Surgery Clinical Demonstration: Urology, Perineum & Hernia Flashcards
Digital rectal examination: General examination
Position:
- Left lateral decubitus
- Lithotomy
- Knee-chest
- Prone
Expose (Part the buttock):
- Anal verge
- Natal / Intergluteal cleft
Digital rectal examination: Inspection
- Perianal skin
- inflammation
- excoriation
- fecal swelling
- anal warts - Anal opening
- scars
- fistula opening
- skin tags
- external haemorrhoids - Proper descend of perineum by coughing
- ***rectal / vagina prolapse
- urine leak - Colour / Consistency of stool once removed finger
- Proctoscope to visual ano-rectal lining
Digital rectal examination: Palpation
- Anal tone
- squeeze finger using anal muscle - Posterior / Lateral wall
- Anterior wall
- prostate
—> 3.5cm wide (**2 finger breadth)
—> **median groove
—> no nodularity / tenderness
—> symmetry
- cervix
- retroverted uterus
Hernia: General examination
1st part:
- Stand up
- Inspect + Palpation
- Groin
2nd part:
- Supine
- Inspect + Palpation
- Nipple to Mid-thigh
Hernia: Inspection
1st part:
- Swelling
- Cough impulse
- direct / indirect
- inguinal / femoral
2nd part:
- Swelling
- Skin changes
- Mass
- Surgical scars
- Cough impulse
Hernia: Palpation
- Size
- Shape
- Consistency
- Tenderness
- Cough impulse
- Reduce hernia (ask the patient to do)
- Differentiate Femoral vs Inguinal hernia
- starts from umbilicus down midline —> pubic symphysis —> lateral to tubercle
- **Medial + **Above tubercle
- ***Occlusion test
***Occlusion test
***Deep inguinal ring: 0.5 inch above midpoint of ASIS and Pubic tubercle
—> Press on Deep inguinal ring
—> Stand up
—> Cough
—> Hernia reappear?
Reappear —> Negative occlusion test —> Direct inguinal hernia
Not reappear —> Positive occlusion test —> Indirect inguinal hernia
Further test:
1. Scrotal examination
—> Any ***undescended testes
- Abdominal examination
—> ***Abdominal mass - PR examination
—> ***Rectal tumour / BPH
Lump / Swelling in groin
- Duration
- Appear / Disappearance with straining / standing / lying
- Unilateral / Bilateral
- Pain
- locally over lump
- midline of abdomen —> colic - Extend down to scrotum
- Evidence of increased intra-abdominal pressure —> chronic cough, constipation, voiding difficulty
- Previous hernia operation
Gland / lump in groin
Inguinal LN
- Duration
- Pain
- Enlarging
- Symptoms related to anus
- Symptoms related to lower urinary tract
- Lumps elsewhere e.g. axillary, neck
Inspection:
- not much to see
Palpation:
- Which group of LN involved
- Size
- Consistency
- Mobility
- Tenderness
Scrotal swelling
- Onset
- Painful
- Present all the time?
- Enlarging
- Irritation urinary symptoms
Anal pain
- Sharp / Dull
- Continuous / Intermittent e.g. only with defaecation
- Associated bleeding
- bright red fresh
- altered blood
Anal / Peri-anal lump/swelling
- Present all the time / only when straining i.e. prolapsing but reducible
- Painful, tender, throbbing
- Bleeding, discharge
Penis
Inspection:
- Phimosis / Paraphimosis
- Site + Appearance of meatus
Palpation:
- Localised, painless induration of one / both Corpora cavernosa
- Floor of urethra from glans to pelvic floor
Scrotal swelling
Inspection:
- Any obvious swelling, only one / generalised
- Redness of scrotal skin
- Enlarged veins of pampiniform plexus on standing, empty when supine
Palpation:
- Site
- Testes / Epididymus - Size
- Consistency
- Tenderness
- Bag of worms
Transillumination:
- Fluid containing ***hydroceles —> translucent
- ***Epididymis cysts —> translucent
Female urethra
Position:
- Dorsal
- Thigh abducted
Inspection:
- Urethral orifice
- Stress incontinence when coughing
Palpation:
1. Finger into vagina and fee floor of urethra for any induration
