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Introduction to Clinical Medicine > Exam V: Pelvic & Junk > Flashcards

Exam V: Pelvic & Junk Flashcards

1
Q

Office Environment

A

ALWAYS have another person in the room while examining genital area or the female breasts.
Explain what you are going to be doing, before you do each step/maneuver
Insure patient comfort, and modesty

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2
Q

Patient Comfort and Modesty

A

Use gowns AND sterile drapes over pt legs
Allow patient to wear socks, shirt- as long as access can be facilitated etc.
Foot of exam table does not face the door
Door is clearly marked to avoid interruption
Another person in the room all the time, taking notes or somehow attentive

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3
Q

Male Anatomy: Penis, Root, Glans, Foreskin, Corona, and Frenulum

A

Penis - formed of three cylindrical masses of erectile tissue - enclosed in separate fibrous coverings - held together by a covering of skin

Root at base of penis, divides into crura which are attached to the pelvic bones

Glans is at the tip of the penis and is the most sensitive part for most men - covered by prepuce or foreskin which may be removed by a surgical procedure called circumcision

Corona (crown) - ridge between glans and foreskin

Frenulum - connects glans to shaft on underside of penis

Smegma - secretion that can accumulate under foreskin of penis and must wash/clean thoroughly to prevent infections

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4
Q

Male Anatomy: Shaft

A 
Contains spongy tissue which fills with blood when a man is aroused, leads to erection (there is no bone in the penis)
Cavernous bodies (corpus cavernosum) - on top - 2 of them
Spongy body (corpus spongiosum) underneath - 1 only - urethra runs through it
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5
Q

Malformations of the Penis

A

Abnormal location of urethral orifice along penile shaft

Hypospadias: urethra on ventral aspect; most common

Epispadias: urethra on dorsal aspect

If these issues are present = congenital issues which mean problems downstream like pelvic organ abnormalities, inguinal hernias, undescended testes

Clinical Consequences: constriction of orifice, urinary tract obstruction leading to infection, impaired reproductive function

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6
Q

Kegel Exercises

A

benefit sexual functioning and pleasure – note that the musculature around the penis is comparable to the pelvic floor muscles in the female

strengthening the muscles with Kegel exercises may produce benefits for men in that are similar to those produced by Kegels in women

Prevents pelvic floor prolapse
Contraction muscles that hold the urine

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7
Q

Seminiferous Tubules and Interstitial Cells

A

Seminiferous tubules are the site of sperm production
sperm maturation occurs in the epididymus (about 20 feet long) on the back of each testicle

Interstitial cells are located between the seminiferous tubules and are the major producer of androgens in men

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8
Q

Epipdidymitis vs. Testicular Torsion

A

BOTH are EMERGENCIES

Testicular torsion: pain is sudden and severe; abnormal axis; acute; early puberty; UA is negative; cremasteric reflex is negative; tx is surgical exploration

Epididymitis: gradual onset of pain of testis or epididymis; the testicle may be warm and/or red and swollen; axis of testicle is normal; insidious onset of symptoms; adolescents; UA can be + or -; cremasteric reflex is positive; tx is antibiotics

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9
Q

Seminal Vesicles

A

Seminal vesicles - two pouch-like structures between the bladder and the rectum - function not completely understood – they secrete an alkaline fluid rich in fructose - sperm become motile here and can propel themselves (got to this point via cilia in ducts) - contribute about 70% of seminal fluid

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10
Q

Prostate

A

Doughnut shaped gland just below the bladder - thin alkaline secretions counteract acidity in male urethra and in the vagina – contributes about 30% of seminal fluid

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11
Q

Cowper’s Glands

A

Or bulbourethral glands
Pea-sized - lie just below prostate - connect to urethra by a duct - secrete a slippery substance when a man is sexually aroused - alkaline - helps lubricate flow of seminal fluid through urethra
can contain active sperm and cause pregnancy without ejaculation occurring

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12
Q

Semen

A

(or seminal fluid)
one teaspoon of fluid – one ejaculation contains 200-500 million sperm which - provide only 1% of volume - rest from seminal vesicles (70%), prostate (30%) and Cowper’s gland (<2%)
semen of a healthy man is not harmful if swallowed – but semen can transmit HIV from an HIV-positive man

