PD Exam 3: Female Genitalia/Rectum/MSK/Behavioral Health

the rectal wall has 3 inward foldings called?

valves of houston

internal anal sphincter

smooth muscle, involuntary, vascular

external anal sphincter

skeletal muscle, voluntary

what is the external anal sphincter innervated by?

perineal branch of sacral nerve 4

anorectal junction

pectinate or dentate line; Serrated line marking change from skin to mucous membrane NOT palpable

squamocolumar junction

Squamous epithelial cells meet columnar cells

prostate gland

heart shaped organ that surround the urethra, two lateral lobes palpable during rectal exam

seminal vesicles

Saclike structure above prostate that are shaped like rabbit ears

Not palpable

Fluid component of semen production

cowper's gland (bulbourethral glands)

Located at the base of the penis

Produces Pre-ejaculate and Prostate Specific Antigen (PSA)

what is the best position for a male rectal exam?

Stand leaning forward over examination table

what should you inspect the sacrococcygeal area and perineum for?

Lumps

Ulcers

Inflammation

Rashes

Excoriations

Fissures

how do you assess for sphincter tone of the anus?

have pt bear down and assess for..

Tenderness

Induration

Nodules/masses

Lesions

what structures are palpable anteriorly on a rectal exam in a male?

Full bladder

Urethra if catheterized

Bulbourethral glands

Prostate

what structures are palpable anteriorly on a rectal exam in a female?

Vagina

Cervix

Body of uterus when retroverted

Rectouterine fossa

what structures are palpable laterally on a rectal exam?

Ischial tuberosity and spine

Sacrotuberous ligament

what structures are palpable posteriorly on a rectal exam?

pelvic surface of sacrum and coccyx

Stool Guaiac Test Or Fecal Occult Blood Test Or Hemoccult (FOBT)

Detect blood invisible in the feces

Perform upon completion of physical exam

Occult blood testing is an adequate screen for colon CA t/f

false

1 multiple choice option

Pilonidal Cyst

Congenital cyst formation (part of newborn exam)

presentation of pilonidal cyst

Small tuft of hair surrounded by halo of erythema

May be asymptomatic with little drainage

Can complicate to abscess, and/or fistula formation. Often recurrent.

internal hemorrhoids

Enlargements of normal vascular cushions located above pectinate line

NOT painful

external hemorrhoids

Originate below pectinate line and covered with skin

Anal pain only if thrombosed

what are the 4 degrees of hemorrhoids?

1st Degree – confined to anal canal

2nd Degree – Mucosal prolapse during straining with spontaneous reduction

3rd Degree – Manual reduction required

4th Degree – Chronic protruding mucosa

rectal procidentia

rectal prolapse

symptoms of rectal prolapse

Fecal incontinence

Rectal bleeding

Mucous discharge

anal fissure

Oval ulceration of anal canal

Associated with constipation, diarrhea, infection, perianal trauma, Crohn's disease

where are anal fissure most commonly location and what may they have just below?

midline - posterior; sentinel skin tag

symptoms of anal fissure

Anal pain

Irritation

Mild hematochezia

anorectal fistula

Inflammatory tract which opens at one end into the anus or rectum and at the other end onto the skin surface

what are 10% of anorectal fistulas associated with?

IBD

symptoms of anorectal fistula

Throbbing pain

Drainage- may increase with defecation

Firm mass

rectal polyps

Pedunculated or Sessile, Soft, Usually asymptomatic but patient may have:

Blood in the stool

Pain, diarrhea, constipation

what are risk factors for colorectal carcinoma?

family hx, diet

what are symptoms of colorectal carcinoma?

May be asymptomatic

Insidious blood loss- symptoms of iron def. anemia (fatigue, palpitations)

Can manifest as an obstruction

Abdominal cramping

Hematochezia, tenesmus, change in stool caliber (pencil thin stools)

Weight loss

Firm, nodular mass on exam

where does an anal carcinoma occur?

between anorectal ring to halfway between the pectinate line and the anal verge

what are anal carcinomas often related to and what are symptoms?

HPV;

Bleeding

Anal pain

Annular mass

Pruritus

prostatits

inflammation of the prostate

symptoms of acute bacterial prostatits

Fever

Urinary symptoms (frequency, urgency, dysuria, incomplete voiding)

Low back pain

Rectal pain

PE of acute bacterial prostatitis

Gland is tender, swollen, boggy and warm on palpation

symptoms of chronic bacterial prostatitis

Asymptomatic

Dysuria or mild pelvic pain

Chronic low grade pelvic/urinary pain/problems

PE of chronic bacterial prostatitis

Normal prostate exam

what is chronic bacterial prostatitis associated with?

recurrent urinary tract infections

symptoms of chronic non bacterial prostatitis (chronic pelvic pain syndrome)

Irritative voiding symptoms

Similar to chronic bacterial prostatitis but show no evidence of prostate infection or UTI

PE of chronic pelvic pain syndrome

Assess for prostate induration or asymmetry to R/O carcinoma

Generally no abnormality appreciated on prostate exam

benign prostatic hyperplasia (BPH)

Nonmalignant enlargement of prostate gland

symptoms of irritative BPH

urgency, frequency, nocturia

symptoms of obstructive BPH

Hesitancy

Decreased force and caliber of the stream

Sensation of incomplete bladder emptying

Post void dribbling

Straining

prostate cancer

Suggested by an area of hardness/nodule in the gland

Distinct hard nodule that alters the contour

Rarely presents with signs of urinary retention

what is the most common site of metastasis in prostate cancer?

axial skeleton

as prostate cancer enlarges...

Feels irregular

Extend beyond confines of gland

Median sulcus obscured

what are the stages of prostate cancer?

