Chapter 23: Male Genitalia & Rectum

After teaching a client about measures to reduce his risk for colon cancer, the nurse determines that the teaching was successful when the client states which of the following?

"I should eat a half-cup of raisins every day." Rationale: Raisins contain tartaric acid and fiber, which reduce bile acids and speed food through the gastrointestinal system, thus decreasing constipation and the risk for cancer. A diet high in animal proteins such as red meats is a risk factor for colon cancer; therefore the client should eat a diet that is low in animal protein. The client also should increase his fiber intake, including fruits and vegetables such as green leafy vegetables.

A 17-year-old male client expresses concern about feeling lumps on his testicles. What response by the nurse would best address the client's concerns?

"The normal testicle contains internal structures that cause lumps on the surface." Rationale: Each normal testicle has a small, coiled tube (epididymis) that can feel like a small bump on the upper or middle outer side of the testicle. Normal testicles also have blood vessels, supporting tissues, and tubes that carry sperm. Asking for the client's opinion on whether or not the testicles are malformed does not yield assessment data or address the client's need for more information. Telling the client not to worry and describing the testicles as normal provides incomplete information to the client. Because the client's given concern is not regarding sexual performance, this is not a statement that the nurse should use; additionally, describing the testicles as lumpy is an inaccurate way to refer to an expected assessment finding.

A 55-year-old client presents to the health care clinic with reports of decreased bowel movements with the passing of hard, dry stool for the past 2 weeks. The client states that he has noticed a small amount of bleeding from the rectum and on the stool. He states he has had trouble with his bowels all his adult life. He admits to drinking a lot of coffee and works in a high-stress job. The nurse observes a large external hemorrhoid upon examination of the anus. Which nursing diagnoses can be confirmed with this data? Select all that apply.

> Constipation > Ineffective Health Maintenance > Risk for Impaired Skin Integrity Rationale: Constipation can be confirmed because of the decrease in bowel elimination and the passage of hard, dry stools, as can Ineffective Health Maintenance related to insufficient knowledge of stress-reducing behaviors. Risk for Impaired Skin Integrity related to the presence of a large hemorrhoid, which could cause irritation and skin breakdown if it became thrombosed, may also be confirmed. There is no indication of acute pain or Readiness for Enhanced Bowel Elimination.

Francis is a middle-aged man who noted right sided lower abdominal pain after straining with yardwork. Which of the following findings would make a hernia a more likely diagnosis?

Absence of symmetry of the inguinal areas with straining Rationale: Even in the presence of a hernia, absolute symmetry to inspection may be preserved. The actions of straining and increasing intra-abdominal pressure cause the hernia to protrude. Hernias will not necessarily be present on CT scans unless this maneuver is undertaken. Pain with straining and bowel sounds heard in the scrotum further support the diagnosis of indirect hernia.

A nurse is palpating the prostate of a client and finds it to be swollen, tender, firm, and warm to the touch. Which condition should the nurse most suspect?

Acute prostatitis Rationale: The prostate is normally nontender and rubbery. A swollen and tender prostate that is firm and warm to the touch 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.

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

African American Rationale: 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 would the nurse most likely document when noting a small opening in the skin surrounding the anal opening?

Anorectal fistula Rationale: An anorectal fistula is observed as a small round opening in the skin that surrounds the anal opening. Pinworm infection would be noted by redness and excoriation from scratching the area. Trauma would be noted by splits in the skin tissue of the anal canal, often with a swollen skin tag below the fissure on the anal margin. Perianal abscess would be noted as a cavity of pus around the anal opening.

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

Any of the above Rationale: 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 Rationale: 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 Rationale: 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.

When examining a newborn male infant, the nurse notes that neither testicle is descended. How would the nurse document this finding?

Cryptorchidism Rationale: Absence of a testis in the scrotum suggests cryptorchidism. Epididymitis is an infection of the epididymis. Orchitis is an inflammation of the testes. Varicocele is an abnormal dilation of veins in the spermatic cord.

