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Methodological Instructions for Students

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Methodological Instructions for Students

Theme: Clinical Assessment of Urological Symptoms.

Aim: To analyze urologic complaints and main symptoms correctly.

Professional Motivation:

Urologic symptoms are very different in nature. They are important in diagnosis of diseases and to differentiate among them. All urologic symptoms can be divided into four groups:

1) low back and flank pain with irradiation;

2) urine output pathology;

3) urine pathology;

4) pathologic urethral discharge and semen pathology.

Basic Level:

1. You should be able to obtain case history.

2. You should be able to determine symptoms from patient's history that could be related to urine output pathology.

3. You should be able to analyze data of urine examination.

4. You should be able to make uretheral discharge slides and to know semen characteristics both in normal and pathology.

Student's Independent Study Program

I. Objectives for Students Independent Studies.

1. Urologic symptoms: pain symptoms, symptoms of abnormal urine output, urine pathology.

2. You must know the symptoms of diseases: as low back pain, altered urination, pathology of urine specimen are typical.

You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:

  1. Anatomy of kidneys, ureters, urine bladder and urethra.

The kidneys lie along the borders of the psoas muscles and are therefore obliquely placed. The position of the liver causes the right kidney to be lower than the left. The adult kidney weighs about 150 g. The kidneys are supported by the perirenal fat (which is enclosed in the perirenal fascia), the renal vascular pedicle, abdominal muscle tone, and the general bulk of the abdominal viscera. Variations in these factors permit variations in the degree of renal mobility. The average descent on inspiration or on assuming the upright position is 4-5 cm.

The adult ureter is about 30 cm long, varying in direct relation to the height of the individual. It follows a rather smooth S curve. Areas of relative narrowing are found (1) at the ureteropelvic junction, (2) where the ureter crosses over the iliac vessels, and (3) where it passes through the bladder wall.

The adult bladder normally has a capacity of 350 – 450 mL. When empty, the adult bladder lies behind the pubic symphysis and is largely a pelvic organ.

  1. Physiology of kidneys, ureters, urinary bladder and urethra.

The kidneys play a central role in the maintenance of a constant internal environment for body cells in response to cellular catabolism and wide variations of dietary intake. It achieves this by regulating extracellular fluid and solute concentrations by the excretion of salts, water, metabolic waste products and foreingn substances. The process involves the productions of a plasma ultrafiltrate of 180 L per day. This passes down two million tubules from which essential solutes and water are reabsorbed into the blood and non-essential solutes secreted from the blood into the remaining fluid, which becomes the final urine. The other functions of the kidney include hormone production and gluconeogenesis.

  1. Main urologic symptoms.

Systemic manifestations, local & referred pain (kidney pain, pseudorenal pain,ureteral pain, vesical pain, prostatic pain, testicular pain, epididymal pain, back & leg pain), gastrointestinal symptoms of urologic disease, symptoms related to the act of urination (frequency, nocturia, & urgency, burning sensation during urination, enuresis, symptoms of prostatic obstruction, symptoms of urethral obstruction, incontinence, oliguria & anuria, pneumaturia, cloudy urine, bloody urine), other objective manifestations (urethral discharge, skin lesions of the external genitalia, visible or palpable masses, edema, bloody ejaculation, gynecomastia, size of penis in infant or child), complaints related to sexual problems.

  1. Pain in urologic pathology: character, localization, and irradiation.

Typical renal pain is usually felt as a dull and constant ache in the costovertebral angle just lateral to the sacrospinalis muscle and just below the 12th rib. This pain often spreads along the subcostal area towards the umbilicus or lower abdominal quadrant. It may be expected in those renal diseases that cause sudden distention of the renal capsule. Acute pyelonephritis and acute ureteral obstruction both cause this typical pain. Such disease include cancer, chronic pyelonephritis, staghorn calculus, tuberculosis, polycystic kidney, and hydronephrosis due to mild ureteral obstruction.

  1. Etiology of renal colic.

The pressure within the renal pelvis is normally close to zero. When this pressure increases because of obstruction or reflux, the pelvis and calices dilate. The degree of hydronephrosis that develops depends upon the duration, degree, and site of the obstruction. The higher the obstruction, the greater the effect upon kidney.

  1. Altered urination: dysuria, pollakiuria, precipitant urination, frequent urination, urinary difficulty, chronic urinary retention, paradoxical ischuria.

