(13) Male Genitalia and Hernias Flashcards
shaft of penis is formed by ?
3 columns of vascular erectile tissue: corpus spongiosum (containing the urethra & extended from bulb of penis to cone spaced glans w/ its expanded base, or corona) and 2 corpora cavernosa
male urethra location
ventral midline of penile shaft (urethral abnormalities may sometimes be felt there)
-urethra opens in to the vertical slit-like urethral meatus locked somewhat ventrally at the tip of the glans
testes
paired ovoid glands consisting primarily of seminiferous tubules and interstitial tissue, covered by a fibrous outer coating, the tunica albuginea
-normally 1.5-2cm
male puberty
- GRH from hypothalamus stimulates pituitary secretion of LH and FSH
- LH acts on interstitial Lydia cells to promote synthesis of testosterone which is converted in target tissues to 5alpha-dihydrotestosterone
- 5alpha-dihydrotestosterone triggers pubertal growth of male genitalia, prostate, seminal vesicles, secondary sex characteristics such as facial and body hair, musculoskeletal growth, enlargement of larynx (low-pitched voice)
- FSH regulates sperm production by the germ cells and Sertoli cells of the seminiferous tubules
scrotum
loose, wrinkled pouch of skin and underlying darts muscle
tunica vaginalis
covers the testis (except posteriorly)
- serous membrane that is derived from the peritoneum of the abdomen and brought down into the scrotum during testicular descent through the deep internal inguinal ring
- parietal layer clocks the anterior 2/3 of the testis, and the visceral layer lines the adjacent scrotum
epididymis
- on posterolateral surface of each testis
- softer, comma shaped
- consists of tightly coiled tubules emanating from the testis that becomes the vas deferens
- normal separated from testis by a palpable sulcus and provides a reservoir for storage, maturation, and transport of sperm
vas deferens
firm muscular cord-like structure
- transports sperm from the tail of the epididymis along a circular route to the urethra
- ascends from the scrotal sac into the pelvic cavity through the inguinal canal then loops anteriorly over the ureter to the prostate behind the bladder where it merges w/ the seminal vesicle to form the ejaculatory duct (which traverses the prostate and empties into the urethra)
- closely associated w/ blood vessele, nerves, muscle fibers (structures make up the spermatic cord)
seminal fluid contains fluid from ?
vas deferens
seminal vesicles
prostate
male sexual function depends on ?
- normal levels of testosterone
- arterial blood flow from internal iliac artery to the internal pudendal artery and its penile watery and branches
- intact neural innervation from alpha-adrenergic and cholinergic pathways
erection from venous engorgement of the corpora cavernous results from:
- visual, auditory, or erotic cues taht trigger sympathetic outflow from higher brain centers to the T11 through L2 levels of the spinal cord
- tactile stimulation initiates sensory impulses from the genitalia to the S2 to S4 reflex arcs and the parasympathetic pathways through the pudendal nerve
(both increase levels o nitric side and cyclic guanosine monophosphate resulting in vasodilation)
if peritoneal lining remains an open channel to the scrotum is can cause
indirect inguinal hernia
parietal and visceral layers form a potential space for the abnormal fluid accumulation of a ?
hydrocele
lymph drainage from the penis passes primarily to
deep inguinal and external inguinal nodes
lymph vessels from the scrotum drain into ?
superficial inguinal lymph nodes
when you find an inflammatory or malignant lesion on penis or scrotum asses what nodes?
inguinal for enlargement or tenderness
lymph drainage from testes parallels ?