A client complains of scrotal pain, and the nurse elicits a positive Prehn sign with relief of the pain. The nurse suspects which of the following?

Epididymitis Rationale: Passive elevation of the testes with relief of scrotal pain is a positive Prehn's sign indicating epididymitis. Painless nodules may indicate a scrotal mass or tumor. Tenderness and swelling may indicate a strangulated hernia. Palpable tortuous veins suggest a varicocele.

A nurse examines the external genitalia of a client and observes that the scrotum is enlarged, reddened, and swollen. On palpation, the epididymis is tender and the client complains of sudden pain. How should the nurse document this condition?

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

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 Rationale: 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 Rationale: 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.

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 Rationale: 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.

During a scrotal exam, the nurse notes an enlarged scrotal sac that easily transilluminates. Which of the following would the nurse suspect?

Hydrocele Rationale: Swelling or masses that contain serous fluid, such as hydrocele or spermatocele, light up with a red glow with transillumination. Swellings or masses that are solid, or filled with blood, such as tumors, hernias, or varicocele, do not transilluminate.

Upon observation, the nurse documents that a male child's urethral meatus is located on the underside of his penis. What is the term for this structural abnormality?

Hypospadias Rationale: A urethral meatus located on the underside of the penis is called hypospadias. A meatus located on the upper surface is called epispadias. These congenital conditions are usually repaired surgically at a young age if they are severe. Cryptorchidism is an undescended testicle, and with phimosis, the foreskin becomes so tight that it will not retract over the glans penis.

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 Rationale: 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.

The nurse is presenting a program about sexually transmitted infections, including HIV, to a group of young men. The nurse would include who as the having the highest incidence of HIV infection in the United States?

Men having sex with men Rationale: Although transmission routes vary (male-to-male anal sex, intravenous drug use, heterosexual sex, mother-to-infant transmission, and other mechanisms of body fluid transfer), the highest incidence of HIV in the United States still occurs in men who have sex with men (MSM), followed by intravenous drug users.

Which of the following is a sign or symptom of benign prostatic hypertrophy (BPH)?

Nocturia Rationale: BPH is usually not associated with systemic symptoms such as weight loss or fever. Bone pain is associated with prostate cancer, which often metastasizes to the lower axial skeleton. Nocturia, sensation of incomplete voiding, weak stream, and difficulty initiating urination are also common symptoms.

While assessing the scrotum of an adult client, the nurse notes thin and rugated scrotal skin with little hair dispersion. The nurse interprets this finding as which of the following?

Normal findings Rationale: Scrotal skin is normally thin and rugated with little hair. Inflammation of the penis and scrotum may be seen in Reiter's syndrome. Absence or scarcity of pubic hair may suggest chemotherapy. A yellow urethral discharge is usually seen with gonorrhea.

When palpating the prostate, the nurse detects a nontender, rubbery prostate with lateral lobes that are 2.5 cm and heart-shaped. The nurse would interpret this finding as indicating which of the following?

Normal prostate Rationale: The prostate is normally nontender and rubbery with two lateral lobes that are smooth, 2.5 cm long, and heart shaped. Swelling and tenderness suggest prostatitis. Enlargement of a smooth, firm, slightly elastic prostate suggests benign hypertrophy. A hardened area on the prostate or hard fixed irregular nodules suggest prostate cancer.

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 Rationale: 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.

When performing the physical assessment of a client, the nurse notes the presence of a small cyst that contains hair, which is located midline in the sacrococcygeal area and has a palpable sinus tract. How should the nurse document this finding?

Pilonidal cyst Rationale: A pilonidal cyst is a congenital disorder characterized by a small dimple or cyst/sinus that contains hair. External hemorrhoids are usually painless papules below the anorectal junction, caused by varicose veins. Anal fissures are splits in the tissue of the anal canal caused by trauma. Perianal abscess is a cavity of pus, caused by infection in the skin around the anal opening.

