One of diagnostic methods in urology is palpation. Let's learn how to palpate organs genitourinary system.

Palpation of the kidneys

Palpation of the kidneys is carried out with both hands supine position patient. One hand is placed in the hypochondrium, and the other is placed under the lower back. As you exhale, bring your fingers together. In a situation where a patient with excess fat is being examined subcutaneous tissue, the procedure is performed by placing the subject on his side with the leg pressed to the body on the side of the study. If palpation is carried out with the patient standing, it is necessary for him to bend slightly forward to relax the muscles of the abdominal anterior wall.

U healthy person the kidneys are not palpable normally. It is possible to palpate an organ only when it is enlarged (due to a tumor, pyonephrosis). However, it is sometimes possible to palpate the lower pole right kidney in absolutely healthy but thin people.

In the absence of pathology, the procedure is painless, but if severe pain occurs on palpation, this indicates the presence of a problem (hydronephrosis). With such diseases, even light tapping in the area of ​​the costovertebral angle can be accompanied painful sensations ().

For the ureters, palpation is impossible. In some cases the stone large size in the lower third of the ureter can be palpated in men through the rectum and through the vagina in women.

Bladder palpation

For the bladder, palpation is possible if its volume exceeds 150 ml or large formations are present. Palpation of the bladder diagnoses its overflow (chronic or acute).

Palpation of the penis and scrotal organs

Palpation of the penis allows you to identify local compaction, for example, with (fibroplastic induration of the penis) or cavernosis (inflammation of the corpus cavernosum). In men, palpation of the urethra is carried out along the lower surface of the penis; a similar examination in women is carried out through the vagina. If palpation of the projection zone urethra reveals some soreness, this may be a sign of pathology inflammatory in nature(), while compaction may indicate the development of sclerotic processes (). Sometimes a stone in the urethra is palpable.

Palpation of the scrotal organs is carried out in a lying and/or standing position. The examination is carried out in a warm room.

On both sides, the presence, consistency and size of the testicles are determined in turn. Then the spermatic cords and appendages are palpated. The examination reveals:

• absence of both testicles or only one (castration, anorchidism, cryptorchidism);
• testicular atrophy or hypoplasia;
• pain, enlargement of the testicles and their appendages (epidydymal cyst, testicular tumor, epididymitis, orchitis);
• in the area of ​​the epididymis, which is fused to the testicle, there is a lumpy compaction and simultaneous thickening, reminiscent of a rosary, of the vas deferens (may be a sign of tuberculous epididymitis).

Feeling the elements of the spermatic cord at rest and when straining allows you to diagnose varicocele ( varicose veins veins).

If there is severe pain and enlargement of the organ in the scrotum area, differential diagnosis and orchiepididymitis. Torsion is typically characterized by a high position of the testicle, and rotation may also occur, as a result of which the epididymis is located anterior to the testicle. Important role plays a role in differentiating these pathologies Prehn's sign. Positive symptom Prena is observed in orchiepididymitis - pain decreases when the testicle is raised. A negative Prehn's sign (preservation or even increased pain during the mentioned manipulation) is a sign of testicular torsion.

Examination of the scrotum may be required if a number of specific pathologies are suspected. Typically, examination of the scrotal organs is first performed manually. Upon palpation, the texture of the tissue is determined, the presence of foreign inclusions and neoplasms is excluded. An experienced doctor will be able to determine the condition of the spermatic cord and main vessels.

It is important to exclude various enlargements and changes in the shape of the testicles. This may indicate development dangerous diseases. About how palpation is carried out and for what characteristic features It is worth paying attention during this medical procedure, as described in this article.

Diseases of the scrotal organs in men

When inspecting this area, keep in mind possible diseases scrotum: hypospadias, varicocele, hydrocele of the spermatic cord and testicle.

Hypospadia (hypospadia; hypo- + Greek spadon - hole; synonym: lower cleft of the urethra; lower cleft (slit) of the urethra) is a developmental anomaly: the absence of the distal part of the male urethra with the localization of its external opening in an unusual place.

