Male Gu Physical Exam

Front 1

Smegma

Back 1

Found in prepuce/foreskin of uncircumcised penis.

Front 2

Corpus spongiosum

Back 2

Contains the urethra
Forms the bulb of the penis that becomes the glans.

Front 3

Balantitis

Back 3

Infection/inflammation around the tip (glans) of the penis

Front 4

Hypospadias

Back 4

Meatus is displaced

Front 5

Scrotum

Back 5

A loose, wrinkled pouch divided into two compartments, each containing a testis.

Front 6

Testis

Back 6

Ovoid, rubbery (3.5-5.5 cm)
Left lies lower than the right
Produce spermatozoa and testosterone

Front 7

Epididymis

Back 7

Ovoid, rubbery (3.5-5.5 cm)
Left lies lower than the right
Produce spermatozoa and testosterone

Front 8

Vas deferens

Back 8

Cordlike structure, begins at the tail of the epididymis

Transports sperm from the tail of the epididymis to the urethra.

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

Front 9

Landmarks in the groin

Back 9

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.

Front 10

Lymphatics in the groin

Back 10

Penis and scrotum drain into the inguinal nodes and may cause inflammation of the nodes.

The testes drain into the abdomen.

No inguinal lymphadenopathy if infections is in the testes.

Front 11

What questions should you ask the patient about sexual activity?

Back 11

How is your sex life?
Are you satisfied with your sex life
Change in level of desire of sexual activity
Sexual preference
STI risk factors

Front 12

What questions should you ask the patient about sexual function?

Back 12

Changes in sexual function/ response
Penile discharge or lesions?
Scrotal pain, swelling or lesions
Sores or growths on the penis
Anal lesions

Front 13

Causes of lack of libido

Back 13

Lack of libido may arise form psychogenic causes as in depression, endocrine dysfunction, or medication side effects.

Front 14

Causes of erectile dysfunction

Back 14

Psychogenic (especially if AM erection is preserved)
Decreased testosterone
Decreased blood flow
Impaired neural innervation

Lack of orgasm with ejaculation is usually psychogenic.

Front 15

Causes of premature ejaculation

Back 15

Medications - SSRIs (Paxil, Zoloft)
Surgery
Neurologic deficits
Lack on androgen

Reduced or delayed ejaculation is less common.

Front 16

Prevention of STIs

Back 16

US is highest STI’s in industrialized world
19 million new STI each year
- ½ in the age group 15-24 years old

19 million currently infected with HIV
Presence of any STD raises need for investigation of HIV co-infection.
CDC 2006 - recommends HIV screening for all people 13-64 year old (despite risks)

Front 17

Testicular self exam

Back 17

15-35 year olds - monthly
Painless lumps, swelling, enlargement, or pain

Front 18

Sexual maturation rating

Back 18

See image

Front 19

Inspection of the penis

Back 19

Prepuce – retract and look for smegma
- Always replace foreskin if you retract it!
Glans - look for lesions, ulcers, scars, nodules, signs of inflammation.

Pubis and pubic hair for distribution, nits or lice.
Note the location of the urethral meatus
Inspect for discharge.

Compress glans between index finger and thumb.
- Mount discharge on a slide for culture.
--- Ask patients to “milk” discharge down for sample.

Front 20

Inspection of the scrotum

Back 20

Skin – lift the scrotum to view its posterior surface
Scrotal contours – note swelling, lumps, veins

Front 21

Palpation of the penis

Back 21

Palpate any abnormal findings from inspection.
Asymptomatic patients do not need to be palpated (except for meatus opening).
If foreskin was retracted, replace it to it’s original position.

Front 22

Palpation of the testes

Back 22

Size, shape, consistency and tenderness
Palpate:
- Each testis and epididymis- between you thumb and first two fingers, locate epididymis
- Each spermatic cord- form epididymis to superficial ring

Front 23

Possible abnormalities of the testes

Back 23

Epididymitis
Orchitis
Torsion
Strangulated hernia
Testicular cancer
Varicocele
Hydrocele
Cryptorchidism

Front 24

Cryptorchidism

Back 24

Testis may be atrophied and lie in the inguinal canal or abdomen or absent testes.

Significant increased risk for testicular cancer is testicle does not descend or removed.

Front 25

Hydrocele

Back 25

Non-tender, fluid-filled mass within the tunica vaginalis.

If testicle transilluminates, it is fluid filled and probably not a mass.
Examining fingers can get above the mass within the scrotum.

Front 26

Varicocele

Back 26

Varicose veins of the spermatic cord
Bag of worms - sometimes seen as a tortuous mass on the surface of the scrotum.
Usually on the left.
Improves when scrotum is elevated
Infertility may be associated due to increased heat production.

Front 27

Testicular torsion

Back 27

Surgical emergency!
Twisting of the testicle on its spermatic cord produces acutely painful, tender, swollen organ that is retracted upward in the scrotum.
- Scrotal edema and erythema
- Most common in adolescents

Front 28

Acute orchitis

Back 28

Acutely inflamed, painful, tender, and swollen testicle.

Seen in mumps and other viral infections.

Usually unilateral

Front 29

Epididymitis

Back 29

Inflamed epididymis that is tender, swollen, and may be difficult to distinguish from testis.
Scrotum and vas deferens may be inflamed.
Mainly found in adults.
Coexisting UTI, prostatitis, or STD may support.

Front 30

Spermatocele or cyst

Back 30

A painless, movable cystic mass just above the testis or epididymis.

