3. Minimizing the Patient’s Anxiety
Be open, direct, and reassuring
Know the language and use it
effectively
Do not apologize
Never make jokes
Light, casual talk or jokes about
genitalia or sexual function are
inappropriate
Be mindful of your facial expression
4. Male Genitalia & Hernia Assessment:
History
Present Problem
Erectile dysfunction
Difficulty with ejaculation
Discharge or lesion on
penis
Infertility
Enlargement in inguinal
area
Testicular pain or mass
Past Medical History
Surgery of GU tract
STDs
Chronic illness
Medications
Family History
Infertility in siblings
Hernias
Personal & Social History
Employment: trauma risk
Exercise: protective
device
TSE practices
Concerns about sexual
practices
Reproductive function
Use of alcohol, cigarettes
& street drugs
6. Male Genitalia:
Inspection and Palpation- with pt. standing
- Have a chaperone in the room for the exam:
Pubic hair
Penis Glans
Dorsal vein
Uncircumcised
• Retract foreskin
• Inspect glans
– smegma
– lesions
Circumcised
• Inspect glans
– Color and texture
Urethral meatus
Shape
Slitlike
Location
Ventral surface
close to tip of
glans
Color/discharge
7. Male Genitalia:
Inspection and Palpation
Penile shaft
Tenderness, induration
Strip urethra for
discharge
Nodules
Replace foreskin!
Scrotum
Color
Texture
Asymmetry
Swelling
Masses
Tenderness
Rashes/lesions
8. Male Genitalia:
Inspection and Palpation
Scrotal Contents
Testes, Epididymis,
Vas deferens
Consistency
Size
Tenderness
Nodules
Transillumination prn
9. Inspection: Trans-illumination prn:
To assess masses, swelling
Strong penlight placed behind scrotum
Red glow seen in fluid filled masses
Hydrocele, spermatocele
No glow seen
in solid masses
hernias,
tumors,
orchitis
10.
11. Testicular Self-Examination (TSE)
Bates text- p. 555-
“Although the USPSTF and the American
Cancer Society have not recommended
routine TSE for screening, the clinician
and the patient my wish to teach the TSE
to enhance health awareness and self
care”
12. Testicular Self-Examination (TSE)
Why: Testicular cancer is the most common cancer
of men ages 15-34 (estimated lifetime risk of 1:260)
When: 1 x each month; Best to perform after a warm
bath or shower, while standing and in front of a mirror
When to see a provider: Any hard lump, absent or
enlarged testicle, painful or swollen scrotum or any
other abnormality
13. TSE- Step 1:
Look for
swelling. Hold your
penis out of the way
and examine the
skin of the scrotum.
14. TSE- Step 2:
Examine each
testicle. Using both
hands, place your
index and middle
fingers under the
testicle and your
thumbs on top.
15. TSE- Step 3:
Gently roll the
testicle between
your thumbs and
fingers. Look and feel
for any changes to your
testicle. These could
include hard lumps,
smooth rounded
bumps, or new changes
in the size, shape or
consistency of the
testicle.
16. Think, Pair, Share
Please pair up with a classmate.
As the Nurse Practitioner, please describe to
your “patient” who has a history of
undescended testicles and is worried about
testicular cancer :
1. the reason why TSE is important and when
to perform
2. the three TSE steps
3. what findings would warrant having them
see their provider
17. Male Genitalia:
Inspection and Palpation
Hernia
Have pt stand and
bear down
Inspect
Have pt relax
Insert finger into
the lower part of
scrotum and follow
the spermatic cord
up towards the
inguinal canal, until
your finger reaches
the external
inguinal ring
18. Hernias- see Bates- p. 561
Indirect- Most common, all
ages, often in children.
Above the inguinal ligament,
near internal inguinal ring.
Often into the scrotum.
Direct- Usually occur in men
over 40 yrs. Above the
inguinal ligament, near the
pubic tubercle and the
external inguinal ring.
Femoral- Least common.
More common in women
than men. Below the inguinal
ligament; more lateral.
21. Male Genitalia:
Inspection and Palpation
Elicit the cremasteric reflex
If neurologically intact, stoking the inside of the
thigh will cause the ipsilateral testicle to retract in
the scrotum
22. Inspection & Palpation of
Inguinal Nodes
• Small, shotty nodes are common
• Enlarged, tender nodes often associated with
• Viral STI’s such as HSV
• Chancroid
• Enlarged, discrete, firm, rubbery, non-tender
often unilateral nodes associated with
– Syphilis
24. Scrotal Masses
Varicocele- varicose veins of
the spermatic cord. Feels like a soft “bag of
worms”. May be associated with pain or
heaviness, but often asymptomatic.
Hydrocele- Non tender, fluid-filled mass within the
tunica vaginalis (serous covering of the testes).
Transilluminates. Common in infancy but can occur
at any age.
25. Scrotal Masses (contd.)
Orchitis- acute inflammation of the
testis- swollen, tender/painful, with
possible erythema. Seen with mumps
and other viral infections- usu. unilateral
Tumors- usually non-tender,
irregular, hard mass fixed on the testes.
