Female/male Repro

Question 1

List changes that occur in the uterus, cervix, and vagina during pregnancy.

Answer 1

Uterus receives increased blood flow, uterus and cervix soften and the cervix takes on bluish color. Vaginal wall thickens which increases length. Vaginal secretions increase and have an acidic pH to prevent bacteria from multiplying.

Question 2

List changes that occur in the external and internal female genitalia in older adult women.

Answer 2

Estrogen levels decrease which cause labia and clitoris to become smaller. Labia Majora becomes flatter and body fat is lost. Decrease in muscle mass and strength. Vaginal introitus constricts and the vagina narrows/shortens. The mucosa becomes thin, pale, and dry. decrease/ lose vaginal rugae. Cervix becomes smaller and paler. Uterus decreases in size and endometrium thins out. Ovaries decrease and follicles gradually disappear.

Question 3

Describe proper patient positioning and draping procedure for a pelvic examination.

Answer 3

Lithotomy position, help patient stabilize feet on stirrups and slide butt to edge of table. Draping should be done with minimal exposure, cover knees and symphysis. You should still have sight of the patient’s face, best accomplished with “dent” in drape between Pt’s legs.

Question 4

Discuss the clinical significance cervical deviation – anterior, posterior, right, or left.

Answer 4

The cervix should be located in the midline. Deviation to the right or left may indicate a pelvic mass, uterine adhesions, or pregnancy. The cervix may protrude 1 to 3 cm into the vagina. Projection greater than 3 cm may indicate a pelvic or uterine mass. The cervix of a patient of childbearing age is usually 2 to 3 cm in diameter

Question 5

Describe the expected size, shape, and contour of a non-pregnant uterus, and distinguish between the following uterine positions: anteverted, retroverted, anteflexed, retroflexed, and midposition.

Answer 5

Anteverted or Anteflexed - Position of most uteri

A - Anteverted, B - Anteflexed, C - Retroverted, D - Retroflexed, E - Midposition

Question 6

Discuss “red flags” for sexual abuse in children or adolescents

Answer 6

Medical Concerns - Evidence of abuse/neglect, trauma in sensitive regions, unusual skin color in sensitive areas, STI, itching/bleeding/pain, rashes/sores.

Behavior - Problems with school, weight changes, depression, anxiety, sleep problems increased aggression

Sexual Behaviors - Provocative mannerisms, inappropriate sexual knowledge

Question 7

Define and describe the following: hydrocolpos, vulvovaginitis, and atrophic vaginitis.

Answer 7

Hydrocolpos - Distention of the vagina caused by accumulation of fluid due to congenital vaginal obstruction
Vulvovaginitis - Inflammation of vulvar and vaginal tissues
Atrophic vaginitis - Inflammation of the vagina due to the thinning and shrinking of the tissues, as well as decreased lubrication

Question 8

Discuss etiology/prevention of female genitalia cancers (breast, cervical, ovarian, uterine…)

Answer 8

Cervical Risks - HPV, 3+ pregnancies, younger than 17 and pregnant, smoking, HIV, poor diet, chlamydia, contraceptives, low SES

Ovarian Risks - Age, genetic mutation, family hx, obesity, fertility drugs, other cancers, oral contraceptives, diet

Endometrial - More menstrual cycles, several pregnancies, obesity, ovarian diseases, diet, diabetes, age, family hx, pelvic radiation

Question 9

Phimosis:

Answer 9

the foreskin is tight and cannot be retracted

Question 10

Paraphimosis:

Answer 10

the inability to replace the foreskin to its usual position after it has been retracted behind the glans

Question 11

Epispadias:

Answer 11

rare birth defect at the opening of the urethra where the urethra does not develop into a full tub, and the urine exits the body from an abnormal location. Causes are unknown.

Question 12

Hypospadias:

Answer 12

congenital defect in which the urethral meatus is located on the ventral surface of the glans penile shaft or the base of the penis

Question 13

Balanitis:

Answer 13

inflammation of the glans (head) of the penis; occurs most often in uncircumcised males

Question 14

Balanoposthitis:

Answer 14

inflammation that affects both the glans penis and prepuce.

