Decreased frequency of BM
ID S/Sx of chronic constipation.
Decreased frequency of BM for at least 12 weeks of last 6 mo; Diarrhea alternating with constipation, abdominal pain/discomfort, pain with defecation, presence of bright red blood, stool black/tarry
Causes of constipation.
Medications (anticholinergics; CCB; Fe suplements; Opiates), DM, Hypothyroidism, Hypercalcemia, MS, Parkinsonﾒs
severe constipation that prevents passage of both stools and gas
What are typical causes of obstipation?
indicates an intestinal obstruction, such as a Volvulus (twisted bowel)
Functional change in frequency or form of bowel movement without known pathology; possibly from a change in intestinal bacteria.
ID S/Sx of IBS
3 patterns possible: Diarrhea predominant; constipation predominant; or mixed. Symptoms present for >6 mo and abdominal pain for >3 mo plus at least 2 of the following 3 features - 1)improvement w/ defecation; 2) onset with change in stool frequency; 3) onset with change in stool form and appearance
What are the two conditions associated with IBS?
Ulcerative colitis & Crohn's disease
What is ulcerative colitis?
Inflammation of the mucosa and submucosa of the rectum and colon with ulceration; typically extends proximally from the rectum
S/Sx of ulcerative colitis.
Soft to watery stools containing blood; mild cramping; lower or generalized abdominal pain; anorexia; weakness; fever in severe attacks. May include episcleritis, uveitis, arthritis, erythema nodosum.
Persons at risk for ulcerative colitis.
Younger people. Increases risk of colon cancer.
What is Crohn's disease?
Chronic transmural inflammation of the bowel wall, in a skip pattern typically involving the terminal ileum and/or proximal colon
S/Sx of Crohn's disease.
Small, soft to loose or watery stools, usually with little or no blood; Crampy periumbilical, RLQ (SI), or diffuse (colon) pain, with anorexia, low fever and/or weight loss. Perianal or perirectal abscesses and fistulae; May cause small or large bowel obstruction.
Persons at risk for Crohn's disease.
Often young people, beginning in late teens, but also in middle age. More common in Jewish descent. Increases risk of colon cancer.
ID three primary forms of mechanical obstruction.
1) cancer of rectum or sigmoid colon; 2) fecal impaction; 3) Other obstructive lesions (diverticulitis; volvulus; intussusception; hernia)
How does cancer cause a bowel obstruction?
Progressive narrowing of the bowel lumen from adenocarcinoma.
ID S/SX of a bowel obstruction related to cancer.
Change in bowel habits; often diarrhea, abdominal pain, bleeding, occult blood in stool. In rectal cancer, tenesmus and pencil-shaped stools. Weight loss.
How does fecal impaction cause a bowel obstruction?
A large, firm, immovable fecal mass, most often in the rectum
ID S/SX of a bowel obstruction related to fecal impaction.
Rectal fullness, abdominal pain, and diarrhea around the impaction; common in debilitated, bedridden, and often elderly patients
How do other causes (not cancer or fecal impaction) cause a bowel obstruction?
Narrowing or complete obstruction of the bowel.
ID S/SX of a bowel obstruction related to other causes (not cancer or fecal impaction).
Colicky abdominal pain, abdominal distension, and intussusception, often "current jelly" stools (red blood & mucus)
What are common causes of melena?
GI bleeding above the Ligament of Triaz; Gastritis, GERD, peptic ulcers; stress ulcers; Esophageal or gastric varices; Mallory-Weiss tear;
What are common causes of hematochezia?
GI bleeding below the Ligament of Triaz; Colon cancer; hyperplasia; adenomatous polyps; diverticula of colon; ulcerative colitis; Crohn's; Infectious diarrhea; Proctitis; Ischemic colitis; hemorrhoids; anal fissure
Describe the anatomy of the rectum.
Balloons out above anorectal junction; turns posteriorly. Includes Valve of Houston.
Describe the anatomy of the anorectal junction.
Dentate line. Boundary between somatic and visceral nerve innervation; not readily palpable, but visible with proctoscope. Boundary between anal canal and rectum.
Describe the anatomy of the anus.
Includes internal and external anal sphincters.
What are the different positions for digital rectal exam (DRE)?
1) Sim's position (on table in decubitus position with top leg flexed at hip); or 2) Standing position (hips flexed, leaning on table)
Steps of DRE
1) Gloves & lubricant; 2) Spread buttocks; 3) Inspect sacrococcygeal & perianal areas; 4) Pt bears down; 5) Inspect anus; 6) Explain urge to have BM or urinate is likely, but won't happen; 7) Finger on anus; 8) Pt bears down & relaxes; 9) Finger in anal canal; 10) Insert finger slowly, pointing it toward umbilicus during insertion; 11) Palpate rectum by rotating 180 clockwise and counterclockwise; 12) Palpate prostate gland; 13) Palpate seminal vesicles and peritoneal cavity above prostate; 14) Pt bears down; 15) Check sphincter tone and remove finger slowly; 16) Give pt tissue to clear up; 17) Use occult stool card
What is a pilonidial cyst?
