Male Genitalia Anatomy and Pathologies & Urinary Bladder Catheterization (male / female) Flashcards
Peyronie’s disease Tx?
expectant vs. surgical
Peyronie’s disease PE?
Nontender, hard, palpable plaques under the skin on penile shaft
Plaques are usually on dorsal surface
Crooked, painful erections
Venereal Warts (Condyloma Acuminatum) is an infection with what ?
HPV
Paraphimosis patho and prevalence ?
Once prepuce is retracted, it cannot be returned to original position
More common in children and elderly (extremes of age)
Types of Catheters: Robinson?
Rubber, latex-coated (not if latex allergy), silicone-coated
One time use, “in-and-out”
To obtain a specimen or episodic relief of chronic obstruction
No balloon to secure position cause it not going to stay
Developmental scale/sexual maturity rating of males - Stage 1?
no pubic hair
fine body hair
Paraphimosis tx?
Compression of head of penis and advancement of prepuce
Emergent circumcision
Acute Orchitis patho?
Acutely inflamed testis
Inguinal Hernias - Course: Femoral?
bowel comes through the femoral canal
feel bulge over femoral area
Syphilis 3 stages?
Early - asymptomatic - people wont know it
Latent - chancre - we will see this one
Late
Physical Exam for Femoral Hernias - Palpation?
Palpate anterior thigh by femoral canal
Note bulge or tenderness with valsalva
Check females for femoral hernias, too
**femoral are less common but females more than men *
Physical Exam for Hernias -Palpation: Inguinal?
Right hand for patient’s right side
Left hand for patient’s left side
Invaginate scrotal skin with finger
Follow course of spermatic cord to external ring
Have pt strain or cough
Feel for a bulge
Catheter sizes: Charriere French scale - 0.33mm = ?
0.33 mm = 1 Fr
Femoral Hernia: point of origin?
below ing. lig.
Balanitis patho?
Inflammation of the glans
Variety of etiologies (yeast, bacteria, etc.)
Testicular Torsion tx if infarcted?
If infarcted – orchiectomy
May need contralateral orchiopexy
Torsion of Spermatic Cord patho?
Testicle twists on its spermatic cord
Causes of paraphimosis ?
Direct trauma
Failure to replace prepuce after urinating or washing
Infection (usually due to poor hygiene)
Inguinal Hernias etiology?
any condition that chronically increases intra-abdominal pressure
e.g. constipation, chronic bronchitis, prostatism, heavy lifting, ascites,
pregnancy, etc.
Nongonococcal urethritis organism?
Usually Chlamydia trachomatis (CT)
Cryptorchidism leads to ___________ _______ by _ y.o. and increased ____________
testicular atrophy
1
increased infertility
UBC follow-up care: Indwelling Catheterization?
Two major risks
Trauma
Infection
Secure with tape at all times, don’t snag tubing
Keep drainage bag below the bladder
Avoid kinks in tubing
Empty bag before completely full
Use care when emptying to avoid contamination
Monitor for signs of infection
Hernias - Severities: strangulated?
blood supply to bowel is compromised
N/V/acutely tender and it requires emergency surgery
Femoral Hernia: gender?
more females
Hypospadias patho and prevalence ?
Congenital displacement of urethral meatus to ventral surface of penis
Common – 1 in 300 male infants
Vas derferens extends up toward? and goes behind the?
toward the external inguinal ring and behind the bladder
Scrotum and contents PE - palpation?
Thumb and first 2 fingers
Examine bilaterally
Testes and Epididymis - Size/shape Consistency Tenderness Nodules
Spermatic cord
Follow its course up to external inguinal ring
If mass is noted in scrotum
Check for reduction when supine
Auscultate for bowel sounds
Try to determine top of mass
Inguinal lymph nodes
Discuss TSE
Scrotal edema is usually associated with ?
generalized edema as in CHF, nephrotic syndrome
Types of Catheters: Coude’?
Rubber, latex-coated (not if latex allergy), silicone-coated
Bent at distal tip so follows anterior surface of male urethra. Helps in patients with false passages which are typically on the posterior surface
bend at the tip to avoid false passages ( most false passages are posterior)
Developmental scale/sexual maturity rating of males - Stage 2?
long, slightly pigmented and curly
Fournier’s Gangrene prevalence and prognosis ?
