Hospital Corpsman Sickcall Screener's Handbook
BUMEDINST 6550:9A
Naval Hospital Great Lakes
1999
Genitourinary System
Anatomy
The urinary system consists of the kidneys, ureters, bladder, and urethra. The two kidneys are located on either side of the vertebral column just above the waistline. The kidneys filter out waste products along with excess fluid and electrolytes. Urine is formed within the nephron (each kidney has one million nephrons). Nephrons provide a cup shaped receptacle called the Bowman’s capsule in which a group of capillaries are inserted. This tuft of capillaries is called a glomerulus. As blood flows into the glomerular capillaries wastes, water, and electrolytes are filtered out of them and into the cup or Bowman’s capsule and into a collecting tubule where reabsorption of water and electrolytes occurs. Urine passes through the tubule to the pelvis of the kidney into the ureters and finally to the urinary bladder. The urine is stored in the bladder until urination occurs passing it out through the urethra.
The male genital system consists of the penis, testicles, epididymidis, scrotum, prostate gland, and the seminal vesicles. The penis is discussed in detail in the STD session. The scrotum contains the testicles, which produce sperm. A lower temperature is needed than the body can provide; therefore the testicles are suspended outside the body. The epididymis is a soft comma shaped structure located on the posterolateral aspect of each testicle, providing storage until the sperm enter the vasdeferens, the tube that carries the sperm to the seminal vesicles and to the urethra via the prostate gland. The prostate gland resembles a large chestnut and surrounds the urethra just under the bladder. It produces the majority of the ejaculatory fluid that carries the sperm.
Physical examination
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Kidney: Inspect the flank for bruising or swelling
Assess each kidney for tenderness. Have the patient sit, then place the palm of your hand over the costovertebral angle (CVA) and strike your hand with the ulnar surface of the fist of your other hand. Direct percussion with the fist over the CVA is also acceptable. The test should not cause any tenderness. If there is tenderness it can be indicated as CVAT (costo Vertebral Angle Tenderness).
Palpation: This is attempted by elevating the flank with one hand while palpating deeply with the other. Normally the kidneys are not palpable.
Bladder: Inspect the lower abdomen (suprapubic area). Look for enlargement or distention. Palpate for tenderness or rigidity.
Male Genitalia Examination
The Penis: Note if circumcised, if not is the foreskin easy to retract, check the external meatus of the urethra, note any discharge. Palpate the shaft for tenderness or lesions.
The Scrotum: The left testicle / scrotum usually hangs lower. Sebaceous cysts are a common lump found on the skin.
Check for hernia: With the patient standing inspect the area of the inguinal canal while he bears down or strains as if having a bowel movement. After inspecting, insert a finger into the lower scrotum. Ask patient to cough. If a hernia is present, you should feel intestine push against your finger.
The testes: Check by palpating using the thumb and first two fingers. They should feel smooth, rubbery, but free of nodules. Irregularities in texture or size may indicate cyst or tumor.
The epididymis: should be smooth, discrete, and non-tender.
History of the Genitourinary Patient
Five Major Symptoms:
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Urgency: a strong desire to urinate due to inflammation to the bladder, prostate, or urethra. May be caused by bacterial infection or chronic prostatitis.
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Frequency: shorter duration between urination, frequent repetitions, w/o increased fluid intake.
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Dysuria: Burning or pain with urination, difficulty voiding.
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Nocturia: Voiding at night, associated with anything that causes frequency.
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Hematuria: Blood in the urine is considered a serious sign.
Painless hematuria is a malignancy until proven otherwise. Seen with tumors, infections, trauma and TB.
Painful hematuria due to infection or stones.
Hematuria always needs investigation and follow-up by Urology.
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Related Symptoms:
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Enuresis: involuntary voiding during sleep.
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Incontinence: inability of the bladder to retain urine.
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Proteinuria: (albuminuria) is seen in all forms of renal disease.
Genitourinary Problems
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Cystitis: Inflammation of the bladder due to ascending urinary tract infection.
