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Physical Examination of the Urinary System
Physical Examination of the Urinary System
Kenneth C. Bovee, D.V.M.*
HISTORY Examination of the urinary system includes a thorough history and general physical examination. The history should include the present illness, chief complaint, general health, previous illness, appetite, weight change, presence of vomiting, and character of urination. It is essential to listen carefully to the entire history. I firmly believe in the old saying, "Listen to the owner; he is telling you the diagnosis." Many laboratory tests can be avoided and false starts prevented with an accurate history. During the general physical examination, certain physical findings that may suggest azotemia or uremia should be noted. These include wasting, dehydration, reddened mucous membrane, ulceration of mucous membranes or tongue, ammoniacal breath, hypothermia, bony changes (particularly of the mandible or maxilla), and ascites. It usually is helpful to leave the physical examination of the urinary system until last. After one has heard the entire story and completed the general physical examination, he may then focus on the urinary history. It often is helpful to ask the owner to repeat certain key information. In fact, the owner may change or clarify certain information after thinking it through a second time. At this point the clinician may gently interrogate the owner to bring forth new information and to clarify previous points. A logical system in interrogation would deal with the following, occurring either individually or in combination: a. changes in pattern of urination; b. changes in total urinary output; c. changes in drinking habits; *Assistant Professor and Head, Section of Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania. Veterinary Clinics of North America- Vol. 1, No. I (January, 1971).
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KENNETH C. BovEE
d. change in appearance and smell of the urine; e. difficulty and pain during micturition; f. frequency and nature of vomition; g. difficulty and nature of bowel movements; h. general symptoms due to abnormal urinary retention of water and electrolytes; i. general symptoms due to abnormal loss of water, electrolytes, and other solutes; j. exposure to potentially toxic agents; k. symptoms due to anemia of renal failure; I. symptoms, the result of trauma to the perirenal area, the kidney, or the urinary bladder; m. generalized and local symptoms, the result of previous treatment, drugs, diet, and surgery. Obviously, all the possible questions one might ask cannot be listed, and seldom would all these questions be asked of the same owner. However, I believe it might be worthwhile to make remarks concerning the questions most frequently emphasized. Nocturia, or urinary frequency at night, is a dramatic sign, since it produces an immediate cleanliness problem in the home. Owners usually can recall when this symptom first began; how often it occurred; and changes in the new pattern of urination and whether it was associated with other symptoms, such as thirst. It may indicate infection, chronic renal failure, hyperaldosteronism, and diabetes. Nocturia that is not due to urinary volume suggests trouble in the lower urinary tract rather than in the kidney. Conversely, nocturnal polyuria is an early and almost constant symptom of chronic renal failure. It is of critical importance to separate simple nocturia from nocturnal polyuria. In polyuria the volume of urine produced in 24 hours may be two to ten times the normal volume. We are not concerned with the transitory polyuria such as occurs after a large fluid intake, during the crisis of many infectious diseases or during the convalescence stage of certain forms of acute nephritis, or that produced by diuretics or corticosteroids. Many animals suffering from polyuria too often are labeled as having chronic renal failure, placed on therapeutic regimens including arbitrary diet, without laboratory evidence to support the diagnosis. Animals with permanent polyuria may be divided into two groupsthose with renal failure and those without. Polyuria is nearly always present in chronic renal failure, except terminally, and accompanied by nocturia and polydipsia. True anuria indicates complete cessation of urine production, which occurs in acute renal failure, but the term more broadly suggests obstruction of urine flow below the kidneys. We propose to define anuria as a reduction of urinary volume less than 3 ml. per pound body weight per 24 hours. True anuria, of course, must be distinguished from re-
PHYSICAL EXAMINATION OF THE URINARY SYSTEM
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tention of urine in the bladder, which is of totally different significance. If there is doubt, a catheter must be passed to make certain the bladder is empty and the urethra patent. Anuria and complete urinary tract obstruction are always medical emergencies, and inevitably lead to acute uremia within a few days. Hematuria most commonly is associated with bacterial cystitis. Learning whether the hematuria is partial (initial, terminal) or total (throughout urination) often helps in determining the site of hemorrhage. Initial hematuria suggests a distal urethral lesion. Terminal hematuria usually arises from the proximal urethra or bladder. Cystic calculi often cause hematuria throughout urination, although frank blood is more commonly seen during terminal dysuria. Silent hematuria must be regarded as a symptom of neoplasm of the bladder, prostate, or kidney until proved otherwise. When a bladder tumor ulcerates, it often is complicated by infection and profuse bleeding. Hematuria may be intermittent, and it may be temporarily controlled with antibiotics which suppress the infectious component. Complacency because the bleeding stops temporarily must be condemned. Dysuria may occur in the presence of an empty, full, or distended bladder. It is mentioned because it is commonly confused with difficulty in defecation. The inexperienced clinician should always investigate patency of the colon and urethra when a history suggesting dysuria is given. A complet~ nephrologic and urologic examination should include: 1. Palpation of the .kidney and abdomen; 2. Palpation of the rectum, prostate, bladder, and pelvis; 3. Examination of the external genitalia; 4. Visual examination of the vagina; 5. Complete urinalysis; 6. Radiographic examination; 7. Clinical laboratory examination; 8. Renal function tests. The scope of this discussion will be limited to the first four areas listed above.
