General Doctor-Patient Idea about Urological signs and symptoms
The Urinary system
More about the Kidney
Anatomy and Physiology of the Kidney
The kidneys lie along the borders of the Psoas muscles and are therefore obliquely placed. The position of the liver causes the right Kidney to be lower than the left. The Adult Kidney weighs about 150g. The kidneys are supported by the perirenal fat (which is enclosed in the perirenal fascia), the renal vascular pedicle, abdominal muscle tone, and the general bulk of the abdominal viscera. Variations in these factors permit variations in the degree of the renal mobidity. The average descent on inspiration or on assuming the upright position is 4-5cm.
The Adult Ureter is about 30cm long, varying in direct relation to the height of the individual. It follows a rather smooth S curve. Areas of relative narrowing are found
- at the ureteropelvic junction
- where the ureter crosses over the iliac vessels, and
- where it passes through the bladder wall.
General/Patient note and main urologic symptoms
The Kidneys play a central role in the maintenance of a constant internal environment for body cells in response to cellular catabolism and wide variations of dietary intake. It achieves this by regulating extracellular fluid and solute concentrations by the excretion of salts, water, metabolic waste products and foreign substances. The process involves the production of a plasma Ultrafiltration of 180L per day. This passes down to about 2 million tubules from which essential solutes and water reasbsorbed into the blood and non-essential solutes secreted from the blood into the remaining fluid which becomes the final urine. The other functions of the kidney incude hormone production and the production of glucose by breaking down other non-carbohydrate substrates (gluconeogenesis).
Main Urologic symptoms
Systemic manifestations, local and referre pain (Kidney pain, Pseudorenal pain, ureteral pain, vesical pain, prostatic pain, testicular pain, epididymal pain, back and leg pain), gastrointestinal symptoms of urologic disease, symptoms related to the act of urination (frequency, nocturia and Urgency, burning sensation during urination, symptoms of prostatic obstruction, symptoms of urethral obstruction, incontinence, oliguria and anuria, Pneumaturia, cloudy urine, bloody urine, enuresis (an inability to control urination. Use of the term is usually limited to describing individuals old enough to be expected to exercise such control) ), other objective manifestations (Urethral discharge, skin lesions of the external genitalia, visible or palpable masses, edema, bloody ejaculation, gynecomastia, size of penis in infant or child), complaints related to sexual problems.
Typical renal pain is usually felt as a dull and constant ache in the Costovetebral angle (pix 3, just by the right) just lateral to the sacrospinalis muscle below the 12th rib. This pain often spreads along the subcostal area towards the umbilicus or lower abdominal quadrant. It may be expected in those renal diseases that cause typical pain. Such disease include cancer, chronic pyelonephritis, staghorn calculus, tuberculosis, polycystic Kidney, and hydronephrosis (is distension and dilation of the renal pelvis calyces, usually caused by obstruction of the free flow of urine from the kidney) due to mild ureteral obstruction. The pressure within the renal pelvis is normally close to zero. When this pressure increases because of obstruction or reflux, the pelvis and renal calices dilate. The degree of hydronephrosis that develops depends upon the duration, degree and site of the obstruction. The higher the obstruction, the greater the effect upon Kidney.
Altered Urination can be in the following forms, dysuria, pollakiuria, precipitant urination, frequent urination, urinary difficulty, chronic urinary retention, paradoxical ischuria. In chronic Urinary retention, this may cause little discomfort to the patient even though there is great hesitancy in starting the stream and marked reduction of its force and caliber. Constant dribbling of urine (paradoxic incontinence) may be experienced. It may be likened to water pouring over a dam. Urinay incontinence (Enuresis) can be in various forms such as, true incontinence (free urine outflow without any true cause), stress incontinence (uncontrolled urine outflow due to stress, fear, anxiety), urge incontinence (free and uncontrolled urine outflow when the urge arises), paradoxic incontinence. Strictly speaking, enuresis means bedwetting at night. It is physiologic during the first 2 to 3 years of Life.
As for Acute retention, it is the sudden inability to urinate. The patient experiences increasingly agonizing suprapubic pain associated with severe urgency to urinate and may dribble only small amounts of urine. Oliguria and Anuria may be caused by acute renal failure (due to shock or dehydration), fluid-ion imbalance, or bilateral ureteral obstruction. Proteins in Urine is called Proteinuria. It can be pathologic and Non-pathologic (which is also physiologic or orthostatic). Therefore, proteinuria of any significant degree (2-4 +) is suggestive of 'medical' renal disease (parenchymal involvement). Bacteria in Urine is called bacteriuria. A presumptive diagnosis of bacterial infection may be made on the basis of results of microscopic examination of the urinary sediment.
