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History & Physical Examination > Exam 2 - Male GU Exam > Flashcards

Exam 2 - Male GU Exam Flashcards

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1
Q

Male GU: PMHx Screening - Whats in it?

A 
Age appropriate male GU screening
Date of last prostate exam
Date of last PSA and result if known
Date of last testicular exam
Gardasil? Zostavax?
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2
Q

What is in the male GU ROS?

A

Frequency of urination, polyuria, nocturia, burning or pain on urination, hematuria, urgency, reduced caliber or force of stream, hesitancy, incontinence, urinary retention, stones.
Hernias, penile discharge or lesions, testicular pain or masses, STIs and their treatments, exposure to HIV, precautions against HIV and STIs.
Sexual interest, orientation, function, satisfaction/problems, method of contraception.

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3
Q

What’s in a MALE sexual history?

A

Sexual interest, orientation, and function
Age of first coitus
Number of sexual partners
Satisfaction, problems, hematospermia
Open ended questions
“Please tell me about your sexual partner(s)”
Abuse
“Have you ever been forced to do something sexual against your will?”
Contraception/protection
Privacy

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4
Q

Why is it common to have hesitant male patients in GU exams?

A

They do not feel comfortable expressing GU pain, symptoms, sexual history, sexual dysfunction

Anxiety is often high and unexpressed

  • -Anticipation of pain/discomfort
  • -Lack of knowledge about procedures
  • -Previous experience with the GU exam
  • -“Urban legends” and myths run rampant

Embarrassment can be a significant barrier
Gender and age may affect interaction

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5
Q

Males have been found to be more reluctant to seek preventive healthcare and are less likely to acknowledge the need to assistance than are females – Where do males access data regarding their health?

A
  • -Media sources, including the internet
  • -Physician/clinician
  • -Family members
  • -Health behaviors often neglected
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6
Q

Male GU Exam: Why is it important to be professional during this exam?

A

Professionalism dispels embarrassment; competence helps with patient trust

Maintaining a professional demeanor eases tension in the patient and the clinician.

Confidence, or lack thereof, is quickly felt by the patient and can create high anxiety.

Acknowledge patient’s bodily responses with a matter-of-fact manner.

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7
Q

Will a male experience erection during the GU exam?

A

Medical students’ anxiety about the patient having an erection during the exam should be openly addressed.

“Although possible, it is rare for a male to become sexually excited, because he will usually be nervous in the circumstances. If the examination is performed in an objective manner, it should not be a source of stimulation to the patient.” (Swartz, 1998. Textbook of Physical Diagnosis, p. 401).

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8
Q

What should you do if a young male experiences erection during this exam?

A

The Bates text provides practical advice:
“A male patient may occasionally have an erection. If so, you should explain to him that this is a normal response, finish your examination, and proceed with an unruffled demeanor.”

Make the patient feel at ease with bodily responses that may not be under voluntary control

Especially in the young male patient
In one focus group participant’s words:
“I don’t know if I want my doctor to be too joking about it [GU exam] because a lot of times, people are kidding too much if they’re uncomfortable…not professional….and that would make me nervous.”

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9
Q

How to approach male GU exam?

A

Relationship building is essential

Ask open-ended questions
“They [physicians] ask questions in a certain way that you can only answer ‘yes’ or ‘no’ and that’s it. You can’t elaborate.”

Maintain non-judgmental, respectful attitude
Display tact, sensitivity, and humor when appropriate

Explain what you are doing as you do it
“Most doctors don’t take the time to explain stuff….they do it [the GU exam], and they leave like they have more important stuff to do.”

Do not rush through the exam

“Many times, when the doctor is in a rush, I hesitate to say something because he’s in a rush.”

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10
Q

When completing a male GU exam, what is important to ask?

What exams do you need to ask this for?

A

Ask permission before proceeding
Patient consent is tremendously essential for invasive procedures!

**Consent needed for rectal exam, a testicular exam, retracting foreskin

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11
Q

What affects patient attitude?

