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179 Cards in this Set

  • Front
  • Back

Anatomy

Penis


Scrotum


Testes


Prostate

Penis

Shaft and glans

External anatomy of Penis

Darter than other surrounding skin, hairless


Visible dorsal vein


Urethra at tip of glans


Glans: may be covered by foreskin

Circumcised

Surgical removal of foreskin


Becoming less popular


No clear medical guidelines for or against


Common in US among caucasians and Jewish


Less common in African Americans and Hispanics


Slight risk of surgical complications: infection, ischemia, necrosis


May have decreased risk of HIV

Uncircumcised

Increased risk of some STIs: syphilis, genital herpes, chlamydia


Increased risk of penile cancer


Increases risk of cervical cancer in female partners


Smegma

Penile cancer

Rare


r/t poor hygiene

Smegma

White cheesy material on glans in uncircumcised male


Formed from sebaceous material (from glans)


Formed from desquamation of epithelial cells (from foreskin)

Proper hygiene of uncircumcised penis

Retraction of foreskin so smegma doesn't accumulate

Internal anatomy of Penis

2 Types of tissue:


- Corpus cavernosa


- Corpus spongiosum


Bulbourethral gland

Corpus cavernosa

Dorsum/Top


Sides

Corpus spongiosum

Ventral/Underneath


Contains urethra

Bulbourethral gland

Cowper's gland


Produces pre-ejaculate fluid


Parallels Bartholin's gland in females


Lubricates the urethra for sperm to pass through and neutralizes acidic urine

Scrotum

Darker than other skin, scant hair


Rugae with deeply pigmented skin and large sebaceous follicles


Scrotal sac divided by septum


Contains testis

Rugae

Skin folds on scrotum

Testes

4x3x2 cm


Left usually lower than righ


Produces sperm and testosterone


Epididymis


Cremaster muscle

Epididymis

Posterior side of testes


Collects and provides transit for sperm

Sperm travel

Through vas deferens


Spermatic cord


Seminal vesicles


Ejaculatory duct


Into urethra

Seminal vesicles

Secretes a fluid that nourishes sperm

Spermatic cord

Consists of arteries, veins, lymphatics, nerves

Cremaster muscle

Raises and lowers testes


Regulates temp, maintain sperm viability


Cold: pulls testes in to body


Hot: lowers testes

Prostate

2.5 x 4 cm


Surrounds the urethra at the bladder neck


Secretes ejaculatory fluid to help sperm mobility


2 lobes, separated by a median sulcus


Palpate through anteriorectal wall

Prenatal Development

Testes located in abd and descend down inguinal canal to scrotum prior to birth

External inguinal ring

Later in life, enlarges the intestines may prolapse into scrotal sac causing an inguinal hernia

Puberty

Begins between ages of 9 and 13


Usually takes 3 yrs


Tanner's Stages

Tanner's Stages

First, enlargement of the testes: testosterone produced, leads to the other changes


Pubic hair growth


Enlargement of the penis


Prostate doubles in size

Adult development

Prostate enlarges throughout life


Testosterone production gradually declines after 60 yrs

Benign prostatic hypertrophy

BPH


Prostatism


May gradually impede urine flow


Bladder outlet obstruction

Testosterone reduction r/t to age

Leads to lower sperm count: decreased fertility


Erectile dysfunction: decreased firmness of erections

Urinary Symptoms

Related to BPH, STI, UTI

BPH urinary symptoms

Frequency


Urgency


Hesitancy


Decreased force of stream (FOS)


Post void dribbling


Post void fullness/residual


Nocturia

STI urinary symptoms

Frequency


Dysuria


Urethral discharge


UTI urinary symptoms

Frequency


Urgency


Dysuria


Pyuria

Frequency

Voiding every 15 min


r/t bladder irritation (UTI)


r/t Urethritis (STI/chlamydia)


r/t Tumor (BPH)

Urgency

Must go "now"


r/t UTI, BPH

Hesitancy

Difficulty starting urine flow


r/t BPH

Decreased force of stream

decreased FOS


r/t BPH

Post void dribbling

r/t BPH

Post void fullness/residual

r/t BPH

Nocturia

Awakening in the night to urinate


r/t incomplete bladder emptying (BPH)


r/t mobilization of fluid and increased renal blood flow in recumbant position (heart failure)

Dysuria

Pain or burning with urination


r/t UTI, STI

Pyuria

Pus in urine


r/t infection

Urethral discharge

Discharge at urethral meatus


r/o STI

Purulent urethral discharge

Gonorrhea

Clear urethral discharge

Chlamydia

Polyuria

Frequent, massive amounts of urine


Seen with DM


High glucose levels cause osmotic diuresis

Enuresis

Bed wetting


Nighttime incontinence after age 5-6 may be psychologic or structural problem with urinary tract

