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 Bowmans 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 Bowmans 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.
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).
Male Genitalia Examination
History of the Genitourinary Patient
Five Major Symptoms:
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 WBCs, RBCs and usually a positive nitrite. Always get a urine culture.
A: Cystitis (UTI)
P: Refer to MO or PA
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.
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: WBCs 15-30,000
P: Refer to MO or PA. Usually requires IV. Antibiotics and hospital admission.
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
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 WBCs
P: Refer to MO or PA. STD work up prior to treatment.
S: Scrotal pain, tenderness, and scrotal enlargement.
O: Tenderness and swelling of the epididymis and the spermatic cord may include the testes.
P: Refer to MO or PA. Bed rest, elevation and support of the scrotum provide symptomatic relief.
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
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.
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!
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).
DIFFERENTIAL DIAGNOSIS OF PAIN IN THE SCROTUM
|Pain:||Common||Absent or mild||Severe|
|Urinary tract Infection||Common||No||No|
|Palpation of Testicle:||Normal||Mass||Usually Individual|
|Structures of the Scrotum: Can not be felt separately|
Hospital Corpsman Sickcall Screeners Handbook
Naval Hospital, Great Lakes