male-gu-slides for lecture

Jong M. Choe, MDJong M. Choe, MDDirector of Continence Program Director of Continence Program

Division of UrologyDivision of UrologyUniversity of Cincinnati College of MedicineUniversity of Cincinnati College of Medicine

Veterans Administration Medical CenterVeterans Administration Medical Center

Male GU ExaminationMale GU ExaminationMale GU ExaminationMale GU Examination

What do Urologists do?What do Urologists do?

UrologyUrologyUrologyUrology

They are surgeons who treat and operate on They are surgeons who treat and operate on

diseases of genitourinary organs in men:diseases of genitourinary organs in men:

• KidneyKidney • • Penis Penis

• UreterUreter • • Urethra Urethra

• BladderBladder • • Vas deferens Vas deferens

• ProstateProstate • • Testes Testes

What do Urologists do?What do Urologists do?

UrologyUrologyUrologyUrology

They are surgeons who treat and operate on They are surgeons who treat and operate on

diseases of genitourinary organs in women:diseases of genitourinary organs in women:

• KidneyKidney

• UreterUreter

• BladderBladder

• UrethraUrethra

Urologic patientUrologic patient

Initial EvaluationInitial EvaluationInitial EvaluationInitial Evaluation

Begins with focused history and physical examination Begins with focused history and physical examination

of pertinent genitourinary organsof pertinent genitourinary organs


FEMALEFEMALE MALEMALE

KidneysKidneys

UretersUreters

BladderBladder

Urinary sphincterUrinary sphincter

ProstateProstate

UrethraUrethra

Urologic patientUrologic patient


Begins with focused history and physical examination of Begins with focused history and physical examination of pertinent genitourinary organspertinent genitourinary organs

• KidneyKidney • • Penis Penis

• UreterUreter • • Urethra Urethra

• BladderBladder • • Vas deferens Vas deferens

• ProstateProstate • • Testes Testes

Medical HistoryMedical HistoryMedical HistoryMedical History

Chief complaint (CC): Chief complaint (CC):

History of present illness (HPI):History of present illness (HPI):

Past medical history (PMH):Past medical history (PMH):

Past surgical history (PSH):Past surgical history (PSH):

Family history (FH):Family history (FH):

Social history (SH):Social history (SH):

Medications:Medications:

Allergies:Allergies:

Review of systems (ROS):Review of systems (ROS):

35 yo white female with history of hematuria. She 35 yo white female with history of hematuria. She needs an intravenous pyelogram (IVP) to evaluate needs an intravenous pyelogram (IVP) to evaluate

the source of bleedingthe source of bleeding

35 yo white female with history of hematuria. She 35 yo white female with history of hematuria. She needs an intravenous pyelogram (IVP) to evaluate needs an intravenous pyelogram (IVP) to evaluate

the source of bleedingthe source of bleeding

CC: CC: HematuriaHematuria

HPI:HPI: Began 2 days ago. Has stopped now. History Began 2 days ago. Has stopped now. History of of smoking x 8 years. smoking x 8 years. Does not think she is Does not think she is

pregnant.pregnant.

PMH:PMH: NoneNone

PSH:PSH: NoneNone

FH:FH: NoneNone

SH:SH: (+) smoke or (-) ETOH(+) smoke or (-) ETOH

Medications:Medications: OCPOCP

Allergies:Allergies: None; None; no reaction to IVP dyeno reaction to IVP dye

ROS:ROS: Non contributoryNon contributory

45 yo male with benign prostatic hyperplasia 45 yo male with benign prostatic hyperplasia (BPH) has difficulty urinating(BPH) has difficulty urinating

45 yo male with benign prostatic hyperplasia 45 yo male with benign prostatic hyperplasia (BPH) has difficulty urinating(BPH) has difficulty urinating

CC: CC: Difficult urinationDifficult urination

HPI:HPI: Weak stream; sense of incomplete emptying, Weak stream; sense of incomplete emptying, straining to urinate; straining to urinate; AUA symptom scoreAUA symptom score

30/35; 30/35; most recent most recent PSAPSA 2.5 ng/ml 2.5 ng/ml

PMH:PMH: Enlarged prostate Enlarged prostate (BPH)(BPH)

PSH:PSH: None - specifically no TURPNone - specifically no TURP

FH:FH: (-) (-) Prostate cancerProstate cancer

SH:SH: (-) smoke or drink ETOH(-) smoke or drink ETOH

Medications:Medications: FlomaxFlomax

Allergies:Allergies: None None

ROS:ROS: Non contributoryNon contributory

Generalized Physical ExaminationGeneralized Physical ExaminationGeneralized Physical ExaminationGeneralized Physical Examination

