Male Flashcards
The penis is comprised of 3…..?
cylindric columns or erectile tissue- the
(1) corpus cavernosa on dorsal side
(2) corpus sponginosum on ventral
(3) corpus sponginosum expands into the Glans (cone of erectile tissue) on distal end
What is the shoulder where the glans joins the shaft?
corona
Frenulum
fold of foreskin extending from urethral meatus ventrally
scrotum
- loose protective sac
- continuation of abdominal wall
- deeply pigmented after adolescence
- large sebaceous follicles
- scrotal wall contains rugae
Cremaster muscle
- in scrotal wall
- ## controls size of scrotum by responding to temp in order to keep testes at 3 degrees below abdominal temp for producing sperm
testis
each half of the scrotum
- produce sperm
- solid oval shape
- compressed laterally
- 4-5 cm long and 3cm wide in adult
- suspended vertically by spermatic cord
- Left is lower than riht because L spermatic cord is longer
epididymis
- cap testis
- coiled ducts that are main storage of sperm
- curved over posterior surface of testis (occasionally in small percent is on anterior of testes)
Vas deferens
lower part of epididymis
- forms spermatic cord
Where do the lymphatics of the penis and scrotal surface drain?
- drain to inguinal lymph nodes
* (the lymphatics of the testes drain into the abdomen)
inguinal area
juncture of lower abdominal wall and thigh
- diagnonal borders are the anterior superior iliac spine and the symphysis pubis
- in between those is inguinal ligament
inguinal canal
narrow tunnel passing obliquely between layers of abdominal muscle
- 4-6 cm long in adult
femoral canal
inferior to inguinal ligament
- medial and parallel with femoral artery
Tanners sexual Maturity Ratings (SMR)- stage 1
- Pubic hair: no pubic hair, fine body hair on abdomen continues over pubic area
- Penis: preadolescent, size and proportion the same as during childhood
- Scrotum: Preadolescent, size and proportion the same as during childhood
SMR- stage 2
- Pubic hair: few straight, slightly darker hairs at base of penis, hair is long and downy
- Penis: little or no enlargement
- Scrotum: testes and scrotum begin to enlarge, scrotal skin reddens and changes in texture
SMR- Stage 3
- Pubilc hair- sparse growth over entire pubis, hair is darker, coarser, and curly
- Penis: begins to enlarge, especially in length
- Scrotum: further enlarged
SMR- stage 4
- Pubic Hair: thick growth over pubic area but not on thighs, hair coarse and curly as in adult
- Penis: penis grows in length and diameter, with development of glans
- Scrotum: testes almost fully grown, scrotum darker
SMR- stage 5
- Pubic Hair: Growth spread over medial thighs, although not yet upward toward umbilicus
- Penis: adult size and shape
- Scrotum: adult size and shape
onset of puberty for boys
- Puberty begins sometime between the ages of 9.5 and 13.5 years. The first sign is enlargement of the testes. Next, pubic hair appears, and then penis size increases.
- The complete change in development from a preadolescent to an adult takes around 3 years, although the normal range is 2 to 5 years
subjective: frequency, urgency, oliguria?
- Frequency= “Are you urinating more than usual?”
Rationale:
Frequency. Average adult voids 5-6 ×/day, varying with fluid intake, individual habits.
Polyuria—excessive quantity.
Oliguria—diminished quantity, <400mL/24 hours.
- Urgency= do you feel as though you cant wait?
- Nocturia occurs together with frequency and urgency in urinary tract disorders. Other origins: cardiovascular, habitual, diuretic medication.
Dysuria
- Any pain or burning with urinating?
Dysuria. Burning is common with acute cystitis, prostatitis, urethritis.
Subjective: Hesitancy or straining?
Hesitancy and straining= Ask
“Any trouble starting the urine stream?”
•Need to strain to start or maintain stream? (straining)
•Any change in force of stream: narrowing, becoming weaker? (Loss of force and decreased caliber)
•Dribbling, such that you must stand closer to the toilet? (terminal dribbling)
•Afterward, do you still feel you need to urinate? (sense of residual urine)
•Ever had any urinary tract infections?(recurrent acute cystitis)
*These symptoms suggest progressive prostatic obstruction.