LUTS

Lower Urinary tract symptoms


BPH symptoms

LUTS/BPH Symptoms

Frequency


Urgency


Hesitancy


Decreased FOS


Post void dribbling


Post void residual/fullness


Nocturia

Incontinence

Involuntary loss of urine

Overflow incontinence

r/t incomplete bladder emptying, overdistended bladder


Prostatism

Stress incontinence

Associated with rapid movement of the diaphragm


Coughing, sneezing, laughing


More common in women r/t shorter urethra

Urgency incontinence

Seen with infection, prostatism, neurologic disorders


No immediate access to toileting

Hematuria

Blood in urine


Always a significant finding that needs further evaluation

Macrohematuria

Visible


Red/Pink urine

Microhematuria

Seen with microscope

Hematuria originates

Kidney


Ureters


Bladder


Prostate

Hematuria causes

Hemorrhagic: clotting disorders


Infection: UTI


Tumor, trauma, TB of kidney


Stone: nephrolithiasis

TB of kidneys

Painless bleed in the urine

Testicular masses

Benign or malignant


Heaviness


Undescended testicle


May affect fertility

Sexual history

Number of partners, time with current partner, mutually monogamous: indicates sexual risk


Reproductive function, contraception


Use of barrier protection


hx STIs, treatment


Difficulties, concerns, problems, satisfaction, performance, sexual preference


Erectile dysfunction: ask about meds


Family hx: prostate cancer in 1st degree relative, age of diagnosis

Meds that cause ED

Antihypertensives

Physical examination: genitilia

Best if pt standing


Examiner sitting

Mons pubis/pubic hair

Distribution: diamond pattern


Infestations: lice, nits (lice eggs)

Lesions

Grouped vesicles


Papules


Chancre

Grouped vesicles

Herpes

Papules

Condyloma accuminata


External genital warts (EGW)


STI

Chancre

Painless sore from syphilis

Penis: inspection

All surfaces for lesions

Inspect glans

Retract prepuce

Prepuce

foreskin

Phimosis

Foreskin can't be retracted


Associated with poor hygiene


Accumulation of smegma

Balanitis

Occurs in uncircumcised


Inflammation of glans: bacterial or fungal


More common with DM


Under foreskin, seen with phimosis

Paraphimosis

Foreskin permanently retracted backward


r/t penile edema


Turnicate-like affect

Priapism

Prolonged painful erection


Serious if lasting > 4hrs


Occurs with leukemia, hemoglobinapathies, meds


May cause sterility

Hemoglobinapathies

Sickle cell trait

Meds that cause priapism

Viagra, Cialis, Levitra, Trazadone

Peyronie's disease

Corpus cavernosis develops scar tissue


Etiology unknown


Thought to be genetic


Usually occurs after 45 yrs


Penis curves when erect


Usually doesn't affect sex life or fertility

Hypospadias

Urethra ventral/underneath


Most common

Epispadias

Urethra dorsal/top


Rare

Discharge at the Urethral Meatus

Milk urethra by compressing the base of penis with thumb and index finger toward the glans

Urethritis

Usually related to STI


Inflammation of urethra

GU

Gonococcal Urethritis

NGU

Non gonococcal urethritis


Chlamydia

Inspect/Palpate scrotum

Scrotal lumps


Scrotal Edema


Hydrocele

Scrotal lumps

Common


R/t sebaceous cysts


Important to differentiate from testicular lumps

Scrotal edema

CHF


Renal failure


Differentiate from masses or lumps

Hydrocele

Serous fluid around testicle


Often r/t trauma (bike seat)


Resolves spontaneously


Transilumination: fluid glows red as light reflects off fluid

Cryptorchidism

Undescended testicle


Decreased spermatogenesis


Decreased fertility

Orchitis

Acute inflammation of testis


Seen with mumps if not immunized

Testicular masses

Testicular cancer


Rare


Ages 17-35

Epididymitis

Acute infection of epididymis


Painful lump in epididymis


Pain improves when lifting scrotum


"It hurts without underwear"


r/t prostatitis, STI, urethral instrumentation


< 35 yrs, likely r/t GC or Chlamydia


> 35 yrs, likely r/t enterobacter or pseudomonas

Spermatocele

Retention cyst


Collection of sperm in epididymis


Most common after vasectomy

Vasectomy

Male sterilization


Vas deferens ligated


Sperm cannot move forward

Testicular torsion

Compromised arterial flow


Ischemic pain


Sudden twisting of spermatic cord, more common on left


Rare after 20 yrs


May occur spontaneously (during sleep) or after trauma


Surgical emergency r/t compromised blood supply

Varicocele

Dilated veins of spermatic cord


More common on left side


May be visible when pt stands


Feels like a bag of worms


May cause infertility r/t increased venous pressure and testicular temp


Symptoms: dull ache along spermatic cord, scrotal pain or heaviness

Lymph nodes

Often able to palpate normally


- 1 to 2 cm, mobile


Penis drains into inguinal nodes (palpable)