HEENTHEENT

CorCor

LungsLungs

ABDABD

FlankFlank

GUGU PenisPenis Pelvic Pelvic

TesticlesTesticles

RectalRectal ProstateProstate

ExtExt

NeuroNeuro

Generalized Physical ExaminationGeneralized Physical ExaminationGeneralized Physical ExaminationGeneralized Physical Examination

HEENTHEENT BenignBenign

CorCor RRRRRR

LungsLungs CTACTA

ABDABD soft, NT/ND, NABSsoft, NT/ND, NABS

FlankFlank (-) CVAT(-) CVAT

GUGU PenisPenis normal phallus, adequate meatusnormal phallus, adequate meatus

TesticlesTesticles descended bilaterally; WNLdescended bilaterally; WNL

ProstateProstate smooth and benign, (-) nodulessmooth and benign, (-) nodules

ExtExt (-) CCE(-) CCE

NeuroNeuro No focal neurologic deficitsNo focal neurologic deficits

Focused Urologic examinationFocused Urologic examination

Physical ExaminationPhysical ExaminationPhysical ExaminationPhysical Examination

• InspectionInspection -- general observationgeneral observation• PalpationPalpation -- gently touch and feelgently touch and feel• PercussionPercussion -- lightly tap over a fingerlightly tap over a finger• Auscultation Auscultation -- listen with stethescopelisten with stethescope

InspectionInspectionInspectionInspection

Cushing’s syndromeCushing’s syndrome

Excess cortisol productionExcess cortisol production

Clinical signs:Clinical signs:

Buffloe humpBuffloe hump

Truncal obesityTruncal obesity

Moon faceMoon face


PhimosisPhimosis

ParaphimosisParaphimosis

PhimosisPhimosis

Inability to retract the foreskinInability to retract the foreskin


Inability to pull down the foreskinInability to pull down the foreskin


Pelvic organ prolapsePelvic organ prolapse

Pelvic organ prolapsePelvic organ prolapse

Condition where one of the pelvic Condition where one of the pelvic organs has herniated out of the vaginaorgans has herniated out of the vagina

Cystocele - bladderCystocele - bladder

Rectocele - rectumRectocele - rectum

Enterocele - bowelEnterocele - bowel

Procidentia - uterusProcidentia - uterus

PalpationPalpationPalpationPalpation

Male - Male - BimanualBimanualexaminationexamination

Prostate examinationProstate examination

Hernia examinationHernia examinationFemale - BimanualFemale - Bimanual

examinationexamination

Kidney examinationKidney examination

Kidney ExaminationKidney ExaminationKidney ExaminationKidney Examination

Method of palpation of the kidneyMethod of palpation of the kidney

The patient lying supineThe patient lying supine

Posterior hand tilts the kidney upwardPosterior hand tilts the kidney upward

Anterior hand feels for the kidneyAnterior hand feels for the kidney

Have patient take a deep breath. This causes the Have patient take a deep breath. This causes the kidney to descendkidney to descend

As the patient inhales, push the anterior hand at As the patient inhales, push the anterior hand at the costoverterbral marginthe costoverterbral margin

If the kidney is mobile or enlarged, it can be felt If the kidney is mobile or enlarged, it can be felt between 2 handsbetween 2 hands


KidneysKidneys

Lie under the diaphragm and ribsLie under the diaphragm and ribs

Well protected from injuryWell protected from injury

Right kidney lower than left due to liverRight kidney lower than left due to liver

Left kidney usually not palpableLeft kidney usually not palpable

Normal kidneys difficult to palpate especially in men due to ABD muscle toneNormal kidneys difficult to palpate especially in men due to ABD muscle tone

Sometimes normal kidneys may be palpable in thin patients and in childrenSometimes normal kidneys may be palpable in thin patients and in children

Palpable kidneys are usually displaced or enlargedPalpable kidneys are usually displaced or enlarged

Renal MassesRenal MassesRenal MassesRenal Masses

Renal mass: may be fluid-filled or may Renal mass: may be fluid-filled or may be solidbe solid