Subjective: urine color
Is the usual urine clear or discolored, cloudy, foul-smelling, bloody
Cloudy in urinary tract infection.
Hematuria—a danger sign that warrants further workup.
Subjective: past genitourinary history
(1) Any difficulty controlling your urine?
Urge incontinence—involuntary urine loss from overactive detrusor muscle in bladder. It contracts, causing urgent need to void.
(2) Accidentally urinate when you sneeze, laugh, cough, or bear down?
Stress incontinence—involuntary urine loss with physical strain, sneezing, or coughing due to weakness of pelvis floor.
(3) Any history of kidney disease, kidney stones, flank pain, urinary tract infections, prostate trouble?
Subjective: Penis
Any problem with penis—pain, lesions?
• Any discharge? How much? Has that increased or decreased since start?
*discharge occurs with infection
• The color? Any odor? Discharge associated with pain or with urination?
Subjective: Scrotum, self-care behaviors
Any problem with the scrotum or testicles?
•Any lump or swelling on testes?
*{Concern about any self-discovered mass (spermatocele, hydrocele, varicocele, rarely testicular cancer) alerts you to careful exploration during examination.}
•Any change in size of the scrotum? Any history of undescended testicle as infant?
•Noted any bulge or swelling in the scrotum? For how long? Ever been told you have a hernia? Any dragging, heavy feeling in scrotum? (Possible hernia)
Subjective: Sexual activity
Are you in a relationship involving sexual intercourse now?
•Are aspects of sex satisfactory to you and your partner?
•Are you satisfied with the way you and your partner communicate about sex?
•Occasionally a man notices a change in ability to have an erection when aroused. Have you noticed any changes?
Do you and your partner use a contraceptive? Which method? Is this satisfactory? Any questions about this method?•How many sexual partners have you had in the past 6 months? (Establishes a database for comparisons with any future sexual activities.
Provides opportunity to screen sexual problems.)
•What is your sexual preference—relationship with a woman, a man, both? (Gay and bisexual men need to feel acceptance to discuss their health concerns. Men who have sex with men (MSM) are at increased risk for STI; psychological distress.)
Questions about sexual activity should be routine in review of body systems for these reasons:
- Communicates that you accept individual’s sexual activity and believe it is important.
- Your comfort with discussion prompts person’s interest and possibly relief that topic has been introduced.
Subjective: STI contact?
Any sexual contact with a partner having an STI, such as gonorrhea, herpes, AIDS, chlamydia, venereal warts, syphilis?
•When was this contact? Did you get the disease?
•How was it treated? Any complications?
•Do you use condoms to help prevent STIs?
•Any questions or concerns about any of these diseases?
Normal findings- Inspect Penis
- The skin normally looks wrinkled, hairless, and without lesions. The dorsal vein may be apparent
Abnormal: Inflammation. Lesions: nodules, solitary ulcer (chancre), grouped vesicles or superficial ulcers, wartlike papules
palpating glans of penis
- The glans is smooth, no lesions. Ask the uncircumcised male to retract the foreskin, or you retract it. It should move easily. Some cheesy smegma (cheesy?…really…gross.) may have collected under the foreskin. After inspection, slide the foreskin back to the original position.
Abnormal: - Inflammation.
- Lesions on glans or corona.
Phimosis—narrowed opening of prepuce so cannot retract the foreskin. Paraphimosis—painful constriction of glans by retracted foreskin.
Inspecting urethral meatus
Normally the urethral meatus is positioned just about centrally.
Abnormal= Hypospadias—ventral location of meatus. Epispadias—dorsal location of meatus
Normal hair distribution
At the base of the penis, pubic hair distribution is consistent with age. Hair is without pest inhabitants.
Abnormal: Pubic lice or nits can be seen with the unaided eye. Excoriated skin usually accompanies.
