Dr. med. Dirk Manski



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Medical History (Anamnesis)

Current Complaints

The medical consultation often begins with the question after current symptoms or problems, that have prompted the medical consultation. With specific questions, the mentioned symptoms are concretised concerning the localization, the temporal occurrence, the degree of severity and known triggers. Whenever possible, the symptoms should be quantified: e.g. visual analogue scale for pain, IPSS for micturition complaints or IIEF for erectile dysfunction.

The knowledge of the different causes for key symptoms is the basis to initiate further investigations and to quickly find the right diagnosis. The initial diagnosis remains a differential diagnosis due to a likelihood of error, but it is the basis for initiation of therapy. In the further course of treatment, the diagnosis must be questioned as long as the healing process continues.

Pain of Urological Organs

Pain from the urogenital tract may cause severe abdominal pain and is usually triggered by sudden obstruction of urinary flow or by inflammation. In contrast, gradually emerging urinary tract obstruction without inflammation is often painless.

Mechanisms of Kidney Pain and Renal Colic:

Kidney pain is caused by acute stretching of the renal capsule and is perceived in the costovertebral angle lateral to the erector spinae muscle. Infection causes continuous pain, whereas undulating pain (renal colic) speaks for a (variable) upper urinary tract obstruction, e.g. by ureteral stones.

Kidney pain may be associated with gastrointestinal symptoms due to autonomic reflexes, this may obscure correct diagnosis. Furthermore, other abdominal organs may cause pain in costovertebral angle. Signs of intraperitoneal diseases are guarding, shoulder pain, and patients who avoid carefully any type of movement to prevent the worsening of abdominal pain. For the differential diagnosis of acute abdominal pain, please see below.

Renal pain may be confused with irritation of the spine or the costal nerves. Typical signs of acute low back pain are motion-dependent pain and lack of colic.

Mechanisms of Ureteral Pain:

Ureteral pain is triggered by a sudden obstruction of the ureteral lumen, this causes strain and hyperperistalsis of the ureter. The pain is usually undulating (renal colic). Obstruction of the proximal ureter is perceived as renal pain in the costovertebral angle (see above). Pain caused by the middle ureter is projecting into the lower abdomen and to the scrotum or labia. Diseases of the distal ureter additionally may cause urinary frequency and dysuria.

Mechanisms of Bladder Pain:

Bladder pain is caused by distension in urinary retention (constant pain) or inflammation of the bladder (pain related to urination). Bladder pain is perceived suprapubic in the lower abdomen, with radiation to the penis. A constant suprapubic pain with normal micturition is usually not causes by bladder diseases.

Mechanisms of Prostate Pain:

Prostate pain is triggered by distension of the prostate capsule, but the pain is hard to localize. The patient reports perineal pain, abdominal pain or rectal pain. Furthermore, dysuria, urinary frequency or urinary retention are present. The most common cause of prostate pain are infections.

Testicular Pain:

Sudden testicular pain is caused by tauma, infection or torsion (of the testis or the hydatid), see also table~\ref{dd_hodentumor}. Pain is not only felt in the scrotum, but it projects also into the lower abdomen. Chronic testicular pain are caused by noninflammatory conditions as hydrocele, varicocele, spermatocele or tumors.

The scrotal pain sensation caused by ureteral diseases is explained by the embryological origin of the testis from the retroperitoneal space of the abdomen.

Penis pain:

Pain of the flaccid penis is caused by trauma, paraphimosis, urethral pain, or projection of bladder pain. Induratio penis plastica or priapism causes pain of the erect penis.

Key Symptoms in Urology

The knowledge of the various causes for signs and symptoms is the basis to target further studies and to quickly find the right diagnosis. The diagnosis stays, due to an error probability, a differential diagnosis. It is however the basis for the initiation of the treatment. As long as the healing process continues, the diagnosis must be questioned and other differential diagnosis must be kept in mind.

Past Medical History

Past or known medical illnesses are of high interest in the assessment of the current clinical picture. In addition, the patient is asked after key symptoms of all organ systems [see table key symptoms].

Review of systems: systematic questioning about different organ systems.
Questions to assess key symptoms
General questions Appetite? Thirst? Sleep problems? Night sweats? Body weight? Fever? Seizures?
Head and neck Eyesight? Headache? Dizziness? Sore throat? Lymph nodes?
Chest Cough? Sputum? Shortness of breath? Heart pain? Irregular pulse? Breast lumps?
Abdomen Diarrhea? Constipation? Blood in stool? Emesis? Abdominal pain?
Genitourinary tract Urine color? Micturition problems? Urinary incontinence? Sexual complaints? Pain or lumps?
Extremities Muscle or joint pain? Palsy? Dermatosis?

Medication

The exact recording of the medication provides valuable information on known diseases. Furthermore, side effects of drugs are often the cause of complaints of micturition or sexuality. Do not forget questions regarding known allergies.

Past Surgical History

Previously performed operations and their success should be recorded with date. Prior to scheduled surgery in pre-operated regions, an operation report from the previous operation is helpful.

Drug use

The assessment of alcohol and tobacco consumption allows for the identification of numerous clinical risks.

Risks associated with smoking:

Bladder cancer, upper urinary tract cancer, renal cell carcinoma, penile cancer, increased cardiovascular risk, erectile dysfunction, increased perioperative complications (wound healing, anastomotic leakage, pulmonary complications).

Risks associated with increased alcohol consumption:

Hypogonadism, peripheral neuropathy with disorders of sexuality or micturition, gynecomastia, increased perioperative complications (hepatic dysfunction, alcohol withdrawal syndrome, wound infection).

Family history

Targeted questions regarding the most common hereditary or family diseases in urology:

Social history

Including occupation, marital status and number of children.







Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z



References



  Deutsche Version: Anamnese und Symptome