Solid renal tumorSolid renal tumor

Hydronephrotic kidneyHydronephrotic kidney


Renal tumorRenal tumorClinically asymptomaticClinically asymptomatic

May present with hematuriaMay present with hematuria

Not palpable unless enlargedNot palpable unless enlarged

Firm, non-tender, often immobileFirm, non-tender, often immobile

PyelonephritisPyelonephritisInfection of the kidneysInfection of the kidneys

Patient septic (fever, toxic)Patient septic (fever, toxic)

Costovertebral angle tenderness (CVAT)Costovertebral angle tenderness (CVAT)


Renal abscessRenal abscessInfection of the kidneysInfection of the kidneys



Anterior abdominal wall tendernessAnterior abdominal wall tenderness

Perinephric abscessPerinephric abscessInfection of the kidneysInfection of the kidneys


Costovertebral angle tenderness (CVAT)Costovertebral angle tenderness (CVAT)Anterior abdominal wall tendernessAnterior abdominal wall tenderness


Kidney stoneKidney stoneComplain of flank painComplain of flank pain

Renal colic - cannot get comfortableRenal colic - cannot get comfortable


Ureteral stoneUreteral stoneComplain of flank painComplain of flank pain

Renal colic - cannot get comfortableRenal colic - cannot get comfortable

Costovertebral angle tenderness (CVAT)Costovertebral angle tenderness (CVAT)Referred pain to groin area Referred pain to groin area Urinary frequency and urgencyUrinary frequency and urgency

kidney

ureter

Prostate ExaminationProstate ExaminationProstate ExaminationProstate Examination

Method of palpation of the prostateMethod of palpation of the prostate

The patient is in left lateral decubitus position or The patient is in left lateral decubitus position or bent forward at the waist with feet shoulder-bent forward at the waist with feet shoulder-width apartwidth apart

A well-lubricated gloved index finger is inserted A well-lubricated gloved index finger is inserted gently into the rectumgently into the rectum

Have the patient Valsalva or bear down as you Have the patient Valsalva or bear down as you are inserting the gloved fingerare inserting the gloved finger

Palpate the prostate in systematic fashion: right, Palpate the prostate in systematic fashion: right, middle, left; apex to basemiddle, left; apex to base


Normal prostateNormal prostate

Normal prostate is size of a chest nutNormal prostate is size of a chest nut

Has consistency of nose or contracted thenar Has consistency of nose or contracted thenar eminenceeminence

Benign prostatic hyperplasia (BPH)Benign prostatic hyperplasia (BPH)

BPH is enlarged prostateBPH is enlarged prostate

Has consistency of nose or contracted hyperthenar Has consistency of nose or contracted hyperthenar eminenceeminence

May be as big as an orangeMay be as big as an orange


Acute prostatitisAcute prostatitis

Patient appears septic (fever, toxic appearing)Patient appears septic (fever, toxic appearing)

Prostate is enlarged, fluctuant, warm, and painfulProstate is enlarged, fluctuant, warm, and painful

Do not be aggressive with prostate exam!Do not be aggressive with prostate exam!

Chronic prostatitisChronic prostatitis

May complain of LUTS or hematospermiaMay complain of LUTS or hematospermia

Prostate feels boggy and is tender to touchProstate feels boggy and is tender to touch

May see expressed prostatic secretions: white May see expressed prostatic secretions: white dischargedischarge


Prostate cancerProstate cancer

Clinically asymptomatic - silent cancerClinically asymptomatic - silent cancer

One area of the prostate may feel firm, nodular, or One area of the prostate may feel firm, nodular, or stony hard.stony hard.

Need to get PSA and perform prostate biopsyNeed to get PSA and perform prostate biopsy

Hernia ExaminationHernia ExaminationHernia ExaminationHernia Examination

Technique of examining inguinal Technique of examining inguinal herniahernia

Inguinal hernia: extrusion of bowel into the inguinal Inguinal hernia: extrusion of bowel into the inguinal canalcanal

Gently insert a gloved index finger into the inguinal Gently insert a gloved index finger into the inguinal canal by invaginating the scrotal skincanal by invaginating the scrotal skin

Palpate the external inguinal ring - feels like a small Palpate the external inguinal ring - feels like a small round openinground opening

Have the patient turn his head to one side and coughHave the patient turn his head to one side and cough

Protrusion of bowel against the index finger Protrusion of bowel against the index finger signifies herniasignifies hernia

Bimanual ExaminationBimanual ExaminationBimanual ExaminationBimanual Examination

Male bimanual examinationMale bimanual examination

Performed in a setting of bladder tumorPerformed in a setting of bladder tumor

Insert a lubricated gloved finger into the rectumInsert a lubricated gloved finger into the rectum

Apply fingers of the anterior hand on the suprapubic Apply fingers of the anterior hand on the suprapubic area area

Attempt to palpate the bladder between 2 handsAttempt to palpate the bladder between 2 hands

Is the bladder palpable? Is it mobile or fixed?Is the bladder palpable? Is it mobile or fixed?