TECHNIQUE OF EXAMINATION AND NORMAL FINDINGS Kidney and Ureters
A careful, meticulous examination is necessary because diseases of the kidney are notoriously silent, and a cursory palpation of organs is seldom helpful. The kidney is considered the upper urinary tract and as such is included in the abdominal examination. When viewing
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KENNETH
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BovEE
the animal the examiner should note asymmetry or bulging of flanks, and carriage of the abdomen. The examination usually is performed with the animal standing. During palpation, the examiner must keep in mind the normal location of the kidneys. The right kidney lies rather high and deep under the posterior ribs. The left kidney is more posterior than the right; it may lie slightly behind the ribs, and is more accessible to palpation. The left kidney usually can be palpated, but it is unusual to feel the right unless it is displaced or grossly enlarged. The examiner should not be disappointed if the kidneys are not clearly discernible; normal kidneys seldom are more than barely palpable except in unusually thin dogs. In palpation of the renal areas, place one hand ventrally beneath the costal margin and press directly upward and anteriorly. Each kidney is palpated individually from its respective side. The technique is similar to that used for palpation of the liver and spleen, except that the hand is gradually passed more deeply into the abdomen. In small dogs the ventral body wall can be gently pressed dorsally to palpate the kidney. In larger breeds with heavy abdominal musculature this is not possible, and digital pressure must begin higher on the abdominal wall near the costal margin. The examination is always more successful if the animal is sedated or under anesthesia. Percussion is not used routinely, but it may be valuable in generally outlining masses in the renal area which are unusually large. Auscultation of possible bruits arising from abnormal vasculature is rarely helpful. The ureters, of course, are routinely inaccessible to physical examination.
Urinary Bladder The urinary bladder is inspected as part of the pelvic examination. It is examined by percussion and palpation (Fig. 1). The region just anterior to the symphysis pubis should be palpated carefully through the ventral abdominal wall. The empty bladder may not be accessible to physical examination, but when distended with urine it may be mistaken for a large abdominal tumor unless the possibility is kept in mind. The empty bladder feels much like a thin-walled, collapsed balloon. It is not tender and freely movable, with no lateral extensions, firmness, or palpable discrete masses. Some discomfort usually is elicited by direct palpation into the suprapubic area. When distended the bladder may produce a bulging mass in the ventral abdomen over which dullness may be elicited by percussion. At times this mass may extend anteriorly as far as the umbilicus. A bimanual examination may be performed at the time of rectal examination. The examiner places one finger in the rectum, pressing forward and ventrally; the opposite hand is placed on the lower abdominal wall. The bladder is easily localized and palpated through the
123
PHYSiCAL ExAMINATION OF THE URINARY SYSTEM
.............
Figure l.
-c ...... _
Bi-manual examinatio n of the urinary bladder and prostate.
abdominal wall. This examination is equally successful in both sexes. In the male it offers the advantage of palpating the urethra, prostate, and bladder neck area, in that order. In males with prostatic enlargement or tumor, the prostate falls anteriorly over the brim of the symphysis and cannot be palpated through the rectum until the bladder is pushed back into the pelvis with the opposite hand. This examination is most easily performed under anesthesia, but an anesthetic is not necessary. Before the rectal examination is made, a specimen of urine for routine analysis should be collected. This is of utmost importance, since prostatic massage or palpation will force prostatic secretion into the urethra. If this secretion contains pus, a specimen of urine voided after the rectal examination will be contaminated. Penis and Urethra
In a normal dog the prepuce should be easily retractable. The penis is examined by gently pressing the bulbus glandis forward while the prepuce is retracted backward. The glans penis is then carefully examined and palpated, searching for areas of tenderness, firmness, or induration; and the urethra is milked forward to express any secretions present. The os penis, ventral groove of the os, and the urethra anterior
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KENNETH
C.
