INVESTIGATION OF UROLOGIC PATIENT

DR ALI TAHER

EXAMINATION OF URINE: Urinalysis is one of the most important and useful urologic tests available . It is best to examine urine that has been properly obtained in the office.

METHOD OF COLLECTION
1. Men midstream urine sample from men. The procedure should include(1) cleansing of the meatus (2) passing the first part of the stream (1530 mL) without collection; and (3) collecting the next or midstream portion (approximately 50100 mL) in a sterile specimen container. A portion of the specimen is prepared immediately for both macroscopic and microscopic examination, and the rest is saved for culture.

2. Women midstream specimen from a woman is as follows: (1) the patient is placed on the examining table in the lithotomy position; (2) the vulva and urethral meatus are Cleaned (3) the labia are separated; and (4) the patient is instructed to initiate voiding into a container held close to the vulva. After she has passed the first 10 20 mL of urine, the next 50100 mL is collected in a sterile container .

3. Children can be obtained from males or females by covering the cleansed urethral meatus with a plastic bag; a urine specimen for culture may require catheterization or suprapubic needle aspiration. suprapubic needle aspiration the patient has been previously hydrated, so that the bladder is full. Suprapubic needle aspiration is performed .

A.Macroscopic Examination COLOR & APPEARANCE : golden yellow . Urine is often colored owing to drugs: phenazopyridine (Pyridium) will turn the urine orange. A red discoloration without erythrocytes in the urine are due to myoglobinuria in significant muscle trauma, or hemoglobinuria following hemolysis. Cloudy urine is commonly represent pyuria or amorphous phosphates

B. SPECIFIC GRAVITY The specific gravity of urine (normal, 1.0031.030) C. CHEMICAL TESTS 1. pHaverage pH varies between 5.5 and 6.5. 2. ProteinDip-strips used to determine the presence of >10 mg/dL protein in urine. 3. GlucoseThe glucose oxidase-peroxidase tests used in dip-strips are quite accurate and specific for urinary glucose. 4. HemoglobinThe dip-strip test for hemoglobin is not specific for erythrocytes and should be used only to screen for hematuria.

5 . Bacteria and leukocytes

Test strips to determine the number of bacteria (nitrite) or leukocytes (leukocyte esterase) as predictors of bacteriuria are as accurate as microscopic sediment analysis. When the nitrite test is positive , it suggests the presence of >100,000 organisms per mL .

D . Microscopic examination 1. Bacteria a finding of more than 5 bacteria per high-power field is generally considered abnormal . 2. W b c:<2 /HPF . 3. Erythrocytesthe presence of even 3 RBC /HPF in the urine is abnormal 4. Epithelial cellssquamous epithelial cells in the urinary sediment indicate contamination of the specimen.

5. CastsCasts are formed in the distal tubules

and collecting ducts and signify intrinsic renal disease. leukocyte casts have been considered suggestive of pyelonephritis. Erythrocyte casts are path gnomonic of underlying glomerulitis or vasculitis . 6. crystals- Identification of crystals in the urine is particularly important in patients with stone disease . 7.Parasites: Schistsoma hematobium eggs

Bacteriuria A. MICROSCOPIC EXAMINATION diagnosis of bacterial infection may be made on the basis of results of microscopic examination of the urinary sediment. If several bacteria per high-power Field >5 are found in a urine specimen diagnosis of bacterial infection can be made and empiric treatment started.

B. BACTERIAL CULTURES diagnosis of bacterial infection based on microscopic examination of the urinary sediment should be confirmed by culture. Estimate number of bacteria in urine Identify the organism Predict which drugs will be effective in treating the infection

UROTHELIAL CANCER TESTS Urine cytology The evaluation of voided or bladder wash (barbotage) urine for bladder urothelial cancer cells has been quite successful for higher grade (23) transitional cell cancers. HORMONAL STUDIES Tests for abnormalities in adrenal hormone secretion are important in the workup of patients with suspected adrenal tumors. Pheochromocytoma and neuroblastoma can be detected by measuring the excretion of vanillylmandelic acid (VMA) IN URINE.

