What is the size range of normal testes?
3.5 to 5.5 cm
What covers each testis (except posteriorly)?
serious membrane of the tunic vaginalis
During ejaculation, the _________ transports sperm from the ________ to the urethra.
Where do lymphatics from penile and scrotal surfaces drain into? Where do lymphatics of the testes drain into?
- inguinal nodes
- abdomen (nodes are clinically undetectable)
Where are the landmarks to look for hernias?
- pubic tubercle
- inguinal ligament
Where are the external and internal inguinal rings located?
- external: just above & lateral to pubic tubercle (palpable)
- internal: approx 1 cm above the midpoint of the inguinal ligament (not palpable)
What produces inguinal hernias?
when loops of bowel force through weak areas of the inguinal canal
What route besides inguinal presents another potential for herniations to occur? How would you estimate the location?
- femoral canal (lies below the inguinal ligament)
- place your index finger on the right femoral artery, the next finger medially will overlie the femoral vein, and the finger after that will overly the femoral canal/empty space
What holds the anal canal closed?
- internal and external sphincters
- **it is liberally supplied with nerves unlike the rectum**
Serrated line marking change from skin to mucous membrane that demarcates the anal canal from the rectum.
How much does the prostate grow after puberty?
Where can you palpate the 2 lateral lobes of the prostate? What should it feel like?
- against the anterior wall of the rectal wall
- smooth with median sulcus
What is the approximate size of the prostate?
2.5 cm long
What part of the prostate is NOT palpable?
- median lobe
- seminal vesicles
What are some concerns about the male GU examination?
- pt often reticent about GU symptoms & sex history
- embarrassment can be a significant barrier
- pt has probably debated and practiced how to bring it up to you on interview
How can a provider overcome concerns in dealing with male pts that need a GU examination?
- maintain profession demeanor (dispels embarrassment, competence engenders trust)
- acknowledge pts bodily responses with a matter-of-fact manner
What is the systematic approach for performing a male GU exam?
- penis, testes, scrotal contents
- perineum, anus & rectum
What are some signs and symptoms of irritative voiding seen with inflammation associated with UTI, STD, or BPH?
- frequency: increased number of voids @ daytime
- urgency: sudden desire to void
- nocturia: nocturnal frequency
- dysuria: painful urination
What are some causes of hematuria?
- kidney stones
- cancer (bladder, kidney)
- excessive exercise
What are the symptoms of obstructive voiding?
- decreased force of stream
- post void dribbling
- double voiding
Tight prepuce that cannot be retracted over the glans.
Tight prepuce that, once retracted, cannot be returned.
Cheesy, whitish material that accumulates under the foreskin.
Inflammation of the glans.
What is looked at when inspecting the penis?
- maturity (tanner's)
- prepuce (retract to inspect)
- base (nits, lice, excoriations)
What are you looking for when inspecting the meatus during penis examination?
Congenital ventral displacement of the urethral meatus.
Congenital dorsal displacement of the urethral meatus.
epispadias (may be associated with incontinence, requiring surgical correction)
Discharge that suggests gonococcal urethritis (GU) or nongonococcal urethritis (NGU).
- **have a glass slide ready during exam for gram stain analysis**
What are you looking for when you palpate the penile shaft between thumb and fingers?
- induration (along ventral surface suggests urethral stricture/carcinoma)
- always replace foreskin before moving to scrotum
Small skin colored bumps that often form in rows around the glans, considered a normal anatomic variant, not contagious, and are asymptomatic. Considered harmless, they will decrease with age, but can last a lifetime.
pearly penile papules
Palpable, nontender, hard plaque(s) found beneath the skin, usually along the dorsum of the penis. Pt c/o crooked, painful erections, it affects middle-aged and older men.
