Ppt13

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 13
Male Genitalia and Hernias

Anatomy and Physiology
• The penis
– The shaft of the penis is formed by three
columns of vascular erectile tissue:
o The corpus spongiosum, containing the
urethra
o The two corpora cavernosa
– The corpus spongiosum forms the bulb of the
penis, ending in the cone-shaped glans with
its expanded base, or corona

Anatomy and Physiology (cont.)
• The penis
– In uncircumcised men, the glans is covered by a
loose, hood-like fold of skin called the prepuce,
or foreskin, where smegma, or secretions of
the glans, may collect
– The urethra opens into the vertical, slit-like
urethral meatus

• The testes
– The testes are ovoid, somewhat rubbery
structures approximately 4.5 cm long
– The left testis usually lies somewhat lower
than the right
– The testes produce spermatozoa and
testosterone

• The testes (cont.)
– The scrotum is a loose, wrinkled pouch divided
into two compartments, each containing a testis
– Covering the testis, except posteriorly, is the
serous membrane of the tunica vaginalis
– On the posterolateral surface of each testis is
the softer comma-shaped epididymis; the
epididymis provides a reservoir for storage,
maturation, and transport of sperm

• The lower genitourinary tract
– The vas deferens, a cordlike structure, begins at
the tail of the epididymis
– It ascends within the scrotal sac (as the
spermatic cord) and passes through the
external inguinal ring on its way to the abdomen
and pelvis
– Behind the bladder, it is joined by the duct from
the seminal vesicle and enters the urethra within
the prostate gland

• The groin
– The basic landmarks of the groin are the
anterior superior iliac spine, the pubic
tubercle, and the inguinal ligament
– The inguinal canal, which lies above and
parallel to the inguinal ligament, forms a tunnel
for the vas deferens
– The exterior opening of the tunnel is the
external inguinal ring; the internal opening
of the canal is the internal inguinal ring

• The groin
– When loops of bowel
force their way
through weak areas of
the inguinal canal,
they produce inguinal
hernias
– Another potential
route for a herniating
mass is the femoral
canal; femoral hernias
protrude here

Tips for Taking the Sexual History
• Explain why you are taking the sexual history
• This information is highly personal, so encourage
the patient to be open and direct
• Assure the patient that you gather a sexual history
on all patients
• Affirm that your conversation is confidential

The Health History
• Sexual preference and sexual response questions
– Begin with a general question, such as “How is sexual
function for you?”
– If there is a problem, direct questions help to assess
each phase of the sexual response.
o Have you maintained interest in sex? (desire)
o Can you achieve and maintain an erection?
(arousal)
o About how long does intercourse last? (orgasm
and ejaculation)

The Health History (cont.)
• Symptoms of infection questions
– Is there any discharge from the penis, dripping, or
staining of underwear? If so, how much and what is
its color and consistency?
– Any associated fever, chills, or rash?
– Any sores or growths on the penis?
– Any pain or swelling in the scrotum?
– Any history of risk factors for sexually transmitted
disease? (promiscuity, homosexuality, illicit drug use)

Health Promotion and Counseling
• Prevention of STDs and HIV
• Testicular self-examination

Techniques of Examination
• It may be reassuring to explain each step of the
examination so the patient knows what to expect
• Occasionally, male patients have erections during
the examination; if this happens, you should
explain that this is a normal response
• Many will feel uneasy about examining a man’s
genitalia

Techniques of Examination (cont.)
• A good genital examination may be done with the
patient either standing or supine
• When checking for hernias, the patient should stand
and the examiner should sit on a chair or stool

Techniques of Examination:
Inspection of the Penis
• Skin
– Check the skin around the base of the penis for excoriations
or inflammation
• Prepuce (if present, ask the patient to retract)
– Smegma, a cheesy, whitish material, may accumulate
normally under the foreskin
• Glans – look for ulcers, scars, nodules, or signs of
inflammation
– Note the location of the urethral meatus
– Compress the glans gently between your index finger above
and thumb below to open the urethral meatus and allow
inspection for discharge (normally there is none)

• The penis
– If the patient has reported a discharge that you
are unable to see, ask him to milk the shaft of
the penis from its base to the glans. This
maneuver may bring some discharge to the
urethral meatus for appropriate examination.
– Palpate any abnormality of the penis, noting
tenderness or induration
– Palpate the shaft of the penis, noting any
induration

Palpation of the Penis
• Palpate any abnormality
• Note tenderness or induration

Scrotum and Its Contents
• Scrotum, testes, epididymis, and spermatic cord
– Inspection
o Skin – lift the scrotum to view its posterior surface
o Scrotal contours – note swelling, lumps, veins
– Palpation
o Each testis and epididymis – note size, shape,
consistency, and tenderness; feel for any nodules
 Epididymis is a soft, nodular, cordlike structure
at the back of the testicle
o Each spermatic cord – note nodules or swelling

Question
A 21-year-old male presents complaining of a “nodule”
on the back of his left testicle found during testicular
self-examination. On examination, you find both
testicles to be of normal size, shape, and consistency.
On the back of the left testicle in the area of the
“nodule,” you find a soft, nodular, tubelike structure with
no areas of abnormal tenderness. Your most likely
diagnosis is:
a. Acute epididymitis
b. Cyst of the epididymis
c. Normal epididymis
d. Carcinoma of the epididymis

Answer
c. Normal epididymis
• The epididymis is located on the superior,
posterior surface of each testicle. It feels
nodular, soft, and cordlike and should not be
confused with an abnormal lump.

• Hernias
– Inspection
o Sit comfortably in front of the standing patient
 Note any areas of bulging or asymmetry
 Ask the patient to strain and bear down,
making it easier to detect any hernias
– Palpation
o Inguinal and femoral hernias

• Evaluating a possible scrotal hernia
– If a large scrotal mass is found, ask the patient to
lie down. If the mass disappears, it is a hernia.
– If the mass remains:
o Listen to the mass with a stethoscope. If
bowel sounds are heard, it is a hernia.
o Shine a strong light from behind the scrotum
through the mass (transillumination). If a red
glow is observed, it is probably not a hernia.

Question
Which of the following statements about hernias is
true?
a. Indirect inguinal hernias are the most common
form of hernia
b. Femoral hernias are the least common form
and are more common in women
c. Direct inguinal hernias are more common in
men over age 40
d. Indirect inguinal hernias originate above the
inguinal ligament near its midpoint
e. All of the above

Answer
e. All of the above
• Indirect inguinal hernias are the most common
form of hernia
• Femoral hernias are the least common form and
are more common in women
• Direct inguinal hernias are more common in men
over age 40
• Indirect inguinal hernias originate above the
inguinal ligament near its midpoint

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