Rare, but high death rate
Female Cath. anatomy?
Easier and more comfortably inserted
1.5 – 2”
**easier and more comfortable, balloon to keep it from falling **
UBC indications?
To obtain a sterile urine sample
To monitor urinary output
To facilitate urinary drainage in incapacitated patients - negates fluid retention
To bypass obstructive processes from disease or trauma of:
Urethra
Prostate
Bladder neck
Hernias - Anatomy: Internal inguinal ring?
internal opening of canal, 1 cm above midpoint of inguinal ligament
more lateral
pg 521
Phimosis tx?
circumcision
Epidermoid cysts PE?
Cysts on scrotal skin
Firm, nontender, yellowish - cause filled with keratin, common
Often +1
Benign
Hydrocele patho?
Peritoneal fluid fills the potential space within the tunica vaginalis
UBC patient positioning: Females?
supine with hips and knees flexed and abducted (dorsolithotomy)
Drape appropriately, expose only what is necessary - for modesty
Encountering Resistance?
Stricture or obstruction
Make sure catheter is well lubricated
Coude’-tipped catheter may help
Bent tip faces the anterior portion of patient’s urethra
If no success, call urologist:
Special bougie and followers
Flexible cystoscope
Suprapubic catheterization
Inguinal Hernias - Course: Direct?
bowel comes through weakness in the floor of the inguinal canal. More medial. Associated with straining and lifting.
Indirect Hernia: point of origin?
Above ing. lig.,
near INTERNAL ing. ring
Varicocele PE?
Asymptomatic if mild
Acute Epididymitis tx?
bedrest
scrotal elevation
p.o. antibiotics
Testicular Torsion tx?
try manual reduction (open book technique)
vs. surgical detorsion
**those directions will generally unkink them , if this doesn’t work then surgical is indicated **
Venereal Warts (Condyloma Acuminatum) tx?
aim is to lengthen intervals and be scar-free
Liquid nitrogen podophyllin CO2 laser No cure Check for other STI’s
Direct Hernia: gender?
usually men
UBC potential complications?
Most complications are in males
Longer urethra
Urethral stricture is more common
Males: mental stenosis/stricture, stricture of urethra, bulbar urethral stricture, false prostatic urethral passages, spastic sphincter of the bladder
Syphilitic Chancre etiology?
Treponema pallidum (spirochete)
labs for confirmation
The vas deferens is joined by a duct from _______ _______ and enters _________ within the prostate
serial vesicle
urethra
Hydrocele PE?
Nontender, soft, oblong mass
Examining fingers CAN get above the “mass”
Transilluminates
Penis anatomy - circumcised means the _______ is removed and the ______ and ______ are now visible
prepuce and the glans and corona are visible
Scrotal edema tx?
treat cause
Nongonococcal urethritis tx?
dual therapy
treat partners!
**first morning urine specimen is th ebest **
Where is the epididymis located?
Posterolateral surface
Penis PE - inspection?
Prepuce Glans Skin Location of urethral meatus Discharge Nits/lice
Balanitis tx?
depends on cause
Bactroban topical cream
Monistat topical cream - if yeast
tests inner lining?
tunica vaginalis
Male: UBC procedure 3?
Hold penis at 90° angle from abdomen
Position urine catch container near or between patient’s legs
With sterile hand, lubricate first several inches of catheter
Some will inject lubricant/anesthetic into urethra directly
Insert catheter
May encounter slight resistance at sphincter, use gentle pressure
**little resistance at bend or a bladder neck - should not be to excessive though **
Syphilitic Chancre PE?
Large inguinal nodes, but nontender
Gonococcal urethritis dx?
Culture via urethral swab
or
DNA probe via urine sample
Peyronie’s disease etiology and age?
Etiology unknown
+45 y.o.
Sems is secreted from?
vas deferens
semi vesicles
prostate
genital herpes dx?
viral culture, HSV antigens
Indirect Hernia: age?
C >A
Male Cath. anatomy?
Distal tip of urethra to bladder 6-7”
More circuitous bends through penis and prostate
More strictures, BPH
more potential for complications
Catheter Sizes?
