9 · Urologic Workup & Diagnostics

Terminology, the focused history and exam, what the dipstick actually means, and how to pick the first test instead of ordering all of them.

Essential terminology

Term	Meaning
Hematuria	Blood in the urine, gross or microscopic. Gross hematuria in an adult is a sign of malignancy until proven otherwise.
Pyuria	White blood cells in the urine
Pneumaturia	Gas or air in the urine — think enterovesical fistula
Renal colic	Acute, unremitting, severe flank pain in waves
Hydronephrosis	Renal urinary obstruction, most often from an obstructing stone
Urinary stone	Any stone in kidney, ureter, bladder or urethra
UTI	Infection anywhere in the urinary tract — although patients and clinicians commonly use it to mean a bladder infection

Procedures and instruments — know what each one reaches

Instrument / procedure	What it does
Cystoscope	Looks in the bladder
Ureteroscope	Operating-room tool that looks up the ureter into the kidney
Nephroscope	Investigates the kidney during percutaneous nephrolithotomy
URS — ureteroscopic laser lithotripsy	Outpatient, general anesthesia; endoscope via urethra and bladder into the ureter; basket extraction or laser fragmentation. A stent is often left to drain the kidney while swelling resolves.
SWL — shock wave lithotripsy	High-energy shock waves from an electrical discharge, transmitted through water and focused on the stone with biplanar fluoroscopy. The density difference between soft tissue and hard stone releases energy at the stone surface and fragments it.
PCNL — percutaneous nephrolithotomy	Flank incision, hollow working sheath to the kidney under fluoroscopic or ultrasound guidance, endoscopic visualization and extraction. For the large stone burden.
Ureteral stent	Internal drainage of the kidney past an obstruction
TURP / nephrectomy / prostatectomy	Resection of obstructing prostate tissue; removal of kidney; removal of prostate

History

OLDCARTS for every new urologic complaint, and place it as acute vs chronic vs acute-on-chronic, stable vs worsening.
Red flags in the general review: fever — infection (prostatitis, pyelonephritis) versus malignancy; weight loss — advanced cancer versus renal insufficiency from obstruction or infection; general malaise — tumor, chronic pyelonephritis, renal failure.
Local versus referred pain. Kidney pain is felt at the costovertebral angle and flank; an inflamed testis hurts in the gonad itself. Ureteral colic from an upper ureteral stone refers severe pain to the ipsilateral testicle.
Many renal diseases are painless because they progress too slowly to distend the capsule suddenly. Absence of pain is not reassurance.
PMH: prior urologic conditions; prior urologic or abdominal surgery including hysterectomy, prostate surgery, bowel or colon surgery; prior GU or gynecologic cancers and their treatment; systemic disease — diabetes, hypertension, cardiovascular disease.
FH: GU cancers (prostate, kidney, bladder, testicular) and the age at diagnosis; stones, BPH, hereditary kidney disease.
Sexual history when warranted — you would not take one on an acute renal colic patient. Ask about partners in the last 3 months, practices, pregnancy potential, contraception, STI exposure, fertility goals, and gender-affirming anatomy when clinically relevant. Ask what outcome the patient actually wants from treatment.

Population	Important considerations
Infants and children	Prenatal abnormalities, urinary stream, toilet training, enuresis, fever without source, recurrent UTI, congenital abnormalities
Adolescents	Confidential history, sexual activity, STI risk, menstrual/pregnancy history, testicular pain, sports or genital trauma
Adults	LUTS, stones, infection, sexual function, fertility, pregnancy status, occupational exposures
Older adults	Retention, incontinence, medications, mobility, cognition, prostate symptoms, malignancy risk, functional status

Physical examination

Before you touch anything: consent, chaperone, proper draping, positioning, and respectful communication. Use an anatomically ordered checklist.
Abdomen and kidney: inspect shape, scars and skin; look along the upper abdomen and CVA for fullness. Auscultate the costovertebral areas and upper quadrants for a systolic bruit — renal artery stenosis or aneurysm. Kidneys are difficult to palpate; percuss for CVA tenderness.
Bladder: not normally visible or palpable. With massive distention from retention it may be visible between umbilicus and pubis in a thin patient, and palpable when moderately or markedly distended.
Penis: retract the foreskin if present. Inspect the glans for meatal position and diameter, scars, lesions, erythema; the shaft for lesions (HPV), erythema, ecchymosis. Palpate for tenderness and nodules and palpate the dorsal surface for a fibrous plaque — Peyronie's disease.
Scrotum and contents: inspect for edema, hydrocele, excoriation, erythema, drainage, necrotic tissue. Palpate testis for firm or hard nodules and tenderness; epididymis on the posterior surface of the testis for size, induration, swelling, tenderness; spermatic cord for the vas and for a varicocele — increased venous fullness with Valsalva.
Lymph nodes: inflammatory lesions of penile, scrotal or vulvar skin involve the inguinal and subinguinal nodes.
Rectal and prostate: sphincter tone, palpate the entire lower rectum through 360°. Prostate — size (heart-shaped, about a walnut), lateral sulci, median furrow, and consistency: normal feels like the contracted thenar eminence of the thumb; abnormal is mushy, indurated, nodular, or stone-hard.
Vaginal palpation: meatus for tenderness, friable lesions, soft masses, induration; vaginal vault — palpate the posterior bladder and assess for cystocele with Valsalva.
Age adjustments: undescended testes, meatal location and congenital abnormalities in children; confidentiality and assent in adolescents; pregnancy considerations; mobility, cognition, skin integrity and functional incontinence in the elderly.