Palpating urinary meatus
- Compress the glans anteroposteriorly between your thumb and forefinger
- The meatus edge should appear pink, smooth, and without discharge.
Abnormal: Stricture—narrowed opening.
Edges that are red, everted, edematous, along with purulent discharge, suggest urethritis. If you note urethral discharge, collect a smear for culture. If no discharge shows but the person gives a history of it, ask him to milk the shaft of the penis. This should produce a drop of discharge.
Inspect Scrotum
Male holds the penis out of the way. You hold the penis out of the way with the back of your hand. Scrotal size varies with ambient room temperature. Asymmetry is normal, with the left scrotal half usually lower than the right.*
Abnormal: Scrotal swelling (edema) may be taut and pitting. This occurs with heart failure, renal failure, or local inflammation.
Lesions.
Palpate scrotum
Spread rugae out between your fingers. Lift the sac to inspect the posterior surface. Normally, no scrotal lesions are present, except for the commonly found sebaceous cysts. These are yellowish, 1-cm nodules and are firm, nontender, and often multiple. (inflammation is abnormal)
Palpating scrotum for testes
- Palpate gently. The scrotal contents should slide easily. Testes normally feel oval, firm, rubbery, smooth, freely movable and slightly tender to moderate pressure.
- Each epididymis normally feels discrete, softer than the testis, smooth, and nontender.
Abnormal findings palpating scrotum for testes
Absent testis—may be a temporary migration or true cryptorchidism
Atrophied testes—small and soft.
Fixed testes.
Nodules on testes or epididymides.
Marked tenderness.
An indurated, swollen, and tender epididymis indicates epididymitis.
palpating spermatogenic cords
Palpate each spermatic cord between your thumb and forefinger, along its length from the epididymis up to the external inguinal ring. You should feel a smooth, nontender cord.
Abnormal:
- Thickened cord.
- Soft, swollen, and tortuous cord—see the discussion of varicocele
What do you do if you feel a mass in scrotum
Normally, no other scrotal contents are present. If you do find a mass, note:
- Any tenderness?
- Is the mass distal or proximal to testis?
- Can you place your fingers over it?
- Does it reduce when the person lies down?
- Can you auscultate bowel sounds over it?
list some abnormalities of the scrotum
Abnormalities in the scrotum: hernia, tumor, orchitis, epididymitis, hydrocele, spermatocele, varicocele
Transillumination is performed when/if??
Perform this maneuver only if you note a swelling or mass. Darken the room. Shine a strong flashlight from behind the scrotal contents. Normal scrotal contents do not transilluminate.
- Serous fluid does transilluminate and shows as a red glow (e.g., hydrocele or spermatocele). Solid tissue and blood do not transilluminate (e.g., hernia, epididymitis, or tumor)
Inspect for hernia
Inspect the inguinal region for a bulge as the person stands and as he strains down. Normally, none is present.
Abnormal:
Bulge at external inguinal ring or at femoral canal. (A hernia may be present but easily reduced and may appear only intermittently with an increase in intra-abdominal pressure.)
Palpate inguinal canal
Palpate the inguinal canal For the right side, ask the male to shift his weight onto the left leg. Place your right index finger low on the right scrotal half. Palpate up the length of the spermatic cord, invaginating the scrotal skin as you go, to the external inguinal ring. It feels like a triangular slitlike opening, and it may or may not admit your finger. If it will admit your finger, gently insert it into the canal and ask the person to “bear down.”* Normally, you feel no change. Repeat the procedure on the left side.
*Abnormal= Palpable herniating mass bumps your fingertip or pushes against the side of your finger
Palpate femoral area for bulge
normally should feel none
Palpate inguinal lymph nodes
- Palpate the horizontal chain along the groin inferior to the inguinal ligament and the vertical chain along the upper inner thigh.
- It is normal to palpate an isolated node on occasion; it then feels small (<1cm), soft, discrete, and movable
- Abnormal nodes are enlarged, hard, matted, fixed nodes.
