FPC - Male GU Exam (Rogers) Flashcards
When palpating the spermatic cord, what is the main structure that you are looking for? What does it mean when a patient does not have this structure?
Vas deferens
The vas deferens should be able to be palpated within the spermatic cord.
Some men do not have a vas deferens. If this is unilateral, it could mean that the patient had abnormal kidney development. Do an ultrasound of the kidney to check for this.
Why is it important to assess the inguinal lymph nodes?
Penile cancer tends to metastasize primarily to the inguinal nodes
What is an intravaginal testicular torsion and which patient population is it most common in?
Intravaginal torsion occurs when the testis twists within the tunica vaginalis.
This is most common in adolescents and presents as a painful swollen testis that is horizontal and high up in the scrotum.
A 17-year-old male comes into the clinic complaining of painful urination, itchiness of the urethra, and a yellow discharge from the penis after having unprotected sex. While examining the glans, what else should be done before palpating the shaft?
Open the urethral meatus to look for discharge and redness
These two symptoms would indicate a bacterial infection of the urethra.
If discharge is present, you should insert a swab about 2mm into the meatus to obtain bacteria for a culture.
When should a digital rectal exam be performed?
When patient is over 40 years old and/or complains of urologic complaints
What is the procedure for performing the digital rectal exam?
- Lube up the finger
- Place the pad of the index finger on the anus and wait a few seconds to allow the sphincter to relax
- Slowly insert the finger up to the knucle
- Sweep the prostate to feel it
- Rotate the hand to feel the rest of the anal canal for any abnormalities and to assess sphincter tone
During the GU exam, you notice that your 67-year-old male patient has lymph nodes that are large and non-tender. What is a possible cause of this?
Malignancy
Remember that penile and scrotal cancers will primarily metastasize to the inguinal lymph nodes.
Normal nodes feel like “jelly beans,” tender nodes indicate infection.
After visual inspection of the penis, what is the next part of the exam? What is the main disease that can be diagnosed from this portion of the exam?
Palpation of the entire length of the shaft
While holding on the glans and stretching the penis, palpate from the base of the shaft to the glans using the opposite hand.
This is important in the diagnosis of Peyronie’s disease
A 22-year-old male comes to your clinic complaining about small, white bumps on the edge of the glans of his penis. He is worried that it could be an STI and that it might scare people away if they saw them. Below is an image of the condition. What is this condition called and what do you tell your patient about them?
Pearly papules
These are benign angiofibromas of the corona of the glans. They are not indicative of an infection, and are perfectly normal.
When palpating the prostate, what does a hard nodule usually indicate? What does a soft, spongy nodule usually indicate?
Hard nodule = cancer
Soft, spongy nodule = prostatitis
Normal prostate should feel like the thenar eminence muscles of the palm of the hand.
In what position(s) do you examine the patient for hernias?
Initially check when the patient is supine, and then check again with the patient standing.
Standing can cause the hernia to be pushed out more, which would make it easier to see on physical exam
Between what two anatomical landmarks does the inguinal canal run?
The pubic tubercle and the anterior superior iliac spine (ASIS)
True or False: The normal adult bladder cannot be palpated or percussed until there is at least 150 mL of urine.
True
What is an extravaginal testicular torsion and which patient population is it most common in?
Extravaginal testicular torsion occurs when the tunica vaginalis twists around the testis because the gubernaculum is not attached to the testis.
Most common in neonates
The gubernaculum normally connects the testis to the scrotum and pulls the testis from the abdomen, through the inguinal canal, and into the scrotum.
What is a spermatocele?
Fluid filled sac that originates at the head of the epididymis.
A 16-year-old male presents to the ED with excrutiating pain and intermittent vomiting. He tells you that he was hit in the groin with a soccer ball during a game, and that the pain has gotten much worse. What does this patient most likely have and how long do you have to correct it before irreversible damage occurs?
Testicular torsion
6 hours until the testicular tissue dies and is no longer salvagable
Torsion is the twisting of the testes and spermatic cord, which causes venous obstruction. This causes extreme pain.