- LAD with penile lesion


Testes drain into Abd nodes (not palpable) and left supraclavicular nodes


- distant metastatic site

Hernia

Prolapse of organs into inguinal canal

Examine for hernia

Pt standing, gravity effect


Finger up through scrotum into inguinal canal


- 2 inches long


Ask pt to cough: soft tissue of intestines if hernia is present

Indirect hernia

Most common


Herniation into inguinal canal


More common in children and young males

Direct hernia

Second most common


Herniation through external inguinal ring


- Bulge seen over inguinal canal


More common in men after 40 yrs

Femoral hernia

Least common


Herniation through femoral ring


Bulge seen in groin over femoral artery


Higher incidence in women

Incarcerated hernia

Non-reducible


May lead to compromised blood supply


Surgical emergency

Reducible

Able to push tissue

Anus anatomy

Anus


Rectum


Sigmoid colon

Anus

Terminal end of the GI tract


2.5 - 4 cm long


Distal end opens to perianal area


Proximal end merges with rectal mucosa at the anorectal junction

Sphincters of Anus

Internal sphincter


External sphincter

Internal sphincter

Involuntary control


When rectum fills with stool, internal sphincter relaxes and results in the urge to defecate

External Sphincter

voluntary control of defecation

Anal columns

Vertical folds of mucosa containing arteries and veins

Hemorrhoids

Varicose anal veins


r/t chronic increased venous pressure


Constipation/straining with BM

Rectum

Distal portion of the GI tract


12 cm long

Sigmoid colon

S Shaped


40 cm long

Flexible sigmoidoscope

Visualizes up to 60 cm


Misses proximal lesions


Anus 4 cm + rectum 12 cm + sigmoid 40 cm =


56 cm


Does not require conscious sedation, quick procedure

Colonoscopy

Scopes the entire colon


Gold standard


Requires conscious sedation

Newborns/infants

First meconium: 24-48 hrs s/p birth


Meconium

Dark green, sticky stool


Substances swallowed in utero, amniotic fluid

Gastro-colic reflex

Newborn/infants


Causing increased peristalsis, BM after each feeding

Imperforate anus

No outlet for stools

Toddlers

No voluntary control of external sphincter until mylinization of nerves


1.5 - 2 yrs old

Older Adults

Fecal incontinence


Constipation

Fecal incontinence: older adults

May occur with loss of internal sphincter tone

Constipation: older adults

Occurs with degeneration of afferent rectal nerves


Poor internal sphincter relaxation in response to stool in rectum

Bowel habits

There is no normal, assess for changes


Controlled by many factors: colon size, diet, exercise, response to stress, medication