Question 15

Smegma:

Answer 15

thick, white, cheesy substances that collects under the foreskin of the penis

Question 16

Explain when complete separation of the prepuce from the glans normally occurs, and explain what harm can come to a young boy if the foreskin is forcibly retracted.

Answer 16

Separation of the prepuce from the glans normally occurs around ages 3 to 4 years in uncircumcised children. If the foreskin is forcibly retracted, it can get permanently stuck behind the glands.

Question 17

Describe how to perform a thorough hernia exam in a male patient.

Answer 17

With the pt standing, ask him to bear down as if having a bowel movement. While he is standing, inspect the area of the inguinal canal and the region of the fossa ovalis. After asking the patient to relax again, insert your examining finger into the lower part of the scrotum and carry it upward along the vas deferens into the inguinal canal ( Fig. 20.12 ). You can auscultate for bowel sounds, which will be present in uncomplicated reducible hernias.
Which finger you use depends on the size of the patient. In the young child, the little finger is appropriate; in the adult, the index or middle finger is generally used. You should be able to feel the oval external ring. Ask the patient to cough. If an inguinal hernia is present, you should feel the sudden presence of a bulge against your finger. The hernia is described as indirect if it lies within the inguinal canal. It may also come through the external canal and even pass into the scrotum. Because an indirect hernia on one side strongly suggests the possibility of bilateral herniation, be sure to examine both sides thoroughly. If the bulge is felt medial to the external canal, it probably represents a direct inguinal hernia.

Question 18

Distinguish between an incarcerated hernia and a strangulated hernia.

Answer 18

Incarcerated Hernia: a mass that neither changes in size nor transilluminates and trapped in the intestine or abdominal tissue
Strangulated Hernia: the blood supply to the protruded tissue is compromised; nonreducible → prompt surgical intervention

Question 19

Question 20

Explain how to perform a thorough clinical testicular exam, and list the related structures that should be palpated. Include what different types of findings may be seen in different pathological conditions such as STIs, cancer.

Answer 20

Palpate the testes using the thumb and first two fingers. The testes should be sensitive to gentle compression but not tender, and they should feel smooth and rubbery and be free of nodules. Transgender women may have testicles that have decreased in size or completely retract. In some diseases (e.g., syphilis and diabetic neuropathy), a testis may be totally insensitive to painful stimuli. Irregularities in texture or size may indicate an infection, a cyst, or a tumor.

The epididymis, located on the posterolateral surface of the testis, should be smooth, discrete, larger cephalad, and nontender. You may be able to feel the appendix epididymidis as an irregularity on the cephalad surface.
Next, palpate the vas deferens. It has accompanying arteries and veins, but they cannot be precisely identified by palpation. The vas deferens itself feels smooth and discrete; it should not be beaded or lumpy in its course as you palpate from the testicle to the inguinal ring. The presence of such unexpected findings might indicate diabetes or old inflammatory changes, especially tuberculosis.
Finally, evaluate the cremasteric reflex. Stroke the inner thigh with a blunt instrument such as the handle of the reflex hammer, or for a child, with your finger. The testicle and scrotum should rise on the stroked side.

Question 21

Describe normal findings associated with palpation of the testes, epididymis, and vas deferens.

Answer 21

Testes: sensitive to gentle compression but not tender, and they should feel smooth and rubbery and be free of nodules

Epididymis: smooth, discrete, larger cephalad, and nontender

Vas Deferens: feels smooth and discrete; it should not be beaded or lumpy in its course as you palpate from the testicle to the inguinal ring.

Question 22

Describe how to instruct a male patient in genital self-examination.

Answer 22

Instruct the patient to hold the penis in the hand and examine the head. If not circumcised, the patient should gently pull back the foreskin to expose the glans. Inspection and palpation of the entire head of the penis should be performed in a clockwise motion while the patient carefully looks for any bumps, sores, or blisters on the skin. Bumps and blisters may be red or light-colored or may resemble pimples. Have the patient also look for genital warts, which may look similar to warts on other parts of the body. The urethral meatus should also be examined for any discharge.
Next, the patient will examine the entire shaft and look for the same signs. Instruct him to separate the pubic hair at the base of the penis and carefully examine the skin underneath. Make sure he includes the underside of the shaft in the examination; a mirror may be helpful.
Instruct the patient to examine the scrotal skin and contents. Instruct the patient to hold each testicle gently and inspect and palpate the skin, including the underneath of the scrotum, looking for any lesions, lump, swelling, or soreness. Educate the patient about other symptoms associated with STIs, specifically pain or burning on urination or discharge from the penis. The discharge may vary in color, consistency, and amount.

