Module 13 & 14: Comprehensive Breast, Reproductive, and Anal/Rectal Assessments

Breast Anatomy and Physiology

• Surface Anatomy and Division

  • The breast is divided into four quadrants for clinical assessment: Upper Outer, Upper Inner, Lower Outer, and Lower Inner.
  • The Tail of Spence is an extension of breast tissue that projects into the axilla.
  • Key surface structures include the areola, the nipple, and Montgomery's glands (small sebaceous glands located on the surface of the areola).

• Internal Structure and Function

  • The female breast consists of fat, lobes, ducts, and nipples.
  • Primary functions of the female breast include lactation and its role in female sexuality.
  • The male breast contains no functional tissue.

Clinical Assessment of the Breast

• Client Preparation and Inspection

  • Both male and female clients must be inspected.
  • Inspection focuses on the skin, looking specifically for dimpling or puckering.
  • Peau d'orange: This term refers to pitting, dimpling, and swelling seen in inflamed skin that overlies inflammatory carcinoma of the breast.

• Lymph Node Assessment

  • Expected Findings: Lymph nodes in the axillae should not be visible, and the client should report no discomfort.
  • Unexpected Findings: Visible lymph nodes may indicate the presence of an infection or cancer.
  • Lymph nodes are better felt with gentle palpation; it is normal for nodes to feel soft and nontender upon palpation.

• Palpation Techniques

  • Palpation is performed using the finger pads, applying light, medium, and deep pressure in small circles.
  • Circular Pattern: Begins at the areola and moves in a circular motion outward to the perimeter.
  • Radial Spoke (Wedge) Pattern: Divides the breast into wedges; palpation starts at the periphery and moves toward the nipple.
  • Vertical Strip Pattern: Starts at the sternum and moves up and down in straight lines toward the outer perimeter, ending in the axillary area.

• Expected vs. Unexpected Findings During Palpation

  • Expected: Soft tissue density, absence of tenderness or lumps, and no discharge (except in pregnancy or breastfeeding). Firmness in the lower curve of each breast is considered normal.
  • Unexpected: Firm or nodular tissue; tenderness or pain (indicating infection/inflammation); lumps or masses (benign or cancerous); loss of nipple elasticity (associated with malignancy).
  • Discharge: Any bloody or milky discharge outside of the postpartum or non-lactation period requires diagnostic assessment.

• Mastectomy Considerations and Education

  • Women who have undergone a mastectomy must continue to perform Breast Self-Examinations (BSE).
  • Assessment should begin on the unaffected side, followed by an incisional BSE.
  • Clinical Safety: Blood pressure should never be taken in the arm on the affected side of the mastectomy.

Breast Health Promotion and Screening

• Breast Self-Examination (BSE)

  • The optimal time for BSE is $7$ to $9$ days after menses, when breasts are least swollen or tender.
  • Pregnant and menopausal women should choose a consistent day each month.
  • Positions for BSE: Standing in front of a mirror, standing in the shower, or lying down on a flat surface.

• Mammogram Screening Guidelines (American Cancer Society)

  • Women ages $40$ to $44$: Option to start yearly screenings.
  • Women ages $45$ to $54$: Should receive yearly mammograms.
  • Women $55$ and older: May switch to every $2$ years or continue yearly.
  • Screening should continue if the woman is in good health and expected to live at least $10$ more years.

• Signs and Symptoms of Breast Cancer

  • Changes in size, shape, or contour.
  • Lumps or thickening near the breast or axilla.
  • Changes in nipple direction (inversion or eversion).
  • Discharge from the nipple.
  • Skin changes: puckered, dimpled, scaly, inflamed, or erythematic appearance; Peau d'orange.

Female Genitourinary (GU) System

• Anatomy

  • External structures include the clitoris, labia majora, labia minora, urethral opening, introitus of the vagina, Bartholin gland region, perineum, and anus.

• Assessment Preparation and Inspection

  • The client should be placed in the lithotomy position with the head and shoulders elevated to maintain eye contact.
  • Clients should void prior to the exam; clinicians must use a gentle touch and provide cover for modesty.
  • Inspection Findings: Expected findings include smooth, clear skin with even hair distribution in an inverted triangle.
  • Variations in Older Adults: Decreased estrogen leads to sparse pubic hair, dry mucous membranes, and atrophy of the mons pubis, labia, and clitoris.
  • Unexpected Findings: Erythema, patchy hair loss, lesions, ulcerations, or pubic lice.

