Week 12: GU

Question 1

What are the current recommendations regarding self-breast exams?

Answer 1

Self-exams recommended for women with very high risk for breast cancer or in a setting with limited resources

Question 2

What are the current recommendations regarding breast cancer screening?

Answer 2

• Mammography
  
  • USPSTF: 50-74 years biennially, start <50 years if patient has high risk factors
  • American Cancer Society: 40-45 years: optional annual screening, 45-54 years: annual screening; >55 years biennial screening with option to continue annual screens; continue screening if good health and life expectancy >10 years
  • American College of Obstetricians and gynecologists: offer screening starting at 40; screening every 1-2 years based on shared decision making; continue screening until 75
  • Consider life expectancy, continue screening if expected to live for at least another 10 years
  • Shared decision making is important for all
• BRCA1 & BRCA 2 Mutations: Begin assessing family history when pt is in her 20s

Question 3

What are the seven characteristics of a breast nodule that should be described?

Answer 3

1. Location: left or right; by quadrant and clock with centimeters from the nipple
2. Size: in cm
3. Shape: round or cystic, disc-like, or irregular in contour
4. Consistency: soft, firm or hard
5. Delimitation: well circumscribed or not
6. Tenderness
7. Mobility

Question 4

What history, exam findings and risk factors are consistent with a fibroadenoma? Cyst? Cancer?

Answer 4

• Fibroadenoma
  
  • History: 15-25 years, puberty and young adulthood up to age 55 years
  • Exam: smooth, rubbery, round, mobile, nontender
• Cyst
  
  • History: 25-50 years, regress after menopause except with estrogen therapy
  • Exam: soft-firm, round, mobile, often non-tender
• Cancer
  
  • History: 30-90 years, most common after 50 years
  • Exam: irregular, firm, mobile or fixed to surrounding tissue, nontender
  • 50+: Consider cancer 1st until proven otherwise

Question 5

What are some visible signs of breast cancer?

Answer 5

• Retraction signs
• Skin dimpling
• Nipple retraction and deviation
• Skin edema (orange peel sign)
• Paget disease of the nipple: scaly, eczema-like lesion on the nipple that may weep, crust or erode

Question 6

What could milky nipple discharge indicate? Bloody? Clear, serous, green or black?

Answer 6

• Clear, serous, green, black or nonbloody discharges that are multi-ductal are usually benign
• Milky discharge unrelated to prior pregnancy/lactation = nonpuerpural galactorrhea
  
  • causes = hyperthyroidism, pituitary prolactinoma, dopamine antagonists (psychotropics and phenothiazines)
• Pathologic: spontaneous, unilateral, bloody, associated with a mass, typically over the age of 40; typically occurs in 1-2 ducts

Question 7

What are considered normal findings of the breasts of newborns?

Answer 7

• Often enlarged from maternal estrogen - takes a few months to resolve
• May be engorged with a white liquid called “witches milk” which should resolve within 1-2 weeks

Question 8

What is premature thelarche?

Answer 8

• Breast development occurs without other signs of puberty or hormonal abnormalities
• Premature breast enlargement - infant to 6 yrs old
• Usually benign and temporary

Question 9

What are the current recommendations regarding testicular self-exams?

Answer 9

• USPSTF does not recommend screening in asymptomatic adolescents and adults
• ACS: does not recommend routine screening but to be aware of testicular cancer and see a provider should they notice any lumps

Question 10

What symptoms and exam findings are consistent with a testicular torsion?

Answer 10

• Acutely painful, tender and swollen organ retracted upwards in the scrotum
• Cremasteric reflex nearly always absent on affected side
• Scrotum may become red and edematous
• No associated urinary infection

Question 11

What is the cremasteric reflex and how is it performed?

Answer 11

Performed by gently stroking upward or downward along the medial aspect of the thigh; testis on the side being stroked will move upward

Question 12

What is the difference between a direct and indirect inguinal hernia?

