L8: Male Genitals & Rectal Flashcards
Anatomy: Male Genitalia
Inguinal Inspection
What are you examining for?
- Ask patient to stand with his back against exam table; legs shoulder- width apart
- Have him lift his gown to his waist
- Ask the patient: “Have you noticed any rashes or anything unusual in this area?”
- Examine the pubic area
- Pubic hair
- Lesions
- Swelling/masses
Inguinal Palpation
Where to palpate?
What is abnormal? What is it suggestive of?
- Tell the patient: “I’ll be checking your groin for lymph nodes. Let me know if you feel any tenderness or discomfort.”
- Start at the iliac crest and palpate down the inguinal ligament medially
- Hard or immobile nodes suggest cancer
Penile Examination
If uncircumcised?
What are you inspecting for?
- Tell the patient, “I’ll now be examining your penis.”
- Visually inspect the penis
- If uncircumcised ask the patient to retract the foreskin
- Palpate both sides of the penis and inspect the urethral meatus
- Gently open the meatus using your fingers
- Inspecting for inflammation or discharge
Scrotal Examination
What are you inspecting? What are you inspecting for?
What are you palpating?
- Tell the patient: “I’ll now be examining your scrotum and testicles.”
- Inspect scrotal skin for moles, rash, etc.
- Move scrotum from side to side and lift to check perineal area.
- Palpate scrotal contents:
- Testes
- Epididymis
- Spermatic cord (vas deferens)
Testicular Examination
What are you palpating for?
Expecting findings?
What shoud you advise your patient?
- Palpate each testicle between your index and middle finger and your thumb
- Consistency like an eraser or a hard-boiled egg
- If irregular needs further evaluation
- Advise monthly exam during shower
- Testicular cancer highest incidence in 15 - 35 year age group
Epididymis
What is it?
Location?
What should it feel like?
- Epididymis: tube that connects a testicle to a vas deferens in the male reproductive system
- Located superiorly and posterolaterally on testicle
- May feel like:
- Bag of worms
- Wad of noodles
Spermatic Cord
What is it?
Location?
What should it feel like?
- Spermatic cord: the cord-like structure in males formed by the vas deferens (ductus deferens) and surrounding tissue that runs from the deep inguinal ring down to each testicle
- Bilateral firm cords that feel like the “inside of a BIC pen” or a “inside of a BIC pen” or a “long al dente macaroni noodle”
- Palpate from the epididymis to the inguinal ring using thumb and index finger
Hernia Examination
How to perform?
What to feel for?
- Invaginate some scrotal skin when inserting index or little finger into inguinal ring
- Insert index finger into inguinal canal
- Use little finger for child or smaller adult. Or sausage fingers.
- Ask patient to “turn your head and cough” or Valsalva.
- Feel for sudden pressure at side or tip of finger
Rectal & Prostate Exam: Patient Positioning
- Have patient lean forward over the exam table, rest elbows on table, legs apart and knees slightly bent
- Patient lying on his side on exam table, with legs flexed at the hip and knee
- Tell the patient: “I’m now going to examine the anal region.”
Rectal and Prostate Exam: perianal area
What are you inspecting for/visualizing?
What are you looking for?
- Inspect perianal area:
- Spread cheeks of buttocks with thumbs
- Visualize the anal opening
- Check for hemorrhoids, fissures, skin tags and other lesions
Rectal and Prostate Exam
How to prep for rectal & prostate exam
- After inspection, apply lubricant to index finger of dominant hand
- Spread buttocks cheeks laterally with the non- dominant hand
- Tell the patient: “I’ll be placing my lubricated finger on your rectal opening, then I’d like you to relax that area. Next, I’ll insert my finger to check your prostate and rectum.”
- Press tip of dominant index finger against anal opening, palm facing downward
- Tell the patient: “Try to relax this area.”
- Slowly begin inserting finger into rectum, proceed to full length of the finger
Prostate Exam
Where is the prostate located?
How to palpate?
Size?
Shape?
Consistency?
- Palpate prostate, located at 6 o’clock
- Move finger over surface of prostate, from side to side, checking right & left lobes
- Size: about size of a walnut
- Shape: “almond”(with 2 lobes)
- Consistency: firm, like tip of nose or thenar area of palm
- Perform a 180° sweep around rectum in each direction to check for rectal lesions
- Slowly remove finger and check stool for blood (Hemoccult/guaiac test)
Condyloma acuminata
What is it?
Cause?
Clinical presentation?
- Sexually transmitted, caused by human papillomaviruses (HPV)
- Most common worldwide
- Usually multiple, grow together and spread to perineum and anal area
- Variably sized soft papules and plaques in anogential regions
Genital Herpes
Type 1 vs. Type 2
Clinical presentation
- Herpes simplex virus type 1
- Affects lips, area around mouth
- Herpes simplex type 2
- Genital infections
- Begins with painful vesicles on an erythematous base
- Vesicles can ulcerate
- Incurable with recurrent outbreaks
Syphilitic chancre
Cause?
Clinical presentation?
Treatment?
- Infection due to the spirochete Treponema pallidum
- Primary (acute) phase begins as a painless papule that erodes into a painless ulcer
- It may become secondarily infected
- Heals without treatment in 4-8 weeks
Urethritis
Gonococcal urethritis vs. non-gonococcal urethritis
Cause?
Clinical presentation?
- Infection or inflammation of the urethra
- Gonococcal urethritis
- caused by Niesseria gonorrhoeae
- Non-gonococcal urethritis
- Caused by Chlamydia Trachomatis and others
- Male with c/o dysuria and urethral discharge
- May see inflamed meatus
Peyronie’s Disease
What is it?