There is a simple laboratory experiment called the Three-glass maneuver, used to test for pyuria. In the sediment from clean-voided midstream specimen from men and those obtained by supra-pubic aspiration or catheterization in women, more than 5-8 white blood cells per high-power field is generally considered abnormal (pyuria). Abnormal Urine specimen can be in the form of altered Urine output or pathological urine sediments and patients with recurrent urolithiasis (stones in kidneys) may have an underlying abnormality of excretion of calcium, uric acid, oxalate, magnesium or citrate. Another simple laboratory experiment is the Two-glass maneuver, used to determine blood in Urine (Hematuria). The presence of even a few red blood cells in the urine (hematuria) is always abnormal and requires further investigation. If red blood cells predominate in the initial portion of the specimen, they are usually from the anterior urethra; those in the terminal portion are generally from the bladder neck or a source above the bladder neck (bladder, ureters or kidneys).
General complaints and manifestations
Patients with diseases of the kidneys most commonly complain of pain in lumbar region, disordered urination, oedema, headache, and dizziness. They may also complain of deranged vision, pain in the heart, dyspnoea (difficulty in breathing), absence of appetite, nausea, vomiting, and elevated body temperature. But diseases of the kindeys may also proceed without any symptoms of renal or general clinical insufficiency.
If the patient complains of pain, its location should first of all be determined. Pain of renal origin often localizes in the lumbar region. If the ureters are affected, the pain is felt by their course. If the bladder is involved, pain is suprapubical. Radiation of pain into the perineal region is characteristic of an attack of nephrolithiasis. The character of pain should then be determined. It is necessary to remember that the renal tissue is devoid of pain receptors. The pain is felt when the capsule or the pelvis is distended -Dull and boring pain in the lumbar region occurs in acute glomerulonephritis, abscess or the perirenal cellular tissue, in heart decompensation ("congestive kidney") in chronic pyelonephritis (usually unilateral) and less frequently in chronic glomerulonephritis. Pain arises due to distension of the renal capsule because of the inflammatory or congestive swelling of the renal tissue.
2. Sharp and suddenly developing pain on one side of the loin can be due to the renal infarction (The death of an area of tissue in the kidney due to a localized lack of oxygen. Usually results from an interruption in the blood supply). The pain persists for several hours or days and then subsides gradually. The pain is rather severe in acute pyelonephritis: inflammatory oedema of the ureter interferes with the normal urine outflow from the pelvis and thus causes its distension. The pain is usually permanent. Some patients complain of attacks of severe piercing pain in the lumbar region or by the course of the ureter 3 The pain increases periodically and then subsides, i.e. has the character of renal colic. Obstruction of the ureter by a calculus or its bending (movable kidney) is the most common cause of this pain, which is usually attended by spasmodic contraction of the ureter, retention of the urine in the pelvis, and hence its distension. The spasmodic contractions and distension of the pelvis account for the pain. Pain in renal colic radiates into the corresponding hypochondrium and most frequently by the course of the ureter to the bladder, and to the urethra. This radiation of pain is explained by th presence of nerve fibres (carrying the impulses from kidneys, ureters, some organs and the corresponding skin zones) in the immediate vicinity of th relevant segments of the spinal cord. This facilitate propagation of the excitation. Patients with renal colic (like those with colic of other aetiology) are restless; they toss in bed. Patients with severe pain of other aetiology would usually lie quiet in their beds (movements may intensify the pain).
The conditions promoting pain should be established. For example pain in nephrolithiasis can be provoked by taking much liquid, jolting nutrition, or the like; pain is provoked by urination in cystitis. Difficult and painful urination is observed in stranguria. Patients with urethritis feel burning pain in the urethra during or after urination.
It is necessary also to establish the agent that lessens or removes the pain. For example, atropine sulphate, hot water-bottle or warm bath in renal colic. Since these remedies only help in spasmodic pain by removing spasm of the smooth muscles, their efficacy in renal colic confirms the leading role of the ureter contraction in the pathogenesis of this pain. Pain of the renal colic-type in patients with movable kidney may lessen with changing posture: urine outflow improves with displacement of the kidney. Pain slightly lessens in patients with acute paranephritis if a bag with ice placed on the lumbar region and if the patient is given amidopyrine and other analgesics.
