Male Repro Flashcards

Question

If there is severe tenderness whilst palpating the scrotum what may this be suggestive of?

Answer 1

Severe tenderness whilst palpating can be suggestive of testicular torsion which is a medical emergency.

Answer 2

Palpate the scrotum. Confirm the presence of both testicles in the scrotal sac. They should be approximately equal in size, smooth and fairly firm. Testes should be palpated between the examiner’s thumb and first two fingers checking for any lumps, hardness or tenderness. Lumps within the testes themselves are of much greater significance than lumps which are separate. If one of the testes is absent, ask about previous surgery or retractile/undescended testicles. On the superior pole of the testes the epididymis and surrounding structures should be palpated for lumps, thickening or tenderness. Epididymal cysts are a very common finding and are benign.

Answer 3

Distended veins that feel like “bag of worms”, are also relatively common and are more often found on the left side.

Answer 4

A hydrocele is a type of swelling in the scrotum. If hydrocele is suspected a bright pen torch should be pressed against the swelling to assess for transillumination, which lights up the scrotal sac, like water in a balloon. It may be necessary to darken the room to see this. The patient should then be asked to stand and the scrotum re-palpated systematically. If an inguinal hernia or varicocele is present, then this will usually increase the size of the swelling.

Answer 5

Inguinal hernia

Answer 6

Testicular carcinoma

Answer 7

Epididymitis

Answer 8

Epididymal cyst

Answer 9

Varicocele

Answer 10

Scrotal lesion

Answer 11

Gonorrhoea, chlamydia and other STIs

Answer 12

1. INTRODUCTION 2. GENERAL INSPECTION 3. CLOSE INSPECTION 4. PENIS 5. SCROTUM 6. OTHER AREAS 7. CONCLUSION

Answer 13

A. Ensure adequate hygiene of hands and appropriate PPE - Wearing PPE of mask, apron + gloves B. Introduce self C. Confirm patient’s name and DOB D. Ask if patient in any discomfort E. Explain procedure and seek permission to examine the genitourinary system - Important to explain the examination as you go along and repeatedly check that you have consent to continue. Reassure the patient you can stop at any stage if they request. F. Offer a chaperone - Chaperone desirable in any intimate examination. Document clearly if patient declines. G. Allow privacy for patient to undress. Provide a cover until examination starts H. Position patient – initially lying on the bed as for an abdominal examination

Answer 14

A. Demeanour, weight change, skin conditions e.g. psoriasis B. Hands – signs of anaemia, scabies, maculopapular rash of secondary syphilis - Maculopapular rash of secondary syphilis typically seen on palms and soles C. Face – mouth ulcers, cold sores NOT looking in mouth during Covid-19 - Cold sores indicate herpes simplex infection, typically but not always, type 1. Recurrent apthous ulceration and oral candida may be present in HIV.

Answer 15

A. Inspect skin – groin, skin creases, perineum and scrotal skin, hair distribution - Look for genital warts, molluscum contagiosum, and pubic lice. There may be alopecia, infestation or ulcers (most commonly herpetic but also consider syphilis). Patients who shave may have dermatitis or folliculitis. Inertrigo (infected eczema) occurs in skin creases and check for fungal rash which often has a scaly surface and well defined border. Scrotal oedema can be caused by systemic or local disease. Heart and liver dysfunction may cause significant genital oedema, as may the nephrotic syndrome and lymphoedema due to para-aortic lymphadenopathy. B. If any swellings in the groin – palpate and describe SPACESPIT - Lymphadenopathy may be due to local or general causes. Tender inguinal lymph nodes are common in genital herpes simplex infection (usually bilateral in primary episodes and unilateral in recurrences.) Enlarged nodes may be due to many causes of genital infection, particularly syphilis. - SPACESPIT Size, Position, Attachment, Consistency, Edge, Surface and shape, Pulsation, thrills and bruits, Inflammation, Transillumination

