Andrology

Question 1

How do you perform the examination of the groin ?

Answer 1

Patient supine or standing (best for hernia) :

• inspect : skin abnormalities (dermatomycoses), signs of hidradenitis (small painful lymph), scars an visible swelling.
• auscultate : femoral artery for bruit
• palpate : femoral artery, inguinal lymph glands

Question 2

What is the cause of an inguinal hernia ?

Answer 2

Weakness in the abdominal wall. At a weak point internal tissue protrude forming a hernia sac within the parietal peritoneum.

Question 3

What is strangulation ?

Answer 3

= incarcerated hernia.

Higher risk if the neck/gate of hernia is narrow. Generally 1-2% of risk.
Cause acute pain due to ischemia of intestinal loop. Symptoms of acute mechanical ileus : vomiting and no stool.

Question 4

Reducible hernia vs non reducible ?

Answer 4

Reducible : can be pushed back
Non reducible : can’t, due to fusion of the mass with the hernia sac or oedema.

Question 5

What are the types of inguinal hernia ?

Answer 5

Lateral inguinal hernia : indirect hernia : exclusively in men

Media inguinal hernia = direct hernia : mainly older men, people who cough frequently.

Femoral hernia : less common generally, more present in women.

Question 6

Characteristics of lateral inguinal hernia ?

Answer 6

Hernia sac is formed by a protrusion of the peritoneum into the inguinal canal. If the tissue within the hernia, end further it protrude into the scrotum = scrotal hernia.

Question 7

What are the border of the inguinal canal ?

Answer 7

Internal inguinal gate/ring : 1 cm above ligament
External inguinal gate/ring : 5 cm medial, above the point of attachment to the pubic bone.

It contains the spermatic cord.

Question 8

Characteristics of medial inguinal hernia ?

Answer 8

Weak spot present just above external ring of inguinal canal.
Bulbous swelling that does not descend into the scrotum, protrusion is not reduced by applying pressure to close the canal.

Question 9

Characteristics of femoral hernia ?

Answer 9

Located below the inguinal ligament, a few cm medial to the palpable femoral artery.
Protrusion of femoral canal mostly non reducible.

Question 10

How do you detect an hernia ? (Position)

Answer 10

With the patient standing so the gravity makes their hernia more visible.

If they cannot stand => Valsalva manoeuvre : blow on the back of their hand.
- it increase intra-abdominal pressure => the hernia sac will fill if present
- if the swelling disappear once pressure is relieved => reducible hernia

Question 11

Inspection of an hernia ?

Answer 11

Look for swellings in the inguinal region.
Valsalva manoeuvre.

Question 12

Auscultation of an hernia ?

Answer 12

If bowel sound in swelling => hernia contains intestinal contain

Question 13

Palpation of an hernia ?

Answer 13

Palpate the external ring to detect is the mass is reducible.

Draw the little finger from base of scrotum, toward the inguinal canal. Place finger between skin and abdominal muscle, lateral of median line cranially.
Search for inguinal ring by pressing toward the abdominal cavity until detection of the annulus.

Repeat Valsalva manoeuvre, fingertips apply pressure in direction of inguinal ring.

Question 14

How do you reduce a lateral inguinal hernia ?

Answer 14

Supine patient. Press gently on the swelling.

Do not try if the hernia is painful => risk of strangulation and ischemia leading to a perforation of the bowel

Question 15

What are the erectile bodies of the penis ?

Answer 15

2 paired corpora cavernosa : dorsal part of the penis. Connected with each other in the external part of the penis

1 corpus spongiosum : ventral part of the penis around the urethra. Swell during the erection and form the glans penis.

Question 16

What give the penis its shape and firmness ?

Answer 16

The tunica albuginea : a firm and elastic capsule of connective tissue that surround the corpora cavernosa

Question 17

What does the foreskin covering the glans consist of ?

Answer 17

Inner layer : attached to the shaft at the corporal sulcus, connected to the urethral meatus by the frenulum preputti (prepuce).
Outer layer.

Question 18

What activity dominate when the penis is flaccid ?

Answer 18

Orthosympathetic activity.
Arterioles and sinusoids of erectile body narrow thus reduced penal perfusion.

Question 19

What activity dominate when the penis is erect ?

Answer 19

Parasympathetic activity.
Arterioles dilate and corpora cavernosa fill with blood. Increase pressure in the sinusoids press the efferent veins against the tunica albuginae. Impeding venous outflow further increase pressure in the corpora cavernosa until it reach systolic blood pressure.
Pressure in corpus spongiosum is lower because there are less layer and enable the release of ejaculate during emission and urinate when having an erection.

