Chapter 25 Male GU

Tinea Cruris

A fungal infection in the crural fold, not extending to scrotum, occurring in postpubertal males ("jock itch") after sweating or wearing layers of occlusive clothing. It forms a red-brown half-moon shape with well-defined borders.

Genital Herpes (HSV-2 Infection

Clusters of small vesicles with surrounding erythema, which are often painful and erupt on the glans, foreskin, or anus. These rupture to form superficial ulcers. May have mild tingling before outbreak or shooting pain in buttock or leg. A STI, the initial infection lasts 7 to 10 days and is treated with oral acyclovir. The virus remains dormant indefinitely; recurrent infections last 3 to 10 days with milder symptoms.

Hypospadias

Congenital defect in which the urethra opens on the underside of the penis

MSM

Men having sex with men

Syphilitic Chancre

Small solitary silvery papule that erodes to a red round or oval superficial ulcer with a yellowish serous discharge

Scrotal Hernia

Usually an indirect inguinal hernia, that comes through the external inguinal ring, so the examining fingers cannot get above it within the scrotum.

Varicocele

Varicosity of the pampiniform plexus of the spermatic cord, forming a scrotal swelling that feels like a "bag of worms"

Penis

composed of three cylindric columns of erectile tissue. Two corpora cavernosa on the dorsal side and the corpus spongiosum ventrally.

3 degrees below the Abdomen

ideal temperature for sperm production in males

Testicular Torsion

twisting of the spermatic cord causing decreased blood flow to the testis

additional hx for aging adult

- Any difficulty urinating? Hesitancy or straining? - Do you ever leak water/urine when you don't want to? - Do you need to get up at night to urinate? -What medications are you taking? - Is it alright to ask about your sexual function? - Any changes in ability to have an erection?

Assess Urinary Function

- Color should be pale yellow to amber - Should be clear - pH range 4.5-8 - Specific gravity

Subjective Data Questions

- Do you urinate more often than usual? - Feel as if you can not wait to urinate? - Any pain or burning when you urinate? - Is your urine clear or discolored? - Hx of kidney disease, stones, flank pain, UTI's or prostate trouble? - Any problems with the penis like pain or lesions? - Are you sexually active? One partner? Multiple partners? Do you use protection? What is your sexual preference?

additional hx for infants and children

- Does your child have any problems urinating? - Any problems with child's penis or scrotum? - Do not retract the foreskin forcibly it will retract on its own when the child has a spontaneous erection then have him clean the glans gently - Ask the child directly if anyone has ever touched their penis or in between their legs and you did not want them to?

Aging Male

-amount of pubic hair decreases -remaining pubic hair turns gray -penis size decreases -scrotal contents hang lower due to decreased tone of DARTOS MUSCLE -rugae of scrotum decrease, scrotum looks pendulous -testes decrease in size and less firm to palpation -increased connective tissue present in tubules, so become thickened and produce less sperm -declined testosterone

Self-Care- Testicular Self-Examination (TSE)

-encourage self-care -teach every male (age 13/14-adulthood) -testicular cancer is still rare, but most common in young men 15-40 -conduct TSE monthly -Undescended testicles are most at risk -tumor has no early symptoms -if detected early by palpation and treated, cure is almost 100% -early detection enhanced if male is familiar with normal consistency

Inspect and Palpate the Scrotum

-inspect scrotum as male holds penis out of the way -OR you may hold the penis out of the way with the back of your hand -scrotal size varies with room temperature -ASYMMETRY is normal, L scrotal half usually lower -spread rugae out between your fingers -lift sac to inspect posterior surface - should be free of lesions; common for sebaceous cysts to be found - testes should feel oval, firm and rubbery, smooth, and equal bilaterally, freely moveable and slightly tender to moderate pressure

palpate inguinal lymph nodes

-palpate the horizontal chain along the groin inferior to the inguinal ligament -palpate the vertical chain along the upper inner thigh -normal to palpate an isolated node on occasion, it then feels small (<1cm), soft, discrete, moveable -do not use the old direction of "turn your head and cough" bc it does not produce the steady increased, intraabdominal pressure you need, and person is likely to cough right in your face