During the typical newborn exam, you notice that the infant has an abnormal looking foreskin that only covers the top of the glans. What is generally associated with an abnormal foreskin?
Abnormal positioning of the urethral opening (meatus)
Generally, abnormal foreskin development means that the patient will have either hypospadias (meatus on underside of penis) or epispadias (meatus on top of shaft).
What is the correct way to “palpate” the kidney?
Place one hand on the patient’s back just below the ribs and place pressure on the area. With the other hand, push deeply to try to feel for the kidney.
What is a varicocele and how are they graded?
Dilation of testicular veins in the spermatic cord
Produces a “bag of worms” feeling upon palpation.
Grading:
- Grade 1 - only felt on palpation when the patient bears down
- Grade 2 - only felt via palpation
- Grade 3 - visible
What is trans-illumination and which condition is it used to diagnose?
Trans-illumination is a diagnostic test used to diagnose hydrocele.
Shining a light behind the scrotum to see how much light passes through.
If lots of light passes through, this indicates a hydrocele. If little to no light passes through, this is normal.
Upon examination of the scrotum, you observe a bulging mass coming from the external inguinal ring. What condition does this indicate?
Indirect inguinal hernia
What are the 3 parts of the epididymis and where is each one located?
Head, body, and tail
The head is located at the top of the testis, the body runs down the back of the testis, and the tail is located at the bottom of the testis.
What is the standard procedure for palpating hernias?
- Point index finger in the direction of the ASIS
- Push the index finger into the scrotum and feel for the external inguinal ring
- Have the patient bear down or turn his head and cough
- Feel for any bulging as this happens
What is phimosis and which age group is this common in?
Phimosis is characterized as a tight foreskin that cannot be retracted.
This is common in boys under the age of 5.
The foreskin is usually able to be retracted by age 5 because it loosens with nocturnal erections.
What is zoon balanitis and what testing should you perform?
Zoon balanitis is an inflammatory process of the glans and prepuce of uncircumcised men.
This requires a biopsy to determine the cause of the inflammation
What is Peyronie’s disease and what causes it?
Peyronie’s disease is characterized by pain with erection and an abnormal curvature of the shaft of the penis
This is caused by sustained microtrauma to the tunica surrounding the corpora cavernosum.
Microtrauma causes fibrosis, which leads to formation of a plaque that bends the shaft of the penis upon erection.
This is why you should stretch the penis while palpating the shaft.
What is a hydrocele?
Fluid filled sac that begins around the bottom of the testicle.
Fluid fills up and pushes the tunica vaginalis outward, creating the hydrocele.
When begining the penile portion of the exam, how do you manipulate the penis?
Grab the glans
Try not to touch the shaft until you have completed the visual portion of the exam.
Be sure to stretch the penis to see all aspects of the shaft (top, bottom, sides) before palpating.
Your patient is a 42-year-old man who is coming in for his routine physical exam. On inspection of the scrotum you see that he has dilated testicular veins that cause a “bag of worms” appearance to the scrotum (seen below). What condition does this patient have?
Varicocele
What is Fabry disease?
Vascular ectasias on the shaft of the penis
Look like small black dots on the shaft of the penis.
What is epispadias?
Abnormal positioning of the urethral meatus on the top of the glans or shaft of the penis.
Typically indicates that there are more developmental abnormalities present and requires surgery to correct
When performing the male GU exam, what is the purpose of the abdominal portion of the exam?
To examine the kidneys and bladder
The genitourinary tract begins with the kidneys, down the ureter, into the bladder, through the urethra, and out of the penis.
Your patient is a 35-year-old male complaining of pain with urination and hematuria. Upon examination of his suprapubic region (between the umbilicus and pubic symphysis) you find that pressure on this region induces pain. Pain in this area indicates a problem with which organ?
Urinary Bladder
What is a hypospadias?
Abnormal positioning of the urethral meatus on the underside of the glans, shaft, or scrotum.
Depending on the location, extensive reconstructive surgery may be required to fix the urinary tract.