Various sizes available
Size selected depends on patient and on catheter’s purpose
Larger French sizes are slightly stiffer- Follow male anatomic curves better and easier, Less likely to double back
Penis PE - palpation?
Compress glans
omit in young health males
Inguinal Hernias - Course: Indirect?
bowel comes through inguinal canal, through external inguinal ring, following the course of the vas deferens into scrotum
Testicular Torsion is a _________ condition.
emergent
Venereal Warts (Condyloma Acuminatum) pathology?
“Cauliflower” shaped, grows rapidly, moist, contagious
Check mouth and perianal areas too
Penile cancer PE?
Nodule or ulcer
Nontender
Slow-growing
Usually in uncircumcised male, hidden by prepuce
Developmental scale/sexual maturity rating of males - Stage 4?
hair assumes normal appearance and is not so think
hair is not on thigh
Femoral Hernia: age?
usually adult
Physical Exam for Inguinal Hernias - Palpation?
Examining fingers cannot get above the scrotal mass
May reduce if supine
No transillumination
Positive bowel sounds in the scrotum
Nongonococcal urethritis gram stain and culture?
neg for GC
Small firm testes think ?
Klinefelter’s syndrome
Female: UBC procedure 1?
Urethral meatus superior to vaginal introitus and inferior to the clitoris
Meatus can sometimes be obscured by vaginal tissue if it is just inside the vaginal introitus
Lymphatic system in and around the penis? what location of nodes?
inguinal nodes
abdominal nodes
Gonococcal urethritis PE?
Profuse yellow discharge and +/- dysuria
True testes position during development?
abdominal
inguinal
suprascrotal
Femoral Hernia: frequency?
least common
Catheter sizes for adult women?
14-18 Fr
Direct Hernia: frequency?
less common
Gonococcal urethritis tx?
cephtriaxone IM + oral azithromycin
Dual therapy needed due to resistance
Treat partners! otherwise it is jus given back and forth
Acute Orchitis PE?
Painful, tender, swollen
Difficult to identify the epididymis
Scrotal skin may be red
Negative Phren’s sign
Syphilis rates are increasing for first time since ?
2006
Femoral Hernia: course?
never in scrotum
3 ports on the cath. for?
three ports ( irrigation, balloon inflation , urine)
Varicocele tx?
none unless infertile
venous ligation, with good results
***couple trying to get pregnant and they cant you want to check sperm count and check for varicocele **
Catheter size for pediatric boys?
5-12 Fr
Acute Orchitis tx?
depends on cause
Direct Hernia: on exam?
hernia pushes anteriorly, pushes side of finger
Female: UBC procedure 3?
Open lubricant package, squirt on sterile tray
Open povidone-iodine swabs, put in dominant hand
OR use forceps and iodine-soaked cotton balls
Separate labia with nondominant hand
Note: This hand is no longer sterile!
Wipe urethral opening from anterior to posterior direction 3 x (R, L, middle)
Place urine container between patient’s legs
Male: UBC procedure 1?
Drape patient with sterile drapes
Under buttocks, shiny side down
Exposing genital area with fenestrated drape
Paraphimosis complications?
edema
Damage to tip of penis
Gangrene
Loss of tip of penis
Male: UBC procedure 4?
Once past the sphincter, continue to pass catheter almost to the hub
Urine should begin to flow
Place end of catheter into urine catch container
Obtain sterile specimen, if necessary
Acute Epididymitis PE?
Phren’s sign – pain is alleviated with scrotal elevation
Fever
Usually in young adult males
Varicocele is associated with ___________
infertility - 30% of infertile males have this
Fournier’s Gangrene patho?
Form of infectious necrotizing fasciitis of the perineal and genital areas
M>F
Rapidly progressive
**flesh eating disease of the groin, men get it more and it is rapidly progressive **
Cryptorchidism have a increased risk of ?
testicular CA
30-50x
UBC indications cont’d?
To hold urethral skin grafts in place
To act as a traction device to control bleeding
To provide bladder irrigation
To decompress a distended bladder from an acute process
To provide intermittent catheterization for patients with neurogenic bladder
To deliver antineoplastic medication directly to the source
UBC patient positioning: Males?
supine with legs flat, partially abducted
Drape appropriately, expose only what is necessary - for modesty
Small testis patho?