BOVEE
to the testes likewise should be palpated. The examiner should be aware of the normal bulbocavernosus reflex when palpating the penis. This reflex should not be confused with the presence of tenderness or pain. In cases of lower urinary tract obstruction or dysuria it is often helpful to observe the stream of urine being passed. Urethral catheterization usually is desirable at some time during the physical examination. In addition to the collection of sterile urine, catheterization helps determine strictures of the urethra, presence of urethral calculi, urinary residuum, and bladder capacity. In the male a human urethral catheter (No. 4-8 French) should pass easily, depending on the size of the animal. Prostate Gland As explained previously, the prostate is palpated during rectal examination. Ample lubrication of the gloved hand facilitates this procedure. The index finger is introduced, pointed toward the umbilicus. The tone of the anal sphincter and the bulbocavernosus reflex is tested by compressing the glans penis with the opposite hand. Normally this produces involuntary contraction of the anal sphincter. The prostate is examined by gentle palpation of the ventral floor of the rectum. The anterior limits, lateral margin, and medial sulcus of the gland are appreciated. Careful palpation should outline each lobe while searching for areas of irregularity, enlargement or pain. The prostate varies greatly in size, and usually increases with age. It is normally smooth, rubbery, nontender, and slightly movable, and the lateral borders are well defined. If a prostatic problem is suspected, the gland should be massaged and its secretions examined microscopically. The basic massage maneuver is to press the gland substance firmly with the pad of the index finger to express secretions into the urethra. Start laterally and massage toward the midline. A rolling of the finger is less traumatic to the rectal mucosa and prostate gland. Copious amounts of secretion may be obtained from some glands and little or none from others. The secretion is collected by placing a catheter in the prostatic region of the urethra and applying gentle suction with a syringe. If no secretion is obtained, a voided urine sample may contain adequate secretions for examination. Very conservative massage approach should be used for animals suspected of having acute prostatitis, prostatic abscess, urinary retention, or prostatic neoplasm. Vaginal Examination Diseases of the female genital tract may secondarily involve the urinary organs, making a thorough gynecologic examination necessary. Renal failure is commonly associated with pyometra, urethrocystitis is secondary to vaginitis, and urethral obstruction is caused by vaginal neoplasms. The vaginal examination is best performed with the aid of
PHYSICAL EXAMINATION OF THE URINARY SYSTEM
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a speculum and powerful headlamp. Unless adequate light is introduced into the vagina, the urethral orifice cannot be visualized. The urethral orifice and surrounding vaginal mucosa normally appear smooth, pink, and glistening. The urethral orifice may be palpated with a well lubricated index finger in larger bitches. A complete examination of the urethra includes passing a flexible or metal catheter into the bladder. The headlamp is extremely useful and avoids unnecessary trauma in this procedure.
ABNORMAL FINDINGS Kidney and Ureters It is true that occasionally one feels a big or shrunken kidney, cyst, or tumor. In general, even after carefully palpating the organ, one has learned very little, and must wait for radiographs or other laboratory examination results to clarify the diagnosis. An enlarged renal mass suggests hydronephrosis, cyst, or a tumor. However, a mass in the perirenal region may be confused with a lesion of the bowel, pancreatic tumor, hepatic mass, or hepatic cyst. Renal agenesis and hypoplasia occasionally can be determined by palpation. The examiner should be aware of possible tenderness in and around the kidney. Acute tubular necrosis, when the kidneys are enlarged, may at times produce severe pain in the lumbar region. Such pain is usually ascribed to tension on the kidney capsule by the swollen organ. Renal calculi, which are relatively silent in the dog, may cause tenderness and pain in the periren~l region. The presence of pyelonephritis cannot be determined by palpation unless the organ is tender due to renal calculi. Chronic renal failure most commonly runs a painless and silent course. Obstructive uropathy, regardless of its location, produces an increase in hydrostatic pressure within the renal collecting system. In general, the higher in the urinary tract the lesion is located, the greater the effect on the kidneys. Abdominal guarding with renal pain is more noticeable in the early severe stages of obstruction. Pain may not be present in chronic hydroureter and hydronephrosis. It is possible to palpate a markedly enlarged ureter in the abdomen of a small thin dog. Also, a dilated ureter or tumor mass in the distal ureter may be palpated through the rectum in the bladder neck area. Ectopic ureter in the male usually opens within the proximal urethra and produces no characteristic physical findings. In the female, the ectopic ureter may empty into the uterus, cervix, vagina, or vestibule, and dribbling incontinence may result. Visual inspection of the vagina or vestibule may disclose the ectopic ureteral orifice.
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C.
