Exam V: Pelvic & Junk Flashcards
Office Environment
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
Patient Comfort and Modesty
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
Male Anatomy: Penis, Root, Glans, Foreskin, Corona, and Frenulum
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
Male Anatomy: Shaft
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
Malformations of the Penis
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
Kegel Exercises
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
Seminiferous Tubules and Interstitial Cells
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
Epipdidymitis vs. Testicular Torsion
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
Seminal Vesicles
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
Prostate
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
Cowper’s Glands
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
Semen
(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
Ejaculation
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
Circumcision Sutures
Interrupted sutures in case one comes out
If continuous, if it is damaged, the whole suture is at risk
Phimosis
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
Penis Enlargement Procedure
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
Inflammatory Lesions of the Penis: STDs
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
Inflammatory Lesions of the Penis: Fungal
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
Neoplasms of the Penis: Squamous Cell Carcinoma
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
3 Parts to Pelvic Exam
- Observation and the speculum exam
- Bimanual exam
- Recto-Vaginal Exam (includes DRE)
History, Inspection, and Palpate
Pubic hair-triangle pattern
Lymph nodes
Orifices
Palpate: Urethral meatus-incontinence Labia Skene’s, then Bartholin’s glands Perineum
Speculum Exam
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
Visual Observation of Cervix
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
Nulliparous Cervix
No baby has passed through
Small and round
Multiparous Cervix
At least one or more children have passed through
Bigger and not round, more linear
Everted Cervix
The endothelium of canal will move out
True cervical tissues and inner cervical tissues
Nabothian Cysts
aka: retention cysts
Pimple like things on the cervix
The Papanicolaou Exam (“Pap”)
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
Three Most Common STDs in Women
HPV, Herpes, Chlamydia, (Now 10’s of millions of existing cases)
In women, often no visible symptoms
Bacterial Vaginosis
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
The Bimanual Exam
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
Recto-Vaginal Exam
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)
Uterine Fibroids
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)
Uterine Fibroids Symptoms
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
Uterine Fibroid Treatment Options
“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
Vaginitis
Inflammation of the vagina caused by: Candidiasis Trichomonas Gardnerella Bartholin’s abscess
Monoliasis or Candidiasis: Signs and Symptoms
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).
Monoliasis or Candidiasis: Assessment and Management
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
Trichomonas Vaginitis: Signs and Symptoms
Leukorrhea, vaginal soreness, burning, pruritus, dyspareunia (pain during intercourse).
Bubbly, yellowish thick discharge, foul smelling.
Strawberry appearance of cervix
Trichomonas Vaginitis: Assessment and Management
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
Bacterial Vaginitis: Signs and Symptoms
also called Gardnerella Vaginitis
Leukorrhea, pruritus, dyspareunia.
Turbid, chalky, white/gray or yellowish discharge; malodorous (“fishy”).
Bacterial Vaginitis: Assessment
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
Bacterial Vaginitis: Management
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
Perineal Pain: Bartholin’s Abscess
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
Bartholin’s Abscess: Management
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
Endometriosis
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
Endometriosis: Risk Factors
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
Endometriosis: Signs and Symptoms
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
Endometriosis: Pattern of Menstruation
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)
Endometrial Lesions
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
Endometrial Dx Confirmation
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
Endometriosis Treatments
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
Endometriosis and Infertility
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
Other Female Pelvic Conditions
Uterine sarcoma (endometrial carcinoma) Cervical carcinoma Ovarian carcinoma Ovarian cysts Uterine, vaginal prolapse
Pregn’s Sign
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
