, because in a patient with significant renal inflammation this may be quite painful. Auscultation of the upper abdomen during deep inspiration may occasionally reveal a systolic bruit associated with renal artery stenosis or an aneurysm. A bruit may also be detected in association with a large renal arteriovenous fistula.

Every patient with flank pain should also be examined for possible nerve root irritation. The ribs should be palpated carefully to rule out a bone spur or other skeletal abnormality and to determine the point of maximal tenderness. Unlike renal pain, radiculitis usually causes hyperesthesia of the overlying skin innervated by the irritated peripheral nerve. This hypersensitivity can be elicited with a pin or by pinching the skin and fat overlying the involved area. Finally, the pain experienced during the pre-eruptive phase of herpes zoster involving any of the segments between T11 and L2 may also simulate pain of renal origin.

Abnormal Findings.

The most common abnormality detected on examination of the kidneys is a mass. In adult patients, particularly those who are obese, renal masses may be difficult to palpate unless these masses are very large. In most cases, palpable renal masses are either benign cysts or malignant renal tumors, and this distinction generally cannot be made based on physical examination. In children, renal masses are frequently easier to palpate than in adults and may be either cystic (multicystic kidney, polycystic kidney, hydronephrosis) or malignant (Wilms' tumor, neuroblastoma). In neonates and younger children, the distinction between cystic, benign, and solid malignant masses can often be made by transillumination.

Bladder

A normal bladder in the adult cannot be palpated or percussed until there is at least 150 mL of urine in it. At a volume of about 500 mL, the distended bladder becomes visible in thin patients as a lower midline abdominal mass.

Percussion is better than palpation for diagnosing a distended bladder. The examiner begins by percussing immediately above the symphysis pubis and continuing cephalad until there is a change in pitch from dull to resonant. Alternatively, it may be possible in thin patients and in children to palpate the bladder by lifting the lumbar spine with one hand and pressing the other hand into the midline of the lower abdomen.

A careful bimanual examination, best done with the patient under anesthesia, is invaluable in assessing the regional extent of a bladder tumor or other pelvic mass. The bladder is palpated between the abdomen and the vagina in the female ( Fig. 3-2 ) or the rectum in the male ( Fig. 3-3 ). In addition to defining areas of induration, the bimanual examination allows the examiner to assess the mobility of the bladder; such information cannot be obtained by radiologic techniques such as CT and MRI, which convey static images.

Figure 3-2 Bimanual examination of the bladder in the female. (From Swartz MH: Textbook of Physical Diagnosis. Philadelphia, WB Saunders, 1989, p 405.)

Figure 3-3 Bimanual examination of the bladder in the male. (From Judge RD, Zuidema GD, Fitzgerald FT [eds]: Clinical Diagnosis, 5th ed. Boston, Little, Brown, 1989, p 376.)

Abnormal Findings.

The most common palpable abnormality involving the urinary bladder is a full bladder resulting from overdistention. This may occur in men with bladder outlet or urethral obstruction due to BPH or urethral stricture disease. In addition, a variety of neurologic conditions may lead to poor bladder emptying in men or women. Large bladder tumors or calculi may also be palpable in some patients, particularly on bimanual examination under anesthesia. Tenderness over the suprapubic area may indicate cystitis.

Penis

If the patient has not been circumcised, the foreskin should be retracted to examine for tumor or balanoposthitis (inflammation of the prepuce and glans penis). Most penile cancers occur in uncircumcised men and arise on the prepuce or glans penis. Therefore, in a patient with a bloody penile discharge in whom the foreskin cannot be withdrawn, a dorsal slit or circumcision must be performed to adequately evaluate the glans penis and urethra.

The position of the urethral meatus should be noted. It may be located proximal to the tip of the glans on the ventral surface (hypospadias) or, much less commonly, on the dorsal surface (epispadias). The penile skin should be examined for the presence of superficial vesicles compatible with herpes simplex and for ulcers that may indicate either venereal infection or tumor. The presence of venereal warts (condylomata acuminata), which appear as irregular, papillary, velvety lesions on the male genitalia, should also be noted.

The urethral meatus should be separated between the thumb and the forefinger to inspect for neoplastic or inflammatory lesions within the fossa navicularis. The dorsal shaft of the penis should be palpated for the presence of fibrotic plaques or ridges typical of Peyronie's disease. Tenderness along the ventral aspect of the penis is suggestive of periurethritis, often secondary to a urethral stricture.

Abnormal Findings Phimosis.

