Male GU Exam Flashcards
Risk factors for erectile dysfunction
DM, HTN, hyperlipidemia, obesity, testoterone deficiency, prostate cancer treatment, anxiety
Medications: antidepressants (SSRIs, SNRIs), tobacco
Age 40-79
Diagnostic testing for ED may include BP, BMI, waist circumference, genital exam, assessment of secondary sex characteristics, A1c or fasting BG, lipid panel, TSH level, etc. as well as international index of erectile function (IIEF-5).
What are some management strategies for ED?
Tobacco cessation, regular exercise, weight loss, improved control of DM/HTN/Hyperlipidemia/etc.
First line med = Oral PDE-5 inhibitors (avanafil, sildenafil, tadalafil, vardenafil)
Second line med = alprostadil and vacuum devices
Gradual onset of unilateral posterior scrotal pain <6 weeks along with dysuria, urinary frequency, fever, hematuria, abd pain, etc. may indicate _____
Epididymitis
Risk factors for epididymitis
Hx of UTI or STI, anatomic abnormalities (bladder outlet obstruction), prostate or urinary tract surgeries or instrumentation, prolonged sitting, cycling, or trauma
[reflux of urine into ejaculatory ducts is considered most common cause of epididymitis in kids <14; N.gonorrheae and C.trachomatis are most common etiologies in sexually active males 14-35]
PE findings associated with epididymitis including diagnostic signs and reflex findings
Swollen and tender epididymis with testis in anatomic position
Elevating scrotum may alleviate pain (Prehn sign)
Intact cremasteric reflex
Treatment recommendations for epididymitis in the following pt groups:
- Sexually active males age 14-35
- Men who practice insertive anal intercourse
- Sexually active males age 14-35 = single IM dose of ceftriaxone with 10 days of oral doxycycline
- Men who practice insertive anal intercourse = ceftriaxone with 10 days of oral levofloxacin or ofloxacin
Aspects of penis and testes exam
Penis — inspect for lesions, palpate for plaques or induration
Testes — inspect, palpate for masses, equal volume, tenderness, cryptorchidism. All masses should be transluminated (light will not go through solid mass, hydrocele will glow soft red). Chronic lesions can cause testicular atrophy. Check cremaster reflex on both sides.
Aspects of epididymis, spermatic cord, and vas deferens exam
Palpation to evaluate induration and to localize pain to the testicle or adjacent structures. Epididymis is posterior to testicle. Valsalva while standing evaluates dilated testicular veins in the spermatic cord forming a varicocele above and behind the testis
Aspects of inguinal canal exam
Canals explored for hernias or cord tenderness. Funiculitis, inflammation of cord structures, may cause inguinal or scrotal pain, but testis is normal. Evaluate for cord lipomas or hydroceles also
A bellclapper deformity is indicative of _____ _____
Testicular torsion
Presentation of testicular torsion including exam findings
Presents in young to middle aged men with sudden, severe, unilateral scrotal pain often associated with nausea/vomiting
Exam reveals a tender, firm affected testis that may appear retracted upward as a result of the twisted spermatic cord. Cremaster reflex is typically ABSENT in testicular torsion
Presentation of urethritis in men and primary pathogens involved
Urethral discharge, penile itching or tingling, and dysuria
Primary pathogens are C.trachomatis and N.gonorrhea
Physical exam considerations in a male presenting with urethral symptoms
Examine for inguinal LAD, ulcers, or urethral discharge. Palpation of the scrotum for evidence of epididymitis or orchitis is advised. DRE of prostate may be cosnidered especially in older pts or if rectal pain is reported
The urethra should be gently “milked” by serial palpation down shaft of penis toward the urethra; any discharge should be tested/cultured
Diagnoses of ______ may include presence of urethral discharge, positive leukocyte esterase test in first-void urine, or at least 10 WBCs per hpf in first-void urine sediment
Urethritis
In what pt populations is routine syphilis screening strongly recommended by USPSTF?
Persons at increased risk
Pregnant women
In what pt populations is routine GC/Chlamydia screening recommended by USPSTF?