Encouraging self-care
Encourage self-care by teaching every male (from 13 to 14 years old through adulthood) how to examine his own testicles.
- It is rare before age 15 years, peaks during ages 20 to 39 years, and then declines
- associated with a history of cryptorchidism.
- Early detection is enhanced if the male is familiar with his normal consistency. Points to include during health teaching are:
• T = timing, once a month
• S = shower, warm water relaxes scrotal sac
• E = examine, check for changes, report changes immediately
Normal urine
- A urinalysis shows a color of pale yellow to amber due to the presence of urochrome pigments.
- Normal urine is clear
- slightly acidic with a pH range of 4.5 to 8.0. - - Specific gravity measures the concentration from very dilute at 1.003 to concentrated at 1.030.
- There is little or no protein, no glucose, and fewer than 5 red blood cells (RBCs) or white blood cells (WBCs) per high-powered field.
Abnormal Urine
Cloudiness suggests presence of WBCs, bacteria, casts. Certain drugs or foods can change urine color (see Table 24-2). Proteinuria indicates glomerular disease in the nephron. Glycosuria suggests hyperglycemia occurring with diabetes. Increased WBCs occur with urinary tract infection (UTI); increased RBCs occur with UTI, glomerulonephritis, renal calculi, trauma, and cancer.
The aging male
- may note thinner, graying pubic hair
- the decreased size of the penis.
- The size of the testes may be decreased and may feel less firm.
- The scrotal sac is pendulous with less rugae.
- The scrotal skin may become excoriated if the man continually sits on it.
Cloudy urine
UTI
Kidney stones
Blue urine
medication side effect: amitriptyline, Indocin
Foods- asparagus
Dye after prostate surgery
Dark Gray Urine
Urine contains melanin, menauria
Tea colored urine
Liver Disease- especially with pale stools, or jaundice
Myoglobinuria
Some Meds or food dyes
Blood in Urine
Pink Urine
With menses Some foods: beets, berries, food dyes Some laxatives Kidney Stones UTI
Red Urine
Blood in Urine
Nephritis, cystitis
Cancer
Following prostate surgery
Orange Urine
Medication side effect: Rifampin for meningitis, Pyridium, Warafin (Coumadin)
Some foods, food dyes, laxatives
Dehydration
Jaundice (Bilirubinemia)
Amber Urine
Gold or concentrated with dehydration
Some Laxatives
Food or supplements with B-complex vitamins
Yellow Urine
Natural yellow is urochrome excretion, a pigment in blood
Bright neon yellow with vitamin supplements
Pale Yellow Urine
Clear watery with excess liquids
Acute viral hepatitis, Cirrhosis
Tinea Cruris
A fungal infection in the crural fold, not extending to scrotum, occurring in postpubertal males (“jock itch”) after sweating or wearing layers of occlusive clothing. It forms a red-brown half-moon shape with well-defined borders.
Genital herp HSV2
Clusters of small vesicles with surrounding erythema, which are often painful, erupt on the glans or foreskin. These rupture to form superficial ulcers. A sexually transmitted infection (STI), the initial infection lasts 7 to 10 days. The virus remains dormant indefinitely; recurrent infections last 3 to 10 days with milder symptoms.
Genital Warts
Soft, pointed, moist, fleshy, painless papules may be single or multiple in a cauliflower-like patch. Color may be gray, pale yellow, or pink in white males, and black or translucent gray-black in Black males. They occur on shaft of penis, behind corona, or around the anus where they may grow into large, grapelike clusters.
These are caused by the human papillomavirus (HPV) and are one of the most common STIs. The HPV infection is correlated with early onset of sexual activity, infrequent use of contraception, and multiple sexual partners.
Syphilitic Chancre
Begins within 2 to 4 weeks of infection, as a small, solitary, silvery papule that erodes to a red, round or oval, superficial ulcer with a yellowish serous discharge. Palpation reveals a nontender indurated base that can be lifted like a button between the thumb and the finger. Lymph nodes enlarge early but are nontender. This is an STI easily treated with penicillin G, but untreated leads to cardiac and neurologic problems, blindness. Almost eradicated in the United States in 1957; epidemics recur cyclically every 7 to 10 years
Carcinoma
Begins as red, raised, warty growth or as an ulcer, with watery discharge. As it grows, may necrose and slough. Usually painless. Almost always on glans or inner lip of foreskin and following chronic inflammation. Enlarged lymph nodes are common.