Answer 16

A. Inspect shaft B. Palpate shaft for fibrous plaques (usually on dorsum) C. Palpate any other lesions and define them D. Retract the prepuce and inspect the glans for red patches or vesicles E. ALWAYS DRAW THE FORESKIN FORWARD AFTER EXAMINATION TO AVOID A PARAPHIMOSIS F. (Take a urethral swab if indicated) Inspect the skin of the shaft of the penis, foreskin and glans, urethral meatus. The rash of psoriasis may only be found in the genital area, typically scrotum and natal cleft. The urethral meatus should be examined for any discharge or inflammation. Inflammation of the foreskin (posthitis) or glans (balanitis) or both (balanoposthitis) is common. Enlarged follicles may mimic warts – numerous uniform pearly penile papules around the corona of the glans are normal. Warts, sebaceous cysts or a hard plaque of Peyronies disease may occur on the shaft and phimosis, adhesions, inflammation or swellings on the foreskin or glans.

Answer 17

A. Ask if any genital pain B. Inspect the scrotum - Note the position of the testes and any paratesticular swellings or tenderness. Looking for redness, swelling, or ulcers, lifting it to inspect the posterior surface and the perineum. Sebaceous cysts are common in scrotal skin. C. Gently palpate the scrotum - Palpate the scrotum gently using both hands. Check that both testes are present: (The right testicle is usually closer to the inguinal canal than the left, but testes may be highly mobile/retractile.) If they are not, examine the inguinal canal and perineum for ectopic testes. Ask about previous excision surgery or retractile/undescended testes. With each testis in turn, place the fingers of both your hands behind the testis to immobilise it and use your index finger and thumb to palpate the body of the testis methodically. Feel the anterior surface and medial border with your thumb and the lateral border with your index finger. Note size and consistency of the testis -they should be approx. equal in size (A normal testis is 5cm long), smooth and fairly firm. Note any nodules or irregularities. Measure the testicular size in cm from one to the other. Small firm testes suggest hypogonadism or testicular atrophy. Lumps within the testes themselves are of much greater significance than lumps which are separate. The epididymis and surrounding structures should also be palpated for lumps, thickening or tenderness. Epididymal cysts are a common finding and benign. The normal epididymis is barely palpable except for its head which feels like a pea separate from the superior pole of the body of the testicle. D. Palpate the spermatic cord - Palpate the spermatic cord with your right hand. Gently pull the testis downward and place your fingers behind the neck of the scrotum. Feel the spermatic cord and within it the vas, like a thick piece of string. E. Transluminate any scrotal swelling - Transluminate to determine if a mass is solid or cystic. Place a torch against the swelling. Fluid filled cysts allow light transmission and the scrotum glows bright red. This is an inconsistent sign which does not differentiate a hydrocele from other causes of intrascrotal fluid e.g. a large epididymal cyst. With thick walled cysts, transillumination may be absent. F. Ask patient to stand and examine whether you can get above any swelling - A varicocele feels like a ‘bag of worms’ in the cord and should disappear when the patient lies down. If it does not then consider a pelvic mass compressing the testicular veins. Decide whether a swelling arises from the scrotum or the inguinal canal. With the patient standing, if you can feel above the swelling it originates in the scrotum; if you can’t the swelling usually originates in the inguinal region, it may be a varicocele or inguinal hernia which has descended into the scrotum. A bulky or painful mass in the scrotum when you cannot palpate the testis needs an ultrasound to clarify the nature of the intrascrotal structures. A retracted testicle accompanied by acute pain and swelling occurs in testicular torsion, which is dealt with as an emergency. Differentials: - Attached to testis: Solid (non-translucent): testicular tumour - Cystic (translucent): hydrocele - Separate from testis: Solid (non-translucent): chronic epididymitis - Cystic (translucent): epididymal cyst

Answer 18

A. Abdominal examination including examination for inguinal hernias B. Prostate exam if indicated C. Cervical/axillary and inguinal lymphadenopathy (generalised lymphadenopathy with HIV, syphilis, malignancy)

Answer 19

A. Thank the patient, dispose of gloves / PPE and wash hands B. Ensure patient has privacy to dress C. Summarise and present findings