their venous drainage
- left: left testicular vein empties into left renal vein
- right: right testicular vein empties into inferior vena cava
(connecting lumbar and pre aortic lymph nodes int he abdomen are clinically undetectable)
inguinal canal
- lies medial to and roughly parallel to inguinal ligament
- forms a tunnel for the vas deferent as it passes through the abdominal muscles
- not palpable through abdominal wall
-when loops of bowel present in inguinal Cala = inguinal hernia
internal inguinal ring
- internal opening of inguinal canal
- approx 1cm above midpoint of inguinal ligament
- not palpable through abdominal wall
eternal inguinal ring
- exterior opening of inguinal canal
- triangular slit-like structure palpable just above and lateral to the pubic tubercle
indirect inguinal hernia
develop at internal inguinal ring where the spermatic cord exits the abdomen
direct inguinal hernia
arose more medially d/t weakness in the floor of inguinal canal and associated w/ straining and heavy lifting
femoral hernia
more likely to present as emergencies w/ bowel incarceration or strangulation
- in femoral canal below the inguinal ligament
- not visible but can estimate location by placing right index finger from below on femoral atery, middle finger will overlie femoral vein, ring finger will overlie femoral canal
male genitalia: common/concerning symptoms
- sexual health
- penile discharge/lesions
- scrotal pain, swelling, lesions
- STIs
tips for taking sexual history
- explain why taking sexually history
- convey you understand that this info is personal and encourage pt to be open/honest
- relate you gather from all pts
- affirm confidential
(avoid assumptions based on disability, illness, age)
low libido may arise from ?
depression
endocrine dysfunction
med side effects
erectile dysfunction may arise from ?
psychogenic causes (esp. if early am erection if preserved)
decreased testosterone
decreased blood flow in hypogastric arterial system
impaired neural innervation
diabetes
premature ejaculation is common & less common in ?
causes?
common - young men
less common - reduced or absent ejaculation in middle-aged, elderly men
causes: medications surgery neurologic deficits lack of androgen
lack of orgasm w/ ejaculation is usually ?
psychogenic
rash, tenosynvovitis, monoarticular arthritis, even meningitis, not always w/ urogenital symptoms occurs in
disseminated gonorrhea
yellow penile discharge suggests
gonorrhea
white penile discharge suggests
non-gonococcal urethritis from Chlamydia
male genitalia: health promotion
- screening for STIs, HPV, HIV, AIDS
- counseling about sexual practices
- testicular cancer screening and self-exam
most common STIs
chlamydia (80%) - recently declining
gonorrhea (18%) - increasing
syphilis (3%) - increasing
HPV vaccine recommendation for males
routine vaccination for all males 11-21 to prevent HPV related illness and transmission
HIV screening recommendation
universal testing for everyone 15-65 and all pregnant women (opt out testing) - one time low risk , yearly high risk
patient counseling for sexual practices
- should be interactive and combine info about general risk reduction w. personalized messages based on pt’s personal risk behaviors
- client centered counseling
- include correct use of male condoms to prevent STIs
correct use of male condoms:
- new condom w/ each sex act
- apply condom before any sexual contact occurs
- only water based lube
- withdraw if condom breaks
- hold condom when withdrawing
testicular cancer risk factors
(rare but highly treatable w/ early detection)
- 20-34 y/o
- white > black
- family hx
- HIV
- hx of cryptorchisism (undescended testicle)
testicular cancer screening
no rec for screening or self-exam but advises to seek attention for: painless lump, swelling, unilateral testicular enlargement, pain/discomfort in testicle/scrotum, heaviness or sudden fluid collection in scrotum, dull ache in groin/lower abdomen
pubic or genital excoriations suggests
lice (crabs) or scabies in pubic hair
Phimosis
tight prepuce that cannot be retracted over the glans
Paraphimosis
tight prepuce that once retracted cannot be returned; edema ensues
Balanitis
inflammation of the glans
Balanoposthitis
inflammation of the glans and prepuce
Hypospadias
congenital ventral displacement of the meatus on the penis
profuse yellow penile discharge suggests
gonococcal urethritis - definitive dx required Gram stain/culture
scanty white or clear penile discharge suggests
nongonococcal urethritis - definitive dx required Gram stain/culture
induration along ventral surface of penis suggests ?
tenderness in indurated area suggests ?
urethral stricture or carcinoma
periurethral inflammation from a urethral stricture
scrotal epidermoid cyst
dome shaped white or yellow papules or nodules formed by occluded follicles filled with keratin debris of desquamated follicular epithelium
-common, frequently multiple, benign
normal testes on palpation
firm but not hard descended symmetric nontender w/o masses
crytorchidism
undescended testicle
-poorly developed scrotum on one or both sides indicates
common scrotal swellings
inguinal hernias
hydroceles
scrotal edema
testicular carcinoma
scrotal erythema and mild excoriation point to
fungal infection
tender painful scrotal swelling is present in ?