Question 20

What nerves innervate the penis ?

Answer 20

Autonomic and somatic system.
Sacral parasympathetic nerve : S2-S4
Thoracolumbar sympathetic nerves : Th10-L2

Question 21

What is the scrotum ?

Answer 21

Part of peritoneum and abdominal wall that protrudes via the inguinal canal and ends in the labial scrotal swellings.

It’s skin is pigmented, hairy and folded. It has sebaceaous glands, sweat glands.
In the midline a raphe can be seen, underlying there’s the intra-scrotal septum.

Question 22

Volume of the prostate ?

Answer 22

Varies in size, become larger with age.
Volume in young men 20mL to 30mL.

Question 23

Steps of the general androgenic inspection ?

Answer 23

Standing or supine (preferred so you can directly proceed to palpation)
General impression of abdomen and groin : skin abnormalities, swellings.
Check if secondary sexual characteristics are normally developed.
Impression of personal hygiene.

Question 24

What do you inspect in the penis ?

Answer 24

Dorsal, ventral side.
Circumcision.
Inspect glans.
Inspect urethral meatus.

Question 25

Inspection of the glans ?

Answer 25

Doctor or patient retract the foreskin : push it back into the coronal sulcus behind the edge of the glans.

White papillae can be seen on the corona (pearl necklace), they are physiological and occur in 20-30% of men.

Look for : scars, warts, redness, ulceration, blister, discharge, inflammation symptoms.

Question 26

Inspection of urethral meatus ?

Answer 26

If glans on both side : squeeze slightly meatus will open further to be examined.
Should be slit shaped, wide open and centered on the tip of the glans

Question 27

Inspection of the scrotum ?

Answer 27

Inspect : skin (pigmented and hairy), raphe (along the midline), level (left one usually lower than right).

Check for skin abnormalities and intrascrotal swellings.

Question 28

Indication to palpate penis ?

Answer 28

Pain, abnormal swellings, penile curvature.

Question 29

Palpation of the penis ?

Answer 29

From base to glans : assess suppleness of the corpus cavernosum.

Hold glans between thumb, index and middle finger. Extend shaft of penis, palpate shaft between thumb and index.

Question 30

Indication to palpate urethra ventrally ?

Answer 30

Weak urine stream, micturition produced by increased intra-abdominal pressure in which urethral abnormality is suspected.

Question 31

Technique of palpation of the testis ?

Answer 31

Displace the penis, hold them between thumb and index of both hands.
Gently squeeze to assess consistency then let them slide between your finger to feel surface.

Question 32

What do you assess palpating the testis ?

Answer 32

Symmetry, size, surface characteristics, consistency, presence of pain.
Use the Prader balls = orchidometer to determine the volume of the testis.

Question 33

Technique of the palpation of the epididymis ?

Answer 33

Slide finger dorsal side after testis examination. Exert minimal pressure.

Vas deferens: runs dorso-medially in the funiculus feels like a solide cord. Can be traced from the cauda epididymis to the external ring.
- thumb in the center of the scrotum, press dorsal and move laterally.
- let the structure slide between fingers.

Question 34

What do you assess palpating the epididymis ?

Answer 34

Integrity, position, painful, swelling.

Question 35

What do you assess in palpation of the vas deferens ?

Answer 35

Cyst, continuity of vas deferens.

Question 36

Position for prostate examination ?

Answer 36

Recovery position this way you can lift the patient upper buttock to facilitate inspection of the saddle area. Genitals are less exposed ne position is more comfortable.

Others position possible but record the position accurately.

Question 37

Preparation of the prostate examination ?

Answer 37

Well fitted gloves, next to the patient. Squeeze gel onto the index. Close the rest of the hands.

Lift upper buttock and inspect : skin around anus, hygiene, redness, minor trauma, swellings, anal fissure.

Question 38

Technique of prostate examination ?

Answer 38

Place index on the anus, wait for the sphincter. Insert finger gently, you can ask patient to push briefly.

Rotate palpating finger until it is in contact with the anterior surface of the rectum.

Slide finger in craniocaudal direction from and lateral to medial over the right and left lobe apply light pressure.

Question 39

What do you assess in the prostate sulcus ?

Answer 39

Surface, symmetry, consistency, presences of nodules, absence of pain.

Question 40

What do you assess in the rectum ?

Answer 40

Feces, tumors, muscle tone

Question 41

How do you assess the scrotum with transillumination ?

Answer 41

In a dark room, shine a light through the scrotum from the back so you can differentiate between solid structures and translucent ones.