Less than 3.5 cm long in an adult
Penis ROS3?
Risk factors for HIV/STD’s
Exposure to HIV (known or suspected)
do you think or do you know?
History of STI’s
Use of condoms - when and how much
Number of partners in past 6 months
Gardasil vaccination -
Oral/anal sex - will give you an idea to look for lesions ( condyloma in other places?)
Indirect Hernia: frequency?
most common
Which testes is lower?
left
UBC contraindications?
Appearance of blood at the urethral meatus in a patient with pelvic trauma
Possible total or partial urethral transection
Allergy to materials used
Latex, rubber, tape, lubricants
Inability to pass the catheter or inflate balloon
Call the urologist!
Penis ROS1?
Penile discharge
color, consistency, associated sxs
Sores/growths on penis or scrotum
Testicular self-exam (TSE)
Testicular pain/swelling
Testicular mass/lesion
Syphilitic Chancre tx?
antibiotics (benzathine penicillin)
treatable and curable
Testicular CA - Lymph drains to _________ nodes not ________ nodes
Lymph drains to abdominal nodes, not inguinal
Hypospadias tx?
dependent on severity (reconstruction)
Torsion of Spermatic cord PE?
Sudden onset of acutely tender testis
No associated UTI
Testis is retracted upward with absent cremasteric reflex
NO relief of pain with testicular support
More common in adolescents
sudden onset , unexplained groin pain, negative phren sign
Three-Way Catheter?
Drain
Irrigate - Helps to prevent clots, clogging
Balloon inflation
Urinary Bladder catheterization (UBC) definition?
Passage of a hollow device into the bladder through the urethra
Historically through perineum, using metal or glass tubes
what is the size of each testes?
4-5 cm
Developmental scale/sexual maturity rating of males - Stage 3?
become darker and curlier
pubic symphysis develops
Male: UBC procedure 5? for foley cath?
Inflate Foley balloon with sterile water in pre-filled syringe
Gently tug on catheter until it stops
Attach drainage bag
Tape catheter to the abdomen:
Penis pointing toward umbilicus (if bedridden)
Apply bacitracin to urethral meatus 1-3 x day
ambulatory - put on leg but never above the bladder line cause then there will be back flow
Cryptorchidism PE?
Empty scrotal sac, usually unilateral
Hernias - Anatomy: External inguinal ring?
above and lateral to the pubic tubercle, triangular slit (Hesselbach’s triangle)
Ectopic testes position during development?
superficial ectopic
presenile
femoral
traverse scrotal
perineal
Varicocele mainly occur on the ?
left 90%
Testicular CA tx?
Potentially curable if dx’d early
TSE - Teach patients to do monthly self-exam
Condyloma incubation?
weeks to months
**penile warts typically seen in patients with other STDs, including genital herpes
got it from someone who maybe didn’t have lesion or anything **
Syphilitic Chancre appearance?
Oval/round dark red lesion on indurated base
Painless
Contagious
Inguinal Hernias H&P?
usually asxs.
Catheter size for adult men?
16-18 Fr
Acute Orchitis etiology?
postpubertal mumps (which can result in infertility) or secondary to epididymitis or virus
**kids w/o MMR vaccine , mumps in older child or adult can cause infertility, usually unilateral **
Female: UBC procedure 2?
Gather supplies
Follow aseptic technique
Open kit in sterile manner
Drape patient – shiny side down
Put on sterile gloves
tunica vaginalis has?
2 layers
and
potential space
what is the function of the testes?
produce sperm and testosterone
Torsion of Spermatic Cord complications?
Circulation is obstructed – testis can become necrotic – get Doppler
**get doppler to check blood flow to support tissue *
Testicular CA peak
15-35 y.o.
Scrotal edema PE?
Taut skin, pitting edema
Varicocele patho?
Multiple tortuous varicose veins of the spermatic cord, separate from testis
Feels like “bag of worms”
Patient must stand for exam
Veins collapse when patient is supine and scrotum is elevated
**varicose veins of the spermatocord **
Donning Sterile Gloves?
