Male-GU-Slides for Lecture

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Male-GU-Slides for Lecture

  1. 1. <ul><li>Jong M. Choe, MD </li></ul><ul><li>Director of Continence Program </li></ul><ul><li>Division of Urology </li></ul><ul><li>University of Cincinnati College of Medicine </li></ul><ul><li>Veterans Administration Medical Center </li></ul>Male GU Examination
  2. 2. <ul><li>What do Urologists do? </li></ul>Urology <ul><li>They are surgeons who treat and operate on </li></ul><ul><li>diseases of genitourinary organs in men: </li></ul><ul><li>Kidney • Penis </li></ul><ul><li>Ureter • Urethra </li></ul><ul><li>Bladder • Vas deferens </li></ul><ul><li>Prostate • Testes </li></ul>
  3. 3. <ul><li>What do Urologists do? </li></ul>Urology <ul><li>They are surgeons who treat and operate on </li></ul><ul><li>diseases of genitourinary organs in women: </li></ul><ul><li>Kidney </li></ul><ul><li>Ureter </li></ul><ul><li>Bladder </li></ul><ul><li>Urethra </li></ul>
  4. 4. <ul><li>Urologic patient </li></ul>Initial Evaluation Begins with focused history and physical examination of pertinent genitourinary organs
  5. 5. Initial Evaluation FEMALE MALE Kidneys Ureters Bladder Urinary sphincter Prostate Urethra
  6. 6. <ul><li>Urologic patient </li></ul>Initial Evaluation <ul><li>Begins with focused history and physical examination of pertinent genitourinary organs </li></ul><ul><li>Kidney • Penis </li></ul><ul><li>Ureter • Urethra </li></ul><ul><li>Bladder • Vas deferens </li></ul><ul><li>Prostate • Testes </li></ul>
  7. 7. Medical History Chief complaint (CC): History of present illness (HPI): Past medical history (PMH): Past surgical history (PSH): Family history (FH): Social history (SH): Medications: Allergies: Review of systems (ROS):
  8. 8. 35 yo white female with history of hematuria. She needs an intravenous pyelogram (IVP) to evaluate the source of bleeding CC: Hematuria HPI: Began 2 days ago. Has stopped now. History of smoking x 8 years. Does not think she is pregnant. PMH: None PSH: None FH: None SH: (+) smoke or (-) ETOH Medications: OCP Allergies: None; no reaction to IVP dye ROS: Non contributory
  9. 9. 45 yo male with benign prostatic hyperplasia (BPH) has difficulty urinating CC: Difficult urination HPI: Weak stream; sense of incomplete emptying, straining to urinate; AUA symptom score 30/35; most recent PSA 2.5 ng/ml PMH: Enlarged prostate (BPH) PSH: None - specifically no TURP FH: (-) Prostate cancer SH: (-) smoke or drink ETOH Medications: Flomax Allergies: None ROS: Non contributory
  10. 10. Generalized Physical Examination HEENT Cor Lungs ABD Flank GU Penis Pelvic Testicles Rectal Prostate Ext Neuro
  11. 11. Generalized Physical Examination HEENT Benign Cor RRR Lungs CTA ABD soft, NT/ND, NABS Flank (-) CVAT GU Penis normal phallus, adequate meatus Testicles descended bilaterally; WNL Prostate smooth and benign, (-) nodules Ext (-) CCE Neuro No focal neurologic deficits
  12. 12. <ul><li>Focused Urologic examination </li></ul>Physical Examination <ul><li>Inspection - general observation </li></ul><ul><li>Palpation - gently touch and feel </li></ul><ul><li>Percussion - lightly tap over a finger </li></ul><ul><li>Auscultation - listen with stethescope </li></ul>
  13. 13. Inspection Cushing’s syndrome Excess cortisol production Clinical signs: Buffloe hump Truncal obesity Moon face
  14. 14. Inspection Phimosis Paraphimosis Phimosis Inability to retract the foreskin Paraphimosis Inability to pull down the foreskin
  15. 15. Inspection Pelvic organ prolapse Pelvic organ prolapse Condition where one of the pelvic organs has herniated out of the vagina Cystocele - bladder Rectocele - rectum Enterocele - bowel Procidentia - uterus
  16. 16. Palpation Male - Bimanual examination Prostate examination Hernia examination Female - Bimanual examination Kidney examination
  17. 17. Kidney Examination Method of palpation of the kidney The patient lying supine Posterior hand tilts the kidney upward Anterior hand feels for the kidney Have patient take a deep breath. This causes the kidney to descend As the patient inhales, push the anterior hand at the costoverterbral margin If the kidney is mobile or enlarged, it can be felt between 2 hands
  18. 18. Kidney Examination Kidneys Lie under the diaphragm and ribs Well protected from injury Right kidney lower than left due to liver Left kidney usually not palpable Normal kidneys difficult to palpate especially in men due to ABD muscle tone Sometimes normal kidneys may be palpable in thin patients and in children Palpable kidneys are usually displaced or enlarged
  19. 19. Renal Masses Renal mass: may be fluid-filled or may be solid Solid renal tumor Hydronephrotic kidney
