PT CARE - Male Genetalia and Hernias

Inspection of the Penis: Prepuce

(if present, ask the patient to retract) Smegma, a cheesy, whitish material, may accumulate normally under the foreskin

Sexual preference and sexual response questions

Begin with a general question, such as "How is sexual function for you?" If there is a problem, direct questions help to assess each phase of the sexual response. Have you maintained interest in sex? (desire) Can you achieve and maintain an erection? (arousal) About how long does intercourse last? (orgasm and ejaculation)

Inspection of the Penis: skin

Check the skin around the base of the penis for excoriations or inflammation

Direct Inguinal Hernia

Less Common. More Common in women than men Above the inguinal ligament, close to the pubic tubercle (near the external inquinal ring) Rarely in the scrotum. Bulges anteriorly and pushes the side of the finger forward

Palpation of the Penis

Palpate any abnormality Note tenderness or induration

Health Promotion and Counseling

Prevention of STDs and HIV Testicular self-examination

Indirect Inguinal Hernia

- Most common in all ages, both sexes. Often in children, but can be in adults - Above inguinal ligament near it's midpoint (the internal inguinal inguinal ring - Often in the scrotum. The hernia comes down the inguinal canal and touches the fingertip.

Inspection of the Penis: Glans

- look for ulcers, scars, nodules, or signs of inflammation Note the location of the urethral meatus Compress the glans gently between your index finger above and thumb below to open the urethral meatus and allow inspection for discharge (normally there is none)

Risks: Ethnicity

- significantly higher in AA men than Caucasian men Prostate Cancer occurs at an earlier age and more advanced state in AA men In AA men with < 12 years of education the risk of death from prostate cancer doubles compared to white men

Risks: Age:

After 50 y/o risk of prostate cancer increases sharply with each advancing decade. White men 2.1% in ages 50-59 --> 8% after age 70. African American men it rises from 3.8% --> 11.2 %

Which of the following statements about hernias is true? a) Indirect inguinal hernias are the most common form of hernia b) Femoral hernias are the least common form and are more common in women c) Direct inguinal hernias are more common in men over age 40 d) Indirect inguinal hernias originate above the inguinal ligament near its midpoint e) All of the above

All of the above: Indirect inguinal hernias are the most common form of hernia Femoral hernias are the least common form and are more common in women Direct inguinal hernias are more common in men over age 40 Indirect inguinal hernias originate above the inguinal ligament near its midpoint

The male patient: Inspect the sacrococcygeal and perianal areas

Assess for lumps, ulcers, inflammation, rashes, or excoriations Palpate any abnormal areas, noting lumps or tenderness Occasionally, severe tenderness prevents entry and internal examination Instead, place your fingers on both sides of the anus, gently spread the orifice, and ask the patient to bear down Look for a lesion, such as an anal fissure, that might explain the tenderness

Health HistoryCommon or Concerning Symptoms

Change in bowel habits - Pencil thin like stools can be a sign of cancer Blood in the stool (hematochezia) - Melena- black tarry stools - Sign of polyps, cancer, hemorrhoids, or GI bleeding. Mucus can be a sign of villous adenoma. Pain with defecation (Tenesmus) rectal bleeding or tenderness - Rectal abscess or hemorrhoids - Proctitis can be caused by gonorrhea, chlamydia, lymphogranuloma, anal intercourse, Anal warts or fissures - Fissures can be a sign of proctitis or Chron's - feels like "someone tearing me w glass" Itching - In younger patients may be pinworms Weak stream of urine - BPH (enlarged prostate) Burning upon urination (dysuria) - Infection

Sexual History

Explain why you are taking the sexual history This information is highly personal, so encourage the patient to be open and direct Assure the patient that you gather a sexual history on all patients Affirm that your conversation is confidential

Testicular Self Exam

How often do you recommend your patients do it? 1x/month Under what age is it most common? Why? - most common cancer in men between the ages of 15 and 34 (bc of more testosterone) USPSTF- Grade D recommendation ACS- As part of a regular check up with the patient participating in self exams (does not state how often)