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13
Q

Ejaculation

A

Two stages = emission and expulsion

Emission phase - prostate, seminal vesicles and upper part of vas deferens (ampulla) contract - moves secretions into ejaculatory duct and prostatic urethra
internal (bladder exit) and external (below prostate) urethral sphincters close - urethral bulb balloons - leads to sensation of ejaculatory inevitability

Expulsion phase - strong rhythmic contractions of the penis expel semen – urethra contracts - external sphincter relaxes allowing semen to be expelled - internal sphincter continues to contract preventing urine from being expelled

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14
Q

Circumcision Sutures

A

Interrupted sutures in case one comes out

If continuous, if it is damaged, the whole suture is at risk

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15
Q

Phimosis

A

Extremely tight foreskin
Prepuce cannot be easily retracted over glans
May be congenital, but usually associated with balanoposthitis (STD) and scarring
Paraphimosis: trapped glans causing urethral constriction

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16
Q

Penis Enlargement Procedure

A

Detach crura to give 2-3 inches and then inject fat behind glans
The erection will be pointing straight instead of angled dorsally so urination and ejaculation flow is different
Must wear a pole attached to the penis to prevent crura from reattaching

Gelking: some men go for the stretch method of enlargement- get ulcers if too much weight stretched the skin

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17
Q

Inflammatory Lesions of the Penis: STDs

A

Balanitis (balanoposthitis): inflammation of the glans plus prepuce associated with poor hygiene in uncircumcised men (smegma); distal penis is red, swollen, tender, and with or without purulent discharge

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18
Q

Inflammatory Lesions of the Penis: Fungal

A

Candidiasis
Especially in diabetics
Erosive, painful, pruritic, simple yeast
Can involve entire external male genitalia
Baby powder and air helps prevent yeast growth – they like warm, dark, and moist areas

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19
Q

Neoplasms of the Penis: Squamous Cell Carcinoma

A

Epidemiology: uncommon aka less than 1% of cancer in males, but mostly in uncircumcised men between 40-70 years old

Pathogenesis: poor hygiene, smegma, smoking, HPV (16 and 18)
CIS first then progression to invasive squamous cell carcinoma

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20
Q

3 Parts to Pelvic Exam

A
  1. Observation and the speculum exam
  2. Bimanual exam
  3. Recto-Vaginal Exam (includes DRE)
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21
Q

History, Inspection, and Palpate

A

Pubic hair-triangle pattern
Lymph nodes
Orifices

Palpate:
Urethral meatus-incontinence
Labia
Skene’s, then Bartholin’s glands
Perineum
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22
Q

Speculum Exam

A

Performed prior to the bi-manual exam so as not to disturb the tissues/samples
Performed without lubricant jelly
Always inserted with the speculum blades warmed with warm water and closed
Inserted at a 45 degree angle posteriorly

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23
Q

Visual Observation of Cervix

A

Position—is it anteverted, deviated, etc
The position of the cervix gives clues to the position of uterus
Color—should be flesh-colored, but ranges from pink to dark brown (blue or pale??); certain colors indicate pregnancy
Surface characteristics—cysts, erythema
Discharge
Size and shape of os- indication of reproductive history

24
Q

Nulliparous Cervix

A

No baby has passed through

Small and round

25
Q

Multiparous Cervix

A

At least one or more children have passed through

Bigger and not round, more linear

26
Q

Everted Cervix

A

The endothelium of canal will move out

True cervical tissues and inner cervical tissues

27
Q

Nabothian Cysts

A

aka: retention cysts

Pimple like things on the cervix

28
Q

The Papanicolaou Exam (“Pap”)

A

A minimum of two samples will be taken:
Cervical cells
Vaginal secretion
Other tests may be done to screen for STDs

The “Pap smear” evaluates the condition of the cervical cells (taken with cervical brush or spatula)
SCREENS FOR CERVICAL CANCER- very accurate and decreased cancer rates