Cause?
Clinical Presentation?
Treatment?
- Idiopathic condition resulting in fibrosis in the tunica albuginea
- Firm plaques in penile shaft are palpable
- May develop penile curvature, painful erections, and occasionally erectile dysfunction
Carcinoma of Penis
Average age?
Most common in?
Clinical presentation?
- Begins as a firm nodule or ulcer that does not heal
- Average age is 50
- Usually nontender
- More common in uncircumcised males
- Inguinal adenopathy often present
Indirect Inguinal Hernia
Most common age? Sex?
Location?
- Most common in all ages, both sexes
- Above inguinal ligament, near the internal inguinal ring
- Often extends into scrotum
- Palpable as impulse down inguinal canal
Direct Inguinal Hernia
How Common?
Most common age? Gender?
Location?
- Less common
- Usually in men over age 40
- Above the inguinal ligament
- Rarely into the scrotum
- Bulges anteriorly
Femoral Hernia
How common?
Most common sex?
Location?
- Least common
- More common in women
- Below the inguinal ligament
- More lateral than an inguinal hernia
- May mimic lymph node
- Never into scrotum
Scrotal Contents
Varicocele
What is it?
What does it feel like?
What is it associated with?
- Varicose veins of scrotal vessels
- Develops slowly
- Feels like a soft “bag of worms”
- May slowly collapse if scrotum elevated while patient supine
- Associated with infertility
Hydrocele
What is it?
- Soft non-tender hemi-scrotal swelling that transilluminates
- Size of swelling may wax and wane; check for concurrent indirect hernia or testicular masses
Spermatocele/Epidermal Cyst
What is it?
How big is it?
- Painless, fluid-filled cyst of the epididymis
- Smaller than hydrocele, usually
- May transilluminate
Acute Epididymitis
What is it?
Presentation?
Prehn’s Sign?
- Infection of the epididymis via the vas deferens
- Fever and chills
- Acute and unilateral, dull to severe scrotal pain radiating to ipsilateral flank
- Hemi-scrotal swelling and tenderness which may progress to erythematous, fluctuant mass
- Prehn’s Sign (elevation of the scrotum providing relief)
Acute Orchitis
What is it?
Presentation?
What is it a complication of?
- Inflammation or infection of the testis
- Testicular swelling and tenderness
- Similar in appearance to epididymitis
- Complication of epididymitis and mumps
Testicular Torsion
What is it?
Presentation?
Treatment?
- Acute onset of scrotal pain, unilateral with hemi scrotal swelling
- Pain on palpation, without relief with elevation
- Often hours after vigorous physical activity/minor trauma
- Absent cremasteric reflex
- Most common in neonates and adolescents
- Bell clapper deformity
- Surgical emergency that requires intervention within 6hrs
- Twisting of testis & spermatic cord results in ischemia
- Doppler ultrasound demonstrates decreased blood flow
Testicular Tumors
What is it?
Presentation?
- Painless, solid testicular swelling or nodule
- Inguinal lymphadenopathy or para-aortic lymphadenopathy
- +/- abdominal pain or with pulmonary symptoms or neurologic deficits
Hemorrhoids
Internal vs. External
-
Hemorrhoids: Internal
- Enlargements of normal vascular
- cushions above pectinate line
- Can cause bright red bleeding with defecation
- Can prolapse and appear as red, moist mass
-
Hemorrhoids: External
- Dilated veins covered with skin
- Tender, swollen, bluish mass at anal margin
- Asymptomatic unless thrombosed
Anal Fissure
What is it?
Cause?
Presentation?
Diagnosis?
- Anal fissure is a tear in the inside lining of the wall of the anus
- Caused by stretching of anal mucosa
- Severe pain with passage of stool and scant bleeding
- Pain causes spasm, worsens fissure
- Diagnosed by history and anoscopy
Anorectal Abscess
What is it?
Cause?
Presentation?
What can it lead to?
- Originates from an infected anal crypt gland
- Severe pain in the anal or rectal area
- Fever and malaise are common
- Perianal erythema and a palpable, often fluctuant mass
- Purulent rectal drainage may be noted if the abscess has begun to drain spontaneously
- Can lead to anorectal fistula
Rectal Polyps
What is it?
Types?
Presentation?
Testing?
- Protuberance into the lumen above the surrounding colonic mucosa
- May be pedunculated (on a stalk) or sessile (attached at base)
- Soft, difficult to feel with finger
- Biopsy needed to r/o malignancy
Rectal Carcinoma
Presentation?
Diagnosis?
- Firm, nodular, rolled edge
- Often have blood per rectum
- Not typically dx’d by physical exam
Prostatitis: Acute vs. Chronic
What is it?
What does it present with?
Treatment?
-
Prostatitis: Acute
- Enlarged, tender prostate gland
- UTI symptoms, often with fever and chills
- Perineal or abd pain
- Examine gently
- Treat with antibiotics
-
Prostatitis: Chronic
- Presents with recurrent UTIs
- Prostate exam may be normal
- Treat with antibiotics for a lot longer
Benign Prostatic Hypertrophy
What is it?
Most common in?
Presentation?
- BPH more common with increasing age
- Symmetrical enlargement of gland
- Slowing of urine stream with difficulty starting stream
Carcinoma of Prostate
What is it?
Presentation?
Metastasis?
- Enlarged, firm nodule or area of hardness
- Irregular contour and median sulcus is obscured
- Usually a slow-growing tumor
- Metastasizes locally and to bone
- May complain of obstructive voiding symptoms