acute epididymitis
actor orchitis
torsion of spermatic cord
strangulated inguinal hernia
normal epididymis on palpation
nodular and cordlike, nontender
don’t confuse w/ abnormal lump
any painless nodule on testis raises possibility of ?
testicular cancer
how to check for variocele
w/ pt standing palpate spermatic cord 2cm above testis
- pt hold breath nd bear down against closed glottis for 4 seconds (Valsalva)
during this maneuver a temp increase in diameter of spermatic cord indicate filling of abnormally dilated spermatic veins draining testis
chronically infected vas deferens may feel
thickened or beaded
cystic structure in spermatic cord suggests
hydrocele of the cord
scrotal flashlight test
red glow/transilluminate: contains serous fluid such as hydrocele
those containing blood or tissue such as normal testis, tomorrow, hernias do not
position for male hernia exam
supine or standing
lie down for scrotal hernia
bulge near external inguinal ring suggests
direct inguinal hernia
bulge near internal inguinal ring suggests
indirect inguinal hernia
if you can place your fingers above a scrotal mass suspect
hydrocele
transillumination of a scrotal mass can help ID a ? from a ?
hydrocele
intestine containing hernia
hernia is incarcerated when ?
its contents cannot be returned to the abdominal cavity
hernia is strangulated when ?
blood supply to the entrapped content is compromised
s/s: tenderness, N/V
Genital Warts
condylomata acuminata
Appearance: Single or multiple papules or plaques of variable
shapes; may be round, acuminate (pointed), or thin and
slender. May be raised, flat, or cauliflower-like (verrucous).
■ Causative organism: HPV, usually subtypes 6, 11; carcinogenic
subtypes rare, approximately 5–10% of all anogenital warts.
Incubation: weeks to months; infected contact may have no
visible warts.
■ Can arise on penis, scrotum, groin, thighs, anus; usually
asymptomatic, occasionally cause itching and pain.
■ May disappear without treatment.
Genital Herpes Simplex
■ Appearance: Small scattered or grouped vesicles, 1 to 3 mm
in size, on glans or shaft of penis. Appear as erosions if
vesicular membrane breaks.
■ Causative organism: Usually Herpes simplex virus 2 (90%), a
double-stranded DNA virus. Incubation: 2 to 7 days after
exposure.
■ Primary episode may be asymptomatic; recurrence usually
less painful, of shorter duration.
■ Associated with fever, malaise, headache, arthralgias; local
pain and edema, lymphadenopathy.
■ Need to distinguish from genital herpes zoster (usually in
older patients with dermatomal distribution) and candidiasis.
Primary Syphilis
Appearance: Small red papule that becomes a chancre, a
painless erosion up to 2 cm in diameter. Base of chancre is
clean, red, smooth, and glistening; borders are raised and
indurated. Chancre heals within 3 to 8 wks.
■ Causative organism: Treponema pallidum, a spirochete.
Incubation: 9–90 d after exposure.
■ May develop inguinal lymphadenopathy within 7 d; lymph
nodes are rubbery, nontender, mobile.
■ 20%–30% of patients develop secondary syphilis while
chancre still present (suggests coinfection with HIV).
■ Distinguish from: genital herpes simplex; chancroid;
granuloma inguinale from Klebsiella granulomatis (rare in the
United States; four variants, so difficult to identify).
Chancroid
Appearance: Red papule or pustule initially, then forms a
painful deep ulcer with ragged nonindurated margins;
contains necrotic exudate, has a friable base.
■ Causative organism: Haemophilus ducreyi, an anaerobic
bacillus. Incubation: 3–7 d after exposure.
■ Painful inguinal adenopathy; suppurative buboes in 25% of
patients.
■ Need to distinguish from: primary syphilis; genital herpes
simplex; lymphogranuloma venereum, granuloma inguinale
from Klebsiella granulomatis (both rare in the United States).
hypospadias
A congenital displacement of the urethral meatus to the inferior
surface of the penis. The meatus may be subcoronal, midshaft,
or at the junction of the penis and scrotum (penoscrotal).
scrotal edema
Pitting edema may make the scrotal skin taut; seen in heart
failure or nephrotic syndrome.
peyroine disease
Palpable, nontender, hard plaques are found just beneath the
skin, usually along the dorsum of the penis. The patient
complains of crooked, painful erections.
hydrocele
A nontender, fluid-filled mass within the tunica vaginalis. It
transilluminates, and the examining fingers can palpate above
the mass within the scrotum.
carcinoma of penis
An indurated nodule or ulcer that is usually nontender.
