Assessment: Assessing Male Genitalia and Rectum

The nurse is palpating the prostate of a 55-year-old client and finds it to be enlarged, smooth, firm, and slightly elastic, without a median sulcus. Which condition should the nurse most suspect?

Benign prostatic hypertrophy Explanation: The prostate is normally nontender and rubbery. A swollen and tender prostate may indicate acute prostatitis. An enlarged smooth, firm, slightly elastic prostate that may not have a median sulcus suggests benign prostatic hypertrophy. This condition is common in men older than 50 years. A hard area on the prostate or hard, fixed, irregular nodules on the prostate suggest cancer. Hydrocele is a painless swelling of the scrotum.

A 68-year-old man comes to the clinic reporting that he is having difficulty obtaining an erection. When reviewing the client's history what might the nurse note that contributes to impotence?

History of hypertension Explanation: Past history of infection, lack of exercise, and use of vitamins do not contribute to impotence. Vascular problems cause about half the cases of impotence in men older than 50 years.

Which of the following should nurses teach all men, especially those who have had cryptorchidism?

How to perform a testicular self-examination. Explanation: The nurses should teach all men, especially those who have had cryptorchidism, to perform testicular self-examination to detect any abnormal mass in the scrotum. The nurse instructs the clients to examine the testicles monthly, preferably when warm, such as in the shower. Having regular PSA levels, lymph node biopsies, and blood tests for measuring serum acid phosphatase are for the clients who are treated for prostate cancer.

Symptoms of prostate disorder include which of the following?

Incomplete emptying, nocturia, weak urinary stream Explanation: Men with prostate disease commonly experience incomplete bladder emptying, frequent voiding at night, and a weak urine flow. Decreased urination and daytime polyuria would be less likely to accompany a prostate disorder.

A client comes to the Emergency Department complaining of sudden sharp testicular pain. Further examination reveals torsion of the spermatic cord. Which of the following would the nurse expect to do next?

Prepare the client for surgery. Explanation: For the client with torsion, immediate surgery is necessary to prevent atrophy of the spermatic cord and preserve fertility. Analgesics would be given preoperatively. Postoperatively, a scrotal support is applied and dressings are inspected for drainage. Circumcision is done to relieve phimosis or paraphimosis.

On inspecting a client's external genitalia, a nurse notes that he is uncircumcised. This means that which of the following covers the glans of the penis?

Prepuce Explanation: If the man has not been circumcised, a hood-like fold of skin called the foreskin, or prepuce, covers the glans. In the center of the corpus spongiosum is the urethra, which travels through the shaft and opens as a slit at the tip of the glans as the urethral meatus. The shaft of the penis is composed of three cylindrical masses of vascular erectile tissue that are bound together by fibrous tissue—two corpora cavernosa on the dorsal side and the corpus spongiosum on the ventral side.

On palpation of a client's prostate, a nurse detects hard, fixed, and irregular nodules on the prostate. Which condition should the nurse most suspect in this client?

Prostate cancer Explanation: The prostate is normally nontender and rubbery. A swollen and tender prostate may indicate acute prostatitis. An enlarged smooth, firm, slightly elastic prostate that may not have a median sulcus suggests benign prostatic hypertrophy. A hard area on the prostate or hard, fixed, irregular nodules on the prostate suggest cancer. Hydrocele is a painless swelling of the scrotum.

Mr. Jackson, 50 years old, has had discomfort between his scrotum and anus. He also has had some fevers and dysuria. Rectal examination is halted by tenderness anteriorly, but no frank mass is palpable. What is the most likely diagnosis?

Prostatitis Explanation: This examination, associated with a history of dysuria, frequency, and incomplete voiding, should lead to a suspicion of acute prostatitis. Prostate cancer, colon cancer, and polyps should not ordinarily cause systemic symptoms such as fever.

An adult male client comes to the clinic complaining of awakening at night to void and voiding more than once in a 2-hour time period. The client has a history of bladder irritation. What would be an appropriate nursing diagnosis for this client?