• Cervical Cancer Screening (U.S. Preventive Services Task Force $2018$)

  • Screening begins at age $21$.
  • Ages $21$ to $29$: Pap test every $3$ years (no HPV testing for screening in this group).
  • Ages $30$ to $65$: Pap test every $3$ years or Pap test plus high-risk HPV testing every $5$ years.
  • Over age $65$: Stop screening if the $10$-year history of regular screening was normal. Continue for at least $20$ years if diagnosed with pre-cancer.

Male Genitourinary (GU) System

• Anatomy

  • External: Penis (shaft should be hairless with a noticeable large dorsal vein on the ventral side) and Scrotum (contains two testes for sperm production).
  • Internal: Testes (sperm and testosterone production), epididymis (stores sperm), vas deferens, ejaculatory duct, urethra, seminal vesicles, and prostate (produces nourishing fluid for sperm).
  • Anatomical Variation: The left testis typically lies lower than the right because the left spermatic cord is longer.

• Inspection and Common Conditions

  • Urethral Meatus: Should be midline, smooth, and without discharge.
  • Unexpected Findings: Hypospadias (meatus on the underside) or Epispadias (meatus on the upper side), Phimosis, nodules, or pubic lice.
  • Benign Prostatic Hypertrophy (BPH): Nonmalignant enlargement of the prostate associated with aging. Signs include urethral compression, weak urine stream, dribbling, and urinary retention leading to bladder distention.
  • Bladder Distention: Inspect the suprapubic area above the symphysis pubis; a distended bladder is palpable along the midline.

• Testicular Self-Examination (TSE)

  • Men over age $14$ should perform monthly examinations.
  • The best time is after a warm shower or bath.
  • The goal is to detect testicular cancer at early, curable stages by checking for lumps.

Anal and Perianal Assessment

• Anatomy

  • Perianal Area: The skin surrounding the anal opening.
  • Rectum: An internal tube ending the sigmoid colon with valves to control feces and flatus.
  • Anal Opening: Controlled by two sphincters. The internal sphincter is involuntary, while the external sphincter is under voluntary control.

• Assessment and Findings

  • Positioning: The client lies on the side with hips and knees bent.
  • Examination: Use clean gloves and water-soluble lubricant. Ask the client to bear down to check for abnormalities.
  • Expected Findings: Skin is darker, coarse, moist, and hairless. The anus should be closed when the client is relaxed.
  • Unexpected Findings: Hemorrhoids (internal/external), skin tags, fissures, and rectal prolapse (a bulging, moist, red, ring-shaped membrane protruding through the anal opening).
  • Older Adult Variations: Weakened perineal muscles can lead to decreased control of the anal opening.

Questions & Discussion

• Breast History Questions

  • Do you have any pain in the breasts or axillae? (Note: Cancerous lumps are often painless).
  • Have you noticed changes in appearance, swelling, rashes, or nipple discharge?
  • Do you have a history of cancer, fibrocystic disease, trauma, or biopsies?
  • Do you perform BSE and have routine clinical screenings?
  • Which family members have had breast cancer and at what age?

• Female GU History Questions

  • Are you currently or have you ever been sexually active? Do you use contraception?
  • Do you have pelvic pain or swollen glands?
  • What is your menstrual history (LMP, age of menarche, cycle frequency, duration, bleeding/clotting issues)?
  • For those over $40$: Do you have menopausal manifestations like sweating, hot flashes, or vaginal dryness?

• Male GU History Questions

  • Do you have difficulty starting a stream, hesitancy, or a feeling of incomplete bladder emptying?
  • What is the frequency, color, and odor of your urine?

• Anal/Rectal History Questions

  • Is there pain or straining during defecation?
  • Have you noticed changes in stool color, consistency, or frequency?
  • Is there blood, pus, or mucus in the stool?
  • What are your current medications and eating habits?

Summary of Older Adult Considerations

• Female: Loss of breast tissue (sagging), decreased interest in sexual activity, and vaginal dryness.
• Male: Scrotal skin thinning, lower-hanging testes, and Benign Prostatic Hypertrophy (BPH).