Does not transilluminate. Must rule out
malignancy. Is the most common tumor
in males ages 15 to 34.
26. Acute Testicular Swelling/ Pain
Torsion
twisting of testis on spermatic
cord
most common in newborns to
adolescences but can occur
at any age.
acute onset of pain
scrotum often becomes red
and edematous
vomiting & anorexia are
common
fever & dysuria are
uncommon
no cremasteric reflex on
affected side
Surgical Emergency!
29. GONORRHEA
- Urethral discharge- green, yellow or white
- Dysuria
- Pain or swelling in one or both testicles
- Majority of men show no symptoms
30. SYPHILLITIC Chancre
Primary stage- chancre- 3 weeks to 3 months after infection
Secondary stage- rash, flu like symptoms- up to 2 years
Late stage- damage to the neurologic symptoms- tumors,
blindness, paralysis, death- 10-20 years after infection
34. Think, pair, share:
Please turn to a classmate and describe the symptoms
and assessment findings associated with 3 of the
following conditions (please choose at least one or two with
which you are less familiar):
varicocele
hydrocele
orchitis
testicular torsion
condyloma acuminate
chlamydia
gonorrhea
syphilis
genital herpes
pediculosis pubis
37. History
Present Problem
Changes in bowel function
Anal discomfort
Rectal bleeding
Males: changes in urinary
function
Past Medical History
Hemorrhoids
Spinal cord injury
Males: prostate hypertrophy or
cancer
Females: cancer,
episiotomy/lacerations
Risk factors for colorectal
cancer (see p. 468 in
Bates)
Family History
Rectal polyps
Colon cancer
Colon or prostate
cancer
Social History
Travel history
Diet/ use of alcohol
38. Cancer Risk Factors
Colorectal cancer- Bates text p. 468
Prostate cancer- Bates text p. 611
39. Physical Examination
General Considerations
Be calm, slowly paced,
and gentle
Explain what you are
going to do step by step
Use appropriate draping
but retain good
visualization
Glove both hands
Positioning
Males
Left lateral with top hip
and knee flexed
Standing, flexed at waist
with upper body
supported on exam
table, toes together and
knees slightly flexed
Females
Most often done as part
of the rectovaginal
exam in the lithotomy
position
40. Physical Examination:
Inspection
Sacrococcygeal &
Perianal Area
Skin
characteristics
Lesions
Pilonidal dimpling
& tufts of hair
Inflammation
Excoriation
Anus
Skin characteristics
Lesions, fissures,
hemorrhoids or
polyps
Fistulas
Prolapse
Ask patient to bear
down…repeat
inspection
41. Physical Examination:
Palpation
Sphincter
Lubricate index finger
Place pad of finger over anus as patient strains down
. . . insert finger tip as patient relaxes
Ask patient to tighten external sphincter around finger
assess tone, tenderness, lesions
Anal Ring
Rotate finger
note: smoothness, evenness
42. Physical Examination:
Palpation
Lateral and Posterior Rectal Walls
Insert finger farther
Rotate hand clockwise
and counterclockwise
noting
nodules, masses, polyps
tenderness
irregularities
Anterior Rectal Wall
Same procedure with patient bearing down
nodules
tenderness
43. Physical Examination:
Palpation
Prostate
Palpate the posterior surface of the prostate
through the anterior rectal wall noting:
Size and symmetry- 4 x 3 x 2cm
Contour
Consistency
Mobility
Tenderness
Nodules
Median sulcus- palpable?
Normal is firm, smooth (like a pencil eraser) and
nontender
44.
45. Physical Examination
Slowly withdraw finger
Examine any fecal material
color
consistency
blood or pus
Test stool for occult blood using chemical
guiac test
46. Prostate Disorders
Benign Prostatic Hypertrophy (BPH)- may
feel enlarged, smooth, and firm with obliteration of the median
sulcus
Prostatitis- may be tender, swollen, boggy and warm
Acute- bacterial
Chronic- may be bacterial or non-bacterial
Prostate Cancer- hard, irregular, painless nodule
See p. 623 of Bates text- Abnormalities
of the Prostate
48. General Symptoms of BPH
• Urinary Frequency; Nocturia
• Urinary Urgency
• Change in stream
– Weak
– Difficulty starting
– Post void dribbling
– Incomplete emptying of the bladder
• Dysuria
• American Urological Association BPH Sx Score Index:
• 7 questions- rank Sx 0-5- the higher the score, the more
severe the Sx.
• See page 620 of your Bates text!
49. Prostatitis Symptoms
Symptoms of acute prostatitis can start quickly, and can include:
Chills
Fever
Flushing of the skin
Symptoms of chronic prostatitis are similar, but not as severe. They often begin
more slowly:
Blood in the urine
Burning or pain with urination (dysuria)
Difficulty starting to urinate or emptying the bladder
Foul-smelling urine
Weak urine stream
Other symptoms that may occur with this condition:
Pain or achiness in the abdomen above the pubic bone, in the lower back, in the
area between the genitals and anus, or in the testicles
Pain with ejaculation or blood in the semen
Pain with bowel movements
http://www.nlm.nih.gov/medlineplus/ency/article/000519.htm
