Urosurgery History taking

  1. Character of Colic Pain?
    • Severe griping character 
    • Disappears completely between the attacks 
    • Accompained by nausea and vomiting (due to pylorospasm). 
    • Develops when the muscular conducting tube gets obstructed 

    Renal Colic is not a colic pain
  2. Nerve supply of upper ureter?

    • Upper ureter, kidney and testis are supplied by T11-12. This is the reason of pain being referred from upper ureter to testis.
    • The pain from the renal stone and upper ureter radiate along the course of ureter to the testicles.
  3. Nerve supply of lower ureter?

    Inner side of thing is also supplied by L1 (Genitofemoral nerve). So, pain from lower ureter are referred to inner thigh.
  4. What is Strangury?
    Painful desire to micturate which starts in the bladder and radiates into the urethra, but it neither produces any urine or relieves the pain.
  5. Feature of prostatic pain?
    Vague discomfort or fullness in perineal or rectal area (S2-4), often associated with difficulty in passing urine.
  6. Features of bladder pain?
    • felt in hypogastrium
    • Pain is usually dull aching or burning in nature 
    • Pain may be referred to the tip of the penis.
  7. Relation of strain with stream of urine?
    • If strain improves stream of urine - Urethral stricture 
    • If strain retards stream of urine - BPH
  8. Types of incontinence?
    • Irritative - Irritation of detrusor muscle by infection, stones, tumor, foreign body etc. causes involuntary contraction of the detrusor.
    • Stress - involuntary passage of urine when the patient strains, loss of support to bladder neck and proximal urethra
    • Urge - large amount of urine lost without warning day and night, Hypertonic detrusor contractions
    • Overflow - Hypotonic bladder (Neurogenic bladder), small amount of urine lost intermittently day and nights.
    • Bypass - Radical pelvic surgery or Radiotherapy, continual urine loss day and night. E.g. vesico-vaginal fistula (VVF)

    • True incontinence - when urine dribbles in absence of full bladder 
    • False incontinence - when urine overflows from a distended bladder
  9. Renal angle?
    Lower border of the 12th  rib and outer border of erector spinae.

    Errector spinae muscle is the set of Iliocostalis, longissimus and Spinalis muscles.
  10. Baldwin's method?
    If there is difficulty in eliciting the colonic resonance, one can inflate the colon with air by means of a rubber catheter introduced through the anus
  11. Extension of normal kidney?
    from top of 1st to the bottom of the 3rd or middle of 4th lumbar vertebra.
  12. Difference between renal stone and gall stone in X-ray?
    • Renal calculus moves with respiration which can be verified by taking two exposures, one at full inspiration and the other at full expiration. 
    • Density of renal calculus is uniform whereas gall stone are less dense in the center. 
    • Renal stones take the shape of the renal pelvis and calyces whereas solitary gallstone may be round or faceted. 
    • In lateral view, the renal stone lies superimposed on the shadow of the vertebral column, whereas gallstones are seen in front of the vertebral bodies.

    Note - Ureteric stone is usually oval and lines along the line of ureter.
  13. Pathway of ureter in X-ray KUB?
    Imaginary line passing along the tips of the transverse process of the lumbar vertebra, over the sacro-iliac joint, down the ischial spine from where this line deviates medially. 

    • Vesical calculus are seen just above the symphysis pubis. 
    • Prostatic calculus appear as small dots behind the sympysis pubis.
  14. Causes of obliteration of psoas shadow?
    Perinephric hematoma, abscess or cold abscess
  15. Excretory urogram?
    • A scout radiograph or KUB (kidneyureter-bladder) film is taken demonstrating the top of the kidneys and the entire pelvis to the pubic symphysis.
    • Contrast is injected as a bolus of 50 to 100 mL of contrast
    • Immediate films - taken immediately after the bolus injection of contrast, typically show dense nephrogram and permit better visualization of renal outlines.
    • A film is taken at 5minutes and then additional films at 5-minute intervals until thequestion that prompted the IVU is answered.
    • At 25 minutes, a film is taken to note the effficacy with which the renal pelvis and ureters drain, ureterograms and also the mobility of the kidneys. 
    • Postvoid films are obtained to evaluate the presence of outletobstruction, prostate enlargement, and bladder filling defects,including stones and urothelial cancers
  16. Contraindications of Excretory urogram?
    • Allergic patients 
    • Multiple myeloma (the dye makes insoluble complex with Bence Jones Protein) 
    • Congenital Adrenal Hyperplasia 
    • Diabetes 
    • Primary Hyperparathyroidism
  17. Location of urethral Orifice?
    4 O'clock and 8 O'clock position
  18. Chromocystoscopy?
    • To find out the ureteric orifices 
    • To assess the function of kidney