Number, frequency, consistency, color of BMs, presence of blood, pungent odor

Constipation

Fluids, fiber, exercise

Diarrhea

Infection: fever, chills


Foreign travel: infection, parasites


Meds


Timing


Psychosomatic diarrhea

No nocturnal stools

Physiologic diarrhea

Nocturnal stools present

Melena

Dark, tarry stools


Foul odor


Upper GI bleed


Gastric/duodenal ulcer or cancer

Iron, bismuth stools

Black stools r/t meds


Iron, peptobismal


Not tar-like

BRBPR

Bright red blood per rectum


Drips of blood in toilet or on tissue


Hemorrhoids, polyps, tumor

Hematochezia

Maroon stools


Lower GI bleed


Upper GI bleed with rapid motility

Clay colored stools

Absence of bile pigment


Bile gives stool brown color


Biliary obstruction, liver disease or cancer, gallstones

Rectal pain

External hemorrhoids


Internal hemorrhoids


Fissures


Burning/itching

External hemorrhoids

Most common cause of painful BMs


Dilated rectal veins around rectal openings

Internal hemorrhoids

Not painful unless prolapsed, infected, or thrombosed


May result in significant bleeding

Thombosed hemorrhoids

Incised to evacuate clot


Relieve symptoms

Fissures

Mucosal tear r/t passage of large, hard stool


Results primarily from constipation and straining with BM


May require corrective surgery


Results in painful BMs

Pruritis ani

Burning and itching of the rectum


Common, etiology may never be found


r/o fungal infection, external hemorrhoids, parasites

Pinworm

Parasite


Scotch tape over anus at bedtime to diagnose

Bowel meds

Laxatives


Constipating medicines

Bulk laxative

Add fiber


Psyllium

Osmotic laxative

MOM


Magnesium citrate - very potent, bowel prep


Golytely - very potent, bowel prep


Miralax


Pull fluid into GI tract

Chemical stimulant

Ex-lax


Senokot


Habit forming

Constipating medication

Especially problematic for elderly


Antidepressants


Antihistamines: benadryl


Calcium channel blocker: verapamil


Iron

ROS

n/v, cramping, pain, distention, flatus, unintentional weight loss


Mucus


Stool character


Medical history

Pencil-like stools

Spasm, stenosis/scarring, mass, decreased fiber

Mucus in GI tract

Intestinal inflammation

Steatorrhea

Excessive fat in stool


Pancreatic problem, malabsorption


Foamy, frothy, pungent

Fecal incontinence

May be related to neurological disorder

Medical history of GI tract

Irritable bowel syndrome


Inflammatory bowel disease

IBS

Irritable bowel syndrome


Common change in stools


Diarrhea to constipation


Exacerbated by psychological stress

IBD

Inflammatory bowel disease


Crohns disease


Ulcerative colitis


Increased colon cancer risk 10 yrs after diagnosis


Severe disability

Colorectal cancer risk

> 50 yrs


High fat/low fiber diet


Obesity


Smoking


Precancerous intestinal polyps


Family hx


IBD

Fiber in diet

Fiber absorbs fat


May absorb toxins and carcinogens

Hypoplastic polyps

Benign


No risk for cancer

Adenomatous

Precancerous


Must be re-evaluated by colonoscopy more frequently than 10 yrs


per recs of GI doc

Purposes of rectal exam

Assess anorectal area


Prostate exam in males


Bi-manual recto-vaginal exam in women

Positioning

Pt stands and leans over exam table


Lithotomy position: as part of pelvic exam


Left-lateral knee-chest position: bedridden

Inspect perianal area

Spread buttocks


Assess for lesions, warts, skin tags, parasites, abscess, scars, fissures, external hemorrhoids

Perianal skin

Darker


With hair

Pilonidal cyst

Located over coccyx/sacrum


Pain or tender


Usually between 15-24 yrs


Cyst: may be r/t ingrown hair aggrivated by prolonged sitting or trauma


Sinus tract opening: may contain hair and skin debris with erythema, swelling, tendernes at coccyx

Digital rectal exam

Apply pressure to anal opening with lubricated gloved index finger


- pt bear down to relax external sphincter


Insert finger and palpate anterior, lateral, posterior surfaces


Pt to tighten external sphincter to assess tone


Note nodule, massess, polyps, tenderness (fissure/fistula), internal hemorrhoids (not usually palpable or painful, may bleed)

Decreased external rectal tone

Neurologic deficit

Tight external sphincter

Scarring r/t fissure/lesion, inflammation, anxiety

Prostate exam

Press down on anterior rectal wall


Only posterior surface assessed


Palpate both posterior lobes: vertical groove separates lobes

Prostate size

Normal: no protrusion into rectum


1+ : protrudes 1-2 cm into rectum


2+ : protrudes 2-3 cm into rectum


3+ : protrudes 3-4 cm into rectum


4+ : protrudes > 4 cm into rectum

Size and symptoms of prostate

Size does not correlate with symptoms


May have significant LUTS with normal prostate exam


Anterior prostate may be significantly enlarged but not change prostate exam

Prostate norms

Smooth, firm, non-tender: tip of nose

BPH physical exam

Symmetrically enlarged


Soft, non-tender

Prostate cancer physical exam

Nodular


Asymmetrical


Non-tender


Middle groove may be obliterated

Acute prostatitis physical exam

Boggy, tender

Monthly screening

Genital self exam (GSE)


Testicular self exam (TSE)

Annual screening

DRE


PSA


FOBT

Screening every 5 yrs

Flexible sigmoidoscopy


Starting at age 50

Screening every 10 yrs

Colonoscopy


Starting at age 50

DRE

Digital rectal exam


Screen for prostate and colon cancer


Reaches 7-8 cm and detects 10% of cancers


> 50 yrs all men


> 40 yrs at risk: African Americans, family hx

PSA

Non specific blood test for prostate cancer


Increase with inflammation and BPH


PSA screening is controversial because of high false positive and false negative rate

FOBT

Fecal occult blood test, guiac test


Only detects 2-11% of colon cancers


+ FOBT: colonoscopy recommended

Genetic risk

First degree relative: parent, child, sibling


Second degree: grandparent, aunts, uncles


Third degree: great-grandparents, cousins