Assessing “transitional zone” of the cervix

29
Q

Three Most Common STDs in Women

A

HPV, Herpes, Chlamydia, (Now 10’s of millions of existing cases)
In women, often no visible symptoms

30
Q

Bacterial Vaginosis

A

aka: Vulvovaginitis
General description for anything that causes symptomatic discharge (an irritant)

May be due to bacteria, viruses, fungi, or protozoans

Patient may talk to you about: vaginal or vulvar itching, burning, or change in color, texture or odor of discharge

31
Q

The Bimanual Exam

A

The bimanual exam is the second part of a complete pelvic exam

Necessary to evaluate the cervix, uterus, and adenexal regions (ovaries, fallopian tubes, surrounding areas)

Move the cervix to assess for PID/Endometriosis

Important even if patient is not sexually active

32
Q

Recto-Vaginal Exam

A

DRE
The Recto-Vaginal exam is the 3rd and final part of the pelvic exam

May help evaluate the posterior aspect of the uterus (esp. if retroverted)

Allows exam of rectal walls (initial screen for colo-rectal cancer or polyps)

33
Q

Uterine Fibroids

A 
AKA: myoma, leiomyoma, fibroma
Very, very common (40% of women > 40)
The most common tumor of the pelvis
The most common reason for a hysterectomy
Benign, benign, benign!

Rick Factors: Nulliparity or delayed childbearing and African American women have 2-3 times the incidence of uterine fibroids

Locations: intramural, subserosal, submucosal, pedunculated (on a stalk and can twist on axis and infarct/become painful)

34
Q

Uterine Fibroids Symptoms

A 
Heavy menstrual bleeding
Abdominal distortion
Pelvic pressure
Low back pain; dyspareunia
Infertility
Frequent urination
Constipation
Miscarriage or premature labor
Can cause negative effects of fetus like distortion because only so much space for baby to grow
35
Q

Uterine Fibroid Treatment Options

A

“Wait and see”
Drug therapy (GnRH agonists)- to alter tumor growth
Uterine Artery Embolization (UAE) to cut blood supply; insert catheter and inject particles and fill up and implode blood supply so fibroid becomes necrotic and dies
Myomectomy
Hysterectomy

36
Q

Vaginitis

A 
Inflammation of the vagina caused by:
Candidiasis
Trichomonas
Gardnerella
Bartholin’s abscess
37
Q

Monoliasis or Candidiasis: Signs and Symptoms

A

Marked leukorrhea, marked redness of vulva, extreme pruritus.
White, creamy, cheesy, sweet smelling discharge, thrush patches.
Commonly seen in pregnancy, diabetics, women on BCP or antibiotics (ampicillin).

38
Q

Monoliasis or Candidiasis: Assessment and Management

A

Assessment - lab KOH wet mount NS KOH 10% 20% look for (branching Hyphae or Mycelium fungus nails).

Management - Nystatin–intravaginal adult tabs 0.1 to 0.2 million units daily times 7 to 10 days

39
Q

Trichomonas Vaginitis: Signs and Symptoms

A

Leukorrhea, vaginal soreness, burning, pruritus, dyspareunia (pain during intercourse).
Bubbly, yellowish thick discharge, foul smelling.
Strawberry appearance of cervix

40
Q

Trichomonas Vaginitis: Assessment and Management

A

Assessment - lab wet prep, microscopic exam reveals pear shaped parasite with long flagella and undulated (wavy outline in appearance) cell membrane.

Management:
Metronidazole (Flagyl) anti protozoal 250 mg TID to 500 mg BID orally for 5 days.
Patient education of feminine hygiene, douching.
Management based on culture results

41
Q

Bacterial Vaginitis: Signs and Symptoms

A

also called Gardnerella Vaginitis
Leukorrhea, pruritus, dyspareunia.
Turbid, chalky, white/gray or yellowish discharge; malodorous (“fishy”).