    5ml of 0.4% of sterile solution of  indigocaramine is injected IV. Normally, a blue jet will be seen to emerge form the ureteric orifices within 3-5 minutes.
  19. Clinical feature of Vesicle calculus?
    • Increased frequency of micturation.  This is not experienced in night. The cause is that in standing posture, the stone comes in contact with trigone and initiates desire to micturate. During night, stone falls off the trigone and frequent desire to micturate goes off.
    • Sudden interruption of the flow due to blockage of the urethral meatus with stone.
  20. Causes of increased frequency of micturation?
    • Renal - any form of pyelitis, stone, tuberculosis, and movable kidney 
    • Ureteric - Stone 
    • Vesicle - any form of cystitis and stone, inflammatory conditions of pelvis e.g salpingitis, appendicitis, secondary infiltration from carcinoma of the uterus or rectum
    • Prostate - Prostatism, BEP 
    • Urethral - Posterior urethritis (gonococcal), stone, phimosis and balanitis
  21. What is Hematuria?
    Presence of blood in the urine; greater than three red blood cells per high-power microscopic field (HPF) is significant
  22. Questions to be asked for hematuria?
    • 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? - indicates a more significant degree of hematuria
    • If the patient is passing clots, do the clots have a specific shape?
  23. Timing of hematuria?
    • Initial hematuria - from the urethra
    • Total hematuria - from the bladder or upper urinary tracts
    • Terminal hematuria - secondary to inflammation in the area of the bladder neck or prostatic urethra.
  24. Shape of clots?
    • Amorphous - bladder or prostatic urethral origin 
    • Vermiform (wormlike) - upper urinary tract (usually associated with pain)
  25. Some facts.
    • 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
    • A firm or hard area within the testis should be considered a malignant tumor until proved otherwise
    • 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).
    • Specific gravity of urine is easily determined from a urinary dipstick and usually varies from 1.001 to 1.035.
    • Osmolality is a measure of the amount of material dissolved in the urine and usually varies between 50 and 1200 mOsm/L.
    • In general, the urinary pH reflects the pH in the serum
  26. Collection of urine sample?
    • In the male patient, a midstream urine sample is obtained.
    • In the female, it is more difficult to obtain a clean-catch midstream
    • Specimen. To evaluate for a possible infection in a female, a catheterized urine sample should always be obtained
    • In patients with a presumed UTI, an alkaline urine with a pH greater than 7.5 suggests infection with a urea-splitting
  27. How to differentiate hematuria from myoglobinuria?
    • Hematuria can be distinguished from hemoglobinuria and myoglobinuria by microscopic examination of the
    • centrifuged urine; the presence of a large number of erythrocytes establishes the diagnosis of hematuria. If erythrocytes are absent, examination of the serum will distinguish hemoglobinuria and myoglobinuria
    • Hematuria of nephrologic origin is frequently associated with casts in the urine and almost always associated with significant proteinuria. Even significant hematuria of urologic origin will not elevate the protein concentration in the urine into the 100 to 300 mg/dL or 2+ to 3+ range on dipstick, and proteinuria of this magnitude almost always indicates glomerular or tubulointerstitial renal disease
    • Erythrocytes arising from glomerular disease are typically dysmorphic and show a wide range of morphologic alterations. Conversely, erythrocytes arising from tubulointerstitial renal disease and of urologic origin have a uniformly round shape
    • This so-called renal threshold corresponds to serum glucose of about 180 mg/dL; above this level, glucose will be detected in the urine
  28. What is CISC?
    Clean Intermittent Self Catheterization (CISC)  is a way to empty the bladder  by using a clean catheter. It involves  putting the catheter in and taking it out several times a day. CISC helps people who cannot empty their bladders the usual way. By emptying your bladder regularly, you can help prevent bladder infections.
  29. What is TWOC?
    Trial Without Catheter (TWOC) is when the catheter  is removed from your bladder for a trial period to determine whether the patient can pass urine without it.
  30. What is nocturia?
    Nocturia is the number of voids recorded during a night’s sleep: each void is preceded and followed by sleep.

    >1 void is significant.
  31. Frequency of urination - definition?
    • Voiding within 2 hours 
    • >8 times in day time 
    • Sudden change in habit
  32. Urine collection
    • For Urine RME - fresh specimen, <1 hour 
    • For TB - morning sample 
    • For cytology - fresh sample
  33. Complete urin
    • Physical Characteristics:
    • - color and odor
    • - turbidity
    • - specific gravity
    • - Osmolarity - 50-1200 mosm/L
    • - pH

    • Chemical Characteristics:
    • - protein
    • - glucose
    • - ketones
    • - urobilinogen
    • - bilirubin
    • - blood
    • - nitrite test
    • - leukocyte esterase test 
    • - other

    • Microscopic Examination:
    • - RBC
    • - epithelial cells
    • - Casts
    • - crystals
    • - bacteria or yeast
    • - protozoan casts
  34. Causes of red urine?
    The urine dipstick test is currently one of the most useful and sensitive tools in detecting hematuria. This test is based on the peroxidase activity of hemoglobin. It can detect trace amounts of hemoglobin (rather than the presence of RBCs) and myoglobin

    • False-positive results can occur in 
    • - Beet root 
    • - Laxatives containing Phenolphthalein 
    • - Ingestion of cakes, cold drinks, fruit juice 
    • - Hemoglobinuria following hemolytic syndromes
  35. Urine is renal tuberculosis?
    • Sterile pyuria 
    • Acidic urine
    • Acid fast staining with the centrifuged sediments.
  36. pH of urine?
    Normal pH - 5.5-6.5

    • Acidic urine <5.5, in diabetic ketoacidosis, 
    • Alkaline urine >6.5, urea splitting  organisms
  37. Specific gravity of urine?

    Specific gravity of urine is measured in the morning sample after 12 hours of overnight restriction of fluid. 

    Fixed specific gravity - 1.010 suggest CKD.
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Urosurgery History taking