BovEE
Urinary Bladder Bacterial cystitis is the most common disorder of the bladder. Tenderness may be elicited by palpation into the suprapubic area, but uncomplicated cystitis usually produces no physical findings. Chronic cystitis may produce a nontender, thickened bladder wall. Calculi in the bladder are very common and are readily palpable. These may occur as a solitary mass or, more commonly, as multiple small gritty particles on palpation. Such bladders are remarkably nontender, although the animal shows signs of dysuria. The majority of tumors of the bladder usually can be palpated as thickened bladder walls or as discrete, firm, tender nodular masses. Chronic partial obstruction of the urethra, due to any cause, may produce a large distended bladder containing l or 2 liters of urine. The bladder may then be palpated in the midabdomen as a large midline mass. As residual urine increases, bladder capacity increases, producing a decompensated or atonic bladder. The animal commonly has dysuria and paradoxic incontinence. This condition must be differentiated from the neurogenic bladder on the basis of other signs and a neurologic examination. The acutely ruptured bladder, as a result of trauma, usually cannot be detected by palpation. A catheter must be passed to determine the integrity of the bladder wall.
Penis and Urethra The most common disorder of the male urethra is obstruction due to calculi. Such calculi usually can be palpated as dense, round masses in the urethra just behind the os penis. Calculi also may lodge higher in the urethra near the iscliial arch. To confirm their presence and determine the patency of the urethra, a catheter is commonly passed. A bloody urethral discharge suggests urethral calculi, neoplasm, infection, or a foreign body. Urethritis produces few abnormal physical signs. Balanoposthitis is rarely seen. There may be erythema, tenderness, and a profuse purulent discharge.
Prostate Gland Acute prostatitis produces an exceedingly tender, warm, and enlarged gland on rectal examination. A urethral discharge and hematuria may be seen intermittently. Abscess formation may occur and can be demonstrated as a fluctuant mass in the prostate gland. Chronic prostatitis is present in almost every prostate gland, and usually is asymptomatic. At times, rectal examination shows the prostate to be boggy or irregular. Areas of fibrous tissue may be palpated, thus simulating neoplasm. Prostatic calculi seldom are of clinical importance. Benign prostatic hypertrophy is exceedingly common in older dogs. The prostate is firm and of variable size. The gland is nontender, sym-
PHYSICAL EXAMINATION OF THE URINARY SYSTEM
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metrical, and has a smooth, rubbery consistency. The median sulcus may be obliterated, but the lateral borders are well defined. A neoplasm of the prostate is readily palpable at rectal examination. An early lesion usually feels firm, irregular, enlarged, and fixed in position. More advanced lesions usually are stony hard, irregular, and painless on palpation. In addition to the digital prostatic examination, the examiner should palpate the lower rectum and rule out rectal stenosis, neoplasm, and perineal hernia. The retroflexed bladder usually is associated with a chronic perineal hernia. The examiner commonly finds the bladder and the prostate pressed adjacent to or into the hernial sac.
VAGINAL EXAMINATION The female urethra is a less frequent site of disease than the male. The female urethra seldom becomes obstructed by calculi, owing to its larger diameter. Urethral obstruction may occur when a neoplasm arises in the vagina or pelvic canal. Catheterization and palpation may reveal the mass; however, radiographic studies usually are necessary to confirm the diagnosis. Chronic urethritis and vaginitis usually produce a reddened, tender, ulcerated urethral orifice seen at vaginal examination. A catheter should be passed to. determine whether urethral stricture or fistula is present
GLOSSARY Anuria-complete cessation or suppression of urine output. Azotemia- plasma elevation of nitrogenous waste products. Balanoposthitis- inflammation of the glans penis and prepuce. Bulbocavernosus reflex- reflex elicited by squeezing the glans penis which results in constriction of the bulbocavernosus muscle and the anal sphincter. Cystitis- inflammation of the urinary bladder. Dysuria- painful, difficult micturition. Enuresis- involuntary voiding during sleep. French (Fr.)-unit of measurement of a tube, l mm. in circumference. Hematuria- blood in the urine; when blood is detected visually it is called gross hematuria; when only microscopically, microscopic hematuria. Hesitance- difficulty in initiating micturition. Hydronephrosis-abnormal enlargement of the renal pelvis and calyces. Micturition- voiding, urination. Nephrocalcinosi1-ca!cification of the parenchyma of the kidney. Neurogenic bladder- dysfunction of bladder secondary to abnormality of its innervation.