STUDIES OF STONE CONSTITUENTS Patients with recurrent urolithiasis may have an underlying abnormality of excretion of calcium, uric acid, oxalate, magnesium. Samples of 24-hour urine collections can be tested to determine abnormally high levels of each. Whenever a stone is recovered, a formal stone analysis is recommended.

EXAMINATION OF URETHRAL DISCHARGE Examination of urethral discharge in males can be particularly helpful in establishing a diagnosis. If the patient presents with the thick yellowish discharge typical of Neisseria gonorrhoeae infection, the discharge should be stained with Grams stain and examined for gram-negative intracellular diplococci.

RENAL FUNCTION TESTS Serum Creatinine Creatinine, the end product of the metabolism of creatine in skeletal muscle, is normally excreted by the kidneys. Because individual daily creatinine production is constant, the serum level is a direct reflection of renal function. Serum creatinine levels remain within the normal range (0.81.2 mg/dL in adults; 0.40.8 mg/dL in young children) . Blood Urea Nitrogen normal rang 15-45mg/dl Urea is the primary metabolite of protein catabolism and is excreted entirely by the kidneys, BUN is influenced by dietary protein intake, hydration status, and gastrointestinal bleeding.

Creatinine Clearance Because creatinine production is stable and creatinine is filtered through the glomerulus , its renal clearance is essentially equal to the glomerular filtration rate. Determination of creatinine clearance requires only the collection of a timed (usually 24-hour) urine specimen and a serum specimen. The resulting clearance is expressed in milliliters per minute, with 90110 mL/min considered normal..

Prostate Cancer Markers Prostate-specific antigen (PSA) is an extremely important prostate cancer marker Serum elevation >4.0 ng/mL is correlated with prostatic cance

Radiology of the Urinary Tract

1. Plain Film of the Abdomen A plain film of the abdomen, frequently called a KUB film. It may demonstrate osseous abnormalities, abnormal calcifications, or large soft-tissue masses. Intravenous Urography Following a preliminary plain film of the abdomen, additional radiographs are taken at timed intervals after the intravenous injection of iodine-containing contrast medium. Normal kidneys promptly excrete contrast agents by glomerular filtration.

Retrograde Urograms requires cystoscopy and the placement of catheters in the ureters. A radiopaque contrast medium is introduced into the ureters or renal collecting structures through the ureteral catheters and radiographs of the abdomen are taken. Percutaneous Urograms contrast medium is introduced either through nephrostomy tubes (nephrostogram) or by direct injection into the renal collecting structures via a percutaneous puncture

3. Cystography, Voiding Cystourethrography Direct instillation of contrast media into the urinary bladder Contrast is usually instilled via a transurethral catheter, but when necessary can be administered via percutaneous suprapubic bladder punctur 4. Urethrography Retrograde injection of radiopaque fluid or in antegrade fashion with voiding cystourethrography,

SONOGRAPHY Ultrasound is commonly used for the evaluation of the kidney, urinary bladder, prostate, testis, and penis
COMPUTED TOMOGRAPHY SCANNING CT evaluation of anatomy and pathology generally requires intravenous injection of iodinated contrast media.

MAGNETIC RESONANCE IMAGING. Applications for MR in renal imaging include demonstration of congenital anomalies, diagnosis of renal vein thrombosis, and diagnosis and staging of renal cell carcinoma.

Urodynamic Studies: Urodynamic study is an important part of the evaluation of patients with voiding dysfunctions, urinary incontinence, neuropathic disorders .

 NUCLEAR SCINTIGRAPHY : Radionuclide evaluation of the genitourinary system offers physiologic and anatomic details . technetium-99m (99mTc) tracers, which have a shorter half life (6 hours) and offer better images. The main tracers used in evaluation of the kidney are diethylenetriaminepentaacetic acid (DTPA), mercaptoacetyltriglycine (MAG3), and dimercaptosuccinic acid (DMSA).

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