Professional Skills Urology Core Module Trustin Domes

Outline Brief Anatomy of Scrotum and Prostate Physical Examination: CVA, Scrotum and DRE Case Scenarios LUTS Hematuria Upper and lower urinary tract obstruction Scrotal Masses/Pain

Anatomy of Scrotal Contents Vessels: Testicle has 3 arterial blood supplies: Testicular artery Cremasteric artery Deferential artery Pampiniform venous plexus Lymphatics Nerves Cremasteric muscle/fascia Vas deferens

Anatomy of Scrotal Contents Vas is the most posterior component of spermatic cord Tunica vaginalis surrounds the anterior 2/3rd of the testicle and creates a potential space for hydroceles and hematoceles

Clinical Anatomy of the Prostate —Schematic shown in sagittal view of prostate illustrates normal zonal description of prostatic anatomy. Verma S , Rajesh A AJR 2011;196:S1-S10

Prostate Anatomy Peripheral Zone = 85% of prostate cancer originate in this zone, therefore are detected on DRE Transition Zone = site of benign prostatic hyperplasia

CVA and Ballottement If CVA tenderness think: Renal colic Pyelonephritis Significant renal trauma Renal vascular occlusion If you can ballot the kidney think: - Large renal mass - Polycystic kidney disease - Severely hydronephrotic kidney

Physical Examination of the Scrotum Best to examine the man in both the supine and upright positions Helps to demonstrate conditions that change with position: hernias and varicoceles Bimanual examination of each testicle, adenxa and spermatic cord Testicular size, consistency, masses, tenderness Normal testis size 16-20 cc (2 x 4 cm) Examine cord upright (+/- valsalva) to assess for presence of vas deferens, inguinal hernia and varicocele

Cremasteric Reflex Reflex elicited by stroking the medial thigh causes an ipsilateral contraction of the cremasteric muscle (bringing the testicle closer to the external inguinal ring) Reflex tests L1-L2 (genitofemoral nerve responsible for afferent and efferent limbs) Typically absent in testicular torsion Negative predictive value of over 90%

Transillumination Important to help differentiate solid from fluid-filled masses Hydroceles and spermatoceles will transilluminate, other scrotal masses typically WILL NOT Hydrocele

Varicoceles Dilated veins of the paminiform plexus Predominant left-sided (98%) Isolated right-sided varicocele may be caused by a retroperitoneal NEED abdominal imaging Varicocele grading: Grade I: palpable only with valsalva Grade II: easily palpable without valsalva Grade III: large, visible through scrotal skin Grade III: “bag of worms”

Digital Rectal Examination Comment on: Prostate Size Symmetry Consistency Tenderness Nodules Rectal/Anal Masses Rectal Tone

Prostate size Average prostate size is approximately 25 cc in men older than 50 years 25 cc 150 cc How many finger-breadths across? Can you get to the top (base)?