Question 42

When and why do you do the genital neurological examination ?

Answer 42

Indicated in case of erectile dysfunction, micturition problems, painful scrotum.
It test the function of the sacral spinal cord.

Question 43

What do you do for the genital neurological examination ?

Answer 43

Sensation in the saddle : S1-S4
- both tip of cotton swab

Bulbocavernosus reflex : S2-S4
- glans is squeezed causing the anal sphincter to contract reflexively

Cremaster reflex : for acutely painful scrotum instead of the examination

Question 44

How do you do the cremaster reflex ?

Answer 44

Superficial reflex to maintain the thermorégulation of the testis and serve a protective function : pull the testis closer to the body.

Finger stroke the inner side of the thigh in caudal direction (L1-L2) and the ipsilateral testis move up.

Correlation between loss of cremasteric reflex and testicular torsion (sometimes)

Question 45

Possible abnormalities of the foreskin ?

Answer 45

Phimosis : foreskin cannot be retracted over the glans. Normal up to 10 years. In older people it is an infectious pathology like balanitis or lichen sclerosis.

Balanoposthitis : infection of skin affecting glands and foreskin. Redness, moist.
- Balanitis = inflammation of the gland
- Posthitis = inflammation of prepuce

Paraphimosis : foreskin isn’t returned to its original position leading to oedema.

Genitals warts

Squamous cell carcinoma.

Question 46

Possible abnormalities of the shaft of the penis ?

Answer 46

Hypospadia: urethral meatus isn’t located over the glans. But ventrally.

Epispadia : urethral meatus on the dorsal side.

Congenital penile curvature : becomes more noticeable during puberty. Long penis with flaccid corpora cavernosa.

Peyronie’s disease : fibrotic plaque in the tunica albuginae resulting in a curvature towards the side on which the plaque is.

Question 47

Possible abnormalities of the glans ?

Answer 47

Mental stenosis : meatus cannot be opened.

Genitals warts = condylomata acuminata. Pink-red-brown skin, benign tumors. Solitary or in large conglomerate. Caused by HPV

Squamous cell carcinoma : check for induration when warts like swellings, ulcer, solid tumors.
Nearest lymph node should be palpated.

Question 48

What are the different STD indication ?

Answer 48

Ulcer, papules, discharge, warts.

Syphilis : can develop into a painful ulcer. Caused by bacteria : treponema pallidum.

Genitals herpes : 40% of men have stage characterised by fever, malaise, muscle pain. Vesicles seen that can burst and develop into a ulcer.

Question 49

What are the different abnormality of the testis ?

Answer 49

Testicular dysgenesis syndrome : small testes can be felt. Associated with impaired spermatogenèses and impaired fertility. Increased risk of testicular cancer.

Sometimes there’s only 1 testes.

Testicular carcinoma : old age make shrinking and softening but there’s a solid painless swelling.

Question 50

What signify the absence of vas deferens ?

Answer 50

Vasectomy.

Congenital bilateral absence of vas deferens : suspected in men with fertility disorder, azoospermia with normal FSH and low ejaculate volume.

Question 51

What are the type of scrotal swelling ?

Answer 51

Painless swelling
Painless tumour : testicular cancer
Painful swelling : inflammation or testicular torsion
Varicocele

Question 52

What are the type of painless swelling in the scrotum ?

Answer 52

Hydrocele : accumulation of fluid between the layer of the tunica vaginalis. You can no longer palpate the testes.
- children can have a communicating hydrocele but it close after 1 year

Spermatocele : from the epididymis. Benign painless cystic swelling. The cyst contaisn clear/milky fluid.

Question 53

What are the characteristics of varicocele ?

Answer 53

Dilated, tortuous and complex testicular veins forming the pampiniform plexus. Painless compressible mass above and around the testis. Most of the time asymptomatic.
- 90% on the left side because the vein open directly into the renal vein.
- 15% of young adult and 40% of older men

Question 54

What are the different abnormalities of the prostate ?

Answer 54

Pelvic floor hypertonicity : tightening of anal sphincter

Prostate enlargements : symmetrically enlarge prostate with micturition problems (weak urine stream, feeling bladder isn’t empty, nocturia)
- palpable (firm elastic) but not painful
- obliterated sulcus

Assymatrical prostate : irregular consistency or hard nodule
- 2-3% of above 50 years old men
- increase risk of prostate cancer

Acute prostatis : painful when pressed or painful soft swellings with fever
- prostate feels soft
- micturition may be painful
- pain in the perianal region