Lecture one (anus, rectum, prostate), EXAM 3

Question 1

Where does the GI tract terminate?

Answer 1

in a short segment, the anal canal

Question 2

• Normally, the anal canal is held in a closed position by what?
• The angle of anal canal lies on what?
• The anal canal is liberally supplied by what?

Answer 2

• Normally, the anal canal is held in a closed position by two muscles, the voluntary external anal sphincter and involuntary internal anal sphincter
• The angle of the anal canal lies on a line roughly between the anus and umbilicus
• The anal canal is liberally supplied by somatic sensory nerves

Question 3

• What demarcates the anal canal from the rectum?
• What is the anorectal junction?

Answer 3

• Aserrated line demarcates the anal canal from the rectum
• The anorectal junction (often called the pectinate or dentate line) is the boundary between somatic and visceral nerve supplies

Question 4

In the male, the prostate gland lies against what?
* What are the characteristics?
* What lobes are palpable?

Answer 4

• against the anterior rectal wall
• It is rounded, heart shaped and normally 2.5 cm long
• Only the lateral lobes and median sulcus are palpable

Aging: larger and harder
Bad: pea nodal or monolobe feeling

Question 5

In the female, the uterine cervix usually is palpable through what?

Answer 5

the anterior wall of the rectum

Question 6

What common/concerning symptoms?

Answer 6

• Change in bowel habits
• Blood in the stool
• Pain with defecation; rectal bleeding or tenderness
• anal warts or fissures
• Weak stream of urine (lose as we age dt prostate)
• Burning upon urination

Question 7

What do you need to ask about lower GI concerns?

Answer 7

• Is there any change in the pattern of bowel function?
• Any change in the size or caliber of the stool?
• Any diarrhea or constipation?
• What color is the stool?
• Any obvious blood or mucus in the stool?
• Any pain on defecation?
• Any itching?
• Any extreme tenderness in the anus or rectum?
• Any purulent discharge or bleeding?
• Any history of anal warts, ulcerations, or fissures?
• Any involvement in anal intercourse?

Question 8

What are lower GU concerns for men?

Answer 8

• Is there any difficulty starting or holding back the urine stream?
• Is the urine flow weak?
• Is there frequent urination, especially at night?
• Is there any pain or burning upon urination or ejaculation?
• Any blood in the urine or semen?
• Any pain or stiffness in the lower back, hips,
  or upper thighs?
• Any discomfort or heaviness at the base of the penis with associated malaise, fever, or chills?

Question 9

What is the health promotion and counseling for males?

Answer 9

Screen for prostate cancer
* Prostate cancer is the leading cancer diagnosed in men in the United States, and the third leading cause of death
* The primary risk factors are age, ethnicity, and family history (although a series of studies have suggested an association between intake of dietary fat and risk of prostate cancer)
* DRE and PSA

Screen for polyps and colorectal cancer
Provide counseling about sexually transmitted diseases

Question 10

• What is the leading cancer diagnosed in men and third leading cause of death?
• What are the primary risk factors?
• What serums levels do you need to check?

Answer 10

• Prostate cancer is the leading cancer diagnosed in men in the United States, and the third leading cause of death
• The primary risk factors are age, ethnicity, and family history (although a series of studies have suggested an association between intake of dietary fat and risk of prostate cancer)
• DRE and PSA

Question 11

In the United States, the lifetime risk of being diagnosed with prostate cancer is approximately _ , and the lifetime risk of dying of prostate cancer is _

Answer 11

In the United States, the lifetime risk of being diagnosed with prostate cancer is approximately 11%, and the lifetime risk of dying of prostate cancer is 2.5%.

Question 12

• Many men with prostate cancer never experience what?
• In autopsy studies of men who died of other causes, more than 20% of men aged 50 to 59 years and more than 33% of men aged 70 to 79 years were found to have what?
• Median age at death from prostate cancer is what?
• What group has an increase risk?

Answer 12

• In the United States, the lifetime risk of being diagnosed with prostate cancer is approximately 11%, and the lifetime risk of dying of prostate cancer is 2.5%.
• Many men with prostate cancer never experience symptoms and, without screening, would never know they have the disease.
• In autopsy studies of men who died of other causes, more than 20% of men aged 50 to 59 years and more than 33% of men aged 70 to 79 years were found to have prostate cancer.
• Median age at death from prostate cancer is 80 years
• Black men have an increased risk

Question 13

Colorectal Cancer

• For the vast majority of adults, the most important risk factor for colorectal cancer is what?
• Most cases of colorectal cancer occur among who?
• A positive family history (excluding known inherited familial syndromes) is thought to be what?