Risk for urge incontinence Explanation: The most appropriate nursing diagnosis is risk for urge incontinence related to irritation of bladder. Risk factors for this diagnosis are voiding more than once every 2 hours and awakening at night. urinary retention would be a concern if the client was unable to urinate, or urinated frequently with only small amounts of urine voided. Frequent urination at night is not a risk for infection. The symptoms noted are not related to ineffective sexuality pattern.

A 29-year-old married computer programmer comes to the clinic complaining of "something strange" going on in his scrotum. Last month while he was doing his self-testicular examination he felt a lump in his left testis. He waited a month and felt the area again but the lump was still there. He has had some aching in his left testis but denies any pain with urination or sexual intercourse. He denies any fever, malaise, or night sweats. His past medical history consists of groin surgery when he was a baby and a tonsillectomy as a teenager. He eats a healthy diet and works out at the gym five times a week. He denies any tobacco or illegal drugs and drinks alcohol occasionally. His parents are both healthy. Examination shows a muscular healthy young man with unremarkable vital signs. On visualization the penis is circumcised with no lesions; there is a scar in his right inguinal region. There is no lymphadenopathy. Palpation of his scrotum is unremarkable on the right but has a large mass on the left. While placing a finger through the inguinal ring on the right, the examiner asks the client to bear down. Nothing is felt. The examiner attempts to place a finger through the left inguinal ring but cannot get above the mass. On rectal examination the client's prostate is unremarkable. What disorder of the testes is most likely?

Scrotal hernia Explanation: Scrotal hernias occur when the small intestine passes through a weak spot of the inguinal ring. The examiner cannot get a finger above the hernia into the ring. Hernias are often caused by increased abdominal pressure such as in weight lifting. Clients who have a hernia on one side often have another hernia on the opposite side.

A teenager presents at the ER with severe scrotal and abdominal pain, vomiting, and nausea. He tells the nurse that he participated in a polar bear plunge in his community (jumping into cold water off-season). What conditions would the nurse suspect?

Torsion of the spermatic cord Explanation: Symptoms of torsion of the spermatic cord include an acute onset of sudden severe scrotal pain, vomiting, abdominal pain, and nausea. Extreme cold, such as with jumping into very cold water, may cause torsion. With hydrocele, the scrotum enlarges; pain and swelling may be present. However, the client with a hydrocele is often asymptomatic. In a client with phimosis, the foreskin becomes so tight that it will not retract over the glans penis. Varicocele can cause pain in the testicle or pain radiating to the other side. Symptoms of varicocele include swelling and a nagging dull pain in the scrotum.

The nurse suspects that a male client may have a hernia. The nurse should further assess the client for

bowel sounds at the bulge. Explanation: Bowel sounds auscultated over the mass indicate the presence of bowel and thus a scrotal hernia.

The Cowper glands

empty into the urethra. Explanation: The Cowper's (or bulbourethral) glands are mucus-producing, pea-sized organs located posterior to the prostate gland. These glands surround and empty into the urethra.

The nurse notes that a male client's scrotal sac is documented as being "normal." What should the nurse expect to assess in this client? Select all that apply.

Rugated Thin skin Few strands of hair Color darker than the penis For a scrotal sac to be considered "normal," the skin should appear thin and rugated. There will be few strands of hair and the color of the skin is darker than the penis. Lesions on the scrotal sac indicate an infection and would not be considered "normal."

A young man feels something in his scrotum and comes to you for clarification. On your examination, you feel what feels like a "bag of worms" in the left scrotum, superior to the testicles. Which of the following is most likely?

Varicocele Explanation: Varicoceles are common in normal men. They are often found in the left scrotum or bilaterally and should normally resolve in the supine position. This is because they represent varicosities within the scrotum. These require further investigation if they occur only on the right side or do not resolve in the supine position. They can contribute to infertility because the testicles are unable to achieve a cool enough temperature for sperm production due to increased blood flow from the varicocele. A hydrocele would be a painless mass on the spermatic cord and the vas deferens is palpated as part of the spermatic cord. You should lightly pinch the scrotum medially and move laterally until you feel the spermatic cord pass between your fingers.

