Primary care physicians (PCPs) are often the first point of contact for most patients seeking help for genitourinary disorders. The PCP is then responsible for initial testing, diagnosis, treatment, and, if indicated, referral to a urological specialist. Because many PCPs lack specialized training in the evaluation and management of most genitourinary conditions but will nevertheless encounter a large number of common ones, having a general understanding of the initial evaluation and management of these conditions is helpful. In this chapter, we seek to familiarize PCPs with the most common urological conditions that they will encounter, from diagnosis to management.
A skillful genitourinary exam can help a clinician localize disease and narrow the differential diagnosis. In male patients, prostate and testicular malignancies can be diagnosed by palpation.
For male patients, the genitourinary exam can be performed with the patient in either the erect or supine position. The practitioner should note the distribution of pubic hair, the Tanner stage of genital development, and the presence of any abnormal skin lesions. Above the pubic bone, percussion and palpation can be used to detect a distended bladder, indicative of inadequate emptying.
In the examination of the penis, note the presence or absence of the foreskin. In adults, the foreskin, if present, should be easily retractable. Any resistance to retraction of the foreskin can be the result of inflammation or scarring. In children, the retractability of the foreskin varies until 5 years of age, where it becomes easily retractable like in an adult. Forcible retraction of the foreskin should not be performed because it is painful and may cause bleeding or scarring. The urethral opening should be solitary and located at the distal tip of the glans penis. Gentle retraction of the meatus can show distal urethral lesions or strictures. Any curvature or irregularities of the penile shaft should be noted. Palpation of the corpus cavernosum and corpus spongiosum can detect plaques or indurations.
The scrotal skin is normally rugated and pliable. The scrotal sac is divided into 2 compartments by a midline septum, with each sac containing a testicle, epididymis, and spermatic cord. These structures are typically freely mobile within the sac. The testicle should be gently palpated and is usually ovoid, measuring 4 cm or longer longitudinally and 2.5 cm or longer transversely. If the testicles are not palpable in the scrotum, physicians should examine the inguinal canal more proximally. The epididymis lies on the superior and posterior surface of the testicle and is softer than the testicle. If the patient is supine, having him stand can be helpful for the rest of the physical exam. Halfway between the testicle and the external ring, the vas deferens can be palpated with its cordlike shape and consistency, not unlike a piece of spaghetti. Check for an inguinal hernia using the index finger to invaginate the scrotal skin ...