Answer 13

• For the vast majority of adults, the most important risk factor for colorectal cancer is older age.
• Most cases of colorectal cancer occur among adults older than 50 years; the median age at diagnosis is 68 years.
• A positive family history (excluding known inherited familial syndromes) is thought to be linked to about 20% of cases of colorectal cancer

Question 14

Colorectal Cancer

• About 3% to 10% of the population has what?
• Screening via colonoscopy begins when?
• Who has increase risk?

Answer 14

• About 3% to 10% of the population has a first-degree relative with colorectal cancer.
• Screening via colonoscopy begins early (40) for those with first degree relatives +
• Male sex and black race increase risk; reason is unclear

Question 15

What are examination techniques for prostate?

Answer 15

• The anorectal and prostate examinations are usually the least popular segments of the physical examination
• A skillfully performed examination should not be truly painful
• Successful examination requires a calm demeanor, explanation to the patient of what
  he or she may feel, gentleness, and slow movement of your finger
• In asymptomatic adolescents, it is appropriate to defer the rectal exam

Question 16

What are some positions that may be used for examination?

Answer 16

• The patient may stand, leaning forward with his upper body resting across the examining table and hips flexed
• The patient may lie on his left side with his buttocks close to the edge of the exam table near you; flex the patients hips and knees, especially the top leg

Question 17

When doing the male exam, what do you need to explain and inspect/assess?

Answer 17

• Explain inspection steps to patient
• Inspect the sacrococcygeal and perianal areas
• Assess for lumps, ulcers, tufts of hair, inflammation, rashes, excoriations, hemorrhoids, warts, tags, erythema, fistula, fissure & discharge

Skin tags from friction dt no underware

Question 18

Male exam:
* severe tenderness prevents what?
* instead what do you do?
* Look for what?

Answer 18

• Occasionally, severe tenderness prevents entry and internal
  examination
• Instead, place your fingers on both sides of the anus, gently spread the orifice, and ask the patient to bear down
• Look for a lesion, such as an anal fissure, that might explain the tenderness

Question 19

When you Examine the Anus, how do you do it?
* What do you need to assess for, palpate for, inspect for?

Answer 19

Question 20

Examine the Posterior Surface of the Prostate

• What do you need to tell the patient?
• Identify what?
• Sweep finger and note what?
• Normal prostate is what?
• If possible, extend your finger where?
• Note what?

Answer 20

o Tell patient that you will be going to feel the prostate gland and he may feel an urge to urinate.
o Identify lateral lobes and median sulcus
o Sweep finger and note size, shape, and consistency of the prostate; identify any nodules or tenderness
o Normal prostate is rubbery and nontender
o If possible, extend your finger above the prostate to the region of the seminal vesicles and the peritoneal cavity; note any nodules or tenderness
o Note the color of any fecal matter on the glove, and test it for occult blood

Question 21

The Female Patient:
When is the rectum usually examined? Why is it done?
If rectum is the only exam done, position the patient how?

Answer 21

• The rectum is usually examined after the female genitalia, while the woman is in the lithotomy position; this position is also ideal for conducting the bimanual examination and is suitable for testing the integrity of the rectovaginal wall and may also help to palpate a cancer high in the rectum
• If the rectum only requires examination, the side-lying position affords a much better view to the perianal and sacrococcygeal areas

* Use the same techniques for examination that are used for men

Question 22

How do you document the exam?

Answer 22

Question 23

A 29‐year‐old graduate student states that he is able to achieve an erection and ejaculate during sexual intercourse; however, he does not experience any pleasurable sensation of orgasm. He is otherwise healthy and is not on any medications. What is the most likely cause of his problem?
a) Psychogenic
b) Androgen insufficiency
c) Peyronie disease
d) Endocrine dysfunction
e) Sexually transmitted infection (STI)

Answer 23

a) Psychogenic

Question 24

A 25‐year‐old graduate student presents to the clinic complaining of scrotal pain, which has been increasing over the past 2 days. He is sexually active and has had unprotected intercourse with multiple partners in the past couple of weeks. On examination, some mild to moderate swelling of the scrotum on the right and tenderness with palpation of the right testicle are notes. What is the most likely diagnosis?
a) Spermatocele
b) Primary syphilis
c) Hydrocele
d) Acute epididymitis
e) Testicular cancer