A nurse is a preparing to assess a male client's anus and rectum. How should the nurse best prepare the client for this assessment?

Position the client in a left side-lying position. Rationale: The most frequently used position for inspection and palpation of the anus, rectum, and prostate is the left lateral position. This position allows adequate inspection and palpation of the anus, rectum, and prostate (in men) and is usually more comfortable for the client. Pain control should not be necessary. Some men may be anxious or fearful during this exam, but the nurse would not normally raise this possibility unless he or she had reason to believe that the client felt this way.

A 55-year-old retired property manager comes to the clinic concerned that she may have a rectal tumor. When asked why, she states that after straining at a bowel movement, she felt a mass around her rectum. She denies any blood in her stool, black stools, or pain with defecation. She admits to having had chronic constipation for 30 years. She often uses laxatives to have a bowel movement. She denies any recent weight gain, weight loss, fever, or night sweats. Past medical history consists of hypothyroidism, and she has had two spontaneous vaginal births. Her mother died recently of colon cancer; her father has high blood pressure but is otherwise healthy. She denies any smoking and only occasionally drinks alcohol. On examination she seems nervous. Her blood pressure is 140/90 and her pulse is 100. Her cardiac, lung, and abdominal examinations are normal. On visualization of her anus, no inflammation, masses, or fissures are noted. When the client bears down, a rosette of red mucosa prolapsing from the anus is visible. Digital rectal examination reveals no masses; no blood is found on the glove. What disorder of the anus or rectum is this likely to be?

Prolapse of the rectum Rationale: Unless someone is bearing down, such as during a bowel movement, the red mucosa is not seen. This is common when there is heavy straining during a bowel movement. This finding in a young child or infant may lead to a suspicion of cystic fibrosis.

An adult male client reports hesitancy when urinating. The nurse would further assess this client for which complication?

Prostate enlargement Rationale: Difficulty urinating, such as hesitancy, could signal a blockage, including prostatic enlargement. Therefore the nurse would need to evaluate the client for prostate enlargement. A heaviness or dragging feeling in the scrotum might suggest a scrotal hernia or testicular tumor. Painful urination may be associated with a sexually transmitted infection.

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 Rationale: 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.

The nurse notes that a male client is diagnosed with a hydrocele. Which diagram will the nurse use to instruct the client about this health problem?

Rationale: A hydrocele is a nontender, fluid-filled mass within the tunica vaginalis. It transilluminates, and it can be palpate above the mass within the scrotum. Choice A is a scrotal hernia which is usually an indirect inguinal hernia that comes through the external inguinal ring. Choice C is acute orchitis which is acute inflammation of the testis. Choice D is a small testis which is seen in cirrhosis or the use of estrogens

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 Rationale: 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.

When the nurse is examining a male client's genitalia, the client experiences an erection. What would be most appropriate for the nurse to do?

Reassure the client that this is not unusual. Rationale: If a client experiences an erection during the exam, the nurse should reassure the client that this is not unusual and continue the exam in an unhurried and unflappable manner. The nurse needs to acknowledge the event, because the client is most likely feeling embarrassed. Stopping the exam and leaving the room may promote additional embarrassment or guilt in the client. Asking if continuing will embarrass him emphasizes what the client is already feeling and would most likely make it worse.

The nurse is aware of the heightened risk of urinary tract infections in older males. In order to reduce this risk, the nurse should prioritize which of the following interventions?

Remove urinary catheters as soon as possible. Rationale: Urinary tract infection (UTI), a type of HAI, accounts for more than 30% of infections reported by acute care hospitals in the United States. Virtually all hospital-associated UTIs are caused by instrumentation of the urinary tract, mainly from indwelling urinary catheters. Prevention of a catheter-acquired urinary tract infection (CAUTI) is a key component of an acute-care hospital's client safety and quality improvement program.

The client received in the ICU was shot in the lower abdomen, suffered bladder trauma, and now has a urinary catheter. With these risk factors, what would be an appropriate nursing diagnosis for this client?