Gives clinical information regarding local invasion Gives clinical information regarding local invasion and extent of the tumorand extent of the tumor

Bimanual ExaminationBimanual ExaminationBimanual ExaminationBimanual Examination

Female bimanual examinationFemale bimanual examination

Performed in a setting of bladder tumorPerformed in a setting of bladder tumor

Insert lubricated 2 gloved fingers into the vaginaInsert lubricated 2 gloved fingers into the vagina


Attempt to palpate the bladder between 2 handsAttempt to palpate the bladder between 2 hands

Is the bladder palpable? Is it mobile or fixed?Is the bladder palpable? Is it mobile or fixed?

Gives clinical information regarding local invasion Gives clinical information regarding local invasion and extent of the tumorand extent of the tumor

Bladder ExaminationBladder ExaminationBladder ExaminationBladder Examination

Technique of bladder examinationTechnique of bladder examination


Apply gentle pressure to the suprapubic areaApply gentle pressure to the suprapubic area

Attempt to palpate the bladderAttempt to palpate the bladder

Is the bladder palpable or not? Is the bladder palpable or not?


Normal bladderNormal bladderNormally holds 400-500 ml of urine Normally holds 400-500 ml of urine

Is not clinically palpableIs not clinically palpable

Urinary retentionUrinary retentionBladder may hold as much as 2000-3000mlBladder may hold as much as 2000-3000ml

Complain of difficulty urination, urinary dribbling, Complain of difficulty urination, urinary dribbling, and straining to urinate and straining to urinate

Suprapubic fullnessSuprapubic fullness

Bladder is palpable and may be tender to touchBladder is palpable and may be tender to touch

Bladder may be palpable up to umbilicusBladder may be palpable up to umbilicus

Normal bladder

Urinary retention

Bladder MassesBladder MassesBladder MassesBladder Masses

Solid bladder tumorSolid bladder tumorUrinary retentionUrinary retention

PercussionPercussionPercussionPercussion

PercussionPercussion

Used to assess kidneys Used to assess kidneys

Used to assess bladderUsed to assess bladder


Gentle tapping over the kidney area Gentle tapping over the kidney area - costovertebral angle - normally - costovertebral angle - normally should elicit no response.should elicit no response.

Presence of costovertebral angle Presence of costovertebral angle tenderness (CVAT) upon percussion tenderness (CVAT) upon percussion suggests:suggests:

• • stonesstones

• • infectionsinfections

• • obstructionobstruction


Urinary Retention: Urinary Retention: sounds like a drum sounds like a drum to percussionto percussion

Normal Bladder: Normal Bladder: sounds “flat” to sounds “flat” to percussionpercussion

Gentle tapping over the bladder area Gentle tapping over the bladder area - suprapubic area - normally should - suprapubic area - normally should elicit no response.elicit no response.

Bladder in retention sounds hollow Bladder in retention sounds hollow like a drum.like a drum.

Penile ExaminationPenile ExaminationPenile ExaminationPenile Examination

InspectionInspection

If the patient has not been circumcised, the If the patient has not been circumcised, the foreskin should be retractedforeskin should be retracted

This may reveal a tumor or balanitisThis may reveal a tumor or balanitis

Erythroplasia of Queyrat

Penile cancer



If retraction is not possible as in the case of If retraction is not possible as in the case of phimosis, circumcision is indicated.phimosis, circumcision is indicated.

Penile LesionsPenile LesionsPenile LesionsPenile Lesions


Penile condylomaPenile condyloma

Reduction of ParaphimosisReduction of Paraphimosis



The position of the meatus should be notedThe position of the meatus should be noted

Normally the meatus should be located at Normally the meatus should be located at the tip of the penisthe tip of the penis

It may be located proximal to the tip of the It may be located proximal to the tip of the glans on either the dorsum glans on either the dorsum (epispadius)(epispadius) or or the ventral surface the ventral surface (hypospadius)(hypospadius)


PalpationPalpation

Palpation of the dorsal surface of the shaft Palpation of the dorsal surface of the shaft may reveal a fibrous plaque involving the may reveal a fibrous plaque involving the fascial covering of the corpora cavernosafascial covering of the corpora cavernosa

This is typical of Peyronie’s diseaseThis is typical of Peyronie’s disease

Tender areas of induration felt along the Tender areas of induration felt along the urethra may signify urethritis - urethra may signify urethritis - inflammaiton of the urethra.inflammaiton of the urethra.