Phimosis
Nonretractable foreskin forming a pointy tip with a tiny orifice. Foreskin is advanced and so tight it is impossible to retract over glans. May be congenital or acquired from adhesions secondary to infection. Poor hygiene leads to retained dirt and smegma, which increases risk for inflammation, calculus formation, obstructive uropathy.
Paraphimosis
Foreskin is retracted and fixed. Once retracted behind glans, a tight or inflamed foreskin cannot return to its original position. Constriction impedes circulation, so glans swells. A medical emergency; the constricting band prevents venous and lymphatic return from the glans and compromises arterial circulation.
Hypospidaisis
Urethral meatus opens on the ventral (under) side of glans, shaft, or at the penoscrotal junction. A groove extends from the meatus to the normal location at the tip. This is a congenital defect that is important to recognize at birth. The newborn should not be circumcised because surgical correction may use foreskin tissue to extend urethral length.
Epispadiasis
Meatus opens on the dorsal (upper) side of glans or shaft above a broad, spadelike penis. Rare; less common than hypospadias but more disabling because of associated urinary incontinence and separation of pubic bones
Priapism
Prolonged painful erection of penis without sexual stimulation and unrelieved by intercourse or masturbation, most common in men in 30s and 40s. A rare condition but when lasting 4 hours or longer can cause ischemia of penis, fibrosis of tissue, erectile dysfunction. Can occur as a side effect of some medications and street drugs and with sickle-cell trait or disease; leukemia in which increased numbers of white blood cells produce engorgement; malignancy; or local trauma or spinal cord injuries with autonomic nervous system dysfunction.
Peyronie Disease
Hard, nontender, subcutaneous plaques palpated on dorsal or lateral surface of penis. May be single or multiple and asymmetric. They are associated with painful bending of the penis during erection. Plaques are fibrosis of covering of corpora cavernosa. Usually occurs after 45 years. Its cause is trauma to the erect penis (e.g., unexpected change in angle during intercourse). More common in men with diabetes, gout, and Dupuytren contracture of the palm.
Chryptorchidism
S: Empty scrotal half
O: Inspection—in true maldescent, atrophic scrotum on affected side
Palpation—no testis
A: Absent testis
*True cryptorchidism—testes that have never descended. True undescended testes have a histologic change by 6 years, causing decreased spermatogenesis and infertility.
Small testes
S: (None)
O: Palpation—small and soft (rarely may be firm)
A: Small testis
*Small and soft (s syndrome (hypogonadism).
testicular torsion
S: Excruciating pain in testicle of sudden onset, often during sleep or following trauma. May also have lower abdominal pain, nausea and vomiting, no fever
O: Inspection—red, swollen scrotum, one testis (usually left) higher owing to rotation and shortening
Palpation—cord feels thick, swollen, tender; epididymis may be anterior; cremasteric reflex is absent on side of torsion
*Sudden twisting of spermatic cord. Occurs in late childhood, early adolescence, rare after age 20 years. Torsion usually on the left side; faulty anchoring of testis on wall of scrotum allows testis to rotate. The anterior part of the testis rotates medially toward the other testis. Blood supply is cut off, resulting in ischemia and engorgement. This is an emergency requiring surgery; testis can become gangrenous in a few hours.
