1. Frequency, urgency, and nocturia.

 •Feel as if you cannot wait to urinate?

 •Awaken during the night because you need to urinate? How often? Is this a recent change?

Frequency.

Polyuria—excessive quantity.

Oliguria—diminished quantity, <400 mL/24 hours.

Urgency.

Nocturia occurs together with frequency and urgency in urinary tract disorders.

Other origins:

cardiovascular,

habitual,

diuretic medication.

2. Dysuria.

Dysuria.

3. Hesitancy and straining.

 •Need to strain to start or maintain stream?

 •Any change in force of stream: narrowing, becoming weaker?

 •Dribbling, such that you must stand closer to the toilet?

 •Afterward, do you still feel you need to urinate?

 •Ever had any urinary tract infections?

Hesitancy.

Straining.

Loss of force and decreased caliber.

Terminal dribbling.

Sense of residual urine.

Recurrent episodes of acute cystitis.

These symptoms suggest progressive prostatic obstruction.

4. Urine color.

Is the usual urine clear or discolored, cloudy, foul-smelling, bloody (Fig. 24-5)?

Cloudy in urinary tract infection.

Hematuria—a danger sign that warrants further workup.

5. Past genitourinary history.

•Accidentally urinate when you sneeze, laugh, cough, or bear down?

 •Any history of kidney disease, kidney stones, flank pain, urinary tract infections, prostate trouble?

Urge incontinence—involuntary urine loss from overactive detrusor muscle in bladder.

It contracts, causing urgent need to void.

Stress incontinence

—involuntary urine loss with physical strain, sneezing, or coughing due to weakness of pelvis floor.

6. Penis.

pain, lesions?

• Any discharge? How much? Has that increased or decreased since start?

 • The color? Any odor? Discharge associated with pain or with urination?

7. Scrotum, self-care behaviors.

 •Any lump or swelling on testes?

 •Any change in size of the scrotum? Any history of undescended testicle as infant?

•Noted any bulge or swelling in the scrotum? For how long?

Ever been told you have a hernia?

Any dragging, heavy feeling in scrotum?

Concern about any self-discovered mass

(spermatocele,

hydrocele,

varicocele,

rarely testicular cancer)

alerts you to careful exploration during examination.

Possible hernia.

8. Sexual activity and contraceptive use.

 •Are aspects of sex satisfactory to you and your partner?

 •Are you satisfied with the way you and your partner communicate about sex?

 •Occasionally a man notices a change in ability to have an erection when aroused. Have you noticed any changes?

*

Questions about sexual activity should be routine in review of body systems for these reasons:

• Communicates that you accept individual's sexual activity and believe it is important.

• Your comfort with discussion prompts person's interest and possibly relief that topic has been introduced.

 •Do you and your partner use a contraceptive? Which method? Is this satisfactory? Any questions about this method? 

•How many sexual partners have you had in the past 6 months?

•What is your sexual preference—relationship with a woman, a man, both?

• Establishes a database for comparisons with any future sexual activities.

• Provides opportunity to screen sexual problems.

Your questions should be objective and matter-of-fact.

Gay and bisexual men need to feel acceptance to discuss their health concerns.

 Men who have sex with men (MSM) are at increased risk for STI; psychological distress.

9.STI contact.

 •When was this contact? Did you get the disease?

 •How was it treated? Any complications?

 •Do you use condoms to help prevent STIs?

 •Any questions or concerns about any of these diseases?

aging adults

Additional History for the Aging Adult

1.Any difficulty urinating? Any hesitancy and straining?

A weakened force of stream? Any dribbling? Or any incomplete emptying?

Early symptoms of enlarging prostate may be tolerated or ignored.

Later symptoms are more dramatic:

hematuria,

urinary tract infection.

aging adults

2 Do you ever leak water/urine when you don't want to?

Do you use pads/tissue to catch urine in your underwear?

aging adult 

3. Do you need to get up at night to urinate? What medications are you taking?

What fluids do you drink in the evening?

Nocturia may be due to diuretic medication, habit, or fluid ingestion 3 hours before bedtime;

especially coffee and alcohol have a diuretic effect.