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Nocturia-urination during the sleeping hours. Oliguria- reduced urine output. Paradoxic incontinence-involuntary dribbling of urine secondary to chronic urinary retention. Phimosis-tightness of the prepuce so that it cannot be retracted from the glans penis. Residual urine-(residuum) urine that remains in the bladder after micturition. Uremia- moderate to severe renal failure associated with retention of nitrogenous waste products, electrolyte disturbances, and multiple metabolic defects. University of Pennsylvania School of Veterinary Medicine Philadelphia, Pa. 19104
Kenneth C. Bovee, D.V.M.*
HISTORY Examination of the urinary system includes a thorough history and general physical examination. The history should include the present illness, chief complaint, general health, previous illness, appetite, weight change, presence of vomiting, and character of urination. It is essential to listen carefully to the entire history. I firmly believe in the old saying, "Listen to the owner; he is telling you the diagnosis." Many laboratory tests can be avoided and false starts prevented with an accurate history. During the general physical examination, certain physical findings that may suggest azotemia or uremia should be noted. These include wasting, dehydration, reddened mucous membrane, ulceration of mucous membranes or tongue, ammoniacal breath, hypothermia, bony changes (particularly of the mandible or maxilla), and ascites. It usually is helpful to leave the physical examination of the urinary system until last. After one has heard the entire story and completed the general physical examination, he may then focus on the urinary history. It often is helpful to ask the owner to repeat certain key information. In fact, the owner may change or clarify certain information after thinking it through a second time. At this point the clinician may gently interrogate the owner to bring forth new information and to clarify previous points. A logical system in interrogation would deal with the following, occurring either individually or in combination: a. changes in pattern of urination; b. changes in total urinary output; c. changes in drinking habits; *Assistant Professor and Head, Section of Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania. Veterinary Clinics of North America- Vol. 1, No. I (January, 1971).
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KENNETH C. BovEE
d. change in appearance and smell of the urine; e. difficulty and pain during micturition; f. frequency and nature of vomition; g. difficulty and nature of bowel movements; h. general symptoms due to abnormal urinary retention of water and electrolytes; i. general symptoms due to abnormal loss of water, electrolytes, and other solutes; j. exposure to potentially toxic agents; k. symptoms due to anemia of renal failure; I. symptoms, the result of trauma to the perirenal area, the kidney, or the urinary bladder; m. generalized and local symptoms, the result of previous treatment, drugs, diet, and surgery. Obviously, all the possible questions one might ask cannot be listed, and seldom would all these questions be asked of the same owner. However, I believe it might be worthwhile to make remarks concerning the questions most frequently emphasized. Nocturia, or urinary frequency at night, is a dramatic sign, since it produces an immediate cleanliness problem in the home. Owners usually can recall when this symptom first began; how often it occurred; and changes in the new pattern of urination and whether it was associated with other symptoms, such as thirst. It may indicate infection, chronic renal failure, hyperaldosteronism, and diabetes. Nocturia that is not due to urinary volume suggests trouble in the lower urinary tract rather than in the kidney. Conversely, nocturnal polyuria is an early and almost constant symptom of chronic renal failure. It is of critical importance to separate simple nocturia from nocturnal polyuria. In polyuria the volume of urine produced in 24 hours may be two to ten times the normal volume. We are not concerned with the transitory polyuria such as occurs after a large fluid intake, during the crisis of many infectious diseases or during the convalescence stage of certain forms of acute nephritis, or that produced by diuretics or corticosteroids. Many animals suffering from polyuria too often are labeled as having chronic renal failure, placed on therapeutic regimens including arbitrary diet, without laboratory evidence to support the diagnosis. Animals with permanent polyuria may be divided into two groupsthose with renal failure and those without. Polyuria is nearly always present in chronic renal failure, except terminally, and accompanied by nocturia and polydipsia. True anuria indicates complete cessation of urine production, which occurs in acute renal failure, but the term more broadly suggests obstruction of urine flow below the kidneys. We propose to define anuria as a reduction of urinary volume less than 3 ml. per pound body weight per 24 hours. True anuria, of course, must be distinguished from re-
PHYSICAL EXAMINATION OF THE URINARY SYSTEM
121
tention of urine in the bladder, which is of totally different significance. If there is doubt, a catheter must be passed to make certain the bladder is empty and the urethra patent. Anuria and complete urinary tract obstruction are always medical emergencies, and inevitably lead to acute uremia within a few days. Hematuria most commonly is associated with bacterial cystitis. Learning whether the hematuria is partial (initial, terminal) or total (throughout urination) often helps in determining the site of hemorrhage. Initial hematuria suggests a distal urethral lesion. Terminal hematuria usually arises from the proximal urethra or bladder. Cystic calculi often cause hematuria throughout urination, although frank blood is more commonly seen during terminal dysuria. Silent hematuria must be regarded as a symptom of neoplasm of the bladder, prostate, or kidney until proved otherwise. When a bladder tumor ulcerates, it often is complicated by infection and profuse bleeding. Hematuria may be intermittent, and it may be temporarily controlled with antibiotics which suppress the infectious component. Complacency because the bleeding stops temporarily must be condemned. Dysuria may occur in the presence of an empty, full, or distended bladder. It is mentioned because it is commonly confused with difficulty in defecation. The inexperienced clinician should always investigate patency of the colon and urethra when a history suggesting dysuria is given. A complet~ nephrologic and urologic examination should include: 1. Palpation of the .kidney and abdomen; 2. Palpation of the rectum, prostate, bladder, and pelvis; 3. Examination of the external genitalia; 4. Visual examination of the vagina; 5. Complete urinalysis; 6. Radiographic examination; 7. Clinical laboratory examination; 8. Renal function tests. The scope of this discussion will be limited to the first four areas listed above.