Urinalysis — what each pad means

Finding	Interpretation
Blood	Confirm with microscopy; consider infection, stone, trauma, renal disease or malignancy
Leukocyte esterase	Suggests pyuria or inflammation
Nitrite	Supports nitrate-reducing bacteriuria; specific for bladder infection
Protein	May suggest renal disease; quantify if persistent
Glucose / ketones	Consider systemic metabolic disease
Specific gravity	Urine concentration / hydration status

An abnormal UA needs more evaluation when there is: persistent or gross hematuria, proteinuria, recurrent pyuria, suspected complicated infection, renal impairment, abnormal casts, or symptoms inconsistent with the dipstick result.
Microscopy high-yield: RBCs, WBCs, bacteria, squamous cells signaling contamination, casts — which localize disease to the kidney rather than the lower tract, and selected crystals.
Cultures identify the organism in repeated or ongoing infection and are crucial in renal insufficiency or drug allergy to tailor therapy and avoid adverse effects.

Other laboratory studies

Urethral discharge — Gram stain when STI is suspected. Semen analysis — fertility.
Renal function — CMP with BUN and creatinine. Prostate — PSA.
Testis cancer markers — β-hCG, AFP and LDH.
Endocrine and sexual function — parathyroid function, adrenal steroids, testosterone, FSH, LH, prolactin.
Tissue — biopsy or excision separates benign from malignant and supplies prognosis. Imaging suggests; histology decides.

Imaging — pick the modality for the question

Ultrasound — kidneys, testis and scrotum, bladder; transrectal for prostate, suprapubic for bladder. Real-time, no radiation, inexpensive, operator-dependent.
CT — the most common and valuable imaging study in urology, with and without contrast, for stones, tumors and structural abnormality.
MRI — less sensitive than CT for stones but superior for soft tissue: renal masses and prostate.
PSMA PET — targets prostate-specific membrane antigen; staging and monitoring metastatic prostate cancer.
Plain-film studies (KUB, IVP, cystogram/VCUG, retrograde pyelography) are infrequently used and largely replaced by cross-sectional imaging, but each retains a specific utility.
Retrograde endoscopic evaluation: urethroscopy (urethra), cystoscopy (bladder), ureteroscopy (ureter), and bilateral retrograde pyelography — contrast injected up both ureters to visualize ureters, renal pelvis and collecting system.

Choosing the initial test

Presentation	Initial evaluation
Dysuria / frequency	UA ± urine culture
Gross hematuria	UA, renal function, imaging and urologic evaluation
Renal colic	UA, renal function, pregnancy test when applicable, non-contrast CT or ultrasound
Scrotal pain	Doppler ultrasound when torsion cannot be excluded clinically
Retention	Bladder scan / post-void residual, UA, renal function
Recurrent UTI	Culture and assessment for contributing factors
Suspected prostate disease	PSA when indicated, DRE when appropriate, urology evaluation

When to refer

Emergent: acute urinary retention, severe flank pain, obstructive uropathy, obstructive uropathy with infection, testicular torsion, priapism, Fournier's gangrene or scrotal abscess.
Prompt: evaluation of gross hematuria; abnormal post-void residuals; suspected testicular malignancy; controlled flank pain with a known ureteral stone.
Routine: persistent microscopic hematuria; abnormal urinary tract imaging; solid or complex renal masses; recurrent UTI (>3 in 6 months or >4 in 12 months); men with moderate-to-severe LUTS not responding to medical therapy; elevated PSA or suspicion of prostate cancer; failure of initial management of urinary incontinence.

⭐ The two sentences that generate most urgent referrals. "Gross hematuria in an adult is malignancy until proven otherwise" — that patient gets upper-tract imaging and cystoscopy, not a course of antibiotics and reassurance. And "blood at the meatus means no catheter". Both are absolute, both are commonly violated, and both are the difference between a routine workup and a preventable disaster.

Order the test that answers the question you actually have. Ultrasound answers "is it obstructed?" and "is it solid or cystic?". Non-contrast CT answers "is there a stone?". CT urogram answers "is there a lesion anywhere from calyx to bladder?". MRI answers "what is this soft tissue?". A dipstick answers none of them — it only tells you which question to ask next.