Answer 24

d) Acute epididymitis

Question 25

A 32‐year‐old elementary teacher requests a workup for infertility. He and his wife have been trying to conceive for the last 2 years. He reports that his wife has been evaluated and does not appear to have any infertility issues. The overall examination does not reveal any significant abnormalities. He is of average height and weight and has normal secondary sex characteristics of the genitalia. Of the following, which would be most likely be abnormal and causing male infertility
a) Follicle‐stimulating hormone (FSH)
b) Luteinizing hormone (LH)
c) Thyroid‐stimulating hormone (TSH)
d) 5α‐Dihydrotestosterone
e) 5α‐Reductase

Answer 25

a) Follicle‐stimulating hormone (FSH)

Question 26

A 67‐year‐old electronics technician with a history of hypertension and type 2 diabetes presents for his yearly physical examination and complains of progressively worsening erectile dysfunction (ED). While counseling him, the clinician mentions that multiple processes must take place to achieve an erection. Which of the following structures would be most affected by vascular deficiencies related to his preexisting medical conditions and is likely contributing to his symptoms?
a) Vas deferens
b) Seminal vesicle
c) Corpora cavernosa
d) Epididymis
e) Ejaculatory duct

Answer 26

c) Corpora cavernosa
- Corpora cavernosa: a conduit for seminal fluid from the seminal vesicle and terminal vas deferens to the urethra and is not involved in the process of an erection
- Epididymis: a structure on top of each of the testicles that provides a reservoir for storage, saturation, and transport of sperm from the testes and is also not involved in the process of erection
- Seminal vesicles: produces secretions that contribute to the seminal fluid and is also not involved in the process of an erection
- Vas deferens: a cord-like structure that transports sperm from the tail of the epididymis to the urethra - not involved in the process of an erection

Question 27

The human papillomavirus (HPV) can cause genital warts in males and females as well as cervical cancer in females. Vaccination against HPV is available and should be offered to males between what ages?
a) 1-3 years
b) 9-21 years
c) 5-7 years
d) 30-50 years
e) 6-9 months

Answer 27

b) 9-21 years

Question 28

A 20‐year‐old college student presents for his annual physical examination. He recently became sexually active and is inquiring about the best means of preventing sexually transmitted infections (STIs). Of the following, which would be the most effective means of prevention?
a) Cervical caps
b) Spermicides
c) Early withdrawal
d) Male condoms
e) Diaphragms

Answer 28

d) Male condoms

Question 29

Multiple processes must take place in order for a male to sustain an erection. Various cues stimulate sympathetic outflow from higher brain centers to the T11-L2 levels of the spinal cord and parasympathetic outflow from S2 to S4 reflex arcs. Local vasodilatation within the penis erectile tissue results from increased levels of which of the following?
a) Testosterone
b) Nitric oxide (NO) and cyclic guanosine monophosphate (cGMP)
c) Luteinizing hormone (LH)
d) Follicle‐stimulating hormone (FSH)
e) Gonadotropin‐releasing hormone (GRH)

Answer 29

b) Nitric oxide (NO) and cyclic guanosine monophosphate (cGMP)

Question 30

A 21‐year‐old college student presents to the student health clinic for a full physical examination. He is generally healthy; however, he reports that he has had sexual intercourse with multiple partners in the past couple of months. He noticed a small lesion on the shaft of his penis a few days ago. While performing the examination, he unwillingly achieves an erection. How should the clinician proceed at this point?
a) Explain this is a normal response and finish the examination.
b) Have him return to see another provider.
c) Tell him the examination cannot proceed until the erection subsides.
d) Assume that he is malingering.
e) Stop the examination immediately.

Answer 30

a) Explain this is a normal response and finish the examination.

Question 31

While performing a physical examination on male patients, it is possible to palpate multiple structures in relation to the inguinal canal and related hernias. Which of the following is not palpable during an external examination of the abdominal wall or inguinal region?

a) Pubic tubercle
b) Internal inguinal ring
c) Direct inguinal hernia
d) Anterior superior iliac spine
e) External inguinal ring

Answer 31

b) Internal inguinal ring

Question 32

A 32‐year‐old male complains of a painless, cystic mass just above his left testicle. During the physical examination, a strong flashlight is placed behind the scrotum through the area in question and transillumination is noted. What is the most likely diagnosis?
a) Spermatocele
b) Varicocele
c) Testicular tumor
d) Indirect hernia
e) Direct hernia

Answer 32

a) Spermatocele