So, the hypostage can be:

• Scrotal ( h. scrotalis) - the spongy part of the urethra is missing, and its external opening is located in the scrotum area;
• Penis (L. penis ; synonym: stem) - the spongy part of the urethra is absent or underdeveloped, and its external opening is located along the spongy body of the penis;
• Perineal ( L. perinealis) - the spongy and membranous parts of the urethra are absent, and its external opening is located on the perineum;
• Penis-scrotal ( L. peniscrotalis) - scrotal, in which the external opening of the urethra is located on the border of the body of the penis and the scrotum.

Varicocele(varicocele; from Latin varix, varicis + Greek kele bulging, swelling) - a disease of the scrotum in men with dilated veins, varicose swelling. This is an expansion and lengthening of the veins of the spermatic cord, accompanied by pain and a feeling of heaviness in the testicular area.

Hydrocele(hydrocele; from hydro + Greek kele - bulging, hernia; synonym: hydrocele of the testicular membranes) - accumulation serous fluid between the visceral and parietal plates of the tunica vaginalis of the testicle.

Hydrocele of the spermatic cord (hydrocele funiculi spermatid; synonym: cyst of the spermatic cord, funiculocele) is an accumulation of serous fluid between the sheets of the membrane of the mixed cord, resulting from premature closure of the communication between the vaginal process of the peritoneum and the peritoneal cavity, sometimes after inflammatory process or injury.

Hydrocele is expressed as a significant enlargement of one of the halves of the scrotum. With this disease of the scrotal organs, the swelling has a fusiform or ovoid shape and distinct contours both on the medial side and in the upper section. At large cluster fluid, the stretched skin appears shiny, the penis appears sharply reduced in size.

Acute orchitis is characterized by a sudden increase in body temperature and progressive enlargement of the testicle.

More often, orchitis occurs against the background infectious disease(flu, mumps, pneumonia), being its complication. Unlike a strangulated hernia, it is not accompanied by symptoms intestinal obstruction. Testicle in case acute inflammation becomes tense and sharply painful on palpation. As a rule, it can be “separated” from the external inguinal ring, which becomes accessible during palpation, which is impossible to do with strangulated hernia. With orchiepididymitis, the epididymis is also involved in the process.

Palpation of the scrotum

When palpating the scrotal area, it is first necessary to establish the presence of testicles in it, their comparative size, consistency, and sensitivity. The absence of a testicle in the scrotum is a consequence of cryptorchidism (criptorchisrrius; synonym: cryptorchidism, cryptorchidism, retencio testis) - a developmental anomaly: the absence of one or both testicles in the scrotum, due to a delay in their intrauterine movement from the retroperitoneal space. In case of inguinal cryptorchidism (c. inguinalis), the area of ​​the inguinal canal is carefully palpated in order to detect the testis retained here (retencio testis inguinalis); if it is absent, abdominal cryptorchidism should be assumed (c. abdominalis, retencio testis abdominalis). It is necessary to distinguish between false cryptorchidism (p. spurius; synonym: pseudoretention of the testicle, migrating testicle), a variant of the location of a normally descended testicle, in which it can periodically be outside the scrotum under the influence of contraction of the levator testis muscle.

For testicular tumors, a painless lump with an uneven or bumpy surface is determined. The epididymis is located on its superior surface. Affected by a specific process, it sharply increases in size and becomes painful on palpation.

Proximal to the epididymis are determined seminal vessels and the vas deferens, which is more dense. Palpation of the spermatic cord (including its veins) is carried out by grasping it between the greater and index fingers through the skin of the scrotum.

The detection of clear-shaped seals in the wall of the vas deferens makes one suspect latent tuberculosis of the genitourinary system. With varicocele, snake-like dilated veins are palpated in the form of elongated, twisted, soft knotted cords, sliding between the fingers, easily collapsing when pressing or lifting the testicle upward.

See how the scrotum is palpated - the video shows the entire technique of this procedure:

Men are sometimes diagnosed rare anomaly development of the reproductive system, in which one of the testicles appears doubled in the scrotum. This pathology is called polyorchidism. Even less common is duplication of both testicles. Experts note that it is superfluous, and in most cases underdeveloped.

Etiology of pathology

Polyorchidism is the appearance of a third testicle in the scrotum or inguinal canal. There are almost isolated cases when it is located in the abdominal cavity. In this case, it is extremely difficult to detect, because the presence of two normal testicles in the scrotum does not in any way indicate the presence of a third, less developed one in the cavity.