42
Q

Bacterial Vaginitis: Assessment

A

Assessment: gram-positive nonmotile coccobacillus that normally inhabits the vagina that just overgrows
Wet smears of this nonspecific vaginitis yields vaginal desquamated epithelial cells covered with many bacteria

43
Q

Bacterial Vaginitis: Management

A

Management:
Metronidazole (Flagyl) 250 mg TID to 500 mg BID orally for 7 10 days.
Ampicillin 500 mg QID x 7 days.
Douching with povidone iodine solution.
About 25% of the patients have recurrence and require treatment in 2 3 months.
Management based on culture results

44
Q

Perineal Pain: Bartholin’s Abscess

A

Definition and etiology - acute or chronic infection of the Bartholin’s gland (streptococci, staphylococci, E. coli, anaerobes; may result in infection).

History - recent intercourse, venereal disease, trauma, spontaneous abortion, wiping from rectum to vagina

Signs and symptoms:
Mass in perineum that is hot, tender, and fluctuant.
Pus draining from Bartholin’s duct

45
Q

Bartholin’s Abscess: Management

A

Management:
I & D
Sitz bath: fill tube up quarter way and hot but not too hot; helps with healing and keeps area clean
Broad-spectrum antibiotics which cover gram-positive organisms and some common vaginal gram-negative organisms

46
Q

Endometriosis

A

Normal endometrium found in abnormal places
Therefore, “ectopic tissue” responds to hormone levels just like the inner layer of the uterus

Retrograde menstrual flow, fallopian tubes, abdomen
Lymphatic or circulatory systems cause spread

47
Q

Endometriosis: Risk Factors

A 
Young age: 10-15% of women ages 25 to 44 have endometriosis
Family History (6 - 12% of cases)
Nuliparity or delayed childbearing
Asians and Caucasians are at highest risk
48
Q

Endometriosis: Signs and Symptoms

A 
Pain, pain, pain  (low back and pelvic)
Pelvic mass
Alterations of menses
Dysmenorrhea (pattern = pain just prior to menses)
Infertility
Dyspareunia
Pain with defecation, urination
49
Q

Endometriosis: Pattern of Menstruation

A 
Women with endometriosis have:
earlier onset of menses
regular cycles
shorter intervals between periods (less than 27 days)
more severe menstrual cramps
prolonged menstrual flow (> 1 week)
50
Q

Endometrial Lesions

A

Endometrial deposits can occur anywhere in pelvis
Ovary—most common (75%); an ideal site for growth
Posterior cul-de-sac—70%
Between the uterus and bowel—35%
Uterosacral ligament—30%
Ureters
Uterus
Bowel
Also known to occur on appendix, gall bladder, stomach, spleen, liver, lung

51
Q

Endometrial Dx Confirmation

A

Suspected by case history
Visible lesions on the vulva or cervix
Red, brown, black (remember—may bleed)
Speculum exam (“shotty nodules”)

Definitive: The definitive diagnosis can only be made by direct visualization of the lesions
Presently, confirmed by laparoscopy

52
Q

Endometriosis Treatments

A

Keep in mind that these patients typically suffer a prolonged course of multiple therapies/surgeries
“Leave it alone”
Drug therapy
Laparotomy
Hysterectomy
Child-bearing (or pseudo-pregnancy conditions)
Tubal ligation

53
Q

Endometriosis and Infertility

A

Peritoneal fluid normally acts as a lubricant.
Endometriosis causes changes in the volume and cellular content of the peritoneal fluid.
Fluid level is increased
Leukocytes are increased
Prostaglandin levels are increased
Enzyme levels are increased
These all cause a localized inflammatory reaction around the lesions

The peritoneal fluid can then act as a toxin to the embryo and/or can alter the normal function of the ovaries and fallopian tubes

54
Q

Other Female Pelvic Conditions

A 
Uterine sarcoma (endometrial carcinoma)
Cervical carcinoma 
Ovarian carcinoma
Ovarian cysts
Uterine, vaginal prolapse
55
Q

Pregn’s Sign

A

Pregn’s Sign: physical lifting of testicles relieves pain of epididymitis but not pain caused by testicular torsion- KEY
Negative: no pain relief with lifting the affected testicle = testicular torsion = surgical emergency
Positive is epididymitis
NOT reliable for identifying other types of testicular issues from torsion

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