Phimosis is a condition in which the foreskin cannot be retracted behind the glans penis. In males younger than 4 years old it is normal for the foreskin to be unretractable; in older boys and adults, however, the foreskin usually can be easily withdrawn to the corona ( Oster, 1968 ). Phimosis is usually not painful, but it may produce urinary obstruction with ballooning of the foreskin and may lead to chronic inflammation and carcinoma.

Paraphimosis.

Paraphimosis is a condition in which the foreskin has been retracted and left behind the glans penis, constricting the glans and causing painful vascular engorgement and edema. Paraphimosis is often iatrogenic and frequently occurs after a well-meaning health care professional has examined the penis or inserted a urethral catheter and forgotten to replace the foreskin in its natural position. Paraphimosis can result in marked swelling of the glans penis such that the foreskin can no longer be drawn forward, necessitating an emergency dorsal slit or circumcision.

Peyronie's Disease.

Peyronie's disease is a common condition that results in fibrosis of the tunica albuginea, the elastic membrane that surrounds each corpus cavernosum, producing curvature of the penis during erection. Peyronie's disease may be difficult to diagnose in the flaccid state; however, the patient's history of curvature with erection establishes the diagnosis. Physical examination reveals fibrous plaques or ridges along the shaft of the penis. Peyronie's disease can be alarming to patients who may fear it represents malignancy. They should be reassured that this is always a benign condition that may resolve or stabilize spontaneously without treatment.

Priapism.

Priapism is a prolonged painful erection that is not related to sexual activity. It occurs most commonly in patients with sickle cell disease but can also occur in those with advanced malignancy, coagulation disorders, and pulmonary disease and in many patients without an obvious etiology. The patient usually presents with a painful, spontaneous erection of several hours' duration. Physical examination reveals the penis to be rigid and mildly tender; the glans penis, however, is usually flaccid.

Hypospadias.

Hypospadias is a congenital abnormality in which the urethral meatus is positioned either along the ventral shaft of the penis or on the scrotum or perineum instead of being located at the tip of the penis. This is a relatively common condition, occurring in about 1 in 300 live male births ( Avellan, 1975 ). In the more common, less severe forms of hypospadias, the urethra is located at or distal to the corona of the penis; these conditions frequently do not necessitate treatment except for cosmetic purposes. The less common but more severe forms of hypospadias, in which the meatus is located on the penile shaft or in the perineum, may interfere with normal urination in the usual male standing position and may, in adult life, interfere with fertility, because the semen is deposited in the distal vagina rather than at the cervix. Such cases are best corrected early in childhood to avoid social embarrassment and psychological trauma. Neonates with hypospadias and bilateral cryptorchidism (undescended testes) should be evaluated for the possibility of intersex, of which the most common cause is adrenogenital syndrome.

Carcinoma.

Carcinoma of the penis usually presents as a velvety, raised lesion arising on the glans penis or inner surface of the prepuce. Alternatively, it may present as an ulcerative lesion. Carcinoma of the penis occurs almost exclusively in uncircumcised men. It is more common in underdeveloped nations where there is poor hygiene. Penile carcinoma is most commonly a squamous cell tumor and is frequently associated with palpable inguinal lymphadenopathy.

Scrotum and Contents

The scrotum is a loose sac containing the testes and spermatic cord structures. The scrotal wall is made up of skin and an underlying thin muscular layer. The testes are normally oval, firm, and smooth; in adults, they measure about 6 cm in length and 4 cm in width. They are suspended in the scrotum, with the right testis normally anterior to the left. The epididymis lies posterior to the testis and is palpable as a distinct ridge of tissue. The vas deferens can be palpated above each testis and feels like a piece of heavy twine.

The scrotum should be examined for dermatologic abnormalities. Because the scrotum, unlike the penis, contains both hair and sweat glands, it is a frequent site of local infection and sebaceous cysts. Hair follicles can become infected and may present as small pustules on the surface of the scrotum. These usually resolve spontaneously, but they can give rise to more significant infection, particularly in patients with reduced immunity and in those with diabetes. Patients often become concerned about these lesions, mistaking them for testicular tumors.

The testes should be palpated gently between the finger tips of both hands. The testes normally have a firm, rubbery consistency with a smooth surface. Abnormally small testes suggest hypogonadism or an endocrinopathy such as Klinefelter's disease. A firm or hard area within the testis should be considered a malignant tumor until proved otherwise. The epididymis should be palpable as a ridge posterior to each testis. Masses in the epididymis (spermatocele, cyst, epididymitis) are almost always benign.

