OBJECTIVE DATA

Physical Examination
Inspection : Assess for changes in the following:
Skin: Pallor, yellow gray cast, excoriations, changes in turgor, bruises, texture (e.g., rough, dry skin) (see
Table 19.9 for assessment of dark skinned individuals).
Mouth: Stomatitis, ammonia breath odor
Face and extremities Generalized edema, peripheral edema
Abdomen : Abdominal contour for midline mass in lower abdomen (may indicate bladder distention and
urinary retention) or unilateral mass (occasionally seen in adults, indicating enlargement of one or both
kidneys from large tumor or polycystic kidney)
Weight: Weight gain secondary to edema. Weight loss and muscle wasting in kidney failure
General state of health: Fatigue, lethargy, and diminished alertness
Palpation : The kidneys are posterior organs protected by the abdominal organs, ribs, and heavy back
muscles. A landmark useful in locating the kidneys is the costovertebral angle (CVA) formed by the rib cage
and the vertebral column. The normal-sized left kidney is rarely palpable because the spleen lies directly on
top of it. Occasionally the lower pole of the right kidney is palpable.
To palpate the right kidney, place your left (anterior) hand behind and support the patient's right side
between the rib cage and the iliac crest. Elevate the right flank with the left hand. Use your right hand to
palpate deeply for the right kidney: The lower pole of the right kidney may be felt as a smooth, rounded
mass that descends on inspiration. If the kidney is palpable, note its size, contour, and tenderness. Kidney
enlargement is suggestive of neoplasm or other serious renal pathologic conditions
The urinary bladder is normally not palpable unless it is distended with urine. if the bladder is full, it
may be felt as a smooth, round, firm organ and is sensitive to palpation.
Percussion : Tenderness in the flank area may be detected by fist percussion (kidney punch). This technique
is performed by striking the fist of one hand against the dorsal surface of the other hand, which is placed flat
along the posterior CVA margin. Normally this type of percussion should not elicit pain. If CVA tenderness
and pain are present, it may indicate a kidney infection or polycystic kidney disease.
A bladder is not normally percussible until it contains at least 150 ml of urine. If the bladder is full,
dullness is heard above the symphysis pubis. A distended bladder may be percussed as high as the umbilicus.

Auscultation : Use the diaphragm of the stethoscope to auscultate the bowels, since they may also affect the
urinary system.
DIAGNOSTIC STUDIES
1) Endoscopy/Cystoscopy – Inspects interior of bladder with a tubular lighted scope (cystoscope). Can
be used to insert ureteral catheters, remove stones, obtain biopsy specimens of bladder lesions and
treat bleeding lesions. Lithotomy position is used. Procedure may be done using local or general
anesthesia, depending on patient’s need and condition. Complications include urinary retention,
urinary tract hemorrhage, bladder infection and perforation of bladder.

2) Computed tomography scan (CT) – Visualizes kidney, ureters and bladder. Can detect tumors,
abscesses, suprarenal masses and obstructions. Done with or without contrast media. Contrast is
iodine based.

3) Cystogram – Visualizes bladder and evaluates vesicoureteral reflux. Evaluates patient with
neurogenic bladder and recurrent UTIs. Can delineate abnormalities of bladder. Contrast media is
instilled into bladder via cystoscope or catheter.

4) Intravenous pyelogram (IVP) – Visualizes urinary tract after IV injection of contrast media.
Evaluates size and shape of kidneys, ureters and bladder. Cysts, tumors, and ureteral obstructions
distort normal appearance of these structures. Patient with decreased renal function should not have
IVP because contrast media can be nephrotoxic.

5) Kidneys, Ureters, Bladder (KUB) – X-ray examination of abdomen and pelvis. Define the size,
shape and position of kidneys, ureters and bladder. Can see radiopaque stones and foreign bodies.

6) Loopogram – Detects obstructions, anastomotic leaks, stones, and reflux when patient has a urinary
pouch of fast conduct. Because urinary diversions are created with bowel, there is risk for absorption
of contrast media.

7) Magnetic resonance angiography – Visualizes renal vasculature. Gadolnium-enhanced studies

8) Magnetic Resonance Imaging (MRI) – Visualizes kidneys. Not proven useful for detecting urinary
stones or calcified tumors.

9) Nephrostogram (Antegrade pyelogram) – Evaluates upper urinary tract when patient has allergy to
contrast media, decreased renal function or abnormalities that prevent passage of a ureteral catheter.
Contrast media may be injected percutaneously into renal pelvis or via a nephrostomy tube that is
already in place when determining tube function or ureteral integrity after trauma or surgery.