The male patient: Examine the posterior surface of the prostate gland

Identify lateral lobes and median sulcus Note size, shape, and consistency of the prostate; identify any nodules or tenderness Normal prostate is rubbery and nontender If possible, extend your finger above the prostate to the region of the seminal vesicles and the peritoneal cavity; note any nodules or tenderness Note the color of any fecal matter on the glove, and test it for occult blood

Evaluating a possible scrotal hernia

If a large scrotal mass is found, ask the patient to lie down. If the mass disappears, it is a hernia. If the mass remains: - Listen to the mass with a stethoscope. If bowel sounds are heard, it is a hernia. - Shine a strong light from behind the scrotum through the mass (transillumination). If a red glow is observed, it is probably not a hernia. Incarcerated hernia: - Contents can not be returned to the abdominal cavity Strangulated: - Suspected stangulation in presence of tenderness, nausea, and vomiting is considered an emergency need surgical intervention

Inspection of the Penis: Penis

If the patient has reported a discharge that you are unable to see, ask him to milk the shaft of the penis from its base to the glans. This maneuver may bring some discharge to the urethral meatus for appropriate examination. Palpate any abnormality of the penis, noting tenderness or induration Palpate the shaft of the penis, noting any induration

Scrotum, testes, epididymis, and spermatic cord

Inspection: - Skin - lift the scrotum to view its posterior surface - Scrotal contours - note swelling, lumps, veins Palpation: - Each testis and epididymis - note size, shape, consistency, and tenderness; feel for any nodules - Epididymis is a soft, nodular, cordlike structure at the back of the testicle - Each spermatic cord - note nodules or swelling

Hernias

Inspection: - Sit comfortably in front of the standing patient - Note any areas of bulging or asymmetry - Ask the patient to strain and bear down, making it easier to detect any hernias Palpation: - Inguinal and femoral hernias

Lower GI concerns

Is there any change in the pattern of bowel function? Any change in the size or caliber of the stool? Any diarrhea or constipation? What color is the stool? Any obvious blood or mucus in the stool? Any pain on defecation? Any itching? Any extreme tenderness in the anus or rectum? Any purulent discharge or bleeding? Any history of anal warts, ulcerations, or fissures? Any involvement in anal intercourse?

Lower GU concerns (for men)

Is there any difficulty starting or holding back the urine stream? Is the urine flow weak? Is there frequent urination, especially at night? Is there any pain or burning upon urination or ejaculation? Any blood in the urine or semen? Any pain or stiffness in the lower back, hips, or upper thighs? (could be sign of prostitis) Any discomfort or heaviness at the base of the penis with associated malaise, fever, or chills? What does this suggest? - infection

Symptoms of infection questions

Is there any discharge from the penis, dripping, or staining of underwear? If so, how much and what is its color and consistency? Any associated fever, chills, or rash? Any sores or growths on the penis? Any pain or swelling in the scrotum? Any history of risk factors for sexually transmitted disease? (promiscuity, homosexuality, illicit drug use

In the male, the prostate gland lies against the anterior rectal wall

It is rounded, heart-shaped, and normally 2.5 cm long Only the lateral lobes and median sulcus are palpable *In the female, the uterine cervix usually is palpable through the anterior wall of the rectum

Techniques of Examination

It may be reassuring to explain each step of the examination so the patient knows what to expect Occasionally, male patients have erections during the examination; if this happens, you should explain that this is a normal response Many will feel uneasy about examining a man's genitalia A good genital examination may be done with the patient either standing or supine When checking for hernias, the patient should stand and the examiner should sit on a chair or stool

Screening for Prostate Cancer

Leading cause of cancer in men and second leading cause of death in men after lung cancer. Lifetime risk is high 60% are confined to organ at diagnosis and slow to invade the prostate capsule Most common method of screening is PSA and DRE, but are far from ideal

Femoral Hernia

Least common. More common in women than men Below the inquinal ligament; appears more lateral than an inguinal hernia. Can be hard to differentiate from lymph nodes Never into the scrotum The inguinal canal is empty

PSA- glycoprotein produced by prostate epithelial cells. Used as a biomarker for early detection of screening.