Open paper package
Grasp fold of paper and pull
laterally
Lift first glove, grasping outside of cuff only
Insert other hand
Gloved hand slips inside of cuff of remaining glove
Pull glove over bare hand
Cryptorchidism patho?
Testis is undescended, lies in inguinal canal or abdomen
Spermatocele Vs. Cyst of Epididymis ?
Painless, mobile, soft, cystic mass
Cannot differentiate the two by exam
Both will transilluminate
Tx
None unless symptomatic
Surgical excision
Spermatocele/Epididymal cyst
Testicular tumor PE?
Painless nodule/mass, grows and spreads – multinodular, firm (not rubbery)
No transillumination - no diffuse glow
Hernias - Anatomy: Femoral canal?
with index finger on artery, middle on vein, ring will be over femoral canal
Acute Epididymitis caused by ?
Can be secondary to UTI or prostatitis – bacteria ascend from urethra or prostate
UBC patient preparations?
Explain the procedure to the patient
It may make him/her feel like he/she must urinate - slightly uncomfortable but they willl not pee
It will be slightly uncomfortable
Need to hold still
abdominal nodes drain?
testes
Catheter sizes: Charriere French scale - 1mm = ?
1 mm = 3 Fr
Penis ROS2?
History of prostate problems/surgery
History of inguinal hernia/repair
Sexual orientation/preference/satisfaction
“Do you prefer sexual partners that are male, female or both”
Libido - sex drive
Impotence - ability to get erection
loss of libido - ACE I , antidepressant
Vas deferent begins where?
tail of epididymis
Hydrocele PE - ascultation?
No bowel sounds
No reduction with
supine position - helps differentiate from hernia
Hernias - Anatomy: Inguinal ligament?
from ASIS to pubic tubercle
Female: UBC procedure 5? for foley cath?
Inflate Foley balloon with sterile water
Gently tug on catheter
Attach drainage bag
Tape catheter to inner thigh
Bacitracin or betadine to meatus 1-3 x daily
Male: UBC procedure 5? for straight cath?
Once bladder is empty, remove catheter
Pinch off end so urine in cath does not spill on patient
Measure and record amount of urine obtained
UBC materials?
Sterile tray or working area
Sterile collection container
Sterile gloves
Sterile lubricant or anesthetic lubricant
Cleansing solution (Betadine) - to clean around uretheral meatus
Sterile gauze or cotton balls
Sterile forceps to grasp cotton balls
(Or povidone-iodine cotton swabs)
Syringe filled with sterile water (5-30mL) - inflating the balloon - cannot be saline only water
Catheter tubing and bag
Sterile drapes
Catheter
Hernias - Severities: incarcerated?
bowel does not return, it is trapped
gentle pressure to try and reduce it
Hernias - Severities: reducible?
bowel returns to abdominal cavity, spontaneously or manually
Acute Epididymitis patho?
Acutely inflamed epididymis
Difficult to identify epididymis on exam due to swelling and tenderness
Hernias - Anatomy: Inguinal canal?
above and parallel to inguinal ligament
is the tunnel for the vas deferens
Male: UBC pre-procedure?
More prone to urethral damage
Improper lubrication - used enough lube with no excessive force
Excessive force
Choose appropriate type and size catheter
Gather supplies
Follow aseptic technique ( extremely important)
Wash hands
Open kit in sterile manner – away from you first
Indirect Hernia: gender?
both, males 4:1
Direct Hernia: point of origin?
Above ing. lig.,
near EXTERNAL
ing. ring
What is the spermatic cord made of?
vas deferens
blood vessels
nerve and muscles
Venereal Warts (Condyloma Acuminatum) prevention?
Gardasil before sexual debut:
encourage young kids
start at age 9
Nongonococcal urethritis PE?
Scant, clear/white discharge
Genital Herpes appearance?
Cluster of small vesicles, become shallow painful ulcers on a nonindurated base ( surrounding tissues is not red or swollen)
Small soft testes think?
atrophy secondary to cirrhosis, myotonic dystrophy, estrogens, hypopituitarism, mumps
Direct Hernia: course?
rarely into scrotum
Penis anatomy - uncircumcised means that the prepuce is ______
intact
Catheter sizes: Charriere French scale - 10mm = ?