A

Cultural or religious beliefs
Previous positive or negative experiences (GU exam)
What their friends tell them about this type of exam

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12
Q

More protocols of GU exam:

A

Warn the patient to expect touching
Minimize physical and emotional discomfort
Maintain professional rapport at all times
Calm the patient’s anxiety

Be courteous and respectful always
Say “please” when asking patient’s compliance

The line that drives ALL patients nuts is “can you do this for me?”
The patient is doing something to aid you in assessment
The patient is not doing something for you- that comes off as condescending
Rather, state, “can you please move your arm to the side?”

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13
Q

How do you incorporate patient sensitivity in the GU exam?

A

Give the patient privacy to remove clothing and change into a gown

Use a drape to limit exposure

Expose only the area to examine, then recover when finished

Allow the patient to cover up completely when the exam is finished

Offer a tissue for removing KY jelly after the exam is completed

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14
Q

What anatomy is reviewed in male GU exam? What parts?

A

Review anatomy and physiology
>Penis (foreskin (prepuce), glans, urethral meatus);
>Scrotum (testis, epididymis, spermatic cord); > Inguinal area (hernias, lymph nodes);
>Anus –» Rectum; Prostate

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15
Q

What’re you looking for in a male GU exam?

A

Practice a focused exam technique
>Note any external abnormalities
>Screening opportunity for testicular cancer
>Detection of hernias, swelling, masses

Relate findings and discuss results with the patient immediately after exam

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16
Q

Before beginning a GU exam?

A

Explain the procedure to the patient

Use models or diagrams to illustrate

Address patient’s concerns about pain

Chaperone in exam room ALWAYS advisable
A must for opposing genders

Always wear gloves

Perform this exam with proper lighting

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17
Q

When is a chaperone required?

A

When exams are performed on opposite genders.

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18
Q

Whats included in PATIENT POSITIONING inspection portion of male GU exam?

A

Patient positioning
Have the patient stand in front of you and raise his gown to level of the umbilicus.
Note bulges or scars in the inguinal region consistent with herniation.
Look for obvious penile or scrotal abnormalities.
Note any skin abnormalities on the penis, scrotum or surrounding areas.

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19
Q

Whats included in PENILE inspection portion of male GU exam?

A

Retract foreskin, note +/-circumcision

Inspect glans, noting:
Inflammation
>Ulcers
>Nodules
>Poor hygiene
Return the foreskin to its normal position
Note location of urethral meatus
>Inspect for discharge
Palpate the shaft of the penis for underlying firm areas 
>Fibrosis or plaque
Examine the base of the penis
>Note vesicles, ulcers, inflammation
>Tanner stage
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20
Q

Whats included in the SCROTUM inspection portion of male GU exam?

A 
Skin of scrotum
>Lesions, inflammation, discoloration
>Contours of scrotum
>Rashes, inflammation
>Swellings or bulges
>“Bag of worms”
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21
Q

Whats included in the TESTICLES inspection portion of male GU exam?

Testicles?
Epididymis?
Spermatic cord?

A

Testicles
>Size, shape, consistency, tenderness
>Undescended testis
>Masses

Epididymis
>Tenderness, swelling, masses

Spermatic cord
>Tenderness, swelling, masses

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22
Q

Testicular palpation - What do you palpate? What are you looking for?

A

Gently palpate the tissue of the testes between your thumb and forefinger; each side should feel the same.

Palpate from the epididymis to superficial inguinal ring

If a testicle is missing, ask the patient why
Surgically absent? Why? Document.
Congenitally absent? Document.

Make note of any swelling, erythema, pain, nodule

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23
Q

Firm nodule in the testicle?

A

Could be malignant.

24
Q

What is the cremasteric reflex?
How is it performed?
What nerves are affected?
What’s a normal finding?

A

Elicited by a light stroke of the superior and medial (inner) part of the thigh

Use the handle of a reflex hammer or a tongue depressor

Utilizes sensory and motor fibers of the genitofemoral nerve (L1,L2)

A subtle rise and fall of the scrotum is a normal finding

25
Q

Hernias – Where is inguinal ring located? What is in the inguinal canal?

A

Inguinal ring lies above and approximately parallel to the inguinal ligament and forms a tunnel for the vas deferens

Exterior opening = exterior inguinal ring

26
Q

Where is the femoral canal? How do you locate it?

A

The femoral canal lies below the inguinal ligament.

