1. Male Examination Gender-Related Health Lisa Zaynab Killinger, DC

2. What can you expect from this class? (Or what do you get in return?)
Fulfill the requirements of your licenses!
Learn info relevant to clinical practice
Learn info for success on boards
Have fun?

3. Let’s get started!

4. The Digital Rectal ExamOr
Why do I have to know this stuff ????

5. What is a DRE? A DRE evaluates the terminal portions of the G-I tract.
Sacrococcygeal and perianal areas
Anus
Sphincter and anal ring
Lateral and posterior rectal walls
Anterior rectal wall and prostate for males
Stool

6. DIGITAL RECTAL EXAM Why should a DRE be performed?
How frequently should a DRE be performed?
Who can perform a DRE?

7. Why? Yearly screening for males As part of an annual exam for females
Over age 50 for most; over age 40 for high risk
As part of an annual exam for females
Yearly after becoming sexually active
History-Perianal pain, problems w/urination/defecation/sexual function
Symptoms? Low Back Pain, hesitancy or dribbling of urine, other local pain, changes

8. Who? Chiropractors---In most states
Family practitioners/General practitioners
Gynecologists
Proctologists/Urologists
Physician’s assistants

9. What do patients say that provide clues that a digital rectal exam should be done?

10. Symptoms Changes in bowel function Changes in bladder function
number, frequency, consistency, color, blood
Changes in bladder function
hesitancy, urgency, nocturia, dysuria, dribbling, discharge, decreased caliber or force
Anal discomfort or rectal bleeding
Sexual dysfunction

11. When can’t a DRE be done? Anal fissures---very painful
Anal fistula--very painful
Spasticity of the sphincter
Rectal prolapse

12. Important issues related to this exam:
Patient modesty
Patient culture
Dr/Pt boundary issues
Patient history of abuse, rape, incest, etc.

13. What should we do? Take a complete history
Always have another individual in the room if you do this exam
Talk to patient about their comfort level with this exam, & with you doing this exam
If you or patient is uncomfortable refer to another health professional for this exam!

14. But, in the end…
Make sure that every patient over 50 (or over 40 with risk factors) is having this exam done annually by SOMEONE!
If you don’t, you are liable for missed diagnoses. (Failure to diagnose is one of the most common successful malpractice claims against DCs.)
Use your education to protect your patients’ health! Be a DOCTOR of Chiropractic.

15. Let’s talk about anatomy!

16. The Rectum The rectum is approximately 12 cm long.
Proximally, it joins the sigmoid colon.
Distally, it joins the anal canal at the anorectal junction (about 2.5 to 4 cm).
The distal end is not palpable.
Folds in rectal walls may be palpable.

17. The Rectum Inferior rectal valve Internal h. plexus Crypts Columns
Internal sphincter
External sphincter

18. Sphincter Control
The internal sphincter is made of smooth muscle and is under involuntary autonomic control.
The external sphincter is made of striated muscle and is under voluntary control.

19. The urge to defecate occurs when the rectum fills with feces which causes reflex stimulation of the internal sphincter.
Defecation is then controlled by the striated external sphincter.

20. The lower half of the anal canal is supplied with somatic sensory nerves, which makes it sensitive to painful stimuli.
The upper half of the anal canal is under autonomic control and is not well-supplied by sensory nerves. Therefore, it is relatively insensitive to pain (lesions).

21. The Prostate Located at the base of the bladder Surrounds the urethra
Made of both fibromuscular and glandular tissue
How big?
Chestnut size: 4cm X 3cm X 2cm
In infants and children—small and inactive
In adolescents—enlarges and becomes active
After age 25—continues to enlarge

22. The Prostate
Urethra
Median lobe
Ejaculatory duct

23. So, what does it do? It is the source of much investigation.
We know that it contributes to the ejaculatory fluid.
Believed to secrete enzymes that decrease the viscosity of the ejaculatory fluid
Believed to lower acidity of the vaginal canal

24. Access to the prostate
The posterior surface of the prostate (what we palpate) is in close contact with the anterior rectal wall.
A sulcus runs through the middle of the prostate and divides it into right and left lobes.

25. So, how do we evaluate the prostate?
Size
Contour
Consistency
Mobility
Protrusion into the rectum
Grade 1, Grade 2, Grade 3, Grade 4
Sulcus present
Pain with palpation

26. What does it feel like?
Pencil eraser
Tip of your nose
Thenar pad

27. Prostate Conditions Benign prostatic hypertrophy Prostate carcinoma
Acute prostatitis
Chronic prostatitis
Others: Prostatic calculi or abscesses

28. Benign Prostatic Hypertrophy (BPH)
Etiology is unknown
VERY common in males over age 50
Symptoms rare before 40
50% have symptoms after age 60
70 to 90% have symptoms after age 70

29. What happens? The normal tissue is replaced by collagen.
Results in expansion of the capsule, leading to pressure on the urethra; bladder and urinary symptoms (as discussed earlier).
All or part of prostate may enlarge.