Epididymitis
S: Severe pain of sudden onset in scrotum, somewhat relieved by elevation (a positive Prehn sign); also rapid swelling, fever
O: Inspection—enlarged scrotum; reddened
Palpation—exquisitely tender; epididymis enlarged, indurated; may be hard to distinguish from testis. Overlying scrotal skin may be thick and edematous
Laboratory—white blood cells and bacteria in urine
A: Tender swelling of epididymis
*Acute infection of epididymis commonly caused by prostatitis, after prostatectomy because of trauma of urethral instrumentation, or due to chlamydia, gonorrhea, or other bacterial infection.** Often difficult to distinguish between epididymitis and testicular torsion.**
Varicocele
S: Dull pain; constant pulling or dragging feeling; or may be asymptomatic
O: Inspection—usually no sign. May show bluish color through light scrotal skin
Palpation—when standing, feel soft, irregular mass posterior to and above testis; collapses when supine, refills when upright. Feels distinctive, like a “bag of worms”
The testis on the side of the varicocele may be smaller owing to impaired circulation
A: Soft mass on spermatic cord
*A varicocele is dilated, tortuous varicose veins in the spermatic cord due to incompetent valves within the vein, which permit reflux of blood. Most often on left side, perhaps because left spermatic vein is longer and inserts at a right angle into left renal vein. Common in young males. Screen at early adolescence; early treatment important to prevent potential infertility when an adult.
Spermatocele
S: Painless, usually found on examination
O: Inspection—does transilluminate higher in the scrotum than a hydrocele, and the sperm may fluoresce
Palpation—round, freely movable mass lying above and behind testis. If large, feels like a third testis
A: Free cystic mass on epididymis
*Retention cyst in epididymis. Cause unclear but may be obstruction of tubules. Filled with thin, milky fluid that contains sperm. Most spermatoceles are small (<1cm); occasionally, they may be larger and then mistaken for hydrocele.
Early Testicular Tumor
S: Painless, found on examination
O: Palpation—firm nodule or harder than normal section of testicle
A: Solitary nodule
*Most testicular tumors occur between the ages of 18 and 35. Practically all are malignant. Occur in whites; relatively rare in Blacks, Mexican Americans, and Asians. Must biopsy to confirm. Most important risk factor is undescended testis, even those surgically corrected. Early detection important in prognosis, but practice of testicular self-examination is currently low.
Diffuse Tumor
S: Enlarging testis (most common symptom). When enlarges, has feel of increased weight
O: Inspection—enlarged, does not transilluminate
Palpation—enlarged, smooth, ovoid, firm
Important—firm palpation does not cause usual sickening discomfort as with normal testis
A: Nontender swelling of testis
* Diffuse tumor maintains shape of testes
Hydrocele
S: Painless swelling, although person may complain of weight and bulk in scrotum
O: Inspection—enlarged, mass does transilluminate with a pink or red glow (in contrast to a hernia)
Palpation—nontender mass, able to get fingers above mass (in contrast to scrotal hernia)
A: Nontender swelling of testis
*Cystic. Circumscribed collection of serous fluid in tunica vaginalis, surrounding testis. May occur following epididymitis, trauma, hernia, tumor of testis, or spontaneously in the newborn.
Scrotal Hernia
S: Swelling, may have pain with straining
O: Inspection—enlarged, may reduce when supine, does not transilluminate
Palpation—soft, mushy mass; palpating fingers cannot get above mass. Mass is distinct from testicle that is normal
A: Nontender swelling of scrotum
* usually due to indirect inguinal hernia
Orchitis
S: Acute or moderate pain of sudden onset, swollen testis, feeling of weight, fever
O: Inspection—enlarged, edematous, reddened; does not transilluminate
Palpation—swollen, congested, tense, and tender; hard to distinguish testis from epididymis
A: Tender swelling of testis
*Acute inflammation of testis. Most common cause is mumps; can occur with any infectious disease.
May have associated hydrocele that does transilluminate.
Scrotal Edema
S: Tenderness
O: Inspection—enlarged, may be reddened (with local irritation)
Palpation—taut with pitting Probably unable to feel scrotal contents
A: Scrotal edema
*Accompanies marked edema in lower half of body (e.g., congestive heart failure, renal failure, and portal vein obstruction). Occurs with local inflammation: epididymitis, torsion of spermatic cord. Also, obstruction of inguinal lymphatics produces lymphedema of scrotum.
