PD E3- Male GU

What age range of patients should you discuss testicular self exam & safe sexual practices as well as prostate & CRC screening, sexual function, & incontinence?

≥ 40

What is an ovoid, rubbery structure that produces testosterone & spermatozoa?

*network of tightly coiled seminiferous tubules that converge and anastomose into efferent tubules encapsulated by tunica albuginea

Testis

What is located on the posterolateral surface of each test and is a soft comma shape?

Epididymis

What begins at the tail of the epididymis, ascends the scrotal sac & passes through the internal inguinal ring into the abdomen and pelvis?

*joins seminal vesicle duct to form ejaculatory duct which passes into prostate gland

Vas deferens

What is a muscular pouch that contains the testes?

Scrotum

What structure is formed by vas deferent, testicular arteries, & veins?

Spermatic cord

What structure?

• lies above & approximately parallel to inguinal ligament & forms tunnel for vas deferens

• exterior opening

Inguinal ring

What structure?

• lies below inguinal ligament

• locate by placing R index finger from below on R femoral artery & middle finger will overlie femoral vein & ring finger will be on femoral canal where herniation may occur

Femoral canal

What are the borders of Hesselbach’s triangle?

Lateral (upper L to center): inferior epigastric vessels

Inferior (upper R to bottom L): Inguinal ligament

Medial (upper L to bottom L): rectus abdominis muscle

What is the region of potential weakness where a direct inguinal hernia can occur?

Hesselbach’s triangle

Direct or indirect inguinal hernia?

• protrudes through both deep inguinal ring & superficial inguinal ring

  • can protrude into scrotum

• due to incomplete closure of deep inguinal ring

  • possibly congenital

• MC in males - infancy or old age

Indirect inguinal hernia

Direct or indirect inguinal hernia?

• protrude through hesselbach triangle into inguinal canal

  • exit inguinal canal through superficial inguinal ring

• lump in groin

• caused by weakness in abdominal wall due to age

Direct inguinal herna

In what position should the patient be when you check for hernias or varicoceles?

Standing

What technique used to determine nature of a scrotal mass applies a light source to the side of scrotal enlargement?

Transillumination

What is cryptorchidism?

Undescended testes

What should you instruct the patient to do when inspecting inguinal / femoral area?

Cough or bear down

How do you elicit the cremasteric reflex?

*presence does NOT eliminate testicular torsion

Lightly stroke superior & medial thigh → utilizes sensory & motor nerve fibers of genitofemoral nerve (L1-L2)

What diagnosis?

• Transillumination: no

• Tenderness: none

• Location: testes > 4cm inferior to pubic tubercle

• Association: smooth with epididymis

Normal testes

What diagnosis?

• Transillumination: no

• Tenderness: none

• Association: risk of testicular cancer

Cryptorchidism

What diagnosis?

• Transillumination: yes

• Tenderness: none

• Location: anterior to testes

• Association: fluid in tunica vaginalis

Hydrocele

What diagnosis?

• Transillumination: yes

• Tenderness: none

• Location: head of epididymis posterior to testes

• Association: benign

Spermatocele

What diagnosis?

• Transillumination: no

• Tenderness: none, unless infarction or torsion

• Location: contiguous with testes anterior & posterior

• Association: irregular nodule or mass

Neoplasm

What diagnosis?

• Transillumination: no

• Tenderness: none to mild

• Location: posterior to tests - left side

• Association: increase with valsalva, decrease with scrotal elevation; “bag of worms”

Varicocele

What diagnosis?

• Transillumination: no

• Tenderness: yes

• Location: posterior to testes

• Association: swelling or discrete nodule or mass

Epididymitis

What diagnosis?

• Transillumination: no

• Tenderness: yes

• Location: swelling and mass tender around testes

• Association: exquisite pain and tenderness, associated with testicular cancer

Torsion

What diagnosis?

• Transillumination: no

• Tenderness: no

• Location: epididymitis anterior to testes

• Association: normal variant

Anteverted epididymitis

Scrotal diagnosis chart

What emergent conditions might cause an acute scrotum?

Testicular torsion, fournier’s gangrene, epididymitis w/ abscess formation, strangulated inguinal hernia

What are hydroceles commonly associated with?

Indirect inguinal hernia

Most epididymides are _____

Posterior

What are RF for the development of Fournier’s gangrene?

Uncontrolled DM, high dose steroids, neutropenia

Where is an indirect inguinal hernia?

Out of hesselbachs triangle → enters inguinal canal lateral to inferior epigastric vessels & exits inferior to inguinal ligament

Where is a direct inguinal hernia?

Within hesselbach’s triangle → breaches posterior inguinal wall & passes medial to inferior epigastric vessels

Hernia charts

What kind of hernia?

• nontender

• easily reduced

• required intervention

Reducible hernia

What kind of hernia?

• tender or nontender

• non reducible

• urgent intervention

Incarcerated hernia

What kind of hernia?