Locate it by placing your right index finger from below, on the right femoral artery.
Your middle finger will then overlie the femoral vein, your ring finger will be on the femoral canal where a herniation may occur.

27
Q

What are the boundaries of Hesselbach’s Triangle?

A

Tracing out the margins of the three surrounding structures

Inferior epigastric vessels: (lateral) run from upper left to center
Inguinal ligament: (inferior) runs from upper right to bottom left
Rectus abdominis muscle: (medial) runs from upper left to bottom left

28
Q

What is the clinical signifiance of checking H. Triangle, Femoral Canal, and Inguinal Canal?

A

Interpretation

Indirect Inguinal Hernia
(outside Hasselbach’s Triangle)
>Enters Inguinal Canal lateral to inferior epigastrics
>Exits Inguinal Canal inferior to inguinal ligament
»>Higher risk of strangulation, bc its in the inguinal canal

Direct Inguinal Hernia 
(within Hasselbach's Triangle) 
>Breaches posterior inguinal wall
>Passes medial to inferior epigastric vessels 
>>>Less risky, through abdominal wall.
29
Q

How is hernia exam performed on males?

What point do you start at?
Where do you go to?
Whats a strong indication of an inguinal hernia?

A

Use you right hand for the right side and left hand for left side

Start at a point low enough in the scrotum so your finger will have enough mobility to reach as far as the internal inguinal canal.

Follow the spermatic cord upward to above the inguinal ligament and find the triangular slit like opening of the external inguinal ring.

If you detect a diffuse swelling amidst the cord structures or note the inguinal canal area to be protuberant, the patient has an inguinal hernia.

30
Q

What do you have the patient do during a male hernia exam? Why is this done?

A

Have the patient bear down and cough
Make sure you have him turn his head as not to cough in your face

This maneuver increases the intra-abdominal pressure forcing intestines/peritoneal fluid through any defect which may exist.

Femoral : place your fingers on the anterior thigh in the region of the femoral canal and ask the patient to strain down again or cough.

Femoral hernia occurs when the bladder or intestine enters the canal carrying the femoral artery into the upper thigh.

31
Q

Whats an indirect inguinal hernia?

A

When small intestines enter the inguinal canal.

32
Q

Whats an indirect femoral hernia?

A

Bulging at the femoral canal.

33
Q

Digital Rectal Exam - 3 things to check for before performing exam:

A

Assess the patient’s strength and mobility before positioning him

Ask the patient if he feels stable and comfortable before proceeding

Make sure lighting is sufficient

34
Q

What positions is the digital rectal exam performed in?

A

Common positions for the DRE

Modified lithotomy
Left lateral position (fetal position)
Standing, flexed at the hips

35
Q

How do you start with the DRE?

A

Glove both hands and spread the buttocks apart

>Talk the patient through each step of the examination prior to performing each step

36
Q

What are you inspecting the sacrococcygeal and perianal areas from?

A

Inspect the sacrococcygeal and perianal areas

>Fissures, skin tags, hemorrhoids, bleeding, abscess drainage

37
Q

What are you palpating for in the rectum and prostate?

What do you ask the patient about?

A

Palpate throughout the rectum and the prostate, noting masses or tenderness

Ask the patient about localized tenderness or pain

38
Q

Steps to performing DRE?

Why do you tell the patient to bear down and try to have a BM?

A
  1. Place lubricant on your gloved fingertip.
  2. Tell the patient you are going to place your finger inside the rectum.

This is where the patient feels the most vulnerable.
Talk him through it and be gentle.

  1. Place your index finger against the anus, ask the patient to bear down as if trying to have a BM.

Why? This helps to relax his external sphincter and should decrease discomfort.

  1. Assess sphincter tone
    As he bears down, gently push forward until your entire finger is in the anal canal.
39
Q

Steps of DRE - Starting with palpation:

Why do we collect stool when performing DRE?

A

Palpate upwards, posteriorly, and laterally to feel for rectal masses

Palpating anteriorly will allow you to examine the prostate gland.

Orient your finger so that it is directed toward the umbillicus.
In this position, your finger should be resting on the prostate.

Collect the stool on the fingertip of the glove to perform a stool guiac for occult blood.