Answer 12

Indirect inguinal hernias: develop at the internal inguinal ring where the spermatic cord exits the abdomen

Direct inguinal hernias: arise more medially due to weakness in the floor of the inguinal canal and are associated with straining and heavy lifting

Question 13

What exam findings are consistent with gonococcal urethritis vs. nongonococcal urethritis?

Answer 13

Nongonoccocal urethrits: scanty white or clear discharge

Gonococcal urethritis: purulent, cloudy or yellow discharge

Question 14

What are some benefits of circumcision?

Answer 14

• Reduced risk of:
  
  • urinary tract infections (UTIs)
  • penile cancer
  • some sexually transmitted infections (STIs), including heterosexually acquired HIV, syphilis, herpes and human papillomavirus (HPV).

Question 15

What is a hypospadias? Chordee?

Answer 15

Hypospadias: congenital displacement of the urethral meatus to the inferior surface of the penis; meatus may be subcoronal, midshaft or at the junction of the penis and scrotum

Chordee: fixed, downward bowing of the penis, usually accompanied by hypospadias

Question 16

What are considered to be normal scrotal findings of the newborn?

Answer 16

• Rugae should be present in a term newborn
• Scrotal edema may be present
• 10mm in width and 15 mm in length

Question 17

What exam findings are consistent with a hydrocele?

Answer 17

• Nontender, fluid-filled mass in tunica vaginals
• Transilluminates
• Fingers can palpate above the mass

Question 18

What exam findings are consistent with a hernia in the newborn/infant?

Answer 18

Reducible scrotal mass

Do not transilluminate

Question 19

How would the FNP classify Tanner stages in males?

Answer 19

• Pubic hair
  
  • Stage 1: preadolescent - no pubic hair except fine body hair
  • Stage 2: sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, chiefly at the base of the penis
  • Stage 3: darker coarser, curlier hair spreading sparsely over the pubic symphysis
  • Stage 4: coarse and curly hair, area covered greater than stage 3 but not entire and does not spread to the thighs
  • Stage 5: hair adult in quantity and quality, spreads to medial surfaces of the thighs but not over abdomen
• Genital
  
  • Stage 1: preadolescent - same size and proportions as childhood
  • Stage 2: slight or no enlargement of the penis; larger tests, scrotum larger, somewhat reddened and altered in texture
  • Stage 3: penis larger in length, testes/scrotum further enlarged
  • Stage 4: penis further enlarged in length and breadth with development of the glans; testes/scrotum further enlarged, scrotal skin darkened
  • Stage 5: penis, testes and scrotum adult in size and shape

Question 20

What is considered delayed puberty in the male? What are some common causes?

Answer 20

Suspected in boys who have no signs of pubertal development by 14 years old

Causes: constitutional delay, primary or secondary hypogonadism, congenital GnRH deficiency

Question 21

What are the current cervical cancer screening recommendations?

Answer 21

• start pap smear at age 21
• 21-29 years: pap every 3 years
• 30-65: pap every 3 years or HPV testing alone or pap plus high-risk HPV testing every 5 years
• Stop at age 65, assuming three consecutive negative results on cytology or two consecutive negative results on cytology plus HPV testing within 10 years before cessation of screening, with the most recent test performed within 5 years

Question 22

What is the difference between perimenopause and menopause?

Answer 22

• Menopause: cessation of menses for 12 months
  
  • Menstrual periods cease between 45-42 years
• Perimenopause: progressive stages of cyclical bleeding, accompanied by vasomotor symptoms (hot flashes, flushing, sweating)

Question 23

What questions are important to ask when assessing for risk for STIs?

Answer 23

• # of sexual partners in the last 3-6 months
• Need to assess sexual orientation, gender identity and sex assigned at birth

Question 24

When considering acute pelvic pain, what are some life threatening conditions that should be on your differential?

Answer 24

• Ectopic pregnancy - most important because it can rupture
• Ovarian torsion
• Appendicitis

Question 25

Trichomonal vaginitis: what would be expected exam findings for discharge, symptoms, vulva/vaginal mucosa and wet mounts?