Peyronie’s diseasePeyronie’s disease

Calcified plaque on the dorsum of penisCalcified plaque on the dorsum of penis

Often associated with abnormal penile Often associated with abnormal penile curvature, erectile dysfunction, and pain curvature, erectile dysfunction, and pain with intercoursewith intercourse

Peyronie’s disease: calcification Peyronie’s disease: calcification of tunica albugineaof tunica albuginea

Testicular ExaminationTesticular ExaminationTesticular ExaminationTesticular Examination

Technique of testicular examTechnique of testicular exam

The testes should be carefully palpated The testes should be carefully palpated with the fingers of both handswith the fingers of both hands

Should look for location, size, texture, Should look for location, size, texture, consistency, and tendernessconsistency, and tenderness

Normal testis has a soft rubbery Normal testis has a soft rubbery consistency with a smooth surfaceconsistency with a smooth surface


Cryptorchid testisCryptorchid testis

This means undescended testisThis means undescended testis

Testis may lie anywhere along the course Testis may lie anywhere along the course of inguinal canal - ectopic if lies outside of inguinal canal - ectopic if lies outside canalcanal

Most common site is the external inguinal Most common site is the external inguinal ringring

Retractile testisRetractile testis

This means testis is present but it has This means testis is present but it has tendency to retract upward into the inguinal tendency to retract upward into the inguinal canal due to overactive cremasteric canal due to overactive cremasteric musclesmuscles


Kliefelter’s syndromeKliefelter’s syndrome

47, XXY47, XXY

Clinical features:Clinical features:

male phenotypemale phenotype

gynecomastiagynecomastia

small, firm testes < 3 cm in lengthsmall, firm testes < 3 cm in length

azospermia (no sperm production)azospermia (no sperm production)

tall and lankytall and lanky


HydroceleHydroceleFluid within tunica vaginalisFluid within tunica vaginalis

Asymptomatic but may cause Asymptomatic but may cause scrotal pain. Feels firm, non-tenderscrotal pain. Feels firm, non-tender

Transillumination in a dark room Transillumination in a dark room helpful. Shine a flashlight behind helpful. Shine a flashlight behind the scrotum. It glows red.the scrotum. It glows red.

When in doubt, obtain scrotal When in doubt, obtain scrotal ultrasoundultrasound

SpermatoceleSpermatoceleEpididymal cyst filled with sperm. Epididymal cyst filled with sperm. Glows green with transillumination. Glows green with transillumination.


Testicular cancerTesticular cancerA firm area in the testis proper must be regarded A firm area in the testis proper must be regarded as a malignant tumor unless proven otherwiseas a malignant tumor unless proven otherwise

Typically asymptomatic and painless. Brought to Typically asymptomatic and painless. Brought to the attention to the patient after infection or the attention to the patient after infection or traumatrauma

If transillumination is performed, light will not If transillumination is performed, light will not transmit through a solid tumor transmit through a solid tumor

Tumors are often smooth but may be nodularTumors are often smooth but may be nodular

Need to obtain scrotal ultrasoundNeed to obtain scrotal ultrasound


TorsionTorsionAbnormal twisting of the spermatic cordAbnormal twisting of the spermatic cord

Patient in severe pain, nausea, vomitingPatient in severe pain, nausea, vomiting

Testicle high riding - retracted upwardTesticle high riding - retracted upward

Abnormal horizontal lieAbnormal horizontal lie

Tender to palpationTender to palpation

May not be able to examine due to patient May not be able to examine due to patient distressdistress

Urologic emergencyUrologic emergency

Need to obtain scrotal US with Doppler studiesNeed to obtain scrotal US with Doppler studies

Epididymal ExaminationEpididymal ExaminationEpididymal ExaminationEpididymal Examination

EpididymisEpididymisSmall cap-like structure located posterior to the Small cap-like structure located posterior to the testicletesticle

Should be carefully palpatedShould be carefully palpated

for size and indurationfor size and induration

Induration means infection - Induration means infection -

epididymitisepididymitis

Epididymis

Epididymal ExaminationEpididymal ExaminationEpididymal ExaminationEpididymal Examination