Risk for infection Rationale: Risk for infection is related to inadequate knowledge, urinary reflux, recent trauma, and urinary catheter placement. The other answers are distracters for the question.

The prostate gland is characterized by which of the following?

Rounded heart shape Rationale: The prostate is a rounded, heart-shaped structure with two lateral lobes separated by a median (not coronal) groove or sulcus. The median lobe and related anterior surface are not normally palpable.

Upon inspection and palpation of the scrotum, the nurse discovers a mass. The nurse asks the client to lie down, and the bulge remains. On auscultation, the nurse finds bowel sounds. The nurse should document this finding as which type of hernia?

Scrotal Rationale: The nurse should document this finding as scrotal hernia if the bulge remains when the client lies down and bowel sounds can be auscultated over it. If the mass in the scrotum cannot be pushed into the abdomen, it could be an incarcerated hernia. A hernia is strangulated if the blood supply is cut off. A bulge or mass on the front of the thigh in the femoral canal area is a femoral hernia.

A group of students is reviewing information about the male genitalia in preparation for a test. The students demonstrate understanding of the material when they identify which of the following as external genitalia?

Scrotum Rationale: The external genitalia include the penis and scrotum. The testis, vas deferens, and spermatic cord are internal genitalia

Which finding should a nurse expect to observe when inspecting the external genitalia of an elderly male client?

Smaller penis with lower hanging testicles Rationale: Normal changes in the external genitalia of the aging male include a smaller penis and the testes hang lower in the scrotum. Testicles do not get smaller with age although they may decrease in size with long term illness. Enlargement of the penis is seen with inflammation and is not a normal for a male of any age. Hardness along the ventral surface of the penis may indicate cancer or a urethral stricture.

The nurse is beginning the physical exam of a male client's genitals. The nurse is sitting on a stool in front of the client. In which position would be best to place the client?

Standing Rationale: When beginning the exam, the nurse sits on a stool in front of the client while the client assumes a standing position. This allows the nurse to inspect the genitalia.

The nurse is assessing the genitalia of an older adult client. What would the nurse document as a normal finding?

Testes hanging lower in the scrotum Rationale: In the older adult male, the testes hang lower in the scrotum, the penis becomes smaller, and pubic hair may be gray and sparse. The testes do not decrease in size with aging; however, they may decrease in size with long-term illness. Bulging in the inguinal area would be considered an abnormal finding associated with a hernia.

A nurse performs transillumination of a client's testicles and observes no light reflection within the scrotal sac. The nurse recognizes ha this client may be experiencing what type of condition?

Testicular tumor Rationale: A testicular tumor will not transilluminate when a light is shined from the back of the scrotum. A hydrocele will transilluminate because it is a collection of fluid in the scrotum. A varicocele is an abnormal dilation of veins within the spermatic cord and these are palpated as a soft, irregular mass or "bag of worms" which collapse when the client is supine. Testicular torsion is a very painful condition that is caused by twisting of the spermatic cord and is a medical emergency.

The nurse is teaching a group of student nurses in the lab about male anatomical differences and assessment. Which of the following should be included in the teaching?

The assessment should be completed in a warm room. Rationale: Scrotal examination should occur in a warm room as the sac rises towards the body in colder temperatures. The arms do not need to be raised for the assessment. The client should be standing or lying comfortably. The skin on the scrotal sac should be loose and wrinkled. If the client is circumcised, the prepuce should be gently retracted for inspection. The prepuce should not be forcibly retracted.

After teaching a group of students about the anal canal, the instructor determines that the teaching was successful when the students state which of the following?

The internal sphincter is under involuntary control. Rationale: The anal canal is the final segment of the digestive system; it begins at the anal sphincter and ends at the anorectal junction (also known as the pectinate line, mucocutaneous junction, or dentate line). It contains two sphincters. The external sphincter is composed of skeletal muscle and is under voluntary control. The internal sphincter contains smooth muscle and is under involuntary control.