  20. 20. Kidney Examination Renal tumor Clinically asymptomatic May present with hematuria Not palpable unless enlarged Firm, non-tender, often immobile Pyelonephritis Infection of the kidneys Patient septic (fever, toxic) Costovertebral angle tenderness (CVAT)
  21. 21. Kidney Examination Renal abscess Infection of the kidneys Patient septic (fever, toxic) Costovertebral angle tenderness (CVAT) Anterior abdominal wall tenderness Perinephric abscess Infection of the kidneys Patient septic (fever, toxic) Costovertebral angle tenderness (CVAT) Anterior abdominal wall tenderness
  22. 22. Kidney Examination Kidney stone Complain of flank pain Renal colic - cannot get comfortable Costovertebral angle tenderness (CVAT) Ureteral stone Complain of flank pain Renal colic - cannot get comfortable Costovertebral angle tenderness (CVAT) Referred pain to groin area Urinary frequency and urgency kidney ureter
  23. 23. Prostate Examination Method of palpation of the prostate The patient is in left lateral decubitus position or bent forward at the waist with feet shoulder-width apart A well-lubricated gloved index finger is inserted gently into the rectum Have the patient Valsalva or bear down as you are inserting the gloved finger Palpate the prostate in systematic fashion: right, middle, left; apex to base
  24. 24. Prostate Examination Normal prostate Normal prostate is size of a chest nut Has consistency of nose or contracted thenar eminence Benign prostatic hyperplasia (BPH) BPH is enlarged prostate Has consistency of nose or contracted hyperthenar eminence May be as big as an orange
  25. 25. Prostate Examination Acute prostatitis Patient appears septic (fever, toxic appearing) Prostate is enlarged, fluctuant, warm, and painful Do not be aggressive with prostate exam! Chronic prostatitis May complain of LUTS or hematospermia Prostate feels boggy and is tender to touch May see expressed prostatic secretions: white discharge
  26. 26. Prostate Examination Prostate cancer Clinically asymptomatic - silent cancer One area of the prostate may feel firm, nodular, or stony hard. Need to get PSA and perform prostate biopsy
  27. 27. Hernia Examination Technique of examining inguinal hernia Inguinal hernia: extrusion of bowel into the inguinal canal Gently insert a gloved index finger into the inguinal canal by invaginating the scrotal skin Palpate the external inguinal ring - feels like a small round opening Have the patient turn his head to one side and cough Protrusion of bowel against the index finger signifies hernia
  28. 28. Bimanual Examination Male bimanual examination Performed in a setting of bladder tumor Insert a lubricated gloved finger into the rectum Apply fingers of the anterior hand on the suprapubic area Attempt to palpate the bladder between 2 hands Is the bladder palpable? Is it mobile or fixed? Gives clinical information regarding local invasion and extent of the tumor
  29. 29. Bimanual Examination Female bimanual examination Performed in a setting of bladder tumor Insert lubricated 2 gloved fingers into the vagina Apply fingers of the anterior hand on the suprapubic area Attempt to palpate the bladder between 2 hands Is the bladder palpable? Is it mobile or fixed? Gives clinical information regarding local invasion and extent of the tumor
  30. 30. Bladder Examination Technique of bladder examination Apply fingers of the anterior hand on the suprapubic area Apply gentle pressure to the suprapubic area Attempt to palpate the bladder Is the bladder palpable or not?
  31. 31. Bladder Examination Normal bladder Normally holds 400-500 ml of urine Is not clinically palpable Urinary retention Bladder may hold as much as 2000-3000ml Complain of difficulty urination, urinary dribbling, and straining to urinate Suprapubic fullness Bladder is palpable and may be tender to touch Bladder may be palpable up to umbilicus Normal bladder Urinary retention
  32. 32. Bladder Masses Solid bladder tumor Urinary retention
  33. 33. Percussion Percussion Used to assess kidneys Used to assess bladder
  34. 34. Kidney Examination Gentle tapping over the kidney area - costovertebral angle - normally should elicit no response. Presence of costovertebral angle tenderness (CVAT) upon percussion suggests: • stones • infections • obstruction
  35. 35. Bladder Examination Urinary Retention: sounds like a drum to percussion Normal Bladder: sounds “flat” to percussion Gentle tapping over the bladder area - suprapubic area - normally should elicit no response. Bladder in retention sounds hollow like a drum.
  36. 36. Penile Examination Inspection If the patient has not been circumcised, the foreskin should be retracted This may reveal a tumor or balanitis Erythroplasia of Queyrat Penile cancer
  37. 37. Penile Examination Inspection If retraction is not possible as in the case of phimosis, circumcision is indicated.