TECHNIQUE OF EXAMINATION AND NORMAL FINDINGS Kidney and Ureters
A careful, meticulous examination is necessary because diseases of the kidney are notoriously silent, and a cursory palpation of organs is seldom helpful. The kidney is considered the upper urinary tract and as such is included in the abdominal examination. When viewing
122
KENNETH
C.
BovEE
the animal the examiner should note asymmetry or bulging of flanks, and carriage of the abdomen. The examination usually is performed with the animal standing. During palpation, the examiner must keep in mind the normal location of the kidneys. The right kidney lies rather high and deep under the posterior ribs. The left kidney is more posterior than the right; it may lie slightly behind the ribs, and is more accessible to palpation. The left kidney usually can be palpated, but it is unusual to feel the right unless it is displaced or grossly enlarged. The examiner should not be disappointed if the kidneys are not clearly discernible; normal kidneys seldom are more than barely palpable except in unusually thin dogs. In palpation of the renal areas, place one hand ventrally beneath the costal margin and press directly upward and anteriorly. Each kidney is palpated individually from its respective side. The technique is similar to that used for palpation of the liver and spleen, except that the hand is gradually passed more deeply into the abdomen. In small dogs the ventral body wall can be gently pressed dorsally to palpate the kidney. In larger breeds with heavy abdominal musculature this is not possible, and digital pressure must begin higher on the abdominal wall near the costal margin. The examination is always more successful if the animal is sedated or under anesthesia. Percussion is not used routinely, but it may be valuable in generally outlining masses in the renal area which are unusually large. Auscultation of possible bruits arising from abnormal vasculature is rarely helpful. The ureters, of course, are routinely inaccessible to physical examination.
Urinary Bladder The urinary bladder is inspected as part of the pelvic examination. It is examined by percussion and palpation (Fig. 1). The region just anterior to the symphysis pubis should be palpated carefully through the ventral abdominal wall. The empty bladder may not be accessible to physical examination, but when distended with urine it may be mistaken for a large abdominal tumor unless the possibility is kept in mind. The empty bladder feels much like a thin-walled, collapsed balloon. It is not tender and freely movable, with no lateral extensions, firmness, or palpable discrete masses. Some discomfort usually is elicited by direct palpation into the suprapubic area. When distended the bladder may produce a bulging mass in the ventral abdomen over which dullness may be elicited by percussion. At times this mass may extend anteriorly as far as the umbilicus. A bimanual examination may be performed at the time of rectal examination. The examiner places one finger in the rectum, pressing forward and ventrally; the opposite hand is placed on the lower abdominal wall. The bladder is easily localized and palpated through the
123
PHYSiCAL ExAMINATION OF THE URINARY SYSTEM
.............
Figure l.
-c ...... _
Bi-manual examinatio n of the urinary bladder and prostate.
abdominal wall. This examination is equally successful in both sexes. In the male it offers the advantage of palpating the urethra, prostate, and bladder neck area, in that order. In males with prostatic enlargement or tumor, the prostate falls anteriorly over the brim of the symphysis and cannot be palpated through the rectum until the bladder is pushed back into the pelvis with the opposite hand. This examination is most easily performed under anesthesia, but an anesthetic is not necessary. Before the rectal examination is made, a specimen of urine for routine analysis should be collected. This is of utmost importance, since prostatic massage or palpation will force prostatic secretion into the urethra. If this secretion contains pus, a specimen of urine voided after the rectal examination will be contaminated. Penis and Urethra
In a normal dog the prepuce should be easily retractable. The penis is examined by gently pressing the bulbus glandis forward while the prepuce is retracted backward. The glans penis is then carefully examined and palpated, searching for areas of tenderness, firmness, or induration; and the urethra is milked forward to express any secretions present. The os penis, ventral groove of the os, and the urethra anterior
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KENNETH
C.