Chronic urinary retention: this may cause little discomfort to the patent even though there is great hesitancy in starting the stream and marked reduction of its force and caliber. Constant dribbling of urine (paradoxic incontinence) may be experienced. It may be likened to water pouring over a dam.

  1. Urinary incontinence. Enuresis.

Incontinence (true incontinence, stress incontinence, urge incontinence, paradoxic incontinence). Strictly speaking, enuresis means bedwetting at night. It is physiologic during the first 2 or 3 years of life.

  1. Acute urinary retention (etiology, treatment).

Sudden inability to urinate may supervene. The patient experiences increasingly agonizing suprapubic pain associated with severe urgency and may dribble only small amounts of urine.

  1. Anuria (settings, emergency aid).

Oliguria and anuria may be caused by acute renal failure (due to shock or dehydration), fluid-ion imbalance, or bilateral ureteral obstruction.

10) Differentiation within real urine incontinence and paradoxical incontinence, acute

urine retention and anuria.

11) Proteinuria, bacteriuria (kinds).

Proteinuria of any significant degree (2-4+) is suggestive of “medical” renal disease (parenchymal involvement).

  1. “Pathologic” proteinurias ; b) “Nonpathologic” proteinurias (physiologic, orthostatic).

A presumptive diagnosis of bacterial infection may be made on the basis of results of microscopic examination of the urinary sediment.

12) Pyuria. Three-glass maneuver.

In the sediment from clean-voided midstream specimen from men and those obtained by suprapubic aspiration or catheterization in women, more than 5-8 white blood cells per high-power field is generally considered abnormal (pyuria).

13) Abnormal urine specimen (altered urine output, pathological urine sediments).

Patients with recurrent urolithiasis may have an underlying abnormality of excretion of calcium, uric acid, oxalate, magnesium, or citrate.

14) Hematuria (settings). Two-glass maneuver.

The presence of even a few red blood cells in the urine (hematuria) is always abnormal and requires further investigation. If red blood cells predominate in the initial portion of the speciment, they are usually from the anterior urethra; those in the terminal portion are generally from the bladder neck or posterior urethra; and the presence of equal numbers of red blood cells in all containers usually indicates a source above the bladder neck (bladder, ureters, or kidneys).

^ Key words and phrases:

Pyuria, proteinuria, bacteriuria, acute urinary retention, dysuria, pollakiuria, paradoxical ischuria.
II. Tests and Assignments for Self-assessment

1. Causes of renal anuria.

A. Incompatible blood transfusion.

B. Shock, collapse.

C. Gall-stones in ureters.

D. Ureters'bandaging during gynaecologic operations.

E. Nephrectomy of solitary kidney.

2. A frequent urination during normal diurnal diuresis. How it’s called?

  1. Polyuria.

  2. Polydipsia.

  3. Pollakuria.

  4. Policetemia.

E. Disuria.

3. Which diurnal diuresis could be related to oliguria?

A. from 250 to 500 ml.

B. from 150 to 700ml.

C. from 0 to 50 ml.

D. from 100 to 500 ml.

E. from 50 to 200 ml.

4. Which diurnal diuresis could be related to polyuria?

A. over 2000 ml.

B. over 3500 ml.

C. 1500-2000 ml.

D. 1000-1500 ml.

E. over 1000ml.

^ Multiple choice. Choose the correct answer/statement:

Real life situations to be solved:

1. Patient S., at the age of 69; was admitted to the urology department, his complaints are urinary difficulty, increased urinary frequency, bloody urine. Was noted after urination dullness of the percussion sound under symphisis. Pastematzkiy's symptom is negative. The urination is 4 times during the night.

How the urinary difficulty and the urinary frequency called? How the bloody urine is called? Name of the diseases that these symptoms are typical for. What does the dullness of the percussion sound mean?

2. Patient C., at the age of 52, was admitted at the urology department; his complained of left low back pains, absence of urine or 2 days. There is one fact from his case history: patient suffers from urolithiasis for 12 years. The operation of right side nephrectonomy 3 years ago.

What is a preliminary diagnosis? How is it possible to differentiate acute urinary retention from anuria?

III. Answers to the Self-assessment.

The correct answers to the tests:

1. A.

2. C.

3. D.

4. A.

The correct answers to the real life situations:

1. Stranguria. Hematuria. These symptoms are typical for nonmalignant hyperplasia of prostate. Chronic urinary retention.

2. Left side renal colic. Postrenal anuria.

To provide catheterization of urinary bladder.