Also, fluid retention from mild heart failure or varicose veins produces nocturia because recumbency at night mobilizes fluid.

aging adult

4. Is it all right to ask you about your sexual function? This is something I ask all the men.

For example, it is normal for an erection to develop slowly at this age.

This is not a sign of impotence, but a man might wonder if it is.

 •Any change in your ability to have an erection?

 •Wanting to have an erection is normal, and it is treatable with medication.

Excluding physical illness, an older man is fully capable of sexual function.

But some assume normal changes mean that they are “old men” and withdraw from sexual activity.

The older person is not reluctant to discuss sexual activity, and most welcome the opportunity.

Depressants to sexual desire and function include antihypertensives, sedatives, tranquilizers, estrogens, and alcohol.

 Alcohol decreases the sexual response even more dramatically in the older person.

The skin normally looks wrinkled, hairless, and without lesions.

The dorsal vein may be apparent

Inflammation.

Lesions:

nodules,

solitary ulcer (chancre),

grouped vesicles or superficial ulcers,

wartlike papules

The glans looks smooth and without lesions.

Ask the uncircumcised male to retract the foreskin, or you retract it.

It should move easily. Some cheesy smegma may have collected under the foreskin.

After inspection, slide the foreskin back to the original position.

Inflammation. Lesions on glans or corona.

Phimosis

Paraphimosis—painful constriction of glans by retracted foreskin.

Hypospadias

Epispadias—dorsal location of meatus

At the base of the penis, pubic hair distribution is consistent with age.

Hair is without pest inhabitants.

Pubic lice or nits can be seen with the unaided eye.

Excoriated skin usually accompanies.

Compress the glans anteroposteriorly between your thumb and forefinger (Fig. 24-7).

The meatus edge should appear pink, smooth, and without discharge.

Stricture—narrowed opening.

Edges that are red, everted, edematous, along with purulent discharge, suggest urethritis

If you note urethral discharge, collect a smear for microscopic examination and a culture.

If no discharge shows but the person gives a history of it, ask him to milk the shaft of the penis.

This should produce a drop of discharge.

Palpate the shaft of the penis between your thumb and first two fingers.

Normally, the penis feels smooth, semifirm, and nontender.

Nodule or induration.

Tenderness.

INSPECT AND PALPATE THE SCROTUM

Inspect the scrotum as the male holds the penis out of the way.

Alternatively, you hold the penis out of the way with the back of your hand (Fig. 24-8).

Scrotal size varies with ambient room temperature.

Asymmetry is normal, with the left scrotal half usually lower than the right.

Scrotal swelling (edema) may be taut and pitting.

This occurs with heart failure, renal failure, or local inflammation.

Lesions.

scrotum

Spread rugae out between your fingers. Lift the sac to inspect the posterior surface.

Normally, no scrotal lesions are present, except for the commonly found sebaceous cysts.

These are yellowish, 1-cm nodules and are firm, nontender, and often multiple.

Palpate gently each scrotal half between your thumb and first two fingers (Fig. 24-9).

The scrotal contents should slide easily.

Testes normally feel oval, firm and rubbery, smooth, and equal bilaterally and are freely movable and slightly tender to moderate pressure.

Each epididymis normally feels discrete, softer than the testis, smooth, and nontender.

Inflammation.

Absent testis—may be a temporary migration or true cryptorchidism (see Table 24-6, Abnormalities in the Scrotum, pp. 704-706).

Atrophied testes—small and soft.

Fixed testes.

Nodules on testes or epididymides.

Marked tenderness.

An indurated, swollen, and tender epididymis indicates epididymitis.

Palpate each spermatic cord between your thumb and forefinger,

 along its length from the epididymis up to the external inguinal ring (Fig. 24-10, A).

You should feel a smooth, nontender cord.

Thickened cord.

Soft, swollen, and tortuous cord—see the discussion of varicocele

Normally, no other scrotal contents are present. If you do find a mass, note:

_ Any tenderness?

_ Is the mass distal or proximal to testis?

_ Can you place your fingers over it?

_ Does it reduce when the person lies down?

_ Can you auscultate bowel sounds over it?