To examine for a hernia, the physician's index finger should be inserted gently into the scrotum and invaginated into the external inguinal ring ( Fig. 3-4 ). The scrotum should be invaginated in front of the testis, and care should be taken not to elevate the testis itself, which is quite painful. Once the external ring has been located, the physician should place the fingertips of his or her other hand over the internal inguinal ring and ask the patient to bear down (Valsalva's maneuver). A hernia will be felt as a distinct bulge that descends against the tip of the index finger in the external inguinal ring as the patient bears down. Although it may be possible to distinguish a direct inguinal hernia arising through the floor of the inguinal canal from an indirect inguinal hernia prolapsing through the internal inguinal ring, this is seldom possible and of little clinical significance because the surgical approach is essentially identical for both conditions.

Figure 3-4 Examination of the inguinal canal. (From Swartz MH: Textbook of Physical Diagnosis. Philadelphia, WB Saunders, 1989, p 376.)

The spermatic cord is also examined with the patient in the standing position. A varicocele is a dilated, tortuous spermatic vein that becomes more obvious as the patient performs a Valsalva maneuver. The epididymis can again be palpated as a ridge of tissue running longitudinally, posterior to each testis. The testis should be palpated again between the fingers of both hands, once again taking care not to exert any pressure on the testis itself so as to avoid pain.

Transillumination is helpful in determining whether scrotal masses are solid (tumor) or cystic (hydrocele, spermatocele). A small flashlight or fiberoptic light cord is placed behind the mass. A cystic mass transilluminates easily, whereas light is not transmitted through a solid tumor.

Abnormal Findings Testicular Cancer.

The most common physical finding in the testis is a mass. A useful guideline is that most masses arising from the testis are malignant, whereas almost all masses arising from the spermatic cord structures are benign. Thus, it is very important to distinguish the testis and epididymis during the physical examination. Testicular tumors usually present as painless, firm, irregular masses on the surface of the testis. They are usually discovered incidentally by the patient when showering or during self-examination. Testicular tumors can be readily distinguished from benign masses arising from the spermatic cord by transillumination and scrotal ultrasound.

Torsion.

Torsion is the twisting of the testis on the spermatic cord, resulting in strangulation of the blood supply and infarction of the testis. Torsion occurs most commonly between the ages of 12 and 20 years, although it does occur less frequently during the first year of life. The patient usually presents with the sudden onset of pain and swelling of the involved testis. The pain may radiate into the groin and lower abdomen; thus, it may be confused with appendicitis unless the physician examines the genitalia carefully. On physical examination, it is difficult to distinguish the testis from the epididymis because of localized swelling. For this reason, the condition is frequently misdiagnosed as epididymitis. Age is the most useful criterion in distinguishing torsion from epididymitis, because torsion usually occurs around puberty whereas epididymitis more often occurs in sexually active males, usually after age 20 years.

Hydrocele.

A hydrocele is a collection of fluid between the tunica vaginalis and the testis. The patient presents with progressive swelling and local discomfort on the involved side of the scrotum. Physical examination reveals smooth, symmetrical enlargement of one side of the scrotum in which it is very difficult to feel the testis. The diagnosis is made by transillumination of the scrotum. However, because about 10% of testicular tumors present as an associated reactive hydrocele, it is important to be sure that the hydrocele transilluminates completely and, if there is any doubt, to confirm the diagnosis with a subsequent scrotal ultrasound.

Varicocele.

A varicocele is an enlarged, tortuous spermatic vein above the testis that almost always occurs on the left side. The patient presents with a soft mass or swelling above the testis noted when he stands or strains. This has been described as a “bag of worms.” Varicoceles typically decrease in size and may disappear when the patient is supine. Patients with the sudden onset of a varicocele, a right-sided varicocele, or a varicocele that does not reduce in size in the supine position should be suspected of having a retroperitoneal neoplasm with obstruction of the spermatic vein where it enters either the renal vein on the left or the inferior vena cava on the right. Such patients should undergo ultrasonography or CT to rule out malignancy before receiving treatment for the varicocele.

Rectal and Prostate Examination in the Male

Digital rectal examination (DRE) should be performed in every male after age 40 years and in men of any age who present for urologic evaluation. Prostate cancer is the second most common cause of male cancer deaths after age 55 years and the most common cause of cancer deaths in men older than 70 years. Many prostate cancers can be detected in an early curable stage by DRE, and about 25% of colorectal cancers can be detected by DRE in combination with a stool guaiac test.