Answer 25

Discharge: profuse frothy yellowish green or gray malodorous

Symptoms: pruritis, pain on urination, dyspareunia

Vulva and vaginal mucosa: vestibule and labia minora may be erythematous, vaginal mucosa may be diffusely reddened, small red granular spots or petechiae in the posterior fornix, mild cases has normal mucosa

Wet mounts: scan saline wet mount for trichomonads

Question 26

What are some normal configurations of the hymen in the prepubertal child?

Answer 26

• Septate
• Crescent shaped
• Annular

Question 27

How would the FNP classify Tanner Stages (Sexual Maturity Rating) in females?

Answer 27

• Breasts
  
  • Stage 1: preadolescent - elevation of nipple only
  • Stage 2: breast bud stage, elevation of breast and nipple as a small mound, enlargement of areolar diameter
  • Stage 3: further enlargement of elevation of breast and areola, no separation of their contours
  • Stage 4: projection of areola and nipple to form a secondary mound above level of the breast
  • Stage 5: mature stage - projection of nipple only, areola has receded to general contour of the breast
• Pubic hair (same as boys)
  
  • Stage 1: preadolescent - no pubic hair except fine body hair
  • Stage 2: sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, chiefly along the labia
  • Stage 3: darker coarser, curlier hair spreading sparsely over the pubic symphysis
  • Stage 4: coarse and curly hair, area covered greater than stage 3 but not entire and does not spread to the thighs
  • Stage 5: hair adult in quantity and quality, spreads to medial surfaces of the thighs but not over abdomen

Question 28

What is considered delayed puberty in the female? What are some common causes?

Answer 28

No breasts or pubic hair by 12

Causes: inadequate gonadotropin from the anterior pituitary due to defective hypothalamic GnRH production; anorexia, turner syndrome (will fall below the 3rd percentile in height) or chronic disease

Question 29

What is primary vs. secondary amenorrhea? What are some possible causes?

Answer 29

• Primary: no menses by age 16
  
  • Causes: anatomic or genetic
• Secondary amenorrhea: cessation of periods after they have been established
  
  • Causes: low body weight, pregnancy, lactation, menopause, stress, eating disorders, excessive exercise

Question 30

What are some physical signs of sexual abuse in the pediatric patient? (Strong - 6, Possible - 7)

Answer 30

• Strong
  
  • Lacerations
  • Ecchymoses
  • Newly healed scars on hymen
  • Lack of hymenal tissue from 3-9 o clock while supine
  • Healed hymenal transections
  • Perianal lacerations
• Possible
  
  • Marked and immediate dilatation of the anus
  • Hymenal notch or cleft that extends >50% of the inferior hymenal rim
  • Condyloma acuminata in a child older than 3 yrs
  • Bruising, abrasions, lacerations or bite marks of labia or perihymenal tissue
  • Herpes of the anogenital area beyond the neonatal period
  • Purulent or malodorous discharge
  • Herpetic lesions

Question 31

What are some causes of vaginal discharge in the pediatric patient?

Answer 31

• Vaginal discharge in early childhood can be from perineal irritation, foreign body, nonspecific vulvovaginitis, candida, pinworms, STI
• Purulent, profuse, malodorous and blood-tinged discharge should be evaluated for the presence of infection, foreign body and trauma
• Finding of vaginal bleeding should be worrisome and warrants further eval

Question 32

What are the current recommendations for prostate cancer screening?

Answer 32

• USPSTF: screen from age 55-69 with PSA
• ACS
  
  • Average risk start at 50 years; high-risk start at 40-45 years
  • Stop offering when life expectancy is less than 10 years
  • PSA, optional digital rectal examination
  • Annual, biennial when PSA <2.5
  • Biopsy referral criteria: PSA >4, abnormal DRE, individualized risk assessment for PSA levels 2.5-4
• AUA
  
  • Average risk start at 55; high risk start at 40
  • Stop offering when life expectancy is less than 10 years
  • PSA, optional digital rectal exam
  • Every 2 years
  • No specific PSA level, consider using biomarkers, imaging and risk calculators to inform biopsy decisions

Question 33

What is a normal PSA level? What is considered abnormal?