S: Frequency, burning, and urgency of urination. Occasionally hematuria and /or incontinence.
O: Suprapubic tenderness, no fever, CVA tenderness or discharge abdominal and genital exam.
U/A shows WBC’s, RBC’s and usually a positive nitrite. Always get a
urine culture.
A: Cystitis (UTI)
P: Refer to MO or PA
Antibiotics: Septra
DS, 1 po BID for 10 days, or
Amoxicillin 250 mg 1 po TID for 10 days.
Pain Medication:
Pyridium
(phenazopyridine HCL) 100-200 mg po TID. May color urine red or orange —inform patient
Note: Repeat urine in 10 days and again in 2-3 wks after tx. If a male patient is diagnosed with a UTI, a Urology Consult is mandatory! An STD must be ruled out prior to tx.
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Acute Pyelonephritis: An inflammation of the renal pelvis, tubules and intersitial tissue (pertaining to the tissue within an organ) of one or both kidneys. May be caused by bacteria (E. Coli. in 25% of cases). Other major causes include obstructions and reflux conditions, stones, congenital abnormalities, and diabetes.
S: Urgency, frequency, dysuria, fever, chills, severe flank pain, nausea, vomiting, hematuria, and headache.
O: CVA (flank) tenderness may be severe. Elevated temp (101-106 F). Normal abdominal exam.
U/A: WBC and RBC (TNTC) to numerous to count, casts, bacteria 4+.
CBC: WBC’s 15-30,000
A: Pyelonephritis.
P: Refer to MO or PA. Usually requires IV. Antibiotics and hospital admission.
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Kidney Stones (Renal Calculi or Urolithiasis): Formation of stones within the urinary tract as a result or a metabolic imbalance. Too much calcium, uric acid, or oxalate. (May be caused by high intake of tea, cocoa, spinach, beets, rhubarb, and nuts.)
S: Unable to find a comfortable position, severe (colicky) flank pain, groin or testicular pain, hematuria — microscopic or gross in nature, urgency, frequency and dysuria in the absence of infection.
O: CVA and flank tenderness, pain may radiate to groin hematuria on U/A, mild shock may be present. An IVP or
KUB (X-ray) may show the obstructing stone.
A: Renal Calculi (Kidney Stones)
P: Refer to MO or PA
Relieve pain with morphine or
Demerol.
Force fluids, strain urine for stone. May need hospital admission.
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Prostatitis: An acute or chronic inflammation of the prostate as a result of infection. May be accompanied by epididymidis, cystitis, or gonococcal infection.
S: Perineal pain (perineum refers to the area between the scrotum and anus), fever, dysuria, frequency, and urethral discharge.
O: Enlarged, tender, boggy prostate on rectal exam. May have tender epididymis and urethral discharge.
U/A shows elevated WBC’s
A: Prostatitis.
P: Refer to MO or PA. STD work up prior to treatment.
Antibiotic: Septra DS 1 po BID for 14 days
Rest; increase fluid intake, analgesics, and stool softeners are used in treatment.
Hospitalization and Urology Consultation may be required.
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Epididymitis: Inflammation of the epididymis as a result of trauma, infection or chemical irritation. May be complication of gonorrhea or prostatitis. Chemical irritation is due to reflux of urine when exercising or being sexually active with a full bladder. Secondary orchitis (inflammation of the testes) with a swollen, painful testicle may occur.
S: Scrotal pain, tenderness, and scrotal enlargement.
O: Tenderness and swelling of the epididymis and the spermatic cord may include the testes.
Associated with a fever and chills if the cause is bacterial.
A: Epididymitis.
P: Refer to MO or PA. Bed rest, elevation and support of the scrotum provide symptomatic relief.
Analgesic: Motrin 600 — 800 mg po TID with food
Antibiotics: For patients under 35 years of age-
Vibramycin 100 mg 1 po BID for 10 days or
Tetracycline 500 mg po QID for 10 days or
Erythromycin 500 mg po QID for 10 days.
If over 35: Septra DS 1 po BID for 10 days.
