Male GU - Biber. Plowign the genitourinary pathway Flashcards
suprapubic pain implies
bladder
infection, inflammation, distension…
polyuria
urinary frequency with high volume per void
not all red urine is hematuria
drugs (rifampin, isoniazid, phenazopyridine)
foods (beets, carrots)
exam preliminaries
have patient empty bladder prior to exam
explain the exam
begin in the supine position for the abdominal, kidney, suprapubic, and genital inspection and exam
hernia exam done in the standing position
perianal and anal inspection, DRE can be done comfortably with patient leaning over the exam table (forearms on the table, feet shoulderwidth apart)
left lateral decubitus and knee chest position OK but cumbersome and embarrassing to some
phimosis vs paraphimosis
phimosis– narrowing of the opening
paraphimosis- foreskin pulled back, glans sweels and the foreskin can’t return
ballanitis
inflammation of the glans penis
posthitis
inflammation of hte foreskin
hypospadius
urethral meatus is ventral
syphilis vs herpes
syphilis- non painful
herpes- hurts a lot
squamous cell carcinoma of hte penis
gradual enlarging
usually painless
extremely rare in circumcised men
associated with previous HPV infection
palpation of the penis
tenderness
induration (swelling and inflammation)
nodularity.. benign vs malignant penile carcinoma
fibrous scar tissue involving the outside lining of the corpus cavernosum… peyronnie’s disease
peyronnie’s disease
fibrous scar tissue involving the outside lining of the corpus cavernosum
absence of vas suggests
ipsilater absence of kidneey
spermatic cord abnormalities
varicocele (primarily on the left, feels like bag of worms)
intratesticular masses
testicular carcinoma until proven otherwise
seminoma, embryonal, chorio, and teratocarcinoma
how do we know benign fluid filled masses?
epidididymal cyst, hydrocele
will transilluminate
scrotal hernia will have bowel sounds.
varicocele will enlarge with valsalva
testicular carcinoma
painless age 15-30 gradual onset mass usually rock hard does not transilluminate diagnosis made with orchicectomy
hydrocele
non tender
can get quite large
can be transilluminated
may be present at birth
epididymal cyst
usually upper pole (spermatocele)
often a history of maternal DES usage
non tender
will transilluminate
epididymitis
gradual onset febrile elevated wbc does not transilluminate EXQUISITELY TENDER
orchitis
similar presentation to epididymitis
often have epididymo-orchitis
varicocele
varicosity of gonadal vein
primarily left sided: right angle entry of L gonadal vein into L renal vein. 15% incidence in post-pubertal males
may be associated with testicular atrophy adn infertility
acute onset of R varicocele is worrisome and shoudl be worked up for retroperitoneal mass
testicular torsion
mot common ages 12-16
sudden onset
severe pain associated with nausea and vomiting
testicle retracts in scrotum
anatomic defect that predisposes is bilateral
4 hour window to de-torse before testicular necrosis
scrotal inguinal hernia
non tender mass extends into the inguinal canal usually unilateral does not transilluminate has bowel sounds
inguinal hernia
hernia (general)- protrusion of a loop or a knuckle of an organ or tissue through an abnormal opening
inspect the inguinal canal and the femoral triangle for bulgin
have the patient perform a valsalva maneuver
unless the hernia is quite large, it is unlikely to be detectedon inspection. exceptions- nonreduceable (incarcerated) hernia
reduceable hernia
the protrusion freely passes back and forth through the abnormal opening
incarcerated hernia
the protrusion (loop of bowel) is stuck in the opening but there is no vascular compromise and the loop is viable and usually tender
strangulated hernia
the loop of bowel is incarcerated, and initially venous return is compromised leading to increased swelling and eventually arterial compromise. result if not emergently treated is dead bowel
indirect inguinal hernia
the hernia sac (peritoneum) exits via the internal inguinal ring
may pass wiht the cord and sometimes into the scrotum
most common
seen in newborns (patent processus vaginalis) and coesxists with a hyrocele in males
direct inguinal hernia
the hernia sac exits through the floor of the inguinal canal via a tear in the transversalis fascia
may pass with the cord to the scrotum
generally occurs later in life and is associated with straining, such as constipation, persistent cough, BPH with obstruction
repair will fail without treatment of underlying cause
femoral hernia
hernia sac exits inferior to the inguinal ligament into the femoral triangle: borders are the inguinal ligament, medial border of the adductor longus, and the medial border of the sartorius
more common in women but not the most common hernia in women
hernia palpation
use your right index finger for the patient’s R inguinal canal and left index finger for the patient’s L inguinal canal
place your finger low on the scrotum and invaginate the scrotum into the canal
follow the cord to locate the external inguinal ring
if wide open external ring (unusual) you may be able to follow the canal toward the internal ring
have the patient valsalva
Perianal/ Anal inspection and DRE
positions: standing leaning over the exam table (preferred)
left lateral decubitus (difficult for examiner)
Knee-Chest (embarassing for patient)
Explain the procedure to the patient’s satisfaction
be sensitive to the patient’s uneasiness
proceed slowly and deliberately. Use plenty of lubricant
If there is significant discomfort DO NOT FORCE THE EXAM
anal fissure
tear in the anal mucosa
very painful
common in people who are chronically constipated and strain moving bowels
anorectal fistula
an abnormal tract bewteen the rectumand the perianal region
almost always caused by an abscess such as those found in Crohn’s disease
Human papilloma virus
generally asymptomatic
caulflower appearance
herpes simplex
usually causes pruritis and pain
vesicles that ulcerate
skin tags
very common
overgrowth of anal epithelium
painless
pale color differentiates them from hemorrhoids
anal cancer
squamous cell
generally painless until the surface becomes ulcerated
usually presents with bleeding so it is often ignored in people with hemmorrhoids
DRE
place a well lubricated index finger on teh anus
apply gentle constant pressure and ask the patient to take a deep breath or bear down
when the sphincter relaxes slowly advance the finger into the rectum
the prostate is anterior (toward the floor if the patient is standing leaning over the table)
assess the size of the prostate
normal prostate is approx 4 cm in diameter (generous walnut) and protrudes about .5-1.0 cm into the rectum. Increase in diameter or protrusion with a beefy feel is consistent with Benign Prostatic Hypertrophy. Discreet middle sulcus of normal size gland will disappear.
Assess consistency of the prostate
rubbery- normal
beeffy and a bit squishy– BPH
fluctuant and tender- prostatitis
rock hard- carcinoma
nodules on the prostate
discreet, hard nodules suspicious for carcinoma
findings on rectal palpation
palpate the walls of the rectum in a sweeping circumferential manner (360 degrees)
rectal walls are normally soft and compliant
note any areas of tenderness
note any masses… cancer will be irregular, nodular and firm
hemoccult stool if present and indicated
