1. 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

2. 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.

3. 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 years old..in ,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.

4. 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)

5. 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

6. 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.

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

8. 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.
                                

9. 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

10. 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
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11. 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

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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

18. 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.

19. DVD FILM CLIP
Schwartz, Mark. Textbook of Physical Diagnosis

20. REFERENCES http://medicine.ucsd.edu/clinicalmed
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