• tender

• non reducible

• emergent intervention

Strangulated hernia

What kind of hernia?

• Transillumination: no

• Tenderness: none, unless incarcerated or strangulated

• Location: base of mass from hesselbach’s triangle floor → may extend into scrotum

• Etiology: reducible or incarcerated or strangulated

Direct inguinal hernia

What kind of hernia?

• Transillumination: no

• Tenderness: none, unless incarcerated or strangulated

• Location:scrotal hernia; congenital; through the internal and external rings

• Etiology: reducible or incarcerated or strangulated

Indirect inguinal hernia

What kind of hernia?

• Transillumination: no

• Tenderness: none, unless incarcerated or strangulated

• Location: thigh hernia under the medial inguinal ligament

• Etiology: reducible or incarcerated or strangulated

Femoral hernia

What is edematous foreskin that becomes trapped behind the head of the penis?

Paraphimosis

What is foreskin that is unable to be retracted from the head of the penis?

Phimosis

What condition?

• inflammation of glans → redness, pain & swelling

• urinary discharge, dysuria, dribbling of urine

• causes: Candida albicans, reiter’s syndrome, or AI disorder

Balantitis

What is a hydrocele?

Nontender, fluid filled mass within the tunica vaginalis that transilluminates on exam

What is epididymitis?

Painful inflammation of epididymis

*exam may be easier for patient in supine

What is a spermatocele?

Painless, moveable cystic mass above the testes that transilluminates on exam

What are varicose veins of the spermatic cord that resemble a “bag of worms”?

Varicocele

What condition?

• firm nodules w/in testicles

• common bt ages 15-45

• instruct pt on self exams → after warm shower, stand in front of mirror & observe any swelling in the scrotum & examine each testicle with both hands

Testicular cancer

What condition?

• abrupt onset of testicular or scrotal pain

  • sometimes abdominal

• MC during puberty - ages 12-18

• cremasteric reflex absent in most

• US & emergency surgery

Testicular torsion

What condition?

• Necrotizing fasciitis of perineum and often involves scrotum

• pain in abd wall & migrates to gluteal muscle, scrotum, & penis

• emergency surgery necessary

Fournier’s gangreneI

Who is fournier’s gangrene MC in?

DM, indwelling catheters, urethral trauma or immunocompromised

What position?

• supine with bent knees

• used for DRE in patient with difficulty standing

Modified lithotomy

What position?

• left lateral prone with right upper leg flexed

• used for DRE in bedridden or weak patients

Sim’s position

What position for DRE allows for thorough inspection of anus and palpation of rectum?

Standing with hips flexed

How do you assess sphincter tone?

Ask patient to squeeze anal muscles around finger

How do you assess posterior and lateral walls of the rectum?

Rotate ringer through 180° by hyper pronating wrist

What is a normal finding in DRE?

Uniformly smooth & pliable

What might indicate an abscess (perirectal sepsis) on DRE?

Extreme tenderness

What is the course of enlargement of the prostate?

Small during childhood → inc 5-fold between puberty & 20 y/o → increasingly enlarges in 5th decade

How do you palpate the prostate during DRE?

Sweep finger anteriorly through rectal wall, identify the 2 lobes with longitudinal groove (median sulcus) between them, & note size, modularity, consistency, and tenderness

What prostate diagnosis?

• 2.5 cm from side to side

• prominent median sulcus

• consistency is rubbery and smooth

• tenderness not usual

• pt should feel urge to urinate when you palpate

Normal prostate

What prostate diagnosis?

• enlargement of gland is symmetrical

• marked protrusion into rectal lumen

• smooth with no modularity

• median sulcus may be indistinguishable

• consistency is rubbery, boggy or slightly elastic

BPH

What prostate diagnosis?

• asymmetric shape

• hard consistency

• discrete nodule may be palpable

• median sulcus often obscured

Prostate cancer

What prostate diagnosis?

• gland is swollen → diffusely enlarged, boggy prostate

• firm consistency

• very tender to touch

• tender palpable seminal vesicles or cowpers glands

• infectious etiology

Acute prostatitis

What prostate diagnosis?

• gland is swollen → diffusely enlarged boggy prostate

• mild to moderate tenderness

• caused by trauma to prostate, as in bicycle riders

• can be painless except for dull perineal pressure during urination or defecation

• common cause of male infertility

Chronic prostatitis

Prostate diagnosis chart

What is a normal PSA?

≤ 4 ng/mL

What is an abnormal PSA?

> 4; doubles within a year

*can be elevated in benign conditions such as prostatitis, BPH

What PSA level is almost always due to cancer?

≥ 10

Prostate guidelines

What does a boggy prostate indicate?

Inflammation

What might the absence of a prostate indicate?

Past radiation or surgery for prostate cancer

What must also be assessed in any case of prostate enlargement?

Size of urinary bladder

What should be included in the exam of any man with suprapubic abdominal discomfort, distended abdomen, or both?

DRE / PSA