Visual Aids and Material Tools:

1. Slides.

2. X-ray photographs.

3. Tables.

Students Practical Activities:

Students must know:

1. Anatomy and physiology of ureters, kidneys, urine bladder, urethra.

2. Etiology of renal colics.

3. Main symptoms of urologic diseases.

4. Altered urination.

5. Abnormal urine specimen.

6. The constants of general urine specimen examination, test of Zemnitski, biochemical indicators of blood.

Students should be able to:

1. Provide catheterisation of urinary bladder with rubber catheter.

2. Measure residual urine volume.

3. Determine main symptoms of urologic diseases.

4. Analyze datas from the antecedent history that could be related to altered urination.

5. Analyze datas of diagnostic tests (general urine specimen examination, urine examination by Netchyporenko, Amburge, test of Zemnitski).

6. Provide palpation and percussion of the kidneys and urinary bladder.

7. Analyze semen test in urologic pathology.

Methodological Instructions to Lesson 2 for Students

Theme: Instrumental Methods of Examination in Urology

Aim: Introduction of instrumental usage in urology (cytoscopy, cathetor etc). To teach the construction and usage of some of them. Showing urinary bladder catheterization, cytoscopy and to introduce process of catheterization of ureter.

^ Professional Motivation:

In every urological practice Instrumental and Endoscopic methods of Examination of urinary bladder in patients plays very important role. To learn the usage of catheters, uretherscopy and cytoscopy.

Basic Level:

1. Usage of Intsruments in Diagnosis and Examination.

2. Anatomic-Morphological functions of the upper and lower urinary tracks.

Student's Independent Study Program

^ I. You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:

1. The method of cathetarisation of urinary canal with plastic cathetor.

After proper cleansing and lubrication, the catheter can be manipulated with a sterile-gloved hand. However, it may be simpler to grasp the catheter near its tip with a sterile clamp and hold the other end of the catheter between the fourth and fifth fingers of the same hand. The catheter can then be advanced with the clamp without being touched by the unsterile hand. Begin catheterization with the penis pointed slightly drawn out.

2. Types of urethral catheters.

In general, straight rubber catheters are used for routine diagnostic catheterization. However, a coude (elbow) catheter, which is stiffer and has a curved tip, may be more readily manipulated over an enlarged prostate that has elevated the bladder neck. Uretheral catheters are: Foley, Whistle-tip, Pezzer, Malecot, Robinson, Coude.

3. Method of catheterization of urinary canal with metallic cathetor (in women and men).

After proper urethral lubrication, the tip of the conductor enters the urethra. The conductor is in the horizontal position over the groin. The penis is pulled out on the conductor, which is advanced drown the urethra and moved simultaneously to the midline; its handle is gradually moved to the vertical position. The conductor will usually pass through the external urinary sphincter if gentle pressure is exerted on the handle at right angles to its shaft with one finger. When the conductor has passed all the way into the bladder it should be possible to rotate it freely.

4. Filiform & Followers.

Filiform and followers are instruments used to dilate narrow strictures. Filiforms have woven fiber cores with a coated surface; they are very pliable and smooth. Useful sizes are 3-6F. The follower is made of metal or of woven pliable fiber. Useful sizes are 8-30F.

5. Technique of passing filliforms.

After lubricant jelly has been instilled into the urethra, the filiform is introduced. If it is arrested, it must be partially withdrawn, and readvanced. If this fails, one or filiforms should be added to the first and all manipulplation should be epeated..

6. Observation of cystoscopy.

Modern cystourethroscopes have a metal sheath ranging in size from 8F to 26F and interchangeable fiberoptic telescopes allowing a view from 0 to 170 degress. The 0- or 30-degree lenses are best for visualizing the urethra, whereas the bladder walls are best inspected with the 70-degree lens. A retrograde (170-degree) lens must be used to see the vesical side of the bladder neck, particularly where prostatic tissue obstructs the view.

Complete endosscopic studies are among the most precise diagnostic tests in all medicine. Any urethral lesion ( eg, verrucae, tumors, strictures and diverticular), as well as the size and configuration of the prostate and bladder neck, are noted before the bladder is inspected. When the bladder is entered, the trigone is visualized and the size, shape, position, and number of ureteral orifices noted. The bladder wall is carefully inspected for tumors, stones, diverticula, ulcers, trabeculation, hemorrhage, and edema. The normal and abnormal cystourethroscopic findings must be specifically described.