While reviewing the medical record before examining a male clinic client, the nurse notes that the urinary meatus is located on the top of the glans of the penis. The nurse understands the correct term for this congenital defect is

epispadias

A male client has a distinctive bulge in the right inguinal area when standing. What should the nurse suspect is occurring with this client?

hernia Explanation: A noticeable bulge in the inguinal area when standing strongly suggests that the male client has a hernia. Hypospadias is a displacement of the urinary meatus. Testicular torsion would be suspected if the scrotum were edematous and painful. An epidermoid cyst is a painless mobile mass in the scrotum. It would not be observed while the client is standing.

What information should nurse include in the teaching plan for a client considering a vasectomy?

offers permanent birth control Explanation: Vasectomy is a method of permanent birth control which results in decreased, not increased, amounts of ejaculate. Vasectomy offers no protection from sexually transmitted infections (STIs). Prostatectomy, not vasectomy, causes urinary incontinence.

A male client tells the nurse that he has received a diagnosis of hernia. He visits the clinic because he is nauseated and has extreme tenderness on the left side. The nurse should

refer the client to an emergency room. Explanation: A hernia is strangulated when its blood supply is cut off. The client typically complains of extreme tenderness and nausea. If you suspect that the client has a strangulated hernia, refer the client immediately to the physician and prepare him for surgery.

The testes in the male scrotum are

suspended by the spermatic cord. Explanation: The testes are suspended in the scrotum by a spermatic cord.

A 25-year-old client asks the nurse how often he should have a testicular examination. After instructing the client about the American Cancer Society's guidelines, the nurse determines that the client has understood the instructions when he says he should have a testicular examination every

3 years. Explanation: Most physicians agree that an examination of a man's testicles should be part of the general physical examination. The ACS recommends a testicular exam as part of a routine cancer-related check-up.

Which client should a nurse recognize has the highest risk to develop prostate cancer?

65-year-old Caucasian male whose father had prostate cancer at age 55 Explanation: Age, African American race, and having a bother or father who was diagnosed with prostate cancer before the age of 60 are the greatest risk factors. Therefore, the older male with a first-degree relative has the highest risk.

Which of the following recommendations should the nurse provide to clients in an effort to reduce their risk of developing colorectal cancer?

A high-fiber diet coupled with regular exercise Explanation: High fiber intake, exercise, moderate alcohol use, smoking cessation, low fat intake, and maintaining a healthy body weight can prevent colon cancer.

A nurse is caring for a client with prostatitis. The nurse knows that what nursing care measure will be employed when caring for this client?

Administer the prescribed dose of antibiotics Explanation: The nurse should administer the prescribed dose of antibiotics when caring for the client. Sitz bath procedures can be provided to relieve the condition. The nurse should encourage the client to increase his fluid intake to flush bacteria out of the bladder. The client can use the prescribed dose of stool softeners to prevent constipation.

What ethnic group has a significantly higher incidence rate of prostate cancer?

African American Explanation: For undetermined reasons, incidence rates are significantly higher in African American men than in Caucasian men: 232 cases per 100,000 compared with 146 cases per 100,000, even after adjustments for access to care. Prostate cancer occurs at an earlier age and more advanced stage in African American men.

Which of the following groups has the highest incidence of prostate cancer?

African American men Explanation: African American men have the highest incidence of prostate cancer—two to three times higher than Caucasian men.

A tender painful swelling of the scrotum should suggest which of the following?

Any of the above Explanation: A tender, painful, swelling of the scrotum can be a medical emergency. All of these conditions should be considered as well as acute orchitis.

A client has undergone a digital rectal examination. This assessment will allow the clinician to diagnose which of the following?