EpididymitisEpididymitisIn acute stage of epididymitis, the testis and In acute stage of epididymitis, the testis and epididymis are indistinguishable by palpationepididymis are indistinguishable by palpation

The testis and epididymis may be adherent to the The testis and epididymis may be adherent to the scrotumscrotum

The scrotal wall is erythematous and tenderThe scrotal wall is erythematous and tender

Epididymis

Spermatic Cord ExaminationSpermatic Cord ExaminationSpermatic Cord ExaminationSpermatic Cord Examination

VaricoceleVaricoceleVaricose veins of pampiniform plexusVaricose veins of pampiniform plexus

Left side more commonly affectedLeft side more commonly affected

Present with scrotal discomfort, heavy dragging Present with scrotal discomfort, heavy dragging sensation of the scrotum esp end of the daysensation of the scrotum esp end of the day

Can cause secondary infertilityCan cause secondary infertility

See mass of dilated tortuous veins lying superior See mass of dilated tortuous veins lying superior to and above the testis - “bag of worms”to and above the testis - “bag of worms”

Degree of dilation accentuated by Valsalva Degree of dilation accentuated by Valsalva maneuver. Feels like “bag of worms”maneuver. Feels like “bag of worms”

Confirmed by scrotal ultrasoundConfirmed by scrotal ultrasound

Pampiniform plexus

Spermatic Cord ExaminationSpermatic Cord ExaminationSpermatic Cord ExaminationSpermatic Cord Examination

VaricoceleVaricoceleRight sided varicocele or prominent varicose Right sided varicocele or prominent varicose veins around the umbilicus suggests renal cell veins around the umbilicus suggests renal cell carcinomacarcinoma

Pampiniform plexus

QuestionsQuestionsQuestionsQuestions

Focused Urologic examination consists of:Focused Urologic examination consists of:

a.)a.) InspectionInspectionb.)b.) PalpationPalpationc.)c.) PercussionPercussiond.)d.) Auscultation Auscultation e.)e.) All of the aboveAll of the above


Paraphimosis is:Paraphimosis is:

a.)a.) Inability to retract foreskinInability to retract foreskinb.)b.) Inability to pull down the foreskinInability to pull down the foreskin


Epispadius is a condition where:Epispadius is a condition where:

a.)a.) Urethral meatus is located on the ventral Urethral meatus is located on the ventral surface of the penissurface of the penis

b.)b.) Urethral meatus is located on the dorsal Urethral meatus is located on the dorsal aspect of the penisaspect of the penis


Right-sided varicocele suggests:Right-sided varicocele suggests:

a.)a.) Renal cell carcinomaRenal cell carcinomab.)b.) Testicular tumorTesticular tumorc.) c.) Prostate cancerProstate cancerd.)d.) EpididymitisEpididymitis


Testicular torsion is:Testicular torsion is:

a.)a.) Benign conditionBenign conditionb.)b.) Urologic emergencyUrologic emergencyc.) c.) Should be treated non-surgicallyShould be treated non-surgicallyd.)d.) Same as orchitisSame as orchitis


All men presenting with Urologic complaints require a prostate All men presenting with Urologic complaints require a prostate examination whereas women require a pelvic examination: examination whereas women require a pelvic examination:

A:A: true true B:B: false false


A A 45 year-old African American male presents with lower 45 year-old African American male presents with lower urinary tract obstructive voiding symptoms. What questions urinary tract obstructive voiding symptoms. What questions should be included in your medical history? should be included in your medical history?

A.A. history of benign prostatic hyperplasia (BPH) history of benign prostatic hyperplasia (BPH) B.B. American Urologic Association (AUA) 7 symptom score American Urologic Association (AUA) 7 symptom score C.C. family history of prostate cancer family history of prostate cancer D.D. prostatic specific antigen (PSA) level prostatic specific antigen (PSA) level E.E. all of the above all of the above


A A 35 year-old female with presents with history of gross hematuria. 35 year-old female with presents with history of gross hematuria. You decide she needs an intravenous pyelogram (IVP). You decide she needs an intravenous pyelogram (IVP). During the medical history you should have asked her about: During the medical history you should have asked her about:

A.A. drug allergies drug allergies B.B. current medications current medications C.C. any possibility she could be pregnant any possibility she could be pregnant D.D. any history of reaction to contrast dyes any history of reaction to contrast dyes E:E:.. all of above all of above

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