After positioning a 34-year-old client for examination of the anal region, the nurse notes a small opening above the gluteal crease that contains a tuft of hair. How should the nurse interpret this assessment finding?

The pilonidal cyst and sinus are usually benign, but can occasionally become infected or develop further sinuses. Rationale: A pilonidal cyst is a congenital, and usually asymptomatic, tract that can become a problem if infection or sinus formation results. It alone does not indicate infection.

A nurse is assessing the genitalia of a male client. The nurse finds that the client has a piercing in his penis. Why is it important to investigate details of the piercing?

To assess for health risks relating to how it was performed Rationale: The nurse needs to know where and how the piercing was done, because health risks such as hepatitis, tetanus, and tuberculosis, among other diseases, are possible when procedures are performed in an unsterile environment. U.S. laws concerning piercing vary in each state, so the nurse should not automatically call the authorities. The nurse can teach optimal care of the site, but this is less important than ascertaining greater health risks first. The nurse should never unprofessionally try to get information to facilitate personal preferences.

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 Rationale: 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.

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

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

The nurse has assessed a male client and determines that one of the testes is absent. The nurse should explain to the client that this condition is termed

cryptorchidism. Rationale: Absence of a testis suggests cryptorchidism (an undescended testicle).

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 Rationale:

During assessment of an adult client, which of the following lifestyle practices would indicate to the nurse that the client may be at high risk for HIV/AIDS? A client who

has anal intercourse with other males. Rationale: Because HIV is preventable, knowing risks and practicing risk-reducing behaviors will help to stem the epidemic of this infection. Risks include having unprotected sex (especially male-on-male anal intercourse).

The rectum is lined with folds of mucosa, and each fold contains a network of arteries, veins, and visceral nerves. When these veins undergo chronic pressure, the result may be

hemorrhoids. Rationale: The anorectal junction is not palpable, but may be visualized during internal examination. The folds contain a network of arteries, veins, and visceral nerves. If the veins in these folds undergo chronic pressure, they may become engorged with blood, forming hemorrhoids.

While assessing an adult male client, the nurse detects pimple-like lesions on the client's glans. The nurse explains the need for a referral to the client. The nurse determines that the client has understood the instructions when the client says he may have

herpes infection Rationale: Pimple-like lesions from herpes are sometimes detected on the glans.

The prostate gland consists of two lobes separated by the

median sulcus Rationale: The prostate gland consists of two lobes separated by a shallow groove called the median sulcus.

A nurse observes that the mucosa of the rectum and the rectal wall of a female client protrudes out through the anal opening. It appears as a red, doughnut-like mass with radiating folds. How should the nurse document this condition of the rectum?

prolapse Rationale: The nurse should document this condition as rectal prolapse. Soft structures like nodules that may be present in the muscular anal ring are called rectal polyps. They are rather common and occur in varying size and number. If cancer metastasizes to the peritoneal cavity, it may be felt as a nodular, hard, shelf-like structure called rectal shelf that protrudes onto the anterior surface of the rectum in the area of the rectouterine pouch in women. Rectal cancer may feel like a firm nodule, an ulcerated nodule with rolled edges, or, as it grows, a large, irregularly shaped, fixed, hard nodule.

A nurse observes that the mucosa of the rectum and the rectal wall of a female client protrudes out through the anal opening. It appears as a red, doughnut-like mass with radiating folds. How should the nurse document this condition of the rectum?

prolapse Rationale: The nurse should document this condition as rectal prolapse. Soft structures like nodules that may be present in the muscular anal ring are called rectal polyps. They are rather common and occur in varying size and number. If cancer metastasizes to the peritoneal cavity, it may be felt as a nodular, hard, shelf-like structure called rectal shelf that protrudes onto the anterior surface of the rectum in the area of the rectouterine pouch in women. Rectal cancer may feel like a firm nodule, an ulcerated nodule with rolled edges, or, as it grows, a large, irregularly shaped, fixed, hard nodule.