BPH Explanation: A rubbery or boggy glandular consistency may indicate BPH, a common finding in men older than 60 years of age. The gland may feel soft, tender, and boggy from infection.

When assessing a client during the physical examination of the genitalia, the nurse palpates the scrotal contents. Which finding should the nurse recognize as an indication that an infection or cysts are present?

Beaded or thickened cord Explanation: A beaded or thickened cord indicates infection or cysts. The presence of palpable and tortuous veins indicates varicocele. A smooth, nontender, and rope-like cord is a normal finding. In most men, one testicle hangs lower than the other; in 65% of males, the left hangs lower than the right.

A 60-year-old coach comes to the clinic complaining of difficulty starting to urinate for the last several months. He believes the problem is steadily getting worse. When asked he says he has a very weak stream, and it feels like it takes 10 minutes to empty his bladder. He also has the urge to go to the bathroom more often than he used to. He denies any blood or sediment in his urine and any pain with urination. He has had no fever, weight gain, weight loss, or night sweats. His medical history includes type 2 diabetes and high blood pressure treated with medications. He does not smoke but drinks a six pack of beer weekly. He has been married for 35 years. His mother died of a myocardial infarction in her 70s, and the client's father is currently in his 80s with high blood pressure and arthritis. Examination reveals a mildly obese alert and cooperative man. His blood pressure is 130/70 with a heart rate of 80. He is afebrile, and his cardiac, lung, and abdominal examinations are normal. Visualization of the anus shows no inflammation, masses, or fissures. Digital rectal examination reveals a smooth, enlarged prostate. No discrete masses are felt. There is no blood on the glove. An analysis of the urine shows no red blood cells, white blood cells, or bacteria. What disorder of the anus, rectum, or prostate is most likely?

Benign prostatic hyperplasia (BPH) Explanation: BPH becomes more prevalent during the fifth decade and is often associated with hesitancy in starting a stream, decreased strength of stream, nocturia, and leaking of urine. On examination an enlarged, symmetrical, firm prostate is palpated. The anterior lobe cannot be felt. These clients may also develop UTIs secondary to their obstruction.

A nurse examining a client's external genitalia notices that his scrotum and testes draw up and he shivers. This phenomenon is known as which of the following?

Cremasteric reflex Explanation: The scrotum can maintain temperature control because the cremaster muscle is sensitive to changes in temperature. The muscle contracts when too cold, raising the scrotum and testes upward toward the body for warmth (cremasteric reflex). This accounts for the wrinkled appearance of the scrotal skin. The patellar reflex occurs when a physician strikes the patellar tendon of the knee and the leg jerks. The rooting reflex occurs in infants when they turn their heads toward anything that strokes the cheek or mouth. The vasovagal reflex is a contraction of muscles in the gastrointestinal tract in response to distension of the tract following consumption of food and drink.

A nurse examines the external genitalia of a client and observes that the scrotum is underdeveloped and the testis cannot be palpated. How should the nurse document this condition?

Cryptorchidism Explanation: The nurse should document this condition as cryptorchidism, a condition in which the scrotum appears underdeveloped and the testis cannot be palpated. Cryptorchidism is the failure of one or both testicles to descend into the scrotum. Orchitis is the inflammation of the testes, associated frequently with mumps; the scrotum appears enlarged and reddened. Epididymitis is an infection of the epididymis; the scrotum appears enlarged, reddened, and swollen, and a tender epididymis is palpated. Hydrocele appears as a swelling in the scrotum and is usually painless.

Which of the following recommendations would a nurse advocate during infancy and childhood to help reduce potential adult complications such as orchitis?

Ensure immunizations against infectious diseases such as mumps. Explanation: Nurses should advocate for infant and childhood immunizations against infectious diseases such as mumps to reduce potential adult complications such as orchitis. Minimizing activities involving heavy lifting or urging limited intake of caffeine have no effect on the potential for adult complications such as orchitis. The nurse should encourage foods that are low in fat and starch; however, this also would have no effect on the potential for orchitis.