Limitations: Elevated for benign conditions like hyperplasia, prostatitis, ejaculation, and urinary retention causing false positives leading to unnecessary biopsies. Some men will not have an elevated PSA (prostate specific antigen), causing a false negative Cancer can be found at all levels of PSA, so setting a cut point is impossible. - Common cutpoint of 4.0 for biopsy, but in the Prostate Cancer Prevention Trial, cancer was found in 10% of men with PSA levels of 0.6 to 1.0 ng/ml, 24% with levels 2.1 to 3.0, and 27% with levels 3.1-4.0. PSA does not distinguish small volume indolent cancers from aggressive life threatening disease. In a number of studies early diagnosis has not been shown to reduce mortality. Screening increases overdiagnosis by 23-43%. Screening can lead to overtreatment, as many overdiagnosed patients receive curative surgery or radiation for cancers that may be indolent. - As many as 20-70% of men who had no problems before a radical prostatectomy or external beam radiation

Questions concerning symptoms related to the anorectal area may be classified into two categories:

Lower gastrointestinal (GI) Lower genitourinary (GU)

The male patient: Examine the anus and rectum

Lubricate a gloved index finger Explain what you are going to do Inspect the anus, noting any lesions Ask the patient to strain down Place finger pad over the anus and gently insert your fingertip into the anal canal; proceed with insertion upon relaxation of the sphincter --> Assess for sphincter tone of the anus, tenderness, induration, irregularities, or nodules

Risks: family hx

Men with one first degree relative (father or brother) are 2-3 times more likely to develop prostate cancer. Risk of diagnosis in men with 2 or more affected relatives increases 3-5 fold. Genetics also play a role- BRCA2 mutation, Presence of autosomal dominant and X linked alleles are also an increased risk and are under investigation

Screening Recommendations

Most organizations recommend discussion of the risks and benefits to patients starting at age 50. USPSTF - The U.S. Preventive Services Task Force (USPSTF) recommends against prostate-specific antigen (PSA)-based screening for prostate cancer. American Urological Association - recommends that PSA screening, in conjunction with a digital rectal examination, should be offered to asymptomatic men aged 40 years or older who wish to be screened, if estimated life expectancy is greater than 10 years 60. It is currently updating this guideline. The American Cancer Society - emphasizes informed decision making for prostate cancer screening: men at average risk should receive information beginning at age 50 years, and black men or men with a family history of prostate cancer should receive information at age 45 years American College of Physicians - Men between the ages of 50 and 69 should discuss the limited benefits and substantial harms of the prostate-specific antigen (PSA) test with their doctor before undergoing screening for prostate cancer. - ACP recommends against PSA testing in average-risk men younger than 50, in men older than 69, or in men who have a life expectancy of less than 10 to 15 years because the harms of prostate cancer screening outweigh the benefits.

A 21-year-old male presents complaining of a "nodule" on the back of his left testicle found during testicular self-examination. On examination, you find both testicles to be of normal size, shape, and consistency. On the back of the left testicle in the area of the "nodule," you find a soft, nodular, tubelike structure with no areas of abnormal tenderness. Your most likely diagnosis is: a) Acute epididymitis b) Cyst of the epididymis c) Normal epididymis d) Carcinoma of the epididymis

Normal epididymis The epididymis is located on the superior, posterior surface of each testicle. It feels nodular, soft, and cordlike and should not be confused with an abnormal lump.