Abnormalities in the scrotum:

hernia,

tumor,

orchitis,

epididymitis,

hydrocele,

spermatocele,

varicocele

Transillumination.

Serous fluid does transilluminate and shows as a red glow

(e.g., hydrocele or

spermatocele).

Solid tissue and blood do not transilluminate

(e.g.,

hernia,

epididymitis,

or tumor)

INSPECT AND PALPATE FOR HERNIA

Inspect the inguinal region for a bulge as the person stands and as he strains down.

Normally, none is present.

Palpate the inguinal canal (Fig. 24-11).

For the right side, ask the male to shift his weight onto the left (unexamined) leg.

Place your right index finger low on the right scrotal half.

Palpate up the length of the spermatic cord, invaginating the scrotal skin as you go, to the external inguinal ring.

It feels like a triangular slitlike opening, and it may or may not admit your finger.

If it will admit your finger, gently insert it into the canal and ask the person to “bear down.”*

Normally, you feel no change. Repeat the procedure on the left side.

Bulge at external inguinal ring or at femoral canal.

 (A hernia may be present but easily reduced and may appear only intermittently with an increase in intra-abdominal pressure.)

Palpable herniating mass bumps your fingertip or pushes against the side of your finger

PALPATE INGUINAL LYMPH NODES

Palpate the horizontal chain along the groin inferior to the inguinal ligament and the vertical chain along the upper inner thigh.

It is normal to palpate an isolated node on occasion;

it then feels small (<1 cm), soft, discrete, and movable

SELF-CARE—TESTICULAR SELF-EXAMINATION (TSE)

Encourage self-care by teaching every male (from 13 to 14 years old through adulthood) how to examine his own testicles.

The overall incidence of testicular cancer is rare, accounting for about 8000 new cases annually.

It is rare before age 15 years, peaks during ages 20 to 39 years, and then declines²⁰ and is associated with a history of cryptorchidism.

Some groups consider teaching TSE controversial because the harms of causing anxiety and unwarranted medical costs¹⁵ exceed the benefits of selective detection of a relatively rare lesion.

However, testicular cancer has no early symptoms.

When detected early and treated before metastasis, the cure rate is almost 100%.

Therefore include the teaching but adjust your message to emphasize familiarity with the young man's own body, rather than only cancer detection, as the goal.

Early detection is enhanced if the male is familiar with his normal consistency. Points to include during health teaching are:

_ T = timing, once a month

_ S = shower, warm water relaxes scrotal sac

_ E = examine, check for changes, report changes immediately

ASSESS URINARY FUNCTION

A urinalysis shows a color of pale yellow to amber due to the presence of urochrome pigments.

 Normal urine is clear and slightly acidic with a pH range of 4.5 to 8.0.

Specific gravity measures the concentration of urine, from very dilute at 1.003 to concentrated at 1.030.

There is little or no protein, no glucose, and fewer than 5 red blood cells (RBCs) or white blood cells (WBCs) per high-powered field.

Serum analysis of kidney function is measured with creatinine, an end-product of muscle metabolism.

 Normal levels range from 0.7 to 1.5 mg/dL and are fairly constant from day to day.

Blood urea nitrogen (BUN) measures urea, an end-product of protein metabolism.

 It measures 10 to 20 mg/dL and rises with a decrease in fluid volume or an increase in protein intake.

Cloudiness suggests presence of WBCs, bacteria, casts. Certain drugs or foods can change urine color (see Table 24-2).

Proteinuria indicates glomerular disease in the nephron.

Glycosuria suggests hyperglycemia occurring with diabetes.

Increased WBCs occur with urinary tract infection (UTI); increased RBCs occur with UTI, glomerulonephritis, renal calculi, trauma, and cancer.

Creatinine measures glomerular filtration rate (GFR).

When the GFR decreases by half, the serum creatinine level doubles,^6a indicating decreased kidney function.

The BUN rises with decreased kidney function but is less specific.

The Aging Adult

In the older male, you may note thinner, graying pubic hair and the decreased size of the penis.

The size of the testes may be decreased and may feel less firm.

The scrotal sac is pendulous with less rugae.

 The scrotal skin may become excoriated if the man continually sits on it.