Many renal diseases are attended by deranged urination: changes in the daily volume of excreted urine and in the circadian rhythm of urination
Secretion of urine during a certain period of time is called diurest Diuresis can be positive (the amount of urine excreted exceeds the volume of liquid taken) or negative (the reverse ratio). Negative diuresis is observed in cases of liquid retention in the body or its excess excretion through the skin, by the lungs (e.g. in dry and hot weather). Positive diuresis occurs resolution of oedema, after administration of diuretics, and in some other cases. Deranged excretion of urine is called dysuria.
Increased amount of excreted urine (over 2L in a day) is called polyuria. can be of renal and extrarenal aetiology. Polyuria is observed in persons who take much liquid, during resolution of oedema (cardiac or renal), and after taking diuretics. Long-standing polyuria with a high relative density of urine is characteristic of diabetes mellitus. In this case polyuria arise due to a deranged resorption of water in renal tubules because of increasing osmotic pressure of the urine rich in glucose. Polyuria occurs in diabetis incipidus because of insufficient supply of antidiuretic hormone secreted into blood by the posterior pituitary. Polyuria also occurs in the absence sensitivity of the tubules to the ADH, in affected interstice of the renal medulla of various nature, in hypokaliaemia (increase of potassium in blood), and hypo- and hyper- calcaemia (increase of calcium in blood).
Persistent polyuria with low specific gravity of urine (hyposthenuria) is usually a symptom of a severe renal disease, e.g. chronic nephritis, chronic pyelonephritis, renal arteriolosclerosis, etc. Polyuria in such cases indicates the presence of a neglected disease with renal insufficiency and decreased absorption in renal tubules.
Decreased amount of excreted urine (less than 500 ml a day) is called iguria. It cannot be connected directly with renal affections (extrarenal iguria). For example, it can be due to limited intake of liquid, during a stay in a hot and dry room, in excessive sweating, intense vomiting, diarrhoea, and during decompensation in cardiac patients. But in certain cases oliguria is the result of diseases of the kidneys and the urinary acts (renal oliguria), such as acute nephritis, acute dystrophy of the kidneys in poisoning with corrosive sublimate, etc.
A complete absence of urine secretion and excretion is called anuria. Anuria persisting for several days threatens with possible development of bacteraemia and fatal outcome. Anuria may be caused by the deranged secretion of urine by the kidneys (secretory anuria) which occurs in severe form of acute nephritis, nephronecrosis (poisoning with sublimate or other ephrotoxic substances), transfusion of incompatible blood, and also some venereal diseases and conditions such as severe heart failure, shock, or profuse blood loss.
In certain cases the secretion of urine is normal but its excretion is obstructed mechanically (obstruction of the ureters or the urethra by a calculus, inflammatory oedema of the mucosa, proliferation of a malignant tumour). This is called excretory anuria. It is usually attended by strong pain in the loin, the renal pelves and the ureters. Exctretory anuria is often attended by renal colic.
Renal (secretory) anuria can be of reflex origin, e.g. in severe pain (contusion, fractures of the extremities, etc). Anuria should be differentiated from ischuria, when the urine is retained in the bladder and the patient is unable to evacuate it. This occurs in compression or other affection of the spinal cord, and in loss of consciousness.
Pollakiuria (frequent micturition) is observed in certain cases. A healthy person urinates from 4 to 7 times a day. The amount of excreted urine during one micturition is from 200 to 300 ml (1000-2000 ml a day). But frequency of micturition may vary within wider range under certain conditions: it may decrease in limited intake of liquid, after eating much salted food, in excessive sweating, in fever, and the like, or the frequency may increase (polyuria) if the person takes much liquid, in getting cold, and the like circumstances. Frequent desire to urinate with excretion of meagre quantity of urine is the sign of cystitis. A healthy person urinates 4-7 times during the day time; a desire to urinate during night sleep does not arise more than once. In the presence of pollakiuria the patient feels the desire to urinate during both day and night. In the presence of chronic renal insufficiency and if the kidneys are unable to control the amount and concentration of excreted urine in accordance with the amount of liquid taken, physical exertion, the ambient temperature, or other factors impor tant for the liquid balance in-the body, the patient urinates at about equal intervals with evacuation of about equal portions of urine. This condition is called isuria.