A nurse examines the anal area of a client and observes the presence of a varicose vein. How should the nurse document this finding?

External hemorrhoid Explanation: Hemorrhoids are usually painless papules caused by varicose veins, either external or internal. If the hemorrhoid becomes thrombosed is can become painful and swollen. A perianal abscess is a cavity of pus caused by infection in the skin around the anal opening. An anal fissure is a split in the tissue of the anal canal caused by trauma. An anorectal fistula is a small, round opening in the skin that surrounds the anal opening. It suggests an inflammatory tract from the anus or rectum out to the skin.

Upon inspection and palpation of the front of the client's thigh, the nurse discovers a bulge that appears when the client coughs. The nurse should document this finding as which type of hernia?

Femoral Explanation: A bulge or mass on the front of the thigh in the femoral canal area is a femoral hernia. A hernia is strangulated if the blood supply is cut off. In this case, the client typically complains of extreme tenderness and nausea. A scrotal mass that remains when the client lies down and over which bowel sounds can be auscultated is a scrotal hernia. If the mass in the scrotum cannot be pushed into the abdomen, it could be an incarcerated hernia.

The intestines of a 32-year-old male weightlifter are palpable in his scrotum. The hernia originates above the client's inguinal ligament. Which of the following hernias can the nurse rule out first?

Femoral Explanation: A femoral hernia never protrudes into the scrotum and originates below the inguinal ligament. Inguinal hernias may protrude into the scrotum, though more commonly in cases of indirect inguinal hernias. Scrotal hernias are not a recognized category.

An Advanced Practice Nurse is preparing to do a rectal examination on a 77-year-old client. The client complains of pain as soon as the examination begins. What might this client have?

Fissures Explanation: Anorectal fissure is a rip in the anal mucosa; it can occur midline or posterior or anterior to the anus. Usually, a fissure is caused by the passage of large hard stool. On observation, a sentinel skin tag may be seen at the lower end of the fissure. Ulcerations may appear at the site. The client has bleeding, pain, and itching. Because the internal sphincter is spastic, anesthesia of the site is necessary for examination.

A client presents to the health care clinic with reports of clay-colored stool. The nurse recognizes that this finding is most likely a result of which of the following?

Lack of bile pigment Explanation: Clay-colored stool results from the lack of bile pigment. Black stools may indicate gastrointestinal bleeding in this client who has not been receiving iron supplements or taking Pepto-Bismol. Yellow stool suggests increased fat content or steatorrhea. Cancer of the rectum or colon may be indicated by blood detected in the stool.

An uncircumcised, 78 year-old male has presented at the clinic complaining that he cannot retract his foreskin over his glans. On examination it is noted that the foreskin is very constricted. What is this condition called?

Phimosis Explanation: Phimosis is the term used to describe a condition in which the foreskin is constricted so it cannot be retracted over the glans. Bowen's disease is an in situ carcinoma of the penis. Peyronie's disease is an acquired, benign condition that involves the buildup of fibrous plaques in the sheath of the corpus cavernosum. Priapism is an uncontrolled, persistent erection of the penis from either neural or vascular causes, including medications, sickle cell thrombosis, leukemic cell infiltration, spinal cord tumors, and tumor invasion of the penis or its vessels.

During the physical examination of the genitalia for an uncircumcised client, the nurse asks the client to retract the foreskin of the penis. The nurse observes that the foreskin is tight and cannot be retracted. How should the nurse document this condition?

Phimosis Explanation: This condition should be documented as phimosis; wherein, the client's foreskin is so tight that it cannot be retracted. A foreskin that once retracted and can not be returned to cover the glans is called paraphimosis. Epispadias is the displacement of the urinary meatus to the dorsal surface of the penis. Hypospadias is the displacement of the urinary meatus to the ventral surface of the penis.

A nurse prepares a male client for a physical assessment of the external genitalia. Which instruction is appropriate for the nurse to give the client before the examination?