Sexually active women age 24 and younger, and in older women who are at increased risk for infection
Polymicrobial cellulitis with genital, groin, or perineal involvement, characterized by signs or symptoms of infection followed by suppuration and necrosis of overlying skin. Not sexually transmitted but associated with/secondary to epididymitis
Fournier’s gangrene
Presentation of prostatitis
Acute onset of irritative (dysuria, urinary frequency, urinary urgency) or obstructive (hesitancy, incomplete voiding, straining to urinate, weak stream) voiding symptoms
Pts may report suprapubic, rectal, or perineal pain
Painful ejaculation, hematospermia, and painful defecation may also be present in addition to systemic symptoms such as fever, chills, nausea, emesis, and malaise
Presentation of cystitis in males
Acute onset of irritative urinary symptoms or other signs/symptoms including cloudy or strong smelling urine, hematuria, feeling of pressure in lower abdomen, pelvic discomfort
Most common causes of genital ulcers in the US
- HSV 1 and 2
- Syphilis
- Chancroid
[other causes include granuloma inguinale, lymphogranuloma venareum (C.trachomatis types L1, L2, L3)]
What tests should be considered in pts who present with genital ulcers?
Serologic tests for syphilis (VDRL or RPR) and darkfield microscopy OR direct fluorescent antibody testing for treponema pallidum
Culture or PCR for HSV
Culture of H.ducreyi in settings with high prevalence of chancroid
Etiology of the following genital ulcer:
Usually multiple vesicular lesions that rupture and become painful, shallow ulcers. Constitutional symptoms, LAD in first time infections
HSV
Etiology of the following genital ulcer:
Single painless well-demarcated ulcer with a clean base and indurated border. Mild or minimally tender inguinal LAD.
Syphilis (primary chancre)
Etiology of the following genital ulcer:
Nonindurated, painful with serpiginous border and friable base; covered with a necrotic, often purulent exudate. Tender, suppurative, unilateral inguinal LAD or adenitis
Chancroid
[H.ducreyi — gram-negative slender rod or coccobacillus in “school of fish” pattern]
Etiology of the following genital ulcer:
Small, shallow, painless, genital or rectal papule or ulcer; no induration. Unilateral, tender inguinal or femoral LAD “Groove sign”
LGV
[RARE and primarily occurs in men who have sex with men]
Fungal infection that affects genital skin, inner thighs, and buttocks, causing an itchy, red, often ring-shaped rash in warm, moist areas of your body
Tinea cruris
Most common of all STIs
HPV
Any sexually active person is at risk for getting HPV. However, genital warts are more common in what pt populations?
Age <30 Smoking Weakened immune system Hx of child abuse Children of a mother who had virus during childbirth
Birth defect in which opening of urethra is on underside of penis instead of the tip
Hypospadias
Development of fibrous scar tissue inside penis that causes curved, painful erections; may develop suddenly or more gradually, typically due to trauma
Peyronie’s disease
Most common male birth defect, characterized by failed descent of one or both testes from the abdomen into the scrotum
Cryptorchidism
Do you need to do male genital exams for preparticipation sports physicals?
Insufficient evidence exists to recommend for or against screening genital exams for boys playing sports
Given the low risk of harm, screening for hernias as a part of preparticipationphysical eval is recommended by several specialty organizations
[Am Fam Physician states genital exam is not recommended for females but may be indicated in males with symptoms or a history of GU problems]
Differentiate hydrocele, varicocele, and spermatocele
Hydrocele — collection of fluid presents as painless scrotal swelling that can be transluminated; may worsen throughout the day. New hydrocele or one that hemorrhages after minor trauma may signal cancer
Varicocele — most commonly on the left side. Mass lying posterior to and above the testis. Classic description is “bag of worms”
Spermatocele — painless cystic mass separate from the testis located superior and posterior to the testis
Signs and symptoms of testicular cancer
Lump or enlargement in either testicle, feeling of heaviness in the scrotum, dull ache in abdomen or groin, sudden collection of fluid in scrotum, pain or discomfort in testicle or scrotum, enlargement or tenderness of breast tissue, back pain
[risk factors include cryptorchidism, personal or family hx of testicular cancer, age, ethnicity, and infertility]
Testicular cancer is the most common solid tumor among males 15-34 years. What is the recommendation regarding testicular cancer screening?
There is inadequate evidence that screening asymptomatic patients by means of self-exam or clinician exam has greater yield or accuracy for detecting testicular cancer at more curable stages
[Grade D evidence]
What screening should be considered in men with ED?
Screen for cardiovascular disease, because symptoms of ED present on average 3 years earlier than symptoms of coronary artery disease