Under certain pathological conditions, the frequency of urination is normal during the day time but increases during night. The amount of urine excreted during night often exceeds the amount of daily urine (nycturia). Nocturnal enuresis (nycturia) and oliguria during day time occur in cardiac decompensation and are explained by a better renal function at night, i.e at rest (cardiac nycturia). Nycturia may concur with polyuria in renal dysfunction, at the initial stage of chronic glomerulonephritis, chronic pyelitis, vascular nephrosclerosis, and other chronic renal diseases (renal1 nycturia). In the presence of isuria and nycturia of renal origin, which arisedue to the loss by the kidneys of their concentrating ability, the specific gravity of the urine is monotonous. The condition is known as isosthenuria. The specific gravity of urine is usually decreased (hyposthenuria). The specific gravity of urine varies from 1.009 to 1.011, i.e. approaches the specific gravity of primary urine (plasma ultrafiltrate) in patients with pronounced nephrosclerosis, which is the final stage of many chronic renal diseases.
Some diseases of the bladder and the urethra are attended by difficult and painful urination. The patient would complain of change in the colour of the urine, its cloudiness, and traces of blood.
Oedema is observed in acute and chronic diffuse glomerulonephritis, nephrotic syndrome, amyloidosis', and acute renal excretory dysfunction (anuria). It is important to ask the patient about the site that was the first to be attacked by oedema, the sequence of oedema spreading, and the rate of intensification of this phenomenon (see "Renal Oedema").
Headache, dizziness, and heart pain may result from kidney affections. These symptoms occur in those renal diseases which are attended by considerable increase in the arterial pressure, e.g. in acute and chronic glomerulonephritis or vascular nephrosclerosis. A pronounced and persistent increase in the arterial pressure can be among the causes of deranged vision (neuroretinitis).
Patients with diseases of the kidneys can complain of weakness, indisposition, impaired memory and work capacity and deranged sleep. Vision may be deranged along with skin itching and unpleasant breath. Dyspeptic disorders sometimes join in: loss of appetite, dryness, vomiting, and diarrhoea. All these phenomena are associated with retention in the body decomposition products due to renal insufficiency which develops at the final stage of many chronic renal diseases, and sometimes in acute diseases attended by retention of urine during several days.
Fever is the common symptom of infectious inflammatory affections of the kidneys, the urinary ducts and perirenal cellular tissue.
History of the present disease. When questioning the patient, it is necessary to establish the connection of the present "disease with previous infections (tonsillitis, scarlet fever, otitis, acute respiratory diseases). This sequence is especially characteristic of acute glomerulonephritis. But it is sometimes difficult to establish the time of onset of the disease because some chronic affections of the kidneys and the urinary ducts can for a long time be latent. Moreover, when questioning the patient, it is necessary to find out if he had deranged hearing or vision in his childhood that might be -suggestive of congenital renal pathology.
Special attention should be given to the presence in the patient's past history of diseases of the kidneys-and the urinary duels.(acute nephritis,v. pyelitis, cystitis) or symptoms that might suggest them (dysuria, haematuria, oedema, arterial hypertension, attacks of pain in the abdomen or loin resembling renal colics), since these symptoms can be connected with the present renal pathology. In certain cases the cause and the time of onset of grave kidney affections (necronephrosis) can be established byrevealing industrial or domestic poisoning, intentional (or by mistake) taking of some poisons (corrosive sublimate, preparations of bismuth, phosphorus, silver, large doses of sulpha preparations, or of some antibiotics, e.g. aminoglycosides, expired tetracyclines, phosphorus compounds), transfusion of incompatible blood, etc. Amidopyrin, phenacetin, barbiturates, camphor, and some other medicines can cause allergic changes in the kidneys.
The patient must be asked about the character of the disease course: it may be gradual (arteriolosclerosis, chronic diffuse glomerulonephritis, amyloidosis of the kidneys), or with periodical exacerbations (chronic pyelonephritis, chronic diffuse glomerulonephritis). It is necessary to establish the cause of exacerbations, their frequency, clinical signs, the chaiacter of therapy given and its efficacy, the causes inducing the patient \ to seek medical help.
Anamnesis. Special attention should be given to the factors that might provoke the present disease or have effect on its further course. For example, a common factor promoting development of acute and chronic nephritis and pyelonephritis is chilling and cooling (poor housing or wrong conditions, drafts, work in the open, acute cooling of the body bef the disease). Spreading of genital infection onto the urinary system can the cause of pyelonephritis. It is necessary to establish the presence absence in the past of tuberculosis of the lungs or other organs. This can establish the tuberculous nature of the present disease of the kidneys.