The accessory testicle is less developed, and its vas deferens is just as imperfect. The system performs its sexual function as usual when normal development scrotal organs. The pathology is detected completely by chance when preventive examinations or palpated by the patient himself. An additional formation is found most often on the left side.

The photo shows the third testicle with polyorchidism

Reasons for the formation of an accessory testicle

The main cause of pathology is considered to be the division of the genital fold even during the formation of the fetus in the womb by ligaments abdominal cavity, called mesenteric. This happens at 4-6 weeks of pregnancy. Duplication affects one or two testicles at once. Similarly, the epididymis or vas deferens can double.

Factors provoking pathology are:

• Genetic predisposition;
• Stressful state of a woman during pregnancy;
• Transferred viral diseases pregnant in the early stages.

Much less often, an anomaly in the intrauterine formation of the sexual and reproductive system in the fetus without the influence of negative external factors.

It is impossible to determine the presence of three testicles in a fetus or even an infant. Their descent into the scrotum occurs some time after birth, and the size of the testicles is so small that the doctor simply cannot determine the pathology upon palpation.

Clinical picture of polyorchidism

The additional testicle does not cause any discomfort or inconvenience. A man can live his whole life without realizing the presence of this pathology. There is no special effort to detect it, since cases of its formation are extremely rare. An extra testicle can degenerate into a tumor, and when identified, the cause of the tumor is determined. Then this pathology can be identified.

Prerequisites for degeneration into a tumor can be:

• Regular hypothermia of the body;
• Viral or bacterial infections genitourinary system;
• Exposure to radiation;
• Failure to maintain intimate hygiene;
• Genetic failure in the background negative influence ecological situation.

Polyorchidism develops asymptomatically. Additional examination, which may reveal pathology, is performed if a hernia is suspected or if there is a defect in testicular descent. Degeneration into a tumor is accompanied by an increase in body temperature and pain in the area where the third testicle is located.

Diagnostic measures

Testicular polyorchidism is most often found in patients in adolescence with the start of planned medical examinations. The main type of diagnosis is palpation of the scrotum. If the additional testicle is located in the abdominal cavity, then such an examination will not reveal it. If pathology is detected, a biopsy is performed.

No matter how harmless the presence of a third testicle may seem, its presence still poses some threat to the patient. There remains a risk of its transformation into a tumor.

If polyorchidism is suspected, several instrumental diagnostic methods are used:

1. Ultrasound examination of the scrotum and abdominal cavity.
2. Computer or magnetic resonance imaging.
3. Laparoscopy.

During diagnosis, it is important to exclude the presence of other pathologies (tumor, cyst, scrotal disease, testicular inflammation). When the accessory testicle is located in the scrotum, its size may be visually larger, which will also attract medical attention to the organ.

When palpating the scrotum by the patient himself or the attending physician, three testicles are felt, one of which is smaller in size than the other two. A noticeable difference in size and underdevelopment of the extra testicle will also be visible on ultrasound. Using this type of study, it is difficult to identify pathology localized in the abdominal cavity. Blood or urine tests, as well as spermogram results, do not show polyorchidism. Palpation of a bifurcated testicle or its display on the monitor are the most accurate when making a final diagnosis.

Treatment

When pathology of the development of the third testicle in men is detected, the only treatment method is surgical intervention. The operation can be performed immediately after diagnosing the deviation. The sooner this is done, the lower the risk of the excess testicle degenerating into a malignant neoplasm.

There are several methods of surgical intervention for polyorchidism:

1. Standard (using a scalpel).
2. Bloodless.

In the second case, the intervention is performed using modern equipment, and the patient is allowed to go home the next day or every other day. During the operation, not only the third testicle, but its appendages and seminal ducts are removed.

The intervention is performed under local anesthesia and takes up to two hours. With standard surgery, the patient is discharged after 4 days. Medical monitoring of the patient lasts about another month.

During this time, men should avoid excessive physical activity, eat well and spend more time on fresh air. If necessary, the time of physical rest from exercise can be increased.

The bloodless operation takes no more than an hour. A catheter is inserted into a small incision on the scrotum, through which a mini-video camera is inserted and necessary tools. The operation is performed under local anesthesia. Painful sensations The patient is observed for 2 days after the intervention.

