Male GU - Biber. Plowign the genitourinary pathway

Question 1

suprapubic pain implies

Answer 1

bladder

infection, inflammation, distension…

Question 2

polyuria

Answer 2

urinary frequency with high volume per void

Question 3

not all red urine is hematuria

Answer 3

drugs (rifampin, isoniazid, phenazopyridine)

foods (beets, carrots)

Question 4

exam preliminaries

Answer 4

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

Question 5

phimosis vs paraphimosis

Answer 5

phimosis– narrowing of the opening

paraphimosis- foreskin pulled back, glans sweels and the foreskin can’t return

Question 6

ballanitis

Answer 6

inflammation of the glans penis

Question 7

posthitis

Answer 7

inflammation of hte foreskin

Question 8

hypospadius

Answer 8

urethral meatus is ventral

Question 9

syphilis vs herpes

Answer 9

syphilis- non painful

herpes- hurts a lot

Question 10

squamous cell carcinoma of hte penis

Answer 10

gradual enlarging
usually painless
extremely rare in circumcised men
associated with previous HPV infection

Question 11

palpation of the penis

Answer 11

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

Question 12

peyronnie’s disease

Answer 12

fibrous scar tissue involving the outside lining of the corpus cavernosum

Question 13

absence of vas suggests

Answer 13

ipsilater absence of kidneey

Question 14

spermatic cord abnormalities

Answer 14

varicocele (primarily on the left, feels like bag of worms)

Question 15

intratesticular masses

Answer 15

testicular carcinoma until proven otherwise

seminoma, embryonal, chorio, and teratocarcinoma

Question 16

how do we know benign fluid filled masses?

Answer 16

epidididymal cyst, hydrocele

will transilluminate

scrotal hernia will have bowel sounds.

varicocele will enlarge with valsalva

Question 17

testicular carcinoma

Answer 17

painless
age 15-30
gradual onset
mass usually rock hard
does not transilluminate
diagnosis made with orchicectomy

Question 18

hydrocele

Answer 18

non tender
can get quite large
can be transilluminated
may be present at birth

Question 19

epididymal cyst

Answer 19

usually upper pole (spermatocele)
often a history of maternal DES usage
non tender
will transilluminate

Question 20

epididymitis

Answer 20

gradual onset
febrile
elevated wbc
does not transilluminate
EXQUISITELY TENDER

Question 21

orchitis

Answer 21

similar presentation to epididymitis

often have epididymo-orchitis

Question 22

varicocele

Answer 22

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

Question 23

testicular torsion

Answer 23

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

Question 24

scrotal inguinal hernia

Answer 24

non tender
mass extends into the inguinal canal
usually unilateral
does not transilluminate
has bowel sounds

Question 25

inguinal hernia

Answer 25

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

Question 26

reduceable hernia

Answer 26

the protrusion freely passes back and forth through the abnormal opening

Question 27

incarcerated hernia

Answer 27

the protrusion (loop of bowel) is stuck in the opening but there is no vascular compromise and the loop is viable and usually tender

Question 28

strangulated hernia

Answer 28

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

Question 29

indirect inguinal hernia

Answer 29

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

Question 30

direct inguinal hernia

Answer 30

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

Question 31

femoral hernia

Answer 31

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

Question 32

hernia palpation

Answer 32

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

Question 33

Perianal/ Anal inspection and DRE

Answer 33

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

Question 34

anal fissure

Answer 34

tear in the anal mucosa
very painful
common in people who are chronically constipated and strain moving bowels

Question 35

anorectal fistula

Answer 35

an abnormal tract bewteen the rectumand the perianal region

almost always caused by an abscess such as those found in Crohn’s disease

Question 36

Human papilloma virus

Answer 36

generally asymptomatic

caulflower appearance

Question 37

herpes simplex

Answer 37

usually causes pruritis and pain

vesicles that ulcerate

Question 38

skin tags

Answer 38

very common
overgrowth of anal epithelium
painless
pale color differentiates them from hemorrhoids

Question 39

anal cancer

Answer 39

squamous cell
generally painless until the surface becomes ulcerated
usually presents with bleeding so it is often ignored in people with hemmorrhoids

Question 40

DRE

Answer 40

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)

Question 41

assess the size of the prostate

Answer 41

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.

Question 42

Assess consistency of the prostate

Answer 42

rubbery- normal
beeffy and a bit squishy– BPH
fluctuant and tender- prostatitis
rock hard- carcinoma

Question 43

nodules on the prostate

Answer 43

discreet, hard nodules suspicious for carcinoma

Question 44

findings on rectal palpation

Answer 44

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