It is necessary to establish if the patient has some other diseases that might cause affections of the kidneys (collagenosis, diabetes mellitus, and other diseases of the blood, etc.). Various chronic purulent diseases (osteomyelitis, bronchiectasis) can be the cause of amyloidosis of kidneys. Occupations associated with walking, riding, weightlifting, can have their effect on the course of nephrolithiasis and provoke attack of renal colic. Some abnormalities of the kidneys, nephrolithiasis amyloidosis, etc., can be inherited. It is also necessary to record thorough, the information on past operations on the kidneys or the urinary duct
When examining women, it is important to remember that pregna can aggravate some chronic diseases of the kidneys and be the cause of so-called nephropathy of pregnancy (toxaemia of late pregnancy).
Inspection of the patient should give the physician the idea of the quality of the patient's condition. Very grave condition with loss of consciousness may be due to severe affections of the kidneys attended by renal insufficiency. The condition may be satisfactory or of moderate gravity (in milder cases). It is necessary to pay attention to the patient's posture in bed: active (at initial stages of many diseases of kidneys), passive (in uraemic coma), or forced (in paranephritis; the patient may lie on his side with the leg flexed, bringing the knee to the domen on the affected side. In the presence of renal colic, the patient is restless, tosses in bed, groans or even cries from pain. Convulsions observed in the presence of uraemic coma, renal eclampsia, nephropathy of pregnancy (toxaemia of late pregnancy with involvem of the kidneys).
Oedema is characteristic of acute and chronic glomerulonephritis, nephrotic syndrome, and amyloidosis of the kidneys. The appearance the patient with oedema of the renal origin is quite specific. The face is pallid, swollen, with oedematous eyelids and narrowed eye-s (facies nephritica). In patients with more pronounced signs of pathologic oedema affects the upper and lower extremities and the trunk. The colour of the patient's skin is also important. Oedematous skin Ironic nephritis is pallid due to the spasm of skin arterioles. The skin is wax-pallid in amyloidosis and lipoid ephrosis. It should be remembered that in cardiac oedema (as distinct from renal oedema) the skin is more or less cyanotic.
When inspecting a patient with chronic nephritis, it is possible to observe scratches on the skin and coated dry tongue; an unpleasant odour if ammonia can be felt from the mouth and skin of the patient (factor iremicus). All these signs characterize chronic renal insufficiency uraemia).
Inspection of the abdomen and the loin does not usually reveal any noticeable changes. But in the presence of paranephritis, it is possible to notice swelling on the affected side of the loin. In rare cases, an especially large tumour of the kidney may be manifested by protrusion of the abdominal wall. Distended bladder can be protruded over the pubic bone in such persons. The distension can be due to overfilling of the bladder, for example, due to retention of urine in adenoma or cancer of the prostate.
The posterior location of the kidneys, and also the absence of anterior approach to them due to the interference of the costal arch, makes palpation of the kidneys difficult. cachexia can be attended by certain ptosis of the kidneys and make them ' accessible to palpation even in healthy subjects. But the results of palpation can only be reliable in considerable enlargement of the kidneys (at least 1.5-2 times, e.g. due to formation of a cyst or a tumour), or their displacement by a tumour, or in cases with a floating kidney. Bilateral enlargement of the kidneys is observed in polycystosis.
It is necessary to remember that the kidneys can move about in the range of 2-3 cm in the proximal and distal directions when the subject changes his position from horizontal to vertical, and also during respiratory movements of the diaphragm. Passive movements of the kidneys transmitted from the diaphragm during inspiration and expiration should be taken into consideration during palpation: the Obraztsov-Strazhesko palpation method should be used. The patient should be palpated in the lying or standing position. When the patient is in the horizontal position, his kidneys are better palpated because the strain of the perilium is absent. But the movable kidney can be palpated in the standing patient because it hangs by gravity and is displaced downward by the pressure of the low diaphragm.