Inspect and Palpate the Penis

-skin normally looks wrinkled, hairless -dorsal vein may be apparent -glans smooth w/o lesions -ask uncircumcised male to retract foreskin or you retract it... it should move easily. slide foreskin back to original position after inspection - at base of penis, pubic hair distribution is consistent with age and should be free of pest inhabitants (crabs) - Urethral meatus is positioned just about centrally

Inspect and Palpate for Hernia

1. inspect the inguinal region for a bulge as the person stands and as he strains down. normally none is present 2. palpate the inguinal canal. for the right side, ask the male to shift his weight onto the left (unexamined) leg. place your right index finger low on the right scrotal half so you carry as much skin as possible. palmate up the length of the spermatic cord, invaginating the scrotal skin as you go, to the external inguinal ring. feels like a triangular slitlike opening. gently insert it into the canal and bear down normally feel no change 3. place your right hand upright on the mans upper thigh, remembering NAVAL (nerve, artery, vein, empty space, lymphatics). locate the femoral artery pulse, and the empty space will be under your 4th finger 4. ask man to bear down and palpate the femoral area for a bulge. normally shouldn't feel one

Epispadias

Congenital defect of males in which the urethra opens on the upper surface of the penis

Testosterone Production

Declines after age 30 but very gradually, so resulting physical changes are not evident until later in life

Glans

Distal end of the shaft of the corpus spongiosum that expands into a cone of erectile tissue

Diffuse Tumor

Enlarging testis, increased weight, does not transilluminate, nontender, maintains shape of testis

Vas Deferens

Lower part of the epididymis, a muscular duct that carries sperm from the epididymis to the urethra

MTF

Male transitioning to Female

Foreskin or Prepuce

Over the glans, the skin folds in and back on itself, forming a hood or flap

Urethral Stricture

Pinpoint, constricted opening at meatus or inside along urethra. Occurs congenitally or secondary to urethral injury. Gradual decrease in force and caliber of urine stream is most common symptom. Shaft feels indurated along ventral aspect at site of stricture.

Renal Calculi

Renal stones (crystals of calcium oxalate or uric acid) form in kidney tubules and then migrate and become urgent when they pass into ureter, become lodged, and obstruct urine flow. Cause abrupt severe flank pain with radiation to the groin or abdomen, nausea and vomiting, restlessness, gross or microscopic hematuria.

Paraphimosis

Retraction of a phimotic foreskin, causing swelling of the glans

Early Testicular Tumor

S: Painless, Found on examination O: Palpation - firm nodule or harder than normal section of testicle A: Solitary nodule

Genital Warts

Soft, pointed, moist fleshy, painless papules may be single or multiple in a cauliflower-like patch. Color may be gray, pale yellow, or pink in white males and black or translucent gray-black in black males. Occur on shaft of penis, behind corona, or around the anus where they may grow into large, grapelike clusters.

Corona

The shoulder where the glans joins the shaft

Urethra

a conduit for both genital and urinary systems. Transverses the corpus spongiosum, and its meatus forms a slit at the glans tip

Spermatocele

a cyst that develops in the epididymis and is filled with a milky fluid containing sperm

Frenulum

a fold of the foreskin extending from the urethral meatus ventrally

Scrotum

a loose protective sac, which is a continuation of the abdominal wall

Epididymis

a markedly coiled duct system and the main storage site of sperm; (comma-shaped structure, curved over the top and posterior surface of the testis)

Priapism

a painful erection that lasts 4 hours or more but is not accompanied by sexual excitement

Inguinal Canal

a short canal passing through the abdominal wall in the region of the groin in males

Circumsision

an elective surgical procedure to remove all or part of the foreskin (prepuce) from the penis.

Spermatic Cord

ascends along the posterior border of the testis and runs through the tunnel of inguinal canal into the abdomen

additional hx for preadolescents and adolescents

ask questions that seem appropriate for the boy's age, but beware of norms and not to sound too judgmental. - Who can you talk to about your body changes? - How do those talks go? - Do you think you get enough information? - Have you ever had a wet dream? - Have you been taught how to do a self-exam? -Has anyone ever touched your genitals when you didn't want them to?