Forecast

After treatment of polyorchidism, men completely retain their sexual and reproductive functions. Surgical intervention, carried out using any of the methods, has a favorable prognosis for the health of patients. After the operation, a month of sexual abstinence is recommended. Adolescence is considered the most favorable age for detection and treatment.

Palpation is the main method of physical examination. Before palpation, the doctor sits at the patient’s bedside so that he can see his face. At the beginning of the examination, the condition of the skin and the thickness of the subcutaneous fat are determined. The degree of participation of the abdominal wall in breathing is assessed. During palpation, pain and tension in different parts of the anterior abdominal wall are determined.

The kidneys are palpated in three positions of the patient: horizontal, on the back and on the side, as well as standing. Palpation of the kidneys begins with the patient lying on his back, while his head should be slightly raised, his arms should be on his chest or extended along the body. The doctor is positioned facing the head of the patient, brings him under the right lumbar region The left hand is placed on the front wall of the abdomen, and the right hand is placed on the front wall of the abdomen. As the patient exhales, the kidney is palpated with the right hand, and the lumbar region is slightly pressed upward and anteriorly with the left hand, towards the fingers of the right hand. For palpation in the lateral position, the patient lies on healthy side and bends his legs slightly. In a standing position, you can palpate a pathologically mobile kidney.

Normally, the kidneys cannot be palpated. Sometimes it is possible to palpate the lower pole of the kidney, more often the right one, in asthenic patients. A healthy kidney has a smooth surface and elastic consistency when palpated, but moves when breathing.

Kidney enlargement is observed in tumors, polycystic disease, hydronephrosis and some other diseases. With a tumor, an enlarged, lumpy kidney is palpated. Unlike neoplasms of intraperitoneal organs, a kidney tumor cannot be displaced beyond the midline of the abdomen. Polycystic kidney disease is indicated by tuberous formations in the lumbar region on both sides. With hydronephrosis, an enlarged, painless kidney of elastic consistency is usually palpable. If nephroptosis is suspected, the kidneys must be palpated in both standing and lying positions.

Soreness of the kidney on palpation is observed in acute pyelonephritis. However, palpation of the kidney in such cases is most often impossible due to tension in the muscles of the anterior abdominal wall.

The ureters are not normally palpable. They can be palpated extremely rarely in thin people and with significant thickening of the ureters.

Palpation of the bladder is possible when the filling is at least 150 ml, since with a smaller volume it will be located behind pubic bone. When the bladder is full, for example in the case of acute or chronic delay urine, a pear-shaped dense elastic formation is palpated in the suprapubic region. Sometimes you can palpate bladder if there is a large tumor in it. In addition to conventional palpation, if a tumor is suspected, it is also recommended to conduct a bimanual examination with the patient in the supine or knee-elbow position. In this case, the doctor presses the area above the pubis to the spine with his left hand, and with his index finger right hand through the rectum presses on the back wall of the bladder. In women back wall this organ is palpable through the vagina. Bimanual examination of the bladder makes it possible to identify not only tumors growing into the bladder wall, but also stones and foreign bodies.

The urethra must be palpated from the lower surface of the penis. With chronic urethritis, the urethra is hardened, sometimes it is possible to palpate paraurethral infiltrates. If there is a urethral diverticulum, it can be identified by palpation as a soft elastic formation that decreases when pressure is applied to it. In patients with urolithiasis, stones that have descended from the bladder and are stuck in the urethra can be felt.

Palpation of the corpora cavernosa of the penis allows one to identify dense infiltrates during its fibroplastic induration; diffuse, with indistinct edges and less dense formations in the cavernous bodies during cavernitis, areas of softening during its abscesses.

The scrotal organs are palpated with the patient lying or standing. The right hand is brought under the scrotum so that the latter is located on the palm. The scrotum is raised slightly upward and the testicle, its epididymis and the spermatic cord are palpated. Upon palpation, it is easy to detect the absence of these organs or their presence in the inguinal canal.

During palpation, the doctor should assess the size and consistency of the testicle and epididymis. Pain on palpation and enlargement of the testicle and its epididymis are characteristic of acute orchitis and acute epididymitis. Detection of fluctuations indicates the presence of a purulent inflammatory process in these organs. If the testicle is enlarged, hardened, but painless, that is, a tumor is suspected. With hydrocele of the testicular membranes (hydrocele), an increase in the size of one half of the scrotum is determined. Enlarged, dense and tuberous epididymis, along with distinct thickenings of the vas deferens and scrotal fistulas, are characteristic signs of genital tuberculosis. Dilated veins of the spermatic cord indicate a varicocele. The veins are palpable in a standing position, and in a lying position their volume decreases significantly.