During palpation of the patient in the lying position, his legs should be bent slightly and the perilium is relaxed and the arms are freely placed on the chest. The physician should assume his position by the right side of the patient with his left hand under the patient's loin, slightly below the 12th rib so that the finger tips be near the spinal column. During palpation of the left kidney, the physician's hand should be moved further, beyond the vertebral column, to reach the left part of the lumbar region. The right hand should be placed on the abdomen, slightly below the corresponding costal arch, perpendicularly to it and somewhat outwardly of the rectus abdominis muscles. The patient is asked to relax the abdominal muscles as much as possible and breathe deeply and regularly. The physician's right hand should press deeper with each expiration to reach the posterior abdominal wall, while the left hand presses the Lumbar region to meet the fingers of the right hand. When the examining hands are as close to each other as possible, the patient should be asked to breathe deeply by "the abdomen" without straining the prelum. The lower pole of the kidney (if it is slightly descended or enlarged) descends still further to reach the fingers of the right hand. As the physician feels the passing kidney, he presses it slightly toward the posterior abdominal wall and makes his fingers slide over the anterior surface of the kidney bypassing its lower pole. If ptosis of the kidney is considerable, both poles and the entire anterior surface of the kidney can be palpated. The physician should assess the shape, size, surface (smooth or tuberculous, tenderness, mobility, and consistency of the kidneys. Bimanual palpation of the kidney can also be done with the patient lying on his side.
In contrast to other organs, an enlarged or ptosed kidney can be Examined by ballottement (Guyon's sign): the right hand feels the kidney while the fingers of the left hand strike rapidly the lumbar region in the angle between the costal arch and the longissimus thoracic muscles: the fingers of the right hand feel vibration of the kidney. In deranged urine outflow through the ureter and in pronounced distension of the renal pelvis by the accumulated urine or pus, liquid fluctuation can be felt during palpation of the kidney.
If the physician palpates some formation where he expects to find a kidney, he must check reliably if this is actually a kidney because it is easy to mistake for the kidney an overfilled and firm part of the large intestine, tumor of perirenal cellular tissue (lipoma, fibroma), an enlarged right lobe of the liver, the gall bladder (during palpation of the right kidney), or an enlarged or displaced spleen (during palpation of the left kidney). The kidney is a bean:shaped organ with a smooth surface, slipping upwards from under the palpating fingers and returning to normal position, tossed up by ballottment and giving tympany during percussion over the kidney(by overlying intestinal loops). Protein and erythrocytes appear in the urine after palpation. But all these signs are of only relative importance. For example, if a malignant tumour develops, the kidney may lose its mobility due to proliferation of the surrounding tissues; its surface becomes irregular and the consistency more firm; if the tumour is large, the kidney moves apart the intestinal loops and percussion gives dullness. But the kidney can nevertheless be identified by the mentioned signs by differenciating it from the neighbouring organs and other formations.
Palpation of the kidneys in the standing patient is such that, During palpation the patient stands facing the physician who sits on a chair. The prelum muscles should be relaxed and the trunk should inclined forward.
Palpation can be used to diagnose ptosis of the kidneys. Three degree of nephroptosis can be distinguished: the lower pole of the kidney can be palpated in cases with ptosis of the first degree; the entire kidney can be palpated in the second degree; and the kidney freely moves about in directions to pass beyond the vertebral column, to the side of the kidney, and to sink downwards to a considerable distance, in the three ,degree ptosis.
Palpation is "also used to examine the bladder. If it contains much urine especially in persons with thin abdominal wall, the urinary bladder can be palpated over the pubic bone as aplastic fluctuating formation. If bladder is markedly distended, its superior border reaches the umbilic
Tenderness in palpation of the ureter along its course and sensitive over the kidneys (sensitive to pressure exerted in the angle between the I rib and the longissimus thoracic muscles) is of certain diagnostic importance. The area overlying the ureter extends on the anterior abdominal region between the superior ureter point (at the edge of the rectus abdominis muscle at the level of the umbilicus) and the inferior point
It is imgossible to percuss the kidneys in a healthy subject because they are covered anteriorly by the intestinal tympany. Dull sounds can only be determined in the presence of very marked enlargement of kidneys.
A much more informative method for examination of the kidney tapping. The physician places his left hand on the patient's loin and us his right hand (palm edge for fingers) taps with a moderate force on right hand overlying the kidney region on the loin. If the patient feels pain, the symptom "is positive (This is called the Pasterhatsky's symptom in Ukraine, Russia and Belarus). This symptom is also positive in nephrolithiasis, paranephritis, inflammation of pelvis, and also in myositis and radiculitis. This decreases the diagnostic value of Pasternatsky's symptom.
A full urinary bladder gives a dull sound on percussion of suprapubic region. The percussion is carried out from the umbilicus downward, along the median line; the pleximeter-finger is placed para to the pubic bone.