Hydrocele

circumscribed collection of serous fluid in tunica vaginalis surrounding testis.

Cremaster Muscle

controls the size of the scrotum by responding to ambient temperature. To keep the testes at 3degrees C below abdominal temperature ( The best temperature for producing sperm)

Peyronie Disease

disorder characterized by a buildup of hardened fibrous tissue in the corpus cavernosum, causing pain and a defective curvature of the penis, especially during erection

Lymphatics of the Penis

drain into inguinal lymph nodes

Ejaculatory Duct

duct formed by the union of the vas deferens with the duct of the seminal vesicle; its fluid is carried into the urethra

Acute Urinary Retention and Urinary Tract Infection

inability to pass urine with bladder distention and lower abdominal pain. Common in older men due to bladder outlet obstruction. Can cause UTI, owing to stasis and turbulent flow. UTI incidence increases among men ages >60 years and presents with dysuria, frequency, urgency, nocturia, suprapubic pain, occasionally gross hematuria, possibly fever. Treated with antibiotics

Urethritis

infection of the urethra that causes painful, burning urination or pruritus. Meatus edges are reddened, everted, and swollen with purulent discharge. Urine is cloudy with discharge and mucus shreds.

Femoral Canal

inferior to inguinal ligament

Epididymitis

inflammation of the epididymis that is frequently caused by the spread of infection from the urethra or the bladder; commonly caused by prostatitis

Orchitis

inflammation of the testes; can follow an injury or viral infection such as mumps

Nocturnal Emmsion

involuntary ejaculation also known as a wet dream

Nocturnal Enuresis

involuntary urination at night after age 5 to 6

Inguinal Ligament

ligament extending from pubic bone to anterior superior iliac spine, forming lower border of abdomen

Testis

male reproductive organ that produces sperm and hormones; (left testis is lower than the right because the left spermatic cord is longer)

Absent testis

may be a temporary migration or true cryptorchidism

Scrotal Swelling (edema)

may be taut and pitting occurs with heart failure, renal failure, or local inflammation

Adolescents

most current evidence suggests that signs of puberty in the US begin now at age 9 on average for black boys and age 10 for white and hispanics. First sign is enlargement of the testes, then pubic hair appears, and then the penis size increases

Gender Identity

never assume sexual orientation by feminine or masculine clothing, hairstyle, physical appearance, or sports preference. Adolescence is a time of sexual expression and experimentation and identity formation.

Adults and Aging Adults

older men do not experience a definite end to fertility like older women. Production of sperm starts to decrease around 40 y.o. although it continues into the 80's and 90's.

SMR in Boys

page 686 in the textbook

Infants

prenatally the testes develop in the abdominal cavity near the kidneys. During later months of gestation the testes migrate pushing the abdominal wall in front of them and dragging the vas deferens, blood vessels, and nerves behind. Descend along the inguinal canal into the scrotum before birth

Carcinoma

red, raised, warty growth or as an ulcer with watery discharge. As it grows, may necrose and slough. Usually painless, almost always on glans or inner lip of foreskin and following chronic inflammation. Enlarged lymph nodes are common.

Atrophied Testis

small and soft testis

Bladder Cancer

the 4th most common cause of cancer in men, with a higher incidence in white Americans than in black Americans.

Inguinal Area aka Groin

the juncture of the lower abdominal wall and the thigh. Diagonal borders are the anterior superior iliac spine and the symphysis pubis.

Transillumination

the passage of strong light through a body structure, to permit inspection by an observer on the opposite side

Rugae

thin skin lying in folds in the scrotal wall

Sexual Minority

those individuals who self-identify as gay if males; lesbian if females; bisexual when sexually attracted to both males and females; transgender when having an innate, deep-seated knowledge that their own orientation differs from their birth assignment.

Phimosis

tightening of the foreskin of the penis that may close the opening of the penis

cryptorchidism

undescended/hidden testicles; common in premature infants. Occur in 3% to 4% of term infants, although most have descended by 3 months of age.