Indurated nodule or ulcer on the penis that is usually nontender, and is limited almost completely to men who are not circumcised (can be masked by prepuce).
carcinoma of the penis (any PERSISTENT penile sore is suspicious)
Pruritic superficial fungal infection of the groin & adjacent skin.
tinea cruris (jock itch)
An infection of the major skin folds caused by Corynebacterium which shows a rash of coral red color under a Wood's light, and is KOH negative for hyphae.
What are you looking at when inspecting the scrotum and their contents?
What does a poorly developed scrotum on one or both sides suggest? What are common reasons for scrotal swelling?
- cryptochordism (undescended teste)
- indirect hernias, hydroceles, edema
Common, benign, dome-shaped, white or yellow papules or nodules formed by occluded follicles filled with keratin debris of desquamated follicular epithelium.
What do you palpate when examining the scrotum and its contents?
- each testis & epididymis between thumb & fingers
- epididymis should feel nodular & cordlike
- testis size, shape consistency, tenderness (feel for nodules, pressure on testis causes deep visceral pain, any painless nodule must raise concern for cancer)
- spermatic cord from epididymis to external ring
When using transillumination to examine scrotum and contents (except testis), what causes transmission of the light as a red glow and what does not?
- hydroceles transilluminate
- blood, tissue, testis, tumors, most hernias do not
Non tender, fluid-filled mass within the tunica vaginalis that transilluminates. Examining fingers can get above the mass within the scrotum.
Single/multiple papules or plaques of variable shapes. Raised, flat, or verrucous (cauliflower-like). Infected contact may not have any visible, and is most commonly asymptomatic (occasionally itchy & painful). What causes this condition?
- genital warts
- HPV (usually 6 or 11)
Small scattered or grouped vesicles 1-3 mm in size (erosions if vesicles have broken open), has an incubation period of 2-7 days. Primary episode may be asx, recurrent episodes are usually less painful & of shorter duration. May have associated fever, malaise, headache, arthralgias, local pain and edema, and lymphadenopathy.
genital herpes simplex (HSV2-90%)
Small red papule that becomes a chancre (painless erosion) up to 2 cm in diameter, base of chancre is clean, red, smooth with raised borders that heals withing 3-8 weeks. Has an incubation of 9-90 days, pt may have inguinal lymphadenopathy within 7 days.
primary syphilis (treponema pallidum)
Red papule or pustule initially, then forms painful deep ulcer with ragged non-indurated margins. Is caused by an anaerobic bacillus with incubation of 3-7 days. Painful inguinal LAD in approx 50% (M>F), nodes may be liquefied and present as fluctuant buboes.
Chancroid (haemophilus ducreyi)
Inflammation of the urethra with yellow discharge and irritative voiding symptoms.
gonococcal urethritis (GU); caused by gonorrhea
Inflammation of the urethra with clear discharge and irritative voiding symptoms.
nongonococcal urethritis (NGU); most commonly caused by chlamydia trachomatis
Testis are acutely inflamed, painful, tender, and swollen. May be difficult to distinguish from epididymitis, and is seen in mumps and other viral infections (usually unilateral).
A painless, movable cystic mass just above the testis that transilluminates and contains sperm.
What are some signs and symptoms of acute epididymitis?
- epididymis is tender and swollen, may be difficult to distinguish from testis
- scrotum may be reddened and the vas inflamed
- occurs mainly in adults
What side does a varicocele usually develop on? What other condition can a varicocele be associated with?
Why is a right sided varicocele more concerning than a left one?
may be due to vena cava obstruction by a tumor
What sign is described as a lack of relief of pain when the scrotum is elevated that supports dx of testicular torsion? What reflex is absent with torsion?
- Prehn's sign
- cremasteric reflex
You should encourage you pts to perform testicular self exams how often? What are the ages of particular concern due to the fact that testicular cancer is the most common for men in that group?
Pts should seek evaluation if a testicular self exam reveals what findings?
- painless lump, swelling/enlargement of testicle
- pain/discomfort of testicle/scrotum
- feeling of heaviness/sudden fluid collection in scrotum
What is the most common type of hernia?
indirect (bowel exits external inguinal ring, palpable with fingers but cannot get above it, can become trapped causing intestinal obstruction and gangrene)
Black tarry stools.