30. Digital Exam of BPH Size—enlarged Consistency: boggy, squishy, smooth
Mobility—remains fairly mobile
Protrusion—Grade depends on stage
Sulcus—may be obscured (vs. obliterated)
Should be nontender

31. The degree of enlargement of the prostate may not be related to symptoms
i.e., a prostate that is markedly enlarged may not obstruct urinary flow

32. “Acute urinary retention” may occur, and in general symptoms may be aggravated by:
Exposure to cold
Immobilization
Attempts to retain urine
Anesthetics, anticholinergics
Ingestion of alcohol

33. Other complications: Incomplete bladder emptying leads to:
Urinary stasis
Predisposes to infection of bladder and tract
Hydronephrosis
Renal calculus formation

34. Treatments for BPH “Wait and see” Drug therapy Herbal remedies
Prostatectomy

35. Questions about BPH?

36. Prostatic Carcinoma 2nd leading cause of cancer death in males over 65
An adenocarcinoma (sarcoma is rare)
Rare before the age of 50
122,000 new cases/year in the US
Etiology is unknown

37. Risk Factors Age?? Race?? History?? Diet?? Age over 50 years
African-American
Family history of CA
High in animal fat
Age over 50, Black or African-American descent, family history, diet high in animal fat

38. Signs and Symptoms In the early stages, asymptomatic!!
Late in its course:
Bladder obstruction
Ureteral obstruction
Hematuria
Pyuria

39. Does it metastasize?
Carcinoma from the prostate is responsible for 60% of all skeletal metastasis
25% is due to lung cancer
Predominantly blastic mets, but may be mixed

40. So, how do we detect it? The DRE! Size— Contour— Consistency—
Mobility—
Protrusion—
Sulcus—
Tenderness–

41. Size—Normal early, enlarged later
Contour—Asymmetrical
Consistency—Hard nodules*
Mobility—May resist movement
Protrusion—Grade 1-4
Sulcus—Obliterated (advanced CA)
Pain—NO- usually asymptomatic

42. Important Differentials
Prostatic CA is not the only lesion with hard nodules:
Prostatic calculi
Prostatic TB
Prostate granulomata

43. But, all hard nodules in the prostate should be considered cancerous, until everything else is ruled out!

44. PSA Prostate Specific Antigen
A glycoprotein specific to the prostate, but not to prostate carcinoma
Produced by both healthy and unhealthy prostate tissue
Serum PSA is moderately elevated in
30 to 50% of patients with BPH

45. PSA Levels* Levels < 4 ng/ml are considered normal
4 to 10 ng/ml are considered borderline
Above 10 ng/ml is considered high

46. The higher the PSA level, the more likely the presence of prostate CA….
However…….
Men with prostate CA can have negative or borderline PSA levels

47. How do we prove otherwise?
PSA—is elevated in 25 to 92% of patients with prostate cancer
TRUS-Trans-rectal ultrasound
Biopsy

48. Borderline PSA levels
PSA density (PSAD): divide the PSA number by the prostate volume (TRUS)
Age-specific ranges: Older men have higher PSA levels, even without CA
PSA velocity: Serial testing that measures how quickly PSA levels rise over time
Free PSA ratio: Bound vs. Unbound
*low levels of free PSA are more likely CA

49. TRUS
Performed when the PSA level is borderline and the DRE is negative
Visualizes the areas needed for biopsy
Helps determine the prostate volume (PSAD)

50. TRUS

51. Normal TRUS Image

52. Abnormal TRUS Image

53. TURP

54. TURP

55. Pre & Post Prostate Resection

56. Other Prostate Conditions
BPH and Prostatic Carcinoma are, by far, the most common conditions associated with the prostate.
Other conditions include….

57. Acute Prostatitis Due to enteric, gram-negative bacteria
High fever, chills, flu-like symptoms
Perineal, prostate, and low back pain
Symptoms of urinary obstruction
Dysuria: Pain or burning with urination
Nocturia
Hematuria (may be gross)
Arthralgia and myalgia

58. What are the DRE results?
Size—enlarged and may be warm
Contour—asymmetrical (within 1 lobe)
Consistency—indurated; fluctuant mass
Mobility—may be fixed
Protrusion—may be present
Sulcus—usually preserved
Pain—YES! Very painful!

59. Prostate Abscess- (Hole)
Develops as a complication of acute prostatitis, urethritis, epididymitis
Gram-negative or Staph. Aureus
Dysuria, frequent urination, retention
Pyuria
Fever is present in some
Leukocytosis is common
Recurrent UTIs and perineal pain should suggest an abscess

60. DRE of an Abscess May palpate as a hole or a divot in the prostate.
Findings may also be normal or a fluctuant mass may be present
Tenderness is possible

61. Chronic Prostatitis Also bacterial and assoc. with UTIs
Some may be asymptomatic
Most have low back and perineal pain
Urinary urgency and frequency
Dysuria
Infection can spread to scrotum and epididymis

62. DRE Findings Size—enlarged, but not like acute
Contour—usually more symmetrical
Consistency—irregularly indurated or boggy
Mobility—may be fixed
Protrusion—not much of an issue
Sulcus—preserved
Tenderness—only moderately tender, if at all

63. Prostatic Calculi Protein stones of corpora amylacea
Theory: normal secretions of the prostate are blocked in the ducts (i.e. due to BPH)
These blocked secretions dry out and calcify
May also be secondary to infection

64. Symptomatic? Passable?
Typically not symptomatic, but may be discovered when BPH becomes symptomatic
Not surrounded by fluid like a kidney stone, but about 1% of men can pass stones in the urine

65. Questions about any of the prostate conditions?