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Inguinal Hernia: A protrusion of the small bowel through the abdominal wall into the inguinal canal or scrotum.
S: Groin pain, swelling, may have the sensation of something tearing in the lower abdomen while lifting or doing heavy exercising. Swelling worsens with standing and reduces while lying down.
O: Palpable mass in the inguinal canal or scrotum, easier to feel when patient bears down or coughs. Tender with palpation. May or may not reduce with the patient in the supine position and while applying gentle pressure.
A: Inguinal Hernia
P: Refer to MO or PA
If non-reducible or extremely painful, refer to surgeon ASAP.
Otherwise, rest and routine referral to surgery are indicated.
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Hydrocele, Spermatocele, Varicocele: All three are disorders found in the scrotum. "Cele" is a suffix indicating a swelling or tumor.
Hydrocele: Common in newborn males. The accumulation of serous fluid from the abdomen in the testicular sac via a connection from the peritoneum to the scrotum. Usually not painful may need surgery to correct the problem.
Spermatocele: A cystic tumor of the epididymis containing spermatozoa. Non-tender, no treatment needed. Usually found on self-exam of the scrotum.
An enlargement of the veins of the spermatic cord known as the pampiniform plexus. Commonly occurs on the left side. Seldom requires treatment. The swelling feels like a bag of worms, and appears bluish through the skin of the scrotum. Due to the heat the veins deliver to scrotum, there may be a problem with the development of sperm and subsequently with fertility. Rarely a feeling of constant pulling or dragging with mild dull pain in the scrotum.
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Torsion of the Testicles: Normally the testicle is attached to the epididymis above and to the scrotal sac below limiting the movement of the testicle. With testicular torsion the testicle in not attached and is free to twist around. The result is loss of blood flow to the testicle. If not resolved within six hours, it may result in testicular necrosis (death). This is an emergency!
S: Sudden severe unabating pain in the testicle, scrotum, groin or lower abdomen, usually associated with nausea and vomiting.
O: The testicle is usually extremely tender and difficult to examine, often riding higher then the other testicle and may be swollen and red. Supporting the testicle does not relieve the pain as it does with Epididymitis.
A: Torsion of the Testicle
P: Refer to MO or PA. This is a surgical emergency! Do not delay action!
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Testicle Cancer: This is the most common cancer in males between the age of 15-34 years of age, and the leading killer in this age group with regard to cancer. Rapidly spreads (metastasis) to form tumors in the lungs, liver, and brain. It is very malignant and is considered an emergency that requires immediate evaluation by Urology or Surgery!
S: Testicle swelling. Heaviness in the scrotum due to the density of the tumor, a lump or hard ball may be found.
O: A hard, painless mass in the testicle. The tumor does not transilluminate, while a hydrocele will.
Gynecomastia (enlargement of the breast) may be present.
A: Testicle Cancer.
P: Refer ASAP to Urology! All men ages 15-34 should be taught TSE (Testicle Self-Exam).
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Cryptochidisim: (Crypt means hidden) This refers to a hidden undescended testicle. Surgery is indicated by age 2 to 5 if not descended. There is a 10 to 40 fold increase in cancer if not corrected.
DIFFERENTIAL DIAGNOSIS OF PAIN IN THE SCROTUM
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Epididymitis
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Tumor
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Torsion
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Pain:
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Common
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Absent or mild
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Severe
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Onset:
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Rapid
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Gradal
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Sudden/Dramatic
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Urinary tract Infection
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Common
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No
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No
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Palpation of Testicle:
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Normal
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Mass
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Usually Individual
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Structures of the Scrotum: Can not be felt separately
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Epididymis
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Tender
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Normal
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Spermatic Cord
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Thickened
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Normal
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Bureau of Medicine and Surgery
Department of the Navy
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Operational Medicine
Health Care in Military Settings
CAPT Michael John Hughey, MC, USNR
NAVMED P-5139
January 1, 2001 |
United States Special Operations
Command
7701 Tampa Point Blvd.
MacDill AFB, Florida
33621-5323 |
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