Answer 33

1-1.5

4 is considered abnormal

Question 34

What history and exam findings are consistent with a normal prostate gland, prostatitis, benign prostatic hyperplasia, and prostate cancer?

Answer 34

• Normal prostate: rounded, heart-shaped structure approximately 2.5cm long; median sulcus can be palpated between the two lateral lobes, posterior surface palpable, anterior and central lesions are not detectable by physical exam as they are not in contact with the rectal wall
• Prostatitis
  
  • Acute: fever and urinary tract symptoms (frequency, urgency, dysuria, incomplete voiding), sometimes low back pain; gland feels tender, swollen, “boggy,” and warm; typically caused by e. coli and enterococcus and proteus; consider n. gonorrhea and chlamydia trachomatis
  • Chronic: recurrent UTIs, dysuria or mild pelvic pain, prostate may feel normal, without tenderness or swelling; cultures usually demonstrate infection with e.coli
• BPH: nonmalignant enlargement of the prostate gland that increases with age; symptoms may be irritative (urgency, frequency, nocturia), obstructive (decreased stream, incomplete emptying, straining) or both; may feel normal in size or may be symmetrically enlarged, smooth and firm, slightly elastic; may be obliteration of the median sulcus and notable protrusion into the rectal lumen
• Prostate cancer: suggested by an area of hardness in the gland, may feel irregular and extend beyond the confines of the gland; median sulcus may be obscured

Question 35

What are the current colorectal screening guidelines?

Answer 35

• Screen from ages 50-75
• Stool-based tests
  
  • FIT annually
  • Fecal occult blood testing annually
  • FIT DNA every 1 or 3 years
• direct visualization tests
  
  • Colonoscopy every 10
  • Sigmoidoscopy every 5
  • Flexible sigmoidoscopy every 10 with FIT every 3
• CT colonography every 5

Question 36

What history and exam findings would be consistent with internal hemorrhoids, external hemorrhoids and a prolapsed rectum?

Answer 36

• Internal hemorrhoids: enlargements of the normal vascular cushions located above the pectinate line, usually not palpable; may cause bright-red bleeding, especially during defecation; may prolapse through the anal canal - appear as a reddish, moist, protruding mass
• External hemorrhoids: dilated hemorrhoidal veins that originate below the pectinate line that are covered with skin, seldom produce symptoms unless thrombosis occurs
  
  • Thrombosis causes acute local pain that increases with defecation and sitting; tender, swollen, bluish, ovoid mass is visible at the anal margin
• Prolapsed rectum: on straining for a bowel movement, the rectal mucosa may prolapse through the anus, telescoping through the anal verge
  
  • Prolapse involving only mucosa is relatively small and shows radiating folds
  • Entire bowel wall involvement causes larger prolapse that is covered with concentrically circular folds

Question 37

Candidal vaginitis: what would be expected exam findings for discharge, associated symptosms vulva and vaginal mucosa and wet mounts?

Answer 37

Note: common in those who take antibiotics or oral steroids

Discharge: white and curdy, may be thin but typically thick, not as profuse as in trichomonal infection, no odor

Symptoms: pruritis, vaginal soreness, pain on urination, dyspareunia

Vulva and vaginal mucosa: vulva and surrounding skin often inflamed and sometimes swollen to a variable extent; vaginal mucosa often reddened with white tenacious patches of discharge, mucosa may bleed when patches are scraped off, mild cases mucosa may look normal

Wet mounts: scan potassium hydroxide (KOH) preparation for the branching hyphae of candida

Question 38

Bacterial vaginosis: what would be expected exam findings for discharge, associated symptosms vulva and vaginal mucosa and wet mounts?

Answer 38

Discharge: small amount of grey or white, thin, homogenous, malodorous, coats the vaginal walls, usually not profuse, may be minimal

Symptoms: unpleasant fishy or musty genital odor, reported to occur after intercourse

Vulva and vaginal mucosa: usually appear normal

Wet mounts: scan saline wet mount for clue cells, sniff for fishy odor after applying KOH, test the vaginal secretions for pH >4.5