Congenital anomaly aggrevated by pressure of sitting; friction of walking; accumulation of sweat. Remember Prof. Williams story about sit-ups.
Where are pilonidial cysts located?
Midline, superficial to coccyx and lower sacrum
S/Sx of a pilonidial cyst.
Opening of a sinus tract; may have tuft of hair; surrounded by halo of erythema; often asymptomatic; slight drainage; prone to abscess formation and secondary sinus tract complication. When aggrevated, cyst may become inflamed, swollen, painful, filled with pus/blood, cause fever or malaise.
S/Sx of anorectal fistula
Inflammatory tract or tube that opens at one end into the rectum/anus and the other onto the skin surface or other viscus. Usually preceded by an abscess. Look for fistulous openings anywhere in skin around anus.
S/Sx of internal hemorrhoids.
Enlargements of the normal vascular cushions located above the pectinate line. Not usually palpable. May cause rectal bleeding (bright red blood), especially during defecation. Usually painless. May prolapse through the anal canal and appear as reddish, moist, protruding masses.
S/Sx of external hemorrhoids.
Dilated hemorrhoidal veins originating BELOW the pectinate line and covered with skin. Typically asymptomatic unless thrombosed. Thrombosed hemorrhoids cause acute local pain that increases with sitting and defecation. Tender, swollen, bluish, ovoid mass visible at anal margin. More likely to be painful than internal hemorrhoid.
S/Sx of hematochezia.
Bright red blood in stools, usually a result of GI bleed below the Ligament of Triaz. May be associated with a change in bowel habits, weight loss, diarrhea, rectal urgency, tenesmus, lower abdominal pain, fever, shock.
S/Sx of melena.
Black, tarry stools with occult blood. Variety of causes. May occur with heartburn, pain after meals, recent ingestion of alcohol, aspirin, or other anti-inflammatory drugs; recent abdominal trauma or surgery; increased ICP; cirrhosis; retching, vomiting
S/Sx of rectal prolapse.
Prolapse through anus of rectal mucosa +/- muscular wall; often as a result of straining for a BM. Doughnut or rosette of red tissue. When only mucosa involved, prolapse is relatively small & shows radiating folds. When entire bowel wall is involved, a larger prolapse occurs with concentrically circular folds
S/Sx of anal fissure.
Very painful oval ulceration of anal canal; most common in posterior midline; may have swollen "sentinel" skin tag below it. Gentle separation of anal margins may reveal lower dege of the fissure. Local anesthesia may be required because sphincter is spastic and exam is painful.
Abnormal findings of DRE indicative of colon polyps.
Common; variable size & #, soft, 2 types: Pedunculated (stalk) & sessile (lies on surface); Difficult to detect even when in reach; Proctoscopy & biopsy necessary
Abnormal findings of DRE indicative of rectal cancer.
Firm, nodular, rolled edge of an ulcerated cancer; Signs/Symptoms: Often asymptomatic; Rectal bleeding, change in bowel pattern/stool, weight loss.
Rectal cancer risk factors.
Inc. age, smoking, FH or personal hx of colon/rectal ca, diet high in fat, no screening.
Procedures that may be used in screening for rectal cancer.
Fecal occult blood test (FOBT), PE/DRE, Flex sig/Rigid sig/colonoscopy/ultrasound
At what age do the risks of colonoscopy outweigh the benefits?
Abnormal findings of DRE indicative of prostate cancer.
Area of hardness on the prostate during rectal exam; enlarged tumor may feel irregular and may extend beyond confines of the gland. Median sulcus may be obscured.
Abnormal findings of DRE indicative of BPH.
Nonmalignant enlargement of prostate gland that increases with age; present in 50% of men over 50. May feel normal in size or may be symmetrically enlarged, smooth, and firm though slightly elastic.
Normal findings of DRE indicative of healthy prostate.
Rounded, heart-shaped structure approximately 2.5 cm long. Median sulcus felt at base between 2 lateral lobes.
S/Sx of BPH.
Increased urinary urgency, frequency, nocturia, decreased stream, retention; straining. REMEMBER - NUTS: Nocturia, Urine dribbles, tried to void but canﾒt, small stream
Gland contributing to seminal fluid. Surrounds urethra at neck of urinary bladder.
Contain interstitial tissue and seminiferous tubules; produces testosterone as a result of hypothalamus stimulation (GRH) of anterior pituitary (FSH & LH). FSH also regulates sperm production.