The gastrointestinal tract terminates in a short segment, the anal canal

Normally, the anal canal is held in a closed position by two muscles, the voluntary external anal sphincter and involuntary internal anal sphincter The angle of the anal canal lies on a line roughly between the anus and umbilicus The anal canal is liberally supplied by somatic sensory nerves A serrated line demarcates the anal canal from the rectum The anorectal junction (often called the pectinate or dentate line) is the boundary between somatic and visceral nerve supplies

Health Promotion and Counseling

Screen for prostate cancer - Prostate cancer is the leading cancer diagnosed in men in the United States, and the third leading cause of death - The primary risk factors are age, ethnicity, and family history (although a series of studies have suggested an association between intake of dietary fat and risk of prostate cancer) Screen for polyps and colorectal cancer Provide counseling about sexually transmitted diseases

Risks: diet

Series of studies suggest an association between prostate cancer and high intake of saturated fat from diary and animal sources, but evidence is inconclusive. Recent study shows decreased risk from selenium or Vitamin E

Techniques of Exam

The anorectal and prostate examinations are usually the least popular segments of the physical examination A skillfully performed examination should not be truly painful Successful examination requires a calm demeanor, explanation to the patient of what he or she may feel, gentleness, and slow movement of your finger In asymptomatic adolescents, it is appropriate to defer the rectal exam Remember no matter how you position the patient, your examining finger will not reach the full length of the rectum. If rectosigmoid cancer is suspected then consider sigmoidoscopy or colonoscopy

The groin

The basic landmarks of the groin are the anterior superior iliac spine, the pubic tubercle, and the inguinal ligament The inguinal canal, which lies above and parallel to the inguinal ligament, forms a tunnel for the vas deferens The exterior opening of the tunnel is the external inguinal ring; the internal opening of the canal is the internal inguinal ring When loops of bowel force their way through weak areas of the inguinal canal, they produce inguinal hernias Another potential route for a herniating mass is the femoral canal; femoral hernias protrude here

The male patient: One of several patient positions may be used for examination

The patient may stand, leaning forward with his upper body resting across the examining table and hips flexed The patient may lie on his left side with his buttocks close to the edge of the exam table near you; flex the patients hips and knees, especially the top leg

The female patient

The rectum is usually examined after the female genitalia, while the woman is in the lithotomy position; this position is also ideal for conducting the bimanual examination and is suitable for testing the integrity of the rectovaginal wall and may also help to palpate a cancer high in the rectum If the rectum only requires examination, the side-lying position affords a much better view to the perianal and sacrococcygeal areas Use the same techniques for examination that are used for men

The penis

The shaft of the penis is formed by three columns of vascular erectile tissue: - The corpus spongiosum, containing the urethra - The two corpora cavernosa The corpus spongiosum forms the bulb of the penis, ending in the cone-shaped glans with its expanded base, or corona In uncircumcised men, the glans is covered by a loose, hood-like fold of skin called the prepuce, or foreskin, where smegma, or secretions of the glans, may collect The urethra opens into the vertical, slit-like urethral meatus

The testes

The testes are ovoid, somewhat rubbery structures approximately 4.5 cm long The left testis usually lies somewhat lower than the right The testes produce spermatozoa and testosterone The scrotum is a loose, wrinkled pouch divided into two compartments, each containing a testis Covering the testis, except posteriorly, is the serous membrane of the tunica vaginalis On the posterolateral surface of each testis is the softer comma-shaped epididymis; the epididymis provides a reservoir for storage, maturation, and transport of sperm

The lower genitourinary tract

The vas deferens, a cordlike structure, begins at the tail of the epididymis It ascends within the scrotal sac (as the spermatic cord) and passes through the external inguinal ring on its way to the abdomen and pelvis Behind the bladder, it is joined by the duct from the seminal vesicle and enters the urethra within the prostate gland

A 65-year-old male presents to clinic for a routine examination. The following is the documentation of his prostate examination. Which statement would be of concern? a) Firm b) Heart-shaped c) 2.5 cm long d) Median sulcus palpable

a) Firm The normal prostate is rubbery.

The female patient may remain in a lateral position for examination of which of the following: a) Adnexal mass b) Perianal fissure c) Integrity of the rectovaginal wall d) Pelvic mass

b) Perianal fissure The rectum is usually examined while the woman is in the lithotomy position, which is also ideal for conducting the bimanual examination and is suitable for testing the integrity of the rectovaginal wall; it may also help to palpate a cancer high in the rectum If the rectum only requires examination, the side-lying position affords a much better view to the perianal and sacrococcygeal areas