Ruth Westra D.O., M.P.H. November 5, 2007 MALE EXAM Ruth Westra D.O., M.P.H. November 5, 2007 History: CIRCUMCISION-matter of hygiene, in past ritualistic..3000BC and Biblical texts in Genesis and Leviticus GONORRHEA-Bible, Hindu literature, and Egyptian papyruses Named by Galen in 2nd century AD –Greek translation – “flow of offspring” Past 400 years – “clap”-red-light district in Paris called “LeClapier” SYPHILLIS-believed to be introduced on the European Continent 1492 sailors returning with Columbus, Frances invasion of Italy and siege of Naples 1495 King’s pox

TUNE YOUR SELF UP It’s Time to Look Under Your Own Hood Will You Do What It Takes To Go 100,000 Miles “Guys understand cars. They know that to get to 100,000 miles on the odometer, you have to take really good care of the internal components: the engine, the drivetrain and the wheels.” Difference is that you don’t have the luxury of buying a new body – only get one chance to maintain your body.

PREVENTIVE MAINTENANCE Every three years from 20 to 39 Every two years from 40 to 49 Every year after 50 BENIGN PROSTATIC HYPERTROPHY(BPH)-most common benign neoplasm in aging men-50% have by age 60, 90% by age 85..by 80 1in 4 men will require treatment for BPH (300,000 surgical procedures annually US) CANCER of GU SYSTEM: Prostate Cancer 29% of all CA in men and Urinary tract CA additional 6% Highest incidence in African American men TESTICULAR CA: 1% of all CA in men-Most common cancer in men age 15-35 years old..in 2000 6,900 new cases in US and 300 deaths..asymptomatic testicular mass…most important progrnostic factor-early detection then 90% cure rate ERECTILE DYSFUNCTION (ED): 30 million Americans-increases with aging Massachusetts Male Aging Study – 52% of men between 40 and 70 had some degree of ED.

PREPARING AND POSITIONING THE PATIENT Last part of the physical exam Explain to the patient Patient standing with gown and physician seated Gloves May cause the patient and you embarrassment (discomfort) – but better with explanation. Have the patient stand in front of you and raise their gown to the level of the umbilicus Gloves prior to beginning (nonsterile)

Greeting and Discussion Explain the procedure Ease apprehension Stress the importance State the reasons Address any misunderstandings Make the patient as comfortable as possible.   During this initial time, the examiner may prepare for the procedure. Hand washing is mandatory and gloves must be worn throughout the procedure. This provides protection for the examiner and the patient

Patient Positioning                                                      Standing allows more in the movement of the testicles. Supine positioning makes it more difficult to detect herniations. A supine position may be used if the patient is unable to stand.

OBSERVATION Bulges or Scars in the Inguinal Region? Penile or Scrotal Abnormalities? Skin Abnormalities on the penis, scrotum or surrounding areas?

Superficial Visual Inspection                                                   Tell the patient that the exam is about to start. Ask the patient about any history of rashes, sores, or lesions prior to the exam while checking for these irregularities. Establish physical contact on the side or lateral leg                             Visually inspect the ventral surface of the penis. Move the scrotum to check the posterior side. Retract foreskin, if present. Inspect the glans for: lesions swellings ulcers scars evidence of inflammation.                                 

THE PENIS The Glans The Opening of the Urethra The Shaft The Pubic Hair Examine the head of the Glans –head of the penis ---if not circumcised draw back the foreskin (prepuce) Return the foreskin back to the normal position – to avoid para-phimosis May not be able to draw back the foreskin – known as phimosis Opening of the urethra Epispadias -- top-side of urethra or Hypospadius ---bottom side urethra Check for discharge -- urethritis 2nd to Chlamydia or Gonorrhea Feel shaft of the penis – fibrosis may occur along the shaft and may cause curvature – Peyronnie’s Dx. Examine the base and the pubic hair – look for skin abnormalities – ulcers or vessicles The blood supply t the penis is from the internal pudendal artery

Palpation of the Penis                                                Inspect the urethral meatus for discharge and irregularities by squeezing above and below the verticle opening. Swab and culture the discharge if present. If discharge is reported but not present, ask the patient to milk or roll the shaft of the penis toward the meatus in an attempt to reproduce the discharge.                              Compress the shaft of the penis between the thumb and the first two fingers, palpating the entire shaft from base to tip for irregularities. Note any abnormality in: size tenderness firmness Back to top  

TESTICULAR EXAM Nodules Hydrocele Pain or tenderness Left testis lies a bit lower in the scrotum than the right - due to longer left spermatic vein Palpate with the thumb and next two fingers - should be able to feel two – if not question the patient if one has been surgically removed – or ?congenitally undescended testis Presence of a firm nodule would be worrisome for testicular malignancy Entire testis may be enlarged – most commonly a hydrocele – collection of fluid that fills a potential space surrounding the testis. Trans-illuminations – a hydrocele will allow transmission of light – with flashlight in dark room – testis will not. Epididymis – discrete structure lies towards the top and back of each testis Note any testicular pain- may be less painful in SUPINE position