Red blood in stool/toilet.
When can you omitt the DRE on the male GU exam?
if pt is adolescent without risk factors
What are some things in a pts history you should know when examining the perineum, anus and rectum?
- changes in bowel habits
- family history of cancer/polyps
- pain with defecation, itching or bleeding
- voiding symptoms
What are the positions a pt can take up when getting a DRE?
- standing & leaning over exam table
- side-lying on exam table with knees & hips flexed (top leg flexed more)
What are you looking at when inspecting the perineum, anus and rectum?
- sacrococcygeal & perianal areas for lumps, ulcers, inflammation, rashes, excoriations (palpate abnormal areas)
- anus & rectum (w/ lubed, gloved finger)
If a pt is severely tender when trying to perform the DRE, do not force it. Instead what should you do?
- place fingers on both sides of anus & gently spread the orifice and have pt bear down
- look for lesions like a fissure that may explain tenderness
A linear crack/tear from large, hard stools, IBS or STDs.
A tender purulent, reddened mass on the anus or perineum with fever or chills usually accompanies what?
an anal ABSCESS
Abscess that tunnels to the skin surface from the anus or rectum.
Describe the technique for performing a DRE.
- insert finger into rectum as far as possible & rotate hand clock then counterclockwise to palpate as much rectal surface as possible
- note nodules, irregularities, indurations
- have pt bear down to bring lesion into reach
Dilated veins that originate below the dentate line and are covered with skin, seldom produce symptoms unless thrombosed (incr with defecation & sitting). Appears as a tender, swollen bluish, ovoid mass visible at the anal margin.
Enlargements of the normal vascular cushions location above the dentate line, not usually palpable or visible, are painless and sometimes (esp w/ defecation) may cause bright red bleeding. They may prolapse through the anal canal and appear as a reddish, moist, protruding mass.
Fairly common & located in the midline superficial to the cocys or lower sacrum. Look for opening of a sinus tract which may exhibit a small tuft of hair & be surrounded by a halo of erythema. Generally asymptomatic except for drainage. Abscess formation & infection become swollen, red, painful & tender.
pilonidal cysts & sinus
Felt as a sessile mass with nodular edges, a stony consistency, and irregular contour.
Pedunculated, usually more smooth, round and semi mobile masses.
Nonmalignant symmetrical enlargement of prostate gland that increases with age (50% at 50), may cause obliteration of the median sulcus.
benign prostatic hyperplasia (BPH)
What causes symptoms with BPH?
- smooth muscle contraction in the prostate & bladder neck
- compression of the urethra
What is suggested by an area of hardness on the prostate gland producing a distinct hard nodule that alters the contour of the gland?
cancer of the prostate (as it enlarges it feels irregular and may extend beyond confines of the gland, median sulcus may be obscured)
Presents with fever and urinary tract symptoms (freq, urgency, dysuria, incomplete void, low back pain), prostate gland feels tender, swollen, "boggy" and warm.
- acute bacterial prostatitis (most commonly caused by gram neg aerobes like E. coli, enterococcus and proteus)
- **consider STD in men <35 (gonorrhea/chlamydia)**
Associated with recurrent UTIs, usually from the same organism that ascends the urinary tract. May be asx or have symptoms of dysuria or mild pelvic pain. Prostate gland may feel normal, without tenderness or swelling. Cultures of prostatic fluid usually show infection w/ E. coli.
chronic bacterial prostatitis
What should do at the end of every exam?
- explain findings to the pt
- set up a follow up plan for pt (next physical, cancer screening)
- address pt concerns and understanding
What are the risk factors for developing prostate cancer?
- age: risk increases sharply w/ each decade after 50 yrs
- ethnicity: higher risk in african-american men and @ earlier age
- fam history
- diet: association w/ saturated fats and fats from animals
- PSA elevation?