Please note: This page is intended for healthcare professionals only. It is designed as a general educational guide and does not replace local guidance, senior clinical advice, or individual clinical judgement. Patients should not use this page as medical advice and should seek advice from an appropriate healthcare professional.
History & Examination
A comprehensive history and examination are as essential in urology as they are in all other specialties. This section will focus on the key areas of a basic urological history, examination and review of investigations. Other resources may be used to hone the aspects these skills outside of urology.
History Taking
Urological history taking should follow the standard basic structure:
1Presenting complaint (PC)
2History of presenting complaint (HPC)
3Past medical history (PMH)
- Urology specific questions:
- Urological conditions in childhood
- Prior abdominal/pelvic surgery – especially urological
- Prior implants, including abdominal, pelvic or inguinal meshes
- Prior abdomino/pelvic radiotherapy – risk of cancer, radiation cystitis, strictures
4Drug history (DH)
- Medications for LUTS
- For voiding aka “Prostate medications” - tamsulosin, finasteride
- For overactivity aka “Bladder medications” - B3 adrenoceptor agonists (mirabegron), anti-muscarinics (eg. solifenacin, tolteradine)
- Androgen deprivation therapy (hormones) for prostate cancer
- SGLT2 inhibitors – may significantly increase the risk of complex UTIs
- Anticoagulants and anti-platelets
5Family history (FH)
6Social history (SH)
- Smoking - important for bladder/upper tract cancer risk
- Alcohol/caffeine/fluid habits - can worsen LUTS, urgency, nocturia
- Sexual history – important in testicular pain or suspected STD
7Allergies
Red flag symptoms
- Visible or persistent non-visible haematuria without a clear cause (UTI, recent traumatic catheterisation)
- New persistent back/bone pain in a patient with known/suspected malignancy
- Constitutional symptoms - unintentional weight loss, loss of appetite, fatigue
- Nocturnal enuresis – may suggest high pressure chronic retention
- Neurological symptoms with urinary retention/incontinence
Prior investigations
It is important to review prior investigations:
- Imaging – do they have known stones?
- Bloods – what is their renal baseline? Is there an unaddressed raised PSA?
- Urine cultures – will your antibiotics work?
Useful adjuncts to urological history taking
Not usually used acutely, but helpful in outpatient assessment and follow-up.
Questionnaires
Risk calculators
(This list is not exhaustive)
Physical Examination
The common examinations specific to urology include:
1Abdominal examination
- Inspecting and palpating the abdomen, flanks and back
- Look for guarding, rebound tenderness
- Is there renal angle tenderness?
- Abnormal masses
- Palpate and percuss the bladder - urinary retention?
- Scars – previous surgery? Transplant?
- If there is a stoma, examine its viability and output
2Testicular examination
- External inspection - skin integrity, evidence of infection or wounds, bruising, large swelling/masses, are both testicles present?
- Examine inguinal region - ?lymphadenopathy ?hernias ?undescended testicle in inguinal canal
- Palpate testicles
- Start with “normal” testicle – that can be your reference
- Palpate
- Testicle – superior, middle, inferior aspect
- Epididymis – head, body, tail
- Cord – is vas present?
What are you looking for?
Masses:
- Hard, discrete masses – may suggest malignancy
- Fluid filled swellings may feel soft, fluctuant and transilluminate
- The whole testicle = hydrocele
- At epididymis only = epididymal cyst
- Can you get above?
- • No = possible inguino-scrotal hernia
- • Yes = originates from testicle/scrotum
- Does it transilluminate?
- • Yes = fluid filled ?hydrocele
- Dilated veins at spermatic cord like “bag of worms = varicocele
Pain
- Pain only at epididymis = epididymitis
- Prehn’s sign – pain relieved on testicular elevation = epididymo-orchitis
- This is not a reliable sign, and its presence or absence should not affect clinical decision making
Position:
- Testicular lie – should be vertical with epididymal head at the top. Abnormal lie suggest torsion.
- • Horizonal?
- • High riding?
- Other stigmata suggestive of testicular torsion
- • Absent cremasteric reflex
- • Twisted spermatic cord
3Perineum
Perineum – assess for possible Fournier’s gangrene, bruising
4Female external genitalia
- Female external genitalia – look for:
- Prolapse
- Thrush
- Atrophic vaginitis
- Meatal stenosis
5Digital rectal examination (DRE)
- Assess prostate
- Size
- Hard nodules suggestive of prostate cancer
- Pain – suggest prostatitis
- Anal tone – if you suspect CES or MSCC
- Haemorrhoids, perianal abscess, PR bleeding and faecal impaction
6Lower limb neurological examination
- Lower limb neurological examination – if:
- Suspected CES or MSCC
- Unexplained retention (esp. retention in young patients)
Bedside investigations to aid diagnosis
- Urine dip
- Post-void bladder scan
- Measure voided volume (ask to void into bottle OR measure pre-void mls and then subtract post-void mls)
- Measure immediately post-void