10) Renal Arteriogram – Visualizes renal blood vessels. Can aid in diagnosing renal artery stenosis,
extra or missing renal blood vessels, and renovascular hypertension. Can aid in distinguishing
between a renal cyst and renal tumor. A catheter is inserted into the femoral artery and passed up the
aorta to the level of renal arteries. Contrast media is injected to outline renal blood supply.

11) Renal Biopsy – Obtains renal tissue for examination to determine type of kidney disease or to follow
progress of kidney disease. Usually done as a skin (percutaneous) biopsy through needle insertion
into lower lobe of kidney under CT or ultrasound guidance.

12) Renal scan – Evaluates anatomic structures, perfusion and function of kidneys, IV radioactive
isotopes are injected. Radiation detector probes are placed over kidney and scintillation counter
monitors radioactive material in kidney. Radioisotope distribution in kidney is scanned and mapped.
Shows location, size and shape of kidney and assesses blood flow, glomerular filtration, tubular
 function and urinary excretion. Abscesses, cysts and tumors may appear as cold spots because of
nonfunctioning tissue. Monitors function of a transplanted kidney.

13) Renal Ultrasound – Detects renal or perirenal masses tumors, cysts and obstructions. Small external
ultrasound probe is placed on patient’s skin, Conductive gel is applied to skin. Non-invasive
procedure involves passing sound waves into body structures and recording images as they are
reflected. Computer interprets tissue density based on sound waves and displays it in picture form.
Can be used safely in patients with renal failure.

14) Retrograde Pyelogram – X-ray of urinary tract taken after injection of contrast material into
kidneys. May be done if an IVP does not visualize the urinary tract or has decreased renal function. A
cystoscope is inserted and ureteral catheters are inserted through it into renal pelvis. Contrast media
is injected through catheters.

15) Urethrogram – Similar to a cystogram, contrast media is injected retrograde into urethra to identify
structures, diverticula or other urethral pathologic conditions. When urethral trauma is suspected, a
urethrogram is done before catheterization.

16) Voiding Cystourethrogram – Voiding study of bladder opening and urethra. Bladder is filled with
contrast media, Fluoroscopic films are taken to visualize bladder and urethra. After urination, another
film is taken to assess for residual urine, Can detect abnormalities of lower urinary tract, urethral
stenosis, bladder neck obstruction, and prostatic enlargement.

17) Cystometrogram – Evaluates bladder’s capacity to contract and expel urine. Involves insertion of
catheter and instillation of water or saline solution into bladder. Measurements of pressure exerted
against bladder wall are recorded. This tube is attached to a small fluid filled balloon to allow
pressure recording.

18) Radionuclide cystography (RNC) – Detects and grades vesicoureteral reflux. Like VCUG with a
small dose of radioisotope tracer instilled into the bladder via urethral catheter.

19) Sphincter electromyography (EMG) – Recording of electrical activity created when nervous
system stimulates muscle tissue. By placing needles, percutaneous wires or patches near the urethra,
pelvic floor muscle activity can be assessed. During the cystometrogram,, sphincter EMG is used to
identify voluntary pelvic floor muscle contractions and response of these muscles to bladder filling,
coughing and other provocative maneuvers.

20) Urine flow study (Uroflow) – Measures urine volume in a single voiding expelled in a period. Used
to assess the degree of outflow obstruction caused by such conditions as benign prostatic
hyperplasia, assess bladder or sphincter dysfunction effects on voiding.

21) Videourodynamics – Combination of cystometrogram, sphincter EMG, and/or urinary flow study
with anatomic imaging of the lower urinary tract, typically via fluoroscopy. Used in selected cases to
identify an obstructive lesion and characterize anatomic changes in bladder and lower urinary tract.

22) Voiding pressure flow study – Combines a urinary flow rate, cystometric pressures and sphincter
EMG for detailed evaluation of micturition. It is completed by assisting the patient to a specialized
toilet to urinate while the various pressure tubes and EMG apparatus remain in place.

23) Whitaker study – Measures the pressure differential between renal pelvis and bladder. Ureteral
obstruction can be assessed. Percutaneous access to renal pelvis obtained by placing a catheter in
renal pelvis, A catheter is placed in bladder. Fluid is perfused through the percutaneous tube or
needle at a rate of 10 ml/min