  38. 38. Penile Lesions Paraphimosis Penile condyloma Reduction of Paraphimosis
  39. 39. Penile Examination Inspection The position of the meatus should be noted Normally the meatus should be located at the tip of the penis It may be located proximal to the tip of the glans on either the dorsum (epispadius) or the ventral surface (hypospadius)
  40. 40. Penile Examination Palpation Palpation of the dorsal surface of the shaft may reveal a fibrous plaque involving the fascial covering of the corpora cavernosa This is typical of Peyronie’s disease Tender areas of induration felt along the urethra may signify urethritis - inflammaiton of the urethra.
  41. 41. Penile Examination Peyronie’s disease Calcified plaque on the dorsum of penis Often associated with abnormal penile curvature, erectile dysfunction, and pain with intercourse Peyronie’s disease: calcification of tunica albuginea
  42. 42. Testicular Examination Technique of testicular exam The testes should be carefully palpated with the fingers of both hands Should look for location, size, texture, consistency, and tenderness Normal testis has a soft rubbery consistency with a smooth surface
  43. 43. Testicular Examination Cryptorchid testis This means undescended testis Testis may lie anywhere along the course of inguinal canal - ectopic if lies outside canal Most common site is the external inguinal ring Retractile testis This means testis is present but it has tendency to retract upward into the inguinal canal due to overactive cremasteric muscles
  44. 44. Testicular Examination Kliefelter’s syndrome 47, XXY Clinical features: male phenotype gynecomastia small, firm testes < 3 cm in length azospermia (no sperm production) tall and lanky
  45. 45. Testicular Examination Hydrocele Fluid within tunica vaginalis Asymptomatic but may cause scrotal pain. Feels firm, non-tender Transillumination in a dark room helpful. Shine a flashlight behind the scrotum. It glows red. When in doubt, obtain scrotal ultrasound Spermatocele Epididymal cyst filled with sperm. Glows green with transillumination.
  46. 46. Testicular Examination Testicular cancer A firm area in the testis proper must be regarded as a malignant tumor unless proven otherwise Typically asymptomatic and painless. Brought to the attention to the patient after infection or trauma If transillumination is performed, light will not transmit through a solid tumor Tumors are often smooth but may be nodular Need to obtain scrotal ultrasound
  47. 47. Testicular Examination Torsion Abnormal twisting of the spermatic cord Patient in severe pain, nausea, vomiting Testicle high riding - retracted upward Abnormal horizontal lie Tender to palpation May not be able to examine due to patient distress Urologic emergency Need to obtain scrotal US with Doppler studies
  48. 48. Epididymal Examination Epididymis Small cap-like structure located posterior to the testicle Should be carefully palpated for size and induration Induration means infection - epididymitis Epididymis
  49. 49. Epididymal Examination Epididymitis In acute stage of epididymitis, the testis and epididymis are indistinguishable by palpation The testis and epididymis may be adherent to the scrotum The scrotal wall is erythematous and tender Epididymis
  50. 50. Spermatic Cord Examination Varicocele Varicose veins of pampiniform plexus Left side more commonly affected Present with scrotal discomfort, heavy dragging sensation of the scrotum esp end of the day Can cause secondary infertility See mass of dilated tortuous veins lying superior to and above the testis - “bag of worms” Degree of dilation accentuated by Valsalva maneuver. Feels like “bag of worms” Confirmed by scrotal ultrasound Pampiniform plexus
  51. 51. Spermatic Cord Examination Varicocele Right sided varicocele or prominent varicose veins around the umbilicus suggests renal cell carcinoma Pampiniform plexus
  52. 52. Questions Focused Urologic examination consists of: a.) Inspection b.) Palpation c.) Percussion d.) Auscultation e.) All of the above
  53. 53. Questions Paraphimosis is: a.) Inability to retract foreskin b.) Inability to pull down the foreskin
  54. 54. Questions Epispadius is a condition where: a.) Urethral meatus is located on the ventral surface of the penis b.) Urethral meatus is located on the dorsal aspect of the penis
  55. 55. Questions Right-sided varicocele suggests: a.) Renal cell carcinoma b.) Testicular tumor c.) Prostate cancer d.) Epididymitis
  56. 56. Questions Testicular torsion is: a.) Benign condition b.) Urologic emergency c.) Should be treated non-surgically d.) Same as orchitis
  57. 57. Questions All men presenting with Urologic complaints require a prostate examination whereas women require a pelvic examination: A: true B: false
  58. 58. Questions <ul><ul><ul><li>A 45 year-old African American male presents with lower urinary tract obstructive voiding symptoms. What questions should be included in your medical history? </li></ul></ul></ul><ul><li>A. history of benign prostatic hyperplasia (BPH) B. American Urologic Association (AUA) 7 symptom score C. family history of prostate cancer D. prostatic specific antigen (PSA) level E. all of the above </li></ul>
  59. 59. Questions A 35 year-old female with presents with history of gross hematuria. You decide she needs an intravenous pyelogram (IVP). During the medical history you should have asked her about: A. drug allergies B. current medications C. any possibility she could be pregnant D. any history of reaction to contrast dyes E: . all of above

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