Scrotal and Testicular Palpation                                                                  Palpate the entire area of the scrotum and each testicle separately manipulating them as needed to cover all the structures contained within the scrotum. Note: Size Shape Consistency Tenderness The left testis may be lower due to a longer testicular vein. Feel for nodules and swelling.                                The epididymus and spermatic cord also must be palpated on the posterior side of the testicles as they course superiorly toward the body into the inguinal canal. Normal testicle oval, firm/rubbery, smooth and freely moveable. Transillumination of swellings within the scrotum may be necessary to distinguish tumors from hydroceles. In a darkened room, place a penlight behind the mass. Light should present as a red glow. Tissues, tumors, and blood will not transilluminate as a hydrocele containing serous fluid does. SCROTUM: divided into halves b the interscrotal septum-major role is temperature regulation of the testes (2 degrees lover than the peritoneal cavity-necessary for spermatogenesis) EPIDIDYMIS:-sminiferous tubuses end in the epididymis-posterior border of the testes continues to the Vas Deferens. VEINS: drian from the pampiniform plexus into the testicular vein. RIGHT Testicular vein drains into the inferior vena cava, LEFT drains into the Left renal vein.

TESTICULAR SELF-EXAM Hard, painless lump in the testicle Pain or dull ache in the scrotum A scrotum that feels heavy or swollen Most common cancer in young men (15 to 34 years old) More likely in White men HX of father or brother with testicular cancer Undescended testicle Klinefelter’s Syndrome 6,900 cases in 2000 – 300 died of the disease AAFP formerly recommended a testicular examination for all males in the 13 year old to 39 year old age group with a history of cryptorchidism, orchiopexy and/or testicular atrophy. Currently, AAFP provides no recommendation for testicular cancer screening in the general population. Insufficient evidence to recommend for or against routine screening for asymptomatic men.

SPERMATIC CORD STRUCTURES Ductus (Vas) deferens Panpiniform plexus of veins Testicular artery Genitofemoral nerve Lymphatics Fatty Tissue All of the above structures make up the SPERMATIC CORD Panpiniform plexus becomes the testicular vein The VAS – can be distinguished – lies along the posterior aspect of the bundle – FIRM and WIRE LIKE Normally will not be able to identify the rest specifically Pay attention to any discrete swellings and relationship to the testes and the inguinal canal Dilated veins – VARICOCELE – (feels like a bag of worms) - palpable throughout length of the cord structures.

HERNIA EXAM Right Inguinal Exam – Your right index finger along the spermatic cord Left Inguinal Exam – Your left index finger along the spermatic cord If you palpate swelling along the cord structures or note the inguinal canal to be protuberant – probably inguinal hernia Have patient bear down (valsalva) or cough – AWAY from you – these increase intra-abdominal pressure – forcing intestines/omentum/peritoneal fluid through any defect that is present and making hernia apparent Hernias are non-tender and no evidence of inflammation – If inflammation or pain present – may indicate incarceration/strangulation of the entrapped contents- constitutes a surgical emergency. Hernias – difficult to tell if indirect of direct by exam (see BATES) Indirect: Most common-Above ingiunal ligament, often into scrotum Direct: Less common-Rarely into the scrotum Femoral: least common, Below the inguinal ligament, Never into scrotum May be performed supine if patient unable to stand (especially helpful to identify a discrete mass or undescended testis.

Hernias                                                  Direct and indirect hernias must be checked during the exam. Palpation of the inguinal ring and canal as well as the femoral triangle are necessary. A mass in either location may be a possible herniation of peritoneal contents. Gastric sounds are often present in such cases.

TYPES OF HERNIAS Indirect: most common Direct: less common Femoral: least common Bates table : Differentiation of Hernias in the Groin Indirect: Most common-all ages both sexes; often in children, may be in adults; origin above the inguinal ligament, near its midpoint (the internal inguinal ring); often into scrotum; touches the fingertip Direct: less common; men over age 40-rare in women; above inguinal ligament close to the pubic tubercle –near external ring; rarely into scrotum; bulges anteriorly and pushes side of the finger forward Femoral: least common;more common in women; below the inguinal ligament-may be hard to differentiate from a node; never into scrotum; inguinal canal is empty

RECTAL/PROSTATE EXAM Inspection Palpation upwards, posteriorly and laterally to feel for rectal masses Palpation anteriorly to examine the prostate gland Stool guiac testing – occult blood Position – Standing leaning over the exam table or laying in the left lateral Simms position Lubrication – KY Jelly Box of tissue paper – for cleaning afterwards. Stool guiac testing – for detection of hemoglobin Tell the patient what you are going to do. ASK them to bear down as you insert index finger of right hand Feel for any resistance – Stool vs mass Gently rotate your hand For prostate – TWO lobes with cleft running between – discrete? Symmetrical? Firm nodules? check to see if freely movable or fixed– does gland feel enlarged??? ( Difficult if pt obese, small fingers or big prostate. ---pain – prostatitis Assess rectal tone Examine stool – color- red or black?- test for blood and add reagent.

DVD FILM CLIP Schwartz, Mark. Textbook of Physical Diagnosis

REFERENCES http://medicine.ucsd.edu/clinicalmed http://cancereducation.uams.edu/Modules/malegu/gu http://www.malehealthcenter.com/Selfcare.html Surgical Options in the Management of Groin Hernias AAFP 1/1/99 Testicular Masses AAFP 2/15/98 The Undescended Testicle AAFP 11/1/2000