10 mm = 30 Fr
Gonococcal urethritis gram stain?
G- diplococci
Physical Exam for Hernias -Inspection?
Inspect for visible bulges – inguinal and femoral areas
Inspect again with Valsalva
Penis anatomy - 3 columns of erectile tissue
2 corpus cavernosa
1 corpus spongiosum – surrounding urethra
Epispadias patho and prevalence ?
meatus on dorsal surface
rare
inguinal nodes drain?
penis and scrotal surface
Epididymis is ____ shaped?
comma
Physical Exam for Hernias - Inspection: patient and examiner positions?
Patient is standing,
Examiner is sitting
Genital Herpes PE?
Tender inguinal nodes
Clear penile D/C, dysuria
On recurrence – fewer lesions and less pain
Indirect Hernia: course?
often to scrotum
Female: UBC procedure 4?
Lubricate first few inches of catheter
Insert catheter until urine starts to flow
If you miss the urethral opening, you need to obtain a new, sterile catheter (leave first one in place)
Insert approx 1/3 of catheter length
Place end of catheter in container
Obtain sterile specimen, if needed
Allow bladder to empty
Female: UBC procedure 5? for straight cath?
Remove catheter
Pinch off end so urine in cath does not spill on patient
Developmental scale/sexual maturity rating of males - Stage 5?
hair appears on thigh now
Femoral Hernia: on exam?
Ing. canal is empty
Direct Hernia: age?
usually +40
UBC potential complications cont’d?
Urinary tract infection (UTI) -most frequent
if not sterile technique
Urinary tract inflammation ( anywhere along tract)
Urethral dilation
Urinary structural trauma
False passage in the urethra
Catheter into side wall of urethra and perforate
Catheter “doubles back”
Catheter tip reappears at urethral meatus
Patient-caused trauma
Patient pulls out inflated Foley
Indirect Hernia: on exam?
hernias comes down canal to finger tip
Types of Catheters: Foley?
Rubber, latex-coated (not if latex allergy), silicone-coated
Remains in the bladder
Balloon-secured after insertion
Inflated with sterile water
Two sizes of balloons
5mL – most common (inflate with 10 mL)
30 mL – traction stent after urologic procedures (inflate with 50mL)
Attached to a drainage bag
**foley is the one that stays, saline can crystalize along the lumen and then it will not deflate thats why only water is used*
Genital Herpes tx?
p.o. acyclovir, valcyclovir, famvir
just help treat sxs.
No cure
- *worse episode is the first one, recurrent bouts are less severe
inch. 2-days
may have fever malaise *
Genital Herpes sxs?
Burning, stinging sensation before vesicles appear
Penis PE? considerations?
Consider having a chaperone in the room
Assess sexual maturity
sometime men will get erection during exam
it often happeneds
UBC follow-up care: Short term or In-and-Out?
Complications are unlikely
Most common complication is UTI and irritation
Reassure that burning with first few urinations is normal
Monitor for dysuria, frequency, hematuria, pyuria, fever, back pain
Small testes tx?
dependent on cause
Male: UBC procedure 2?
Squirt lubricant packet onto sterile tray
Open packet of povidone-iodine cotton swabs and hold swabs in dominant hand
Or use forceps and sterile cotton balls dipped in betadine
Grasp penis with non-dominant hand
Note: this hand is no longer sterile!
Cleanse penis with iodine swabs
Swab head of penis first at meatal opening, then glans
If not circumcised, retract foreskin first
Hernias considerations?
Difficult to differentiate direct from indirect on exam, but both need surgical correction
Femoral hernias more likely to strangulate because of thinner neck
When do you want to use larger french catheters e.g.. 20-30 Fr?
to evaluate for blood clots
Fournier’s Gangrene Tx?
Antibiotics and aggressive debridement
Phimosis patho?
Inability to retract the prepuce
Congenital or acquired ( scarring - recurrent balanitis)
Possibly secondary to recurrent balanitis
Scrotum and contents PE - inspection?
Skin
Rash, ulcer, inflammation
Include posterior surface
Contour ( visual assessment of size of scrotum)
Transillumination
Fluid ( transilluminate) vs. mass
what is the epididymis ?
coiled spermatic ducts