Question 23

Discuss the significance of a bifid (deep cleft) scrotum in a newborn.

Answer 23

Bifid scrotum is usually assoc. w/ other GU anomalies or ambiguous genitalia

Question 24

Discuss management considerations in newborn with undescended testicles. - couldn’t find in book

Answer 24

There are two treatment options: hormonal and surgical.
(hCG)
orchidopexy- if you can feel in groin
laproscopic orchidopexy- if you can feel in abdomen
testicular auto-transplant - if located very high in the abdomen

Question 25

Discuss the techniques used to distinguish between a hydrocele & hernia

Answer 25

If a bright penlight transilluminates the mass, and there is no change in size when reduction is attempted, it most likely contains fluid (hydrocele with a closed tunica vaginalis). A mass that does not transilluminate but does change in size when reduction is attempted is probably a hernia.

Question 26

Discuss etiology/prevention of male genitalia cancer (testicular, penile, prostate…)

Answer 26

Penile: Etiology: assoc. w/ HPV 16 & 18 | Prevention: HPV vaccine, safe sex practices, smoking cessation, circumcision
Testicular: Etiology: seminomas and nonseminomas arise from germ cells and non-germ cell tumors arise from supportive and hormone-producing tissue; germ cell cancers | Prevention: safe sex practices
Prostate: Etiology: | Prevention: screening? DRE (digital rectal exam)?

Question 27

Describe the normal size of a prostate.

Answer 27

● The normal size of a prostate is a large chestnut and approx. the size of a testis (4 x 3 x 2cm).
● Diameter is ~ 4cm

Question 28

Discuss the three patient positions commonly used to perform the rectal examination.

Answer 28

1. Knee-chest
2. Left lateral w/ hips & knees flexed
3. Standing w/ hips flexed and upper body supported by examining table

Question 29

Explain how to properly document the location of anal lesions by clock position and quadrant description.

Answer 29

Anal lesions can be documented as if looking at the face of a clock or by dividing the perianal area into (4) anatomic quadrants: right anterior, right posterior, left anterior, left posterior.

Question 30

Explain where the 12:00 reference position is located.

Answer 30

The 12:00 reference position is located at the anterior portion of the perianal area, between the left/right anterior quadrants.

How is clock face oriented? From the examiner’s perspective looking at posteriorly? From Pt’s perspective?

Question 31

Identify common abnormalities associated with rectal pain on a digital exam.

Answer 31

Rectal pain is almost always indicative of a local disease. Look for irritation, rock-hard constipation, rectal fissures, fluctuance from a perianal abscess, or thrombosed hemorrhoids. Always inquire about previous episodes of pain.

Question 32

Discuss the proper prostate size quantification on exam and documentation in the medical record.

Answer 32

Prostate enlargement classified by amount of protrusion into the rectum
● Grade I: 1-2 cm
● Grade II: 2-3 cm
● Grade III: 3-4 cm
● Grade IV: more than 4 cm

Question 33

Discuss the consistency of the prostate in each of the following conditions: prostate cancer, benign prostatic hypertrophy, and prostatic infection.

Answer 33

Question 34

Discuss the significance of “shelf lesions” above the prostate in males or in the cul-de-sac of females.

Answer 34

Hard, nodular lesions felt at the anterior rectal wall. Because the anterior rectal wall is in contact w/ the peritoneum, you may be able to detect the tenderness of peritoneal inflammation and nodularity of peritoneal metastases.

Question 35

Discuss the significance of the following stool characteristics: very light tan or gray stools, tarry black stools, pencil-like stools, ribbon stools, mucoid stools, and fatty stools.

Answer 35

Question 36

Explain how to test for fecal occult blood.

Answer 36

Rectal exam to obtain fecal sample on finger that can then be tested for occult blood using a chemical guaiac procedure.

Question 37

Discuss the significance of an absent “anal wink” reflex.

Answer 37

Lack of contraction may indicate a lower spinal cord lesion or chronic abuse.