7. Contraindications to cystoscopy.

Cystoscopy is contraindicated in acute urinary tract infection, because trauma may exacerbate the infection and lead to sepsis. It is relatively contraindicated in the presence of severe symptoms of prostatic obstruction, since trauma may produce just enough edema of the bladder neck to cause complete urinary retention. Of course, if cystoscopy is essential, this risk must be accepted.

8. Condition which is not necessary to carry on with cystoscopy.

Passage of urethra, volume of bladder more than 75 ml, transparence of environment.

9. Normal cystoscopic picture.

The bladder wall is dynamic, and as the bladder fills, small lesions will move away and may escape the examiner`s field. Special care must be taken not to overdistend the bladder and to make sure that all areas have been completely inspected, often with the bladder minimally filled initially. In adults, most of the bladder wall cannot be seen if the bladder contains more than 200-300 mL of urine.

10. Method of punction of urinary bladder.

A suprapubic catheter is useful in males when the urethra is impassable (eg, traumatic disruption or stricture), when there is epididymitis or severe urethritis, or when prolonged bladder drainage by means of an indwelling catheter is necessary. An indwelling urethral catheter predisposes to meatitis, urethritis, and epididymitis.

The skin of the suprapubic area is prepared and infiltrated with a local anesthetic. If the patients is in urinary retention, the bladder is usually readily palpated. The bladder must usually contain a minimum of 200-300 mL of urine before a suprapubic catheter can be inserted successfully.

The patient may be placed in the Trendelenburg position to move the intestine upwards. A thin lumbar puncture needle is inserted above the symphysis pubica and angled toward the perineum to locate the bladder a trocar is inserted into the bladder and the suprapubic tube passed. Size 8F, 10F, and 12F suprapubic catheters are available in prepackaged sets.

11. Ureteral catheterization.

These techniques are utilized in the evaluation of hematuria, chronic or recurrent urinary infection, unexplained urologic symptoms (eg, enuresis, frequency), and evaluation of congenital anomalies. They are also useful in any clinical situation in which excretory urograms have suggested pathologic change but have not furnished all the information necessary for definitive diagnosis and treatment.

^ Key words and phrases:

Cystoscope, cromocystoscopy, catheter.

П. Tests and Assignments for Self-assessment

1. With the help of which substance below, urological instruments work out?

(cystoscope, rezektoscope)?

A. Glycerin.

B. Vasilin.

C. Kolargol.

D. Novokain.

2. What is the physiological capacity of urinary bladder?

A. 100-150 ml.

B. 400-450 ml

C. 200-250 ml.

D. 300-400 ml.

^ Multiple choice. Choose the correct answer/statement:

Real life situation to be solved:

1. Patient P., 36 years complains of intensive pain in the left abdominal and right below the rib cage, a frequent urination. She fealt sick a day ago after a very tiredsome travel (vibrations). On examination stomach was normal and soft, in accordance to the left part under the rib cage. Symptom Pasternatskiy’s positive on the left part.

Approximate diagnosis?

What should be done to give exact diagnosis?

2. Patient L., 68 years after frequent urge to avoid urination, pain below stomach, after wich there was retention or (suppresion) of urine ischuria. Which type of medical aid is necessary to provide? What should be done to give accurate diagnosis?

III. Answers to the Self-assessment.

The correct answers to the tests:

1. A.

2. С.

The correct answers to the real life situations:

1. Left sided Renal colic. Chromocystoscopy should be done.

2. Catheterate urinary bladder. To get accurate diagnosis cystoscopy should be done.

Visual Aids and Materials.

1. Slides

1. 1 Rezektoscopy.

1. 2 Uretroscopy.

2. Instrumentation (different types of catheters, bouge, catheterization cystoscop, operative cystoscop).

Students' Practical Activities:

Students must know:

1. Anatomical and physiologal position especially the upper and lower urinary canals.

2. Method of catheterization of urinary bladder with metallic catheter.

3. To know catheters, bouge, cystoscope.

4. How to use cystoscope and chromocystoscope.

5. Normals in cystoscope.

6. Methodic of punction of urinary bladder.

Students should be able to:

1. Know how to provide catheterization of urinary bladder with elastic catheter.

2. Know all instruments ready to be used in urology.

3. To know normal graphs in instrumental examination of patients (cystoscope, chromoscope and etc).

Methodological Instruction to Lesson 3 for Students

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