The prostate gland is palpated through the rectum with the patient positioned on his back with legs apart and bent, on his side with the lower limbs brought to the stomach, and in the knee-elbow position. The last position is the most convenient for research. The index finger of the right hand is slowly inserted into the rectum. The mobility of the rectal wall over the prostate gland is assessed. Then they begin to examine the gland itself. When palpating, pay attention to changes in shape, size, consistency, boundaries, as well as soreness of the prostate gland.

The normal prostate gland resembles a chestnut in shape and size and measures approximately 4 cm in cross section, and about 3 cm in longitudinal section. The contours of the gland are clear, the consistency is elastic. The median groove is clearly contoured, dividing the prostate gland into two symmetrical lobes. Palpation of the unchanged prostate gland is painless.

The condition of the prostate gland can change due to various diseases. Enlargement of the prostate gland, smoothness of the median sulcus in the absence of pain are characteristic of benign hyperplasia. Significant enlargement of the prostate gland, when it is palpated in the form of one round formation, and severe pain are observed in acute prostatitis. The symptom of fluctuation indicates a developed prostate abscess. A slight enlargement of the prostate gland, doughy consistency, moderate or slight pain indicate congestive chronic prostatitis. With cancer, the prostate gland is palpated as a lumpy formation of “stony” density. Small or large nodular tuberosity of the prostate gland is characteristic of tuberculous lesions.

The seminal vesicles are located above the prostate gland on both sides of the median sulcus. They are palpated through the rectum with the patient in a squatting or knee-elbow position. Normally, they are usually not palpable and are detected only during an inflammatory process, tuberculosis or tumor. On palpation, the seminal vesicle is determined in the form of an oblong elastic bulge or in the form of a tuberous formation, sometimes painful when palpated.

Rice. 4.22. Transrectal sonogram: seminal vesicles (1) and bladder (2) are normal

Rice. 4.23. Sonogram of the scrotum. The testicle is normal

datka, which has a shape close to triangular. Adjacent to the caudal portion of the testicle is the tail of the epididymis, which follows the shape of the testicle. The body of the appendage is not clearly visible. In terms of its echogenicity, the epididymis is close to the echogenicity of the testicle itself, is homogeneous, and has clear contours. The interthecal fluid is anechoic, transparent, and is normally determined in the form of a minimal layer of 0.3 to 0.7 cm, mainly in the projection of the head and tail of the appendage.

Minimally invasive diagnostic and surgical interventions under sonographic control. Implementation ultrasound scanners has made it possible to significantly expand the arsenal of minimally invasive methods in the diagnosis and treatment of urological diseases. These include:

diagnostic:

■ puncture biopsy of the kidney, prostate gland, scrotal organs;

■ puncture antegrade pyeloureterography; medicinal:

■ puncture of kidney cysts;

■ puncture nephrostomy;

■ puncture drainage of purulent-inflammatory foci in the kidney, retroperitoneal tissue, prostate gland and seminal vesicles;

■ puncture (trocar) epicystostomy.

Depending on the method of obtaining the material, diagnostic punctures are divided into cytological and histological. Cytological material obtained by performing fine-needle aspiration biopsy. More wide application has histological biopsy, in which sections (columns) of organ tissue are taken. Thus taken full histological material can be used to make a morphological diagnosis, conduct immunohistochemical studies and determine sensitivity to chemotherapy.

The method of obtaining diagnostic material is determined by the location of the organ of interest and the capabilities of the ultrasound device. Puncture of kidney formations, retroperitoneal volumetric formations are performed using transabdominal sensors that allow visualization of the entire area puncture intervention. Puncture can be performed using the “free hand” technique, when the doctor combines the trajectory of the needle and the area of ​​interest, working with a puncture needle without a fixing guide nozzle. Currently, a technique with fixation of the biopsy needle in a special puncture channel is predominantly used. A guide channel for the puncture needle is provided either in a special model ultrasonic sensor, or in a special puncture nozzle, which can be attached to a conventional sensor. Organ puncture and pathological formations small