Both transilluminate (clinically indistinguishable otherwise).

Front 31

Testicular tumor

Back 31

Usually painless nodule
May be within or near surface of testis, or replace the entire organ.
Irregular, non-mobile, and does NOT transilluminate

Front 32

Inspection of hernias

Back 32

Sit comfortably in front of the patient while he is standing.
Inspect the inguinal region for masses/asymmetry
Ask the patient to strain or bear down (valsalva maneuver).

Front 33

Palpation of hernias

Back 33

The inguinal area for hernia (right side with right index)
Place the tip of your index finger close to the inferior margin of the scrota sac, then move you finger upward along the inguinal canal invaginating the scrotum.
Follow the cord to the inguinal ligament. Find the triangular shaped slit-like opening for the external inguinal ring just above and lateral to the pubic tubercle.
Ask the patient to bear down. Search for bulges/masses
Palpate obliquely the internal ring
Palpate for femoral hernia

Front 34

Indirect inguinal hernia

Back 34

Most common type of hernia
Intra-abdominal contents protrude through the abdominal ring lateral to the inferior epigastric vessels.
Origin is above the inguinal ligament (internal inguinal ring)
Congenital lesion
Most Common and in all ages
Often into scrotum
Comes down inguinal canal and touches the tip of finger.

Front 35

What is the most common type of hernia?

Back 35

Indirect inguinal hernia

Front 36

How do you determine the type of inguinal hernia?

Back 36

Insert finger into inguinal ring.
- Indirect will press on tip of finger
- Direct will press on side of finger

Front 37

Direct inguinal hernia

Back 37

Direct – protrusion of intra-abdominal contents medial to the inferior epigastric vessels. Origin is above the inguinal ligament, close to the pubic tubercle, near external inguinal ring
Rarely into scrotum
Less common
Hernia bulges anteriorly and pushes the side of the finger forward

Front 38

Femoral hernia

Back 38

Defect is through the femoral canal
Inferior to inguinal ligament
Short medial attachment of transverus abdominus onto coopers ligaments that results in an enlarged femoral ring
Least common
Below inguinal ligament and appears more lateral to inguinal hernia
Never into scrotum

Front 39

How do you distinguish a scrotal mass versus a hernia?

Back 39

With the patient supine
Palpate superior to the mass
Can you enter the inguinal canal?
Listen with stethoscope
Transilluminate the mass
Attempt to reduce the mass
Have the patient bear down

Front 40

Anus

Back 40

Terminal canal of GI tract
Closed by :
- Internal anal sphincter
- External anal sphincter
Anorectal junction
- Aka pectinate line
- Dentate line
Somatic innervation

Front 41

Health history of anus and rectum

Back 41

Change in bowel habits?
Blood in stool?
Caliber of stool?
Color of stool?
Pain with defecation?
Itching?
Rectal bleeding?
Anal warts or fissures?

Front 42

Health history of prostate

Back 42

Weak stream with urination?
Hesitancy starting urination?
Urinary frequency?
Nocturia?
Burning with urination?
Blood in urine?
Feeling of discomfort or heaviness in pelvis or at the base of the penis.
Back pain?

Front 43

What is the leading cause of cancer in men?

Back 43

Prostate cancer
3rd leading cause of death in men
Risk factors
- Age >50
- African American >Caucasian
- Family history of 1st degree relative

Front 44

Test to evaluate prostate cancer.

Back 44

DRE
PSA (not recommended every year)
Limitations of tests
Lack of sensitivity and specificity
Screening recommended at age 50
(age 40 for African American or positive family history
Combination of DRE and PSA exam)

Front 45

Positioning ptient for DRE anal exam

Back 45

Standing
Have the patient expose his anus
Flex at the hips and rest the upper body on the exam table

Lying
- Lie in the left lateral decubitus position
- Flex the patients knees and hips

Front 46

Inserting finger into rectm

Back 46

Lubricate your gloved index finger
Notify the patient of what you are going to do
- May get the urge to defecate
- Have the patient strain down
Press against the anal sphincter but wait to insert you finger
The sphincter will relax with gentle pressure
Do not force the examination

Front 47

Palpation of the prostate

Back 47

Insert index finger as far as possible
Rotate clockwise, palpating the right side
Rotate counterclockwise to palpate the left
Return to center to palpate the prostate
Note tenderness, Induration, Irregularities, Nodules, masses (use clock notations or ventral/dorsal terms to describe location)

Front 48

Prostate

Back 48

Pt may feel the need to urinate when palpating the prostate
Identify the lateral lobes and the sulcus in the middle
Try to palpate the seminal vesicle
Note
Shape, size, consistency, tenderness, nodules
Normal prostate feels rubbery and non-tender

Front 49

Prostate/rectal exam

Back 49

Remove finger gently
Wipe the anus or hand the patient tissue to do so
Note color of fecal matter on the glove
When the exam is complete, look for frank blood on the gloved finger.

Front 50

Guaiac/hemocult card

Back 50

Tests for occult blood in stool
Positive test is blue on the test side (-)

Front 51

Phimosis

Back 51

Tight prepuce that cannot be retracted over the glans

Front 52

Cryptorchidism

Back 52

Testis is atrophied and may lie in inguinal canal or abdomen, resulting in unfilled scrotum.

Raises risk for testicular cancer

Front 53

Acute orchitis

Back 53

Acutely inflamed, painful, tender and swollen
May be difficult to distinguish from epididymis
Scrotum may be reddened
Seen in mumps and other viral infections
Usually unilateral