DRE should be performed at the end of the physical examination. It is done best with the patient standing and bent over the examining table or with the patient in the knee-chest position. In the standing position, the patient should stand with his thighs close to the examining table. The feet should be about 18 inches apart, with the knees flexed slightly. The patient should bend at the waist 90 degrees until his chest is resting on his forearms. The physician should give the patient adequate time to get in the proper position and relax as much as possible. A few reassuring words before the examination are helpful. The physician should place a glove on the examining hand and should lubricate the index finger thoroughly.

Before performing the DRE, the physician should place the palm of his other hand against the patient's lower abdomen. This provides subtle reassurance to the patient by allowing the physician to make gentle contact with the patient before touching the anus. It also allows the physician to steady the patient and provide gentle counterpressure if the patient tries to move away as the DRE is being performed. The DRE itself begins by separating the buttocks and inspecting the anus for pathology, usually hemorrhoids, but, occasionally, an anal carcinoma or melanoma may be detected. The gloved, lubricated index finger is then inserted gently into the anus. Only one phalanx should be inserted initially to give the anus time to relax and to easily accommodate the finger. Estimation of anal sphincter tone is of great importance; a flaccid or spastic anal sphincter suggests similar changes in the urinary sphincter and may be a clue to the diagnosis of neurogenic disease. If the physician waits only a few seconds, the anal sphincter will normally relax to the degree that the finger can be advanced to the knuckle without causing pain. The index finger then sweeps over the prostate; the entire posterior surface of the gland can usually be examined if the patient is in the proper position. Normally, the prostate is about the size of a chestnut and has a consistency similar to that of the contracted thenar eminence of the thumb (with the thumb opposed to the little finger).

The index finger is extended as far as possible into the rectum, and the entire circumference is examined to detect an early rectal carcinoma. The index finger is then withdrawn gently, and the stool on the glove is transferred to a guaiac-impregnated (Hemoccult) card for determination of occult blood. Although there may be a significant incidence of false-positive and false-negative results associated with fecal occult blood testing, particularly without dietary and drug restrictions, the guaiac test is simple and inexpensive and may lead to the detection of significant gastrointestinal abnormalities ( Bond, 1999 ). Adequate tissues, soap, and towels should be available for the patient to cleanse himself after the examination. The physician should then leave the room and allow the patient adequate time to wash and dress before concluding the consultation.

Abnormal Findings Acute Prostatitis.

Acute prostatitis most commonly occurs in sexually active men between the ages of 20 and 40 years. Symptoms include fever, malaise, perineal and rectal discomfort, urinary frequency, urgency, dysuria, and sometimes urinary retention. When acute prostatitis is suspected, rectal examination should be performed carefully. Examination reveals the prostate to be warm, tender, and sometimes fluctuant or boggy in consistency. A localized fluctuant, tender region within the prostate may indicate a prostatic abscess for which surgical drainage is required. The prostate should never be massaged for secretions in men with acute prostatitis. Massage of the acutely infected prostate is not only unnecessary but also extremely uncomfortable for the patient. In addition, massage may disseminate bacteria through the vas deferens, causing secondary epididymitis or, more significantly, may disseminate bacteria into the bloodstream, producing gram-negative septicemia.

Benign Prostatic Hyperplasia.

The physical findings in BPH are usually limited to the prostate. In BPH, the prostate remains rubbery in consistency, but may be variably enlarged from normal chestnut size to the size of a lemon, or, occasionally, even as large as an orange. There is only a general correlation between prostatic size and degree of symptoms.

Because BPH affects almost all men older than age 50 years, the finding of an enlarged prostate on physical examination is not a reason per se to initiate further urologic evaluation. The severity of the disease and the need for treatment are best determined by the patient's symptoms as well as the results of further urologic testing, such as measurement of a urinary flow rate and postvoid residual urine.

Carcinoma of the Prostate.

Prostate cancer usually arises in the posterior peripheral region of the prostate and, therefore, is frequently palpable in its early stages on rectal examination. On physical examination, prostatic carcinomas are palpable as firm, indurated nodules or regions within the prostate. These areas of induration are characterized by having a woodlike consistency. As prostatic carcinomas progress, the entire gland becomes firmer than usual. Eventually, these tumors may progress beyond the capsule of the prostate, extending cephalad into the seminal vesicles and laterally toward the pelvic side wall.

It should be emphasized that men with early, localized carcinoma of the prostate are almost always asymptomatic. Therefore, a patient should never be allowed to dissuade the urologist from performing a rectal examination simply because he is asymptomatic. Urinary obstructive symptoms and skeletal pain are symptoms of advanced, incurable disease.