BOVEE
to the testes likewise should be palpated. The examiner should be aware of the normal bulbocavernosus reflex when palpating the penis. This reflex should not be confused with the presence of tenderness or pain. In cases of lower urinary tract obstruction or dysuria it is often helpful to observe the stream of urine being passed. Urethral catheterization usually is desirable at some time during the physical examination. In addition to the collection of sterile urine, catheterization helps determine strictures of the urethra, presence of urethral calculi, urinary residuum, and bladder capacity. In the male a human urethral catheter (No. 4-8 French) should pass easily, depending on the size of the animal. Prostate Gland As explained previously, the prostate is palpated during rectal examination. Ample lubrication of the gloved hand facilitates this procedure. The index finger is introduced, pointed toward the umbilicus. The tone of the anal sphincter and the bulbocavernosus reflex is tested by compressing the glans penis with the opposite hand. Normally this produces involuntary contraction of the anal sphincter. The prostate is examined by gentle palpation of the ventral floor of the rectum. The anterior limits, lateral margin, and medial sulcus of the gland are appreciated. Careful palpation should outline each lobe while searching for areas of irregularity, enlargement or pain. The prostate varies greatly in size, and usually increases with age. It is normally smooth, rubbery, nontender, and slightly movable, and the lateral borders are well defined. If a prostatic problem is suspected, the gland should be massaged and its secretions examined microscopically. The basic massage maneuver is to press the gland substance firmly with the pad of the index finger to express secretions into the urethra. Start laterally and massage toward the midline. A rolling of the finger is less traumatic to the rectal mucosa and prostate gland. Copious amounts of secretion may be obtained from some glands and little or none from others. The secretion is collected by placing a catheter in the prostatic region of the urethra and applying gentle suction with a syringe. If no secretion is obtained, a voided urine sample may contain adequate secretions for examination. Very conservative massage approach should be used for animals suspected of having acute prostatitis, prostatic abscess, urinary retention, or prostatic neoplasm. Vaginal Examination Diseases of the female genital tract may secondarily involve the urinary organs, making a thorough gynecologic examination necessary. Renal failure is commonly associated with pyometra, urethrocystitis is secondary to vaginitis, and urethral obstruction is caused by vaginal neoplasms. The vaginal examination is best performed with the aid of
PHYSICAL EXAMINATION OF THE URINARY SYSTEM
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a speculum and powerful headlamp. Unless adequate light is introduced into the vagina, the urethral orifice cannot be visualized. The urethral orifice and surrounding vaginal mucosa normally appear smooth, pink, and glistening. The urethral orifice may be palpated with a well lubricated index finger in larger bitches. A complete examination of the urethra includes passing a flexible or metal catheter into the bladder. The headlamp is extremely useful and avoids unnecessary trauma in this procedure.
ABNORMAL FINDINGS Kidney and Ureters It is true that occasionally one feels a big or shrunken kidney, cyst, or tumor. In general, even after carefully palpating the organ, one has learned very little, and must wait for radiographs or other laboratory examination results to clarify the diagnosis. An enlarged renal mass suggests hydronephrosis, cyst, or a tumor. However, a mass in the perirenal region may be confused with a lesion of the bowel, pancreatic tumor, hepatic mass, or hepatic cyst. Renal agenesis and hypoplasia occasionally can be determined by palpation. The examiner should be aware of possible tenderness in and around the kidney. Acute tubular necrosis, when the kidneys are enlarged, may at times produce severe pain in the lumbar region. Such pain is usually ascribed to tension on the kidney capsule by the swollen organ. Renal calculi, which are relatively silent in the dog, may cause tenderness and pain in the periren~l region. The presence of pyelonephritis cannot be determined by palpation unless the organ is tender due to renal calculi. Chronic renal failure most commonly runs a painless and silent course. Obstructive uropathy, regardless of its location, produces an increase in hydrostatic pressure within the renal collecting system. In general, the higher in the urinary tract the lesion is located, the greater the effect on the kidneys. Abdominal guarding with renal pain is more noticeable in the early severe stages of obstruction. Pain may not be present in chronic hydroureter and hydronephrosis. It is possible to palpate a markedly enlarged ureter in the abdomen of a small thin dog. Also, a dilated ureter or tumor mass in the distal ureter may be palpated through the rectum in the bladder neck area. Ectopic ureter in the male usually opens within the proximal urethra and produces no characteristic physical findings. In the female, the ectopic ureter may empty into the uterus, cervix, vagina, or vestibule, and dribbling incontinence may result. Visual inspection of the vagina or vestibule may disclose the ectopic ureteral orifice.
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KENNETH
C.
