Clinical Skills

Question 1

Urogenital Clinical Skills

Answer 1

1. Physical Examination of Hernia and Perineum/Urology.
2. Basic urinalysis, and Introduction to Peritoneal Dialysis and Vascular Access for Hemodialysis.
3. Obstetric and Gynaecological Examination.

Question 2

Key diagnosis of Physical Examination of Hernia and Perineum/Urology

Answer 2

1. inguinal hernia
2. scrotal pathology
3. perianal and rectal conditions

Question 3

Standard procedures of perineum physical examination

Answer 3

1. History taking
2. Inspection of inguinal scrotal region
3. Palpation – supine and erection positions.
4. Inspection of perianal condition, positioning of patient for digital rectal examinations.

Question 4

History taking (Perineum examination)

Answer 4

This anatomical region includes a number of body systems and therefore the main “complaints” that will be listed here are relatively disconnected from each other.

A lump/swelling in the groin
 duration
 is it there all the time or does it “appear and disappear” – with straining, standing/lying
 unilateral or on both sides
 pain – locally over the lump, or in the midline of the abdomen (colic)
 does the swelling extend down into the scrotum?
 any evidence of increased intra-abdominal pressure-chronic cough, constipation, voiding difficulty etc.
 any previous hernia operation(s)

A lump/gland in the groin
A patient may present having noticed a groin lump(s) in the area of the inguinal lymph nodes, without any symptoms, like those above that suggest a hernia
 duration
 pain
 enlarging
 any symptoms related to the anus
 any symptoms related to lower urinary tract
 other “lumps” noted elsewhere – e.g. axilla, neck

scrotal swelling
 onset – sudden or developed slowly
 painful
 present all the time
 growing larger
 any irritating urinary symptoms

Anal pain
 sharp, dull
 continuous or intermittent e.g. only with defaecation
 associated bleeding – bright red, fresh or altered blood

Anal or peri-anal lump/swelling
 present all the time or only when straining i.e. prolapsing but reducible
 painful, tender, throbbing
 bleeding, discharge

Question 5

Male penis examination

Answer 5

**1) Self-introduction, explanation, surgical gloves and proper exposure **(running commentary all the way)

2) Retreat prepuce gently to expose glans penis

-  Note in case of phimosis much resistance experienced,  

3) Inspection

i) any phimosis, paraphimosis
ii) inspect site and appearance of external urethral meatus
iii) observe for urethral discharge
iv) look for abnormal curvature \* <sup>see 5.iii</sup>
v) look for abnormal lumps and mass
vi) look for genital ulcers or warts

4) Pull the prepuce back

- if not properly returned (esp. in older men), prepuce may form tight ring over the penis (Paraphimosis)

5) Palpation

i) palpate for any localized, painless induration of one or both corpora cavernosa
ii) palpate the floor (ventral side) of male urethra from glans to the pelvic floor - look for retention of urine or stone formation
iii) \* in case of abnoraml curvature, palpate for fibrosis/induration of the penis

Question 6

Male Scrotal examination

Answer 6

1) Self-introduction, explanation, surgical gloves and proper exposure (running commentary all the way)

2) Inspection

i) any obvious swelling – e.g. one testis much larger, or a generalised swelling
ii) redness of the scrotal skin
iii) enlarged veins of the pampiniform plexus on standing, empty with patient in lying position (varicocele)
iv) surgical scar (e.g. transverse incision)

3) Ask for pain and tenderness

- palpate more tender side first

4) Palpation position

- index finger of left hand over scrotum midline to fix scrotum and testes in place for palpation by the right hand

5) Palpation (testes, epidydimis, spermatic duct)

i) consistency, tenderness, swelling, mass (solid or fluid-filled)
ii) size of testes or mass
iii) palpate for epidydimis (posterior of testicle surface, thin cord) and spermatic duct (upper lateral testes)
iv) site of interest – in the testis or in the epididymus
v) \* varicocele if feeling "a bag of worms"
vi) scrotal mass differentiation: [if one can get above the mass, genuine scrotal mass] [if one cannot get above the mass, indirect inguinal hernia, etc.]

6) Transillumination

i) turn off lights
ii) fold a paper cylinder
iii) shine torch to scrotum via paper cylinder
iv) fluid containing hydrocoeles and epididymal cysts will be translucent and allow light shine out

Question 7

Inguinal lymph nodes examination

Answer 7

1) Inspection

- usually not much to see on inspection

2) Palpation

- first identify which group of nodes is involved
- size, consistency, mobility
- tenderness

Question 8

Hernia examination

Answer 8

1) Inspection

- any obvious swelling present in the groin, or one which appears when the patient is asked to cough ("cough impulse"), strain, or when the patient stands up
- if a cough impulse appears, you must note that it is "expansile" – and also you must observe whether the bulge seems to be "direct" or "indirect"
- also, on inspection, you should note if the swelling seems to be over the inguinal or the femoral region

Palpation

For this part of the examination of a hernia you will learn to differentiate between the varieties of groin herniae by performing a set of clinical tests. These need to be demonstrated on an actual patient.

Question 9

perineum, anus and digital per rectal examination

Answer 9

1) Self-introduction, explanation, surgical gloves and proper exposure (running commentary all the way)

2) Inspection

i) usually left lateral position
ii) first look carefully at the skin of the perineum for fistulae, scars etc.
iii) next you need to inspect the anus and the peri-anal area for fissure, external piles, abscess, surgical scars etc.

3) Palpation

- you should palpate over the same area for any tenderness, induration

4) Palpation (Digital per-rectal exam)

i) Explanation of "invasiveness"
ii) Patient position (never use the old knee-chest position due to condescending nature; resume patient in _left lateral position_ with knee thigh bended upwards; if patient too weak, dorsal position with abducted thighs)
ii) Stand behind patients (dorsal of patient)
iii) inspection of anus and peri-anal region \* <sup>see 2.iii</sup>
iv) Lubricate gloved right hand with KY jelly (~toothpaste size)
v) Press distal phalanx of right index finger on anus, flex to feel anal tone and slowly insert the index finer
vi) insert your well lubricated, gloved right index finger into the anal canal and rectum
vii) Palpate posterior part to feel for coccyx
viii) Turn finger clockwise and anti-clockwise to palpate lateral sides of rectal mucosa - look for irregularity, tumour, ulcer, hardness
ix) kneel down to assume a more comfortable stance
x) turn finger anteriorly to palpate prostate
xi) Report consistency, symmetry, size \* <sup>see 6 </sup>(estimates only; by finger breadth, normally 1-2, or by gram, normally 20 to 30), texture (normally rubbery), irregular hard areas and nodules
xii) Inspect finger for discharge or bleeding

5) Proctoscopy

The examination of the rectum would then be completed by inserting a proctoscope to visualise the ano-rectal lining.

6) MRI

Use MRI to accurately estimate prostatic size

Question 10

Prostatic massage for collection of specimens

Answer 10

Prostatic massage for collection of specimens

 knee-elbow position

 slow, firm strokes with the pressure applied evenly, after which the contents of the penile urethra are milked down