Detection of early prostatic carcinoma on rectal examination takes practice and has been greatly facilitated by the discovery of PSA. An elevated PSA value should raise the suspicion of prostatic carcinoma, regardless of the findings on rectal examination. Conversely, a normal PSA test does not exclude the possibility of early prostate cancer, and, in fact, 30% of men with early prostate cancer will have a normal serum PSA test ( Partin et al, 1993 ).

A prostatic biopsy should be performed for any palpable lesion within the prostate. In one study, the detection rate of prostate cancer was 18% among men with an abnormal DRE and a PSA less than 4.0 ng/mL ( Crawford et al, 1999 ). In contrast, 56% of men with palpable abnormalities and a PSA greater than 4.0 ng/mL were found to have malignancy. Other causes of prostatic induration besides cancer include calculi (which are typically harder than tumors), inflammation, fibrous BPH, and infarction. Biopsies are now done easily using topical anesthesia under transrectal ultrasound guidance. There is no excuse for delaying a prostatic biopsy in an otherwise healthy younger man with either an abnormal DRE or an elevated PSA level. It serves no purpose to have the patient return in 6 months for a repeat examination to see whether the nodule has changed, because prostate cancers usually grow very slowly; the fact that a nodule does not change appreciably with time is of no clinical significance.

Pelvic Examination in the Female

Male urologists should always perform the female pelvic examination with a female nurse or other health care professional present. The patient should be allowed to undress in privacy and be fully draped for the procedure before the physician enters the room. The examination itself should be performed in standard lithotomy position with the patient's legs abducted. Initially, the external genitalia and introitus should be examined, with particular attention paid to atrophic changes, erosions, ulcers, discharge, or warts, all of which may cause dysuria and pelvic discomfort. The urethral meatus should be inspected for caruncles, mucosal hyperplasia, cysts, and mucosal prolapse. The patient is then asked to perform a Valsalva maneuver and is carefully examined for a cystocele (prolapse of the bladder) or rectocele (prolapse of the rectum). The patient is then asked to cough, which may precipitate stress urinary incontinence. Palpation of the urethra is done to detect induration, which may be a sign of chronic inflammation or malignancy. Palpation may also disclose a urethral diverticulum, and palpation of a diverticulum may cause a purulent discharge from the urethra. Bimanual examination of the bladder, uterus, and adnexa should then be performed with two fingers in the vagina and the other hand on the lower abdomen (see Fig. 3-3 ). Any abnormality of the pelvic organs should be evaluated further with a pelvic ultrasound or CT scan.

Abnormal Findings.

A careful bimanual examination of the female pelvis may reveal a variety of abnormalities of the uterus, ovaries, and cervix, including benign and malignant masses and inflammatory lesions. Various forms of pelvic prolapse, such as cystocele, rectocele, and enterocele, may also be detected. Inspection of the urethral meatus and vaginal introitus may also be helpful in identifying condylomata, urethral lesions, and other abnormalities.

Neurologic Examination

There are a variety of clinical situations in which the neurologic examination may be helpful in evaluating urologic patients. In some cases, the level of neurologic abnormalities can be localized by the pattern of sensory deficit noted during physical examination using a dermatome map ( Fig. 3-5 ). Sensory deficits in the penis, labia, scrotum, vagina, and perianal area generally indicate damage or injury to sacral roots or nerves. In addition to sensory examination, testing of reflexes in the genital area may also be performed. The most important of these is the bulbocavernosus reflex (BCR), which is a reflex contraction of the striated muscle of the pelvic floor that occurs in response to a variety of stimuli in the perineum or genitalia. This reflex is most commonly tested by placing a finger in the rectum and then squeezing the glans penis or clitoris. If a Foley catheter is in place, the BCR can also be elicited by gently pulling on the catheter. If the BCR is intact, tightening of the anal sphincter should be felt and/or observed. The BCR tests the integrity of the spinal cord mediated reflex arc involving S2-S4 and may be absent in the presence of sacral cord or peripheral nerve abnormalities.

Figure 3-5 Sensory dermatome maps used to help localize the level of neurologic deficit.

The cremasteric reflex can be elicited by lightly stroking the superior and medial thigh in a downward direction. The normal response in males is contraction of the cremasteric muscle that results in immediate elevation of the ipsilateral scrotum and testis. There is limited clinical utility for testing superficial reflexes such as the cremasteric when investigating neurologic dysfunction. However, there may be a role for testing this reflex when assessing patients with suspected testicular torsion or epididymitis. Finally, an overly active cremasteric reflex in children can lead to the mistaken diagnosis of an undescended testis in some cases.