Why do we collect stool?
–To check for occult blood.

40
Q

Possible findings of rectal exam?

A

NORMAL:
Normal rectal mucosa feels uniformly smooth and pliable

ABNORMAL:
1. Polyps may be attached by a stalk or base

  1. Masses or irregularly shaped nodules
  2. Areas of unusual hardness
  3. Abscesses may be indicated by extreme tenderness
  4. External hemorrhoids
41
Q

Describe prostate size:

(A) During childhood?

(B) Puberty?

(C) 50 yrs?

A

(A) Small during childhood

(B) Increases 5 times its size (5-fold) between puberty and 20 years of age.

**By the 50YR (5th decade), increasingly enlarges.

42
Q

What is the size of a normal prostate?

Is tenderness normal?

What feeling happens from palpation?

A
  1. Normal prostate
    About 2.5 cm from side to side
    >Prominent median sulcus
    >Consistency is rubbery and smooth
  2. Tenderness not usual
  3. patients should feel urge to urinate when you palpate it
43
Q

How do you approach a prostate exam?

A

Inform the patient that you are going to examine his prostate gland (Same as rectal exam).
»When you perform a DRE, you will also do the prostate exam at the same time.

44
Q

Describe prostate exam technique.

What are you noting for in this exam?

A

Sweep your finger over the prostate gland
Found anteriorly through rectal wall

Identify the two lobes with a longitudinal groove (median sulcus) between them

Note the size, nodularity, consistency and tenderness of the prostate

45
Q

What position is the prostate exam done in?

A

The prostate can be easily examined with the patient in either the decubital or the dorsal lithotomy position.

46
Q

What is indicated by a boggy prostate?

A

Boggy prostate indicates inflammation.

47
Q

If a prostate is absent, what does this indicate?

A

The absence of a prostate may indicate past radiation or surgery for prostate cancer.

Absence of the prostate must be documented

48
Q

If there is any prostate enlargement, what else needs to be assessed? Why?

A

Important to assess the size of the urinary bladder in any case of prostate enlargement.

49
Q

When else should prostate exams be done?

A

Include prostate examination in any man who has suprapubic abdominal discomfort, a distended abdomen, or both.

50
Q

What is done during conclusion of prostate exam?

What is done during withdrawal of the finger?

A

Inform the patient before withdrawing your finger

Note the color of any fecal matter on glove

Use fecal material for occult blood testing as this is indicated for colorectal cancer screening

Offer the patient tissues for wiping

Always remove your gloves outside of the view of the patient.

Allow the patient to cover up and rise to sitting position before discussing results

51
Q

What test is performed at the end of a rectal exam, why?

A

Note the color of any fecal matter on glove

Use fecal material for occult blood testing as this is indicated for colorectal cancer screening

52
Q

End of Male GU Exam, you must take time for patient education. What types of questions should you be answering?

A

When should the patient follow up?
Are you sending that patient to a specialist?
Are there screening exams that need to be performed?
When will the next physical exam be?

53
Q

Patient education for a young adult male (

A

Young adult males (

54
Q

Patient education for an older adult male (>40yrs)?

A

Older adult males (40+ years)

Prostate and colorectal cancer screening
Sexual function, libido, arousal, ED
Lower urinary tracts symptoms that affect quality of life (incontinence, BPH - benign prostatic hyperplasia)

55
Q

Male GU Documentation Ex

A

Genitalia: Pubic hair in adult male pattern without lesions, rashes, nits or lice.

Circumcised penis without lesions, indurations or discharge. Meatus patent centrally at the distal-most tip of the glans.

Scrotal contents are smooth without tenderness, swelling, or masses; testes descended bilaterally. Inguinal and femoral areas are smooth without palpable nodes. Bilateral inguinal canals without masses, bulges or tenderness.

Anus and rectum: Perianal area without lesions, rashes, excoriation; anus without lesions, fissures, fistulas or hemorrhoids.

Digital rectal exam: Tightening of sphincter evenly without discomfort; rectal walls smooth without nodules, masses, or tenderness. Prostate is firm, smooth, non tender with symmetric lateral lobes; stool hemoccult negative.

History & Physical Examination (19 decks)

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