Limited almost completely to men who are not circumcised, it
may be masked by the prepuce. Any persistent penile sore is
suspicious.
scrotal hernia
Usually an indirect inguinal hernia that comes through the
external inguinal ring, so the examining fingers cannot get
above it within the scrotum.
cryptochochidism
The testis is atrophied and lies outside the scrotum in the inguinal canal, abdomen, or near the pubic tubercle; it may also be congenitally absent. There is no palpable left testis or epididymis in the unfilled scrotum. Cryptorchidism, even with surgical correction, markedly raises the risk of testicular cancer
small testis
In adults, testicular length is usually ≤3.5 cm. Small firm testes usually ≤2 cm suggest Klinefelter syndrome. Small soft testes suggesting atrophy are seen in cirrhosis, myotonic dystrophy, use of estrogens, and hypopituitarism; may also follow orchitis.
actor orchitis
The testis is acutely inflamed, painful, tender, and swollen. It may be difficult to distinguish from the epididymis. The scrotum may be reddened. Seen in mumps and other viral infections; usually unilateral.
tumor of testis: early vs late
EARLY: Usually appears as a painless nodule. As a testicular neoplasm grows and
LATE: Any nodule within the testis warrants spreads, it may seem to replace the
investigation for malignancy. entire organ. The testicle characteristically
feels heavier than normal.
spermatocele and cyst of epididymis
A painless, movable cystic mass just above the testis suggests
a spermatocele or an epididymal cyst. Both transilluminate.
The former contains sperm, and the latter does not, but they
are clinically indistinguishable.
varicocele of the spermatic cord
Varicocele refers to gravity-mediated varicose veins of the
spermatic cord, usually found on the left. It feels like a soft
“bag of worms” in the spermatic cord above the testis, and if
prominent, appears to distort the contours of the scrotal skin.
A varicocele collapses in the supine position, so examination
should be both supine and standing. If the varicocele does
not collapse when the patient is supine, suspect a left
spermatic vein obstruction within the abdomen.
acute epididymitis
An acutely inflamed epididymis is indurated, swollen, and
notably tender, making it difficult to distinguish from the
testis. The scrotum may be reddened and the vas deferens
inflamed. Causes include infection from Neisseria gonorrheae,
Chlamydia trachomatis (younger adults), Escherichia coli, and
Pseudomonas (older adults); trauma; and autoimmune
disease. Barring urinary symptoms, urinalysis is often
negative.
torsion of spermatic cord
Torsion, or twisting, of the testicle on its spermatic cord
produces an acutely painful, tender, and swollen organ that is
often retracted upward in the scrotum. The cremasteric reflex
is nearly always absent on the affected side in boys or men
with testicular torsion. If the presentation is delayed, the
scrotum becomes red and edematous. There is no associated
urinary infection. Torsion is most common in neonates and
adolescents, but can occur at any age. It is a surgical
emergency because of obstructed circulation.
tuberculous epididymitis
The chronic inflammation of tuberculosis produces a firm
enlargement of the epididymis, which is sometimes tender,
with thickening or beading of the vas deferens.
indirect inguinal hernia
frequency, age, sex: most common, all ages, both sexes, often in kids may occur in adults
point of origin: above inguinal ligament near its midpoint (the internal inguinal ring)
course: often into scrotum, hernia comes down the inguinal canal and touches fingertip in inguinal anal during cough/straining
direct inguinal hernia
frequency, age, sex: less common, men >40, rare in women
point of origin: above inguinal ligament close to the pubic tubercle ( near external inguinal ring)
course: rarely into scrotum, hernia bulges anteriorly and pushes side of fingertip in inguinal anal during cough/straining forward
femoral hernia
frequency, age, sex: least common, more common in women than men
point of origin: below inguinal ligament, appears more lateral than an inguinal hernia, can be hard to differentiate from lymph nodes
course: never into scrotum, inguinal canal is empty