Reassure him that it is not unusual to have an erection during the examination Explanation: The nurse should reassure the client that it is not unusual to have an erection during the examination; this will avoid unnecessary embarrassment in the client. The nurse should ask the client to empty the bladder before the examination so that he will be comfortable during the examination. The client should be informed that he may need to stand for most of the examination. The nurse should encourage the client to ask questions during the examination, and, at the same time, ease the client's anxiety by explaining in detail the significance of each portion of the examination.

A client reports the new onset of mucous in the stool. How should the nurse document this in the client's history?

Steatorrhea Explanation: The proper term for mucus in the stool is steatorrhea, which indicates the presence of excessive fat in the stool. Diarrhea is an increase in the frequency of loose stool. Change in bowel habits is not specific to the problem the client reported. Fecal incontinence is the inappropriate release or inability to control the bowels.

During the assessment of a client, the nurse recognizes that which of the client's lifestyle practices may predispose to the development of an inguinal hernia?

Strenuous activity Explanation: Strenuous activity and heavy lifting may predispose a client to the development of an inguinal hernia. Exposure to radiation and certain chemicals increases the risk of developing cancer. Erectile dysfunction occurs frequently in adult males and may be attributed to various factors, some of which include the use of alcohol, diabetes, or depression. Fear can cause stress and inhibition and decrease sexual satisfaction.

A client presents at the clinic with severe scrotal pain. What is the presumptive diagnosis?

Testicular torsion Explanation: Any client with scrotal pain should be presumed to have testicular torsion until another diagnosis can be proven.

A 15-year-old high school football player comes to the office with his mother. He complains of severe testicular pain since 8:00 this morning. He denies any sexual activity and states that it hurts so bad he can't even urinate. He is nauseated and vomiting. He denies any recent illness or fever. Past medical history is unremarkable. He denies any tobacco, alcohol, or drug use. His parents are both in good health. Examination shows a young teenager lying on the bed with an emesis basin. He is very uncomfortable and keeps shifting his position. Blood pressure is 150/100, pulse is 110, and respirations are 24. On visualization of the penis he is circumcised; there are no lesions or discharge from the meatus. Scrotal skin is tense and red. Palpation of the left testicle causes severe pain and causes the client to cry. His prostate examination is unremarkable. His cremasteric reflex on the left is absent but normal on the right. Catheterization is necessary to get a urine sample, the analysis of which is unremarkable. The boy is admitted to the emergency department of a nearby hospital for further workup. What is the most likely cause of this young man's symptoms?

Torsion of the spermatic cord Explanation: Torsion is caused by twisting of the testicle on its spermatic cord and blood vessels, leading to severe pain. The scrotum becomes red and tense. Torsion is usually seen in adolescents and is a true surgical emergency. If not quickly surgically repaired, the testicle's function is lost and it has to be removed. Presence of a cremasteric reflex is reassuring, but in this case a thorough evaluation must take place as soon as possible.

A 23 year old male comes to the clinic complaining of sudden and severe pain in his scrotum. The nurse would suspect what?

Torsion of the spermatic cord Explanation: Torsion of the spermatic cord is usually accompanied by a sudden, severe pain of the scrotum and is a urological emergency. A spermatocele is a sperm-filled cystic mass located on the epididymis. Orchitis is inflammation of the testes. A varicocele is an abnormal dilation of veins in the spermatic cord.

During assessment of the genitalia of an adult male, the client has an erection. The nurse should

continue the examination in an unhurried manner. Explanation: Examiners and the client are often worried that the male client will have an erection during the hands-on examination. Usually the client is too nervous for this to occur. If it does occur, reassure the client that it is not unusual and continue the examination in an unhurried and calm manner.

During assessment of an elderly male client, the client tells the nurse that he has had difficulty urinating for the past few weeks. The nurse should refer the client to the physician for possible

prostate enlargement. Explanation: Difficulty urinating may indicate an infection or blockage, including prostatic enlargement.