Stage I: Small and only in prostate

Stage II: Still within prostate but larger and may involve both sides of the prostate

Stage III: Cancer has spread beyond the prostate to nearby tissues

Stage IV: Cancer has spread to distant parts of the body such as lymph nodes

what are prostate cancer risk factors?

age, ethnicity, family hx, meds, environmental, diet

how far does breast tissue expand?

Extends from the inferior clavicular line to the inframammary fold, and from mid sternum to the axilla

anatomy of the areola and nipple

Pin-point openings

Small bumps

Smooth muscle

Sensory Innervation

Montgomery gland

aveoli

glandular tissue that makes milk

excretory duct

lactiferous duct that transports the milk; "highways"

lactiferous sinuses

storage of milk; "holding tanks"

what are 4 chains of axillary lymphatic's and how do they drain?

Central (deep in axilla)

Pectoral (anterior)

Lateral (proximal humerus)

Subscapular (posterior)

Pectoralis/Lateral /Subscapular → Central → Infraclavicular/Supraclavicular

what are the 5 tanner stages of breast development?

Stage 1 - preadolescent

Stage 2 - breast bud

Stage 3 - further enlargement, elevation of areola and breast

Stage 4 - projection of areola and nipple, secondary mound

Stage 5 - Mature stage. Projection of only, areola recedes to general contour of breas

what are the recommendations for clinical breast exams?

20-40 - at least every 3 years

40 and up - annually

CBE replace mammography t/f

false

1 multiple choice option

when doing a CBE, you notice your patient has a inversion nipple, should you be concerned?

no, only concerning if happens out of the blue/not normal for the patient

what are the methods of palpation for a CBE?

Circles

Wedges

Lines

why is noting the consistency of tissue during a CBE important?

Physiologic nodularity

+/- inframammary ridge

what are you accessing during palpation for tenderness in a CBE?

Premenstrual fullness

Fibrocystic tissue

what lymph nodes are you palpating during an axillae exam?

Central

Pectoral

Lateral

Subscapular

Supra/infraclavicular

what are some types of breast surgies?

Mastectomy

Lumpectomy

Augmentation

Reduction

Reconstruction

mastectomy

removal of all breast tissue

lumpectomy

removal of some/a lot or little tissue (not all)

aumentation

breast implants; normally will be no breast tissue

reconstruction

after mastectomy to rebuild shape/look of breast

Gynecomastia

enlargement of breast tissue in males - harder to identify in larger men but will have other signs like the nipple

Self breast exam

no longer recommended however breast self-awareness is still important (Encourage patients to just be familiar with their bodies!)

name 4 types of breast masses

fibroadenoma

cyst

fibrocystic disease

cancer

fibroademona

15-25 yo

Single or multiple

Round, disc or lobular

Usually firm

Well-demarcated

Mobile

Nontender

cyst

30-50 yo

Regress after menopause

Single or multiple

Round

Soft/firm, rubbery

Well -demarcated

Mobile

Often tender

fibrocystic disease

25-50

Nodular, rope-like densities

+/- tender

what is the most common cause of cancer in women?

breast cancer

breast cancer

30-90 yo (mostly > 50)

Usually single mass

Irregular or stellate shape

Firm, hard consistency

Not well-demarcated

May be fixed

Usually nontender

May see skin changes or nipple retraction

what are non-modifiable risk factors for breast cancer?

Gender

Age

Race

Family history

Early menarche

Late menopause

High breast density

what are modifiable risk factors for breast cancer?

Postmenopausal obesity

Use of combination HRT

Alcohol use

Physical inactivity

Estrogen containing contraceptive use

Nulliparity

>30yo at first full-term pregnancy

Never breast fed a child

what area of the breast (in males and females) is at highest risk for breast cancer?

upper outer quadrants

what are changes are on PE on the breast that can be associated with cancer?

Retraction, dimpling, contour change

Nipple retraction/deviation

peau d-orange

Code orange (looks like an oranges skin)

Sign of inflammatory breast cancer

inflammatory breast cancer

the most aggressive and least common form of breast cancer; Automatic grade 4

pagets disease of the nipple

uncommon form of breast cancer, starts as scaly eczema like lesion that may weep, crust, or erode

what is the best way to screen for breast cancer?

mammography

Traditional mammography

low dose x-ray with images viewed on 2 dimensional film

Digital mammography

addition of digital technology allows images to be viewed on a computer screen

3D Tomosynthesis

addition of 3D technology allows images to be viewed in multiple planes/layers

what is an advantage of 3D tomosynthesis?

Fewer false negative results

Fewer false positive results

Increased breast density is known to increase breast cancer risk in what two ways?

1. As an independent risk factor

2. By obscuring small findings

what are the BI-RADS categories?

A- Almost entirely fatty

B- Scattered areas of fibroglandular density

C- Heterogeneously dense

D- Extremely dense

what are supplemental screening tools for dense breast?

Contrast Enhanced MRI

Whole Breast Ultrasound

Emerging Technologies

Contrast Enhanced MRI

More sensitive than mammography

Limited by cost and availability

Requires local expertise in reading breast MRIs

Whole Breast Ultrasound

Two types, handheld US and automated breast US

High risk of false positive results

Affect of repetitive doses of contrast gadolinium is unknown

what are the emerging technologies for screening dense breasts?

Abbreviated MRI

Molecular breast imaging

Contrast enhanced mammography

what is a potential future screening method that is approved by the FDA as an adjunct to mammography?

thermography

what genetic mutations increase the risk of possible breast/ovarian cancer?

BRCA1 and BRCA2

who should get a mammogram?

All women should be encouraged to have breast self- awareness.

All women age 40yo and older should be talking to their health care provider about breast cancer screening

All healthcare providers must be knowledgeable about screening modalities, risk, and benefits for the patient