BovEE
Urinary Bladder Bacterial cystitis is the most common disorder of the bladder. Tenderness may be elicited by palpation into the suprapubic area, but uncomplicated cystitis usually produces no physical findings. Chronic cystitis may produce a nontender, thickened bladder wall. Calculi in the bladder are very common and are readily palpable. These may occur as a solitary mass or, more commonly, as multiple small gritty particles on palpation. Such bladders are remarkably nontender, although the animal shows signs of dysuria. The majority of tumors of the bladder usually can be palpated as thickened bladder walls or as discrete, firm, tender nodular masses. Chronic partial obstruction of the urethra, due to any cause, may produce a large distended bladder containing l or 2 liters of urine. The bladder may then be palpated in the midabdomen as a large midline mass. As residual urine increases, bladder capacity increases, producing a decompensated or atonic bladder. The animal commonly has dysuria and paradoxic incontinence. This condition must be differentiated from the neurogenic bladder on the basis of other signs and a neurologic examination. The acutely ruptured bladder, as a result of trauma, usually cannot be detected by palpation. A catheter must be passed to determine the integrity of the bladder wall.
Penis and Urethra The most common disorder of the male urethra is obstruction due to calculi. Such calculi usually can be palpated as dense, round masses in the urethra just behind the os penis. Calculi also may lodge higher in the urethra near the iscliial arch. To confirm their presence and determine the patency of the urethra, a catheter is commonly passed. A bloody urethral discharge suggests urethral calculi, neoplasm, infection, or a foreign body. Urethritis produces few abnormal physical signs. Balanoposthitis is rarely seen. There may be erythema, tenderness, and a profuse purulent discharge.
Prostate Gland Acute prostatitis produces an exceedingly tender, warm, and enlarged gland on rectal examination. A urethral discharge and hematuria may be seen intermittently. Abscess formation may occur and can be demonstrated as a fluctuant mass in the prostate gland. Chronic prostatitis is present in almost every prostate gland, and usually is asymptomatic. At times, rectal examination shows the prostate to be boggy or irregular. Areas of fibrous tissue may be palpated, thus simulating neoplasm. Prostatic calculi seldom are of clinical importance. Benign prostatic hypertrophy is exceedingly common in older dogs. The prostate is firm and of variable size. The gland is nontender, sym-
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metrical, and has a smooth, rubbery consistency. The median sulcus may be obliterated, but the lateral borders are well defined. A neoplasm of the prostate is readily palpable at rectal examination. An early lesion usually feels firm, irregular, enlarged, and fixed in position. More advanced lesions usually are stony hard, irregular, and painless on palpation. In addition to the digital prostatic examination, the examiner should palpate the lower rectum and rule out rectal stenosis, neoplasm, and perineal hernia. The retroflexed bladder usually is associated with a chronic perineal hernia. The examiner commonly finds the bladder and the prostate pressed adjacent to or into the hernial sac.
VAGINAL EXAMINATION The female urethra is a less frequent site of disease than the male. The female urethra seldom becomes obstructed by calculi, owing to its larger diameter. Urethral obstruction may occur when a neoplasm arises in the vagina or pelvic canal. Catheterization and palpation may reveal the mass; however, radiographic studies usually are necessary to confirm the diagnosis. Chronic urethritis and vaginitis usually produce a reddened, tender, ulcerated urethral orifice seen at vaginal examination. A catheter should be passed to. determine whether urethral stricture or fistula is present
GLOSSARY Anuria-complete cessation or suppression of urine output. Azotemia- plasma elevation of nitrogenous waste products. Balanoposthitis- inflammation of the glans penis and prepuce. Bulbocavernosus reflex- reflex elicited by squeezing the glans penis which results in constriction of the bulbocavernosus muscle and the anal sphincter. Cystitis- inflammation of the urinary bladder. Dysuria- painful, difficult micturition. Enuresis- involuntary voiding during sleep. French (Fr.)-unit of measurement of a tube, l mm. in circumference. Hematuria- blood in the urine; when blood is detected visually it is called gross hematuria; when only microscopically, microscopic hematuria. Hesitance- difficulty in initiating micturition. Hydronephrosis-abnormal enlargement of the renal pelvis and calyces. Micturition- voiding, urination. Nephrocalcinosi1-ca!cification of the parenchyma of the kidney. Neurogenic bladder- dysfunction of bladder secondary to abnormality of its innervation.
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KENNETH
C.
BovEE
Nocturia-urination during the sleeping hours. Oliguria- reduced urine output. Paradoxic incontinence-involuntary dribbling of urine secondary to chronic urinary retention. Phimosis-tightness of the prepuce so that it cannot be retracted from the glans penis. Residual urine-(residuum) urine that remains in the bladder after micturition. Uremia- moderate to severe renal failure associated with retention of nitrogenous waste products, electrolyte disturbances, and multiple metabolic defects. University of Pennsylvania School of Veterinary Medicine Philadelphia, Pa. 19104