Loose, wrinkled pouch divided into two compartments, each containing one testis. Important in temperature regulation of testes. Covering testis within scrotum, except posteriorly, is serous membrane, tunica vaginalis which cloaks anterior 2/3 of testis and can accumulate fluid. On posterolateral surface of each testis is softer, comma-shaped epididymis.
Tightly coiled spermatic ducts that provide a reservoir for storage, maturation, and transport of sperm from testis to vas deferens.
Within scrotum, vas deferens is closely associated with blood vessels, nerves, and muscle fibers. These structures make up the spermatic cord.
Cordlike structure that transports sperm from tail of epididymis along a somewhat circular route to the urethra during ejaculation. The vas ascends from the scrotal sac into the pelvic cavity through the external inguinal ring, then loops over the ureter to teh prostate behind the bladder. There it merges with the seminal vesicle to form the ejaculatory duct, which traverses the prostate and empties into the urethra. Secretions from the vas deferentia, seminal vesicles, and prostate all contribute to seminal fluid.
Shaft - 3 columns of vascular erectile tissue: 1) corpus spongiosum, containing urethra and forming bulb of penis ending in the glans, which has expanded base known as corona; 2 & 3) corpora cavernosa. Foreskin/prepuce covers glans in uncircumcised men, where smegma (secretions of glans) may collect. Urethra opens in external urethral meatus.
4 Types of Prostatitis
Acute bacterial prostatitis; chronic bacterial prostatitis; chronic nonbacterial prostatitis; asymptomatic inflammatory prostatitis
S/Sx of acute bacterial prostatitis
Fever, chills, dysuria, perineal & low back pain; +/- signs of sepsis; warm, tender, dilated prostate
Common ages for acute bacterial prostatitis
Men in 20's
Causes of acute bacterial prostatitis.
80% from Gram (-) bacteria such as E. coli, Enterococcus, Proteus; May be secondary to chlamydia, gonorrhea, herpes, or syphilis in men in 20s and 30s.
S/Sx of chronic bacterial prostatitis
Recurrent infection of prostate; pain in perineal, low back, suprapubic, groin, and/or scrotal regions; dysuria, inc. freq., urgency, nocturia; pain on ejaculation; low libido; abd, testicular, epididymal, prostate, and/or DRE tenderness; normal sized or enlarged prostate
Causes of chronic bacterial prostatitis.
Most often E. coli
S/Sx of chronic nonbacterial prostatitis
Recurrent infection of prostate; pain in perineal, low back, suprapubic, groin, and/or scrotal regions; dysuria, inc. freq., urgency, nocturia; pain on ejaculation; low libido; abd, testicular, epididymal, prostate, and/or DRE tenderness; normal sized or enlarged prostate; pelvic pain often exaggerated by stress, diet, vigorous exercise
Causes of chronic nonbacterial prostatitis.
S/Sx of noninflammatory chronic pelvic pain syndrome (CPPS)
Prostadynia; pelvic pain; voiding symptoms; negative urine cultures; normal prostate DRE; aggrevated/induced by stress
Common ages for chronic pelvic pain syndrome
Men ages 20-50
Commonly used methods for rectal examination/visualization in office/outpatient facilities.
FOBT; DRE; possibly sigmoidoscopy (every 5 years after 50)
Commonly used methods for rectal examination/visualization in with sedation in a facility.
Possibly sigmoidoscopy; colonoscopy (every 10 years after 50)
Indications for ordering a PSA test
Discussion of risks and benefits of PSA testing and individualized screening decisions beginning at age 50
What is PSA?
Prostate-specific antigen; a glycoprotein produced by prostate epithelial cells that is a biomarker for early detection of prostate cancer with a variety of limitations.
What causes elevated PSA values?
Hyperplasia, prostatitis, ejaculation, urine retention, prostate cancer
S/SX of condyloma acuminatum.
Most common viral STI in US; increased risk of anogenital, head, and neck cancer. Single/multiple papules/plaques, may be raised or cauliflower like (verrucous); HPV subtypes 6, 11 ﾖ weeks to months from exposure ﾖ partner may not have visible warts; Can cause itching and pain; Arise on penis, scrotum, groin, thighs, anus, vagina, labia; May disappear without treatment.
Congenital anomaly with displacement of urethral meatus to inferior surface of penis
Congenital (very rare) anomaly with displacement of urethral meatus to dorsal surface of penis
S/SX of genital herpes (herpes simplex type 2).
Leading cause of genital ulcer disease (multiple, shallow, tender ulcers that may be vesicular); recurrence is expected. Small scattered or grouped vesicles 1-3mm in size on glans, shaft, vagina; appear as erosion if vesicles break; HSV 2 (double stranded DNA virus) ﾖ 2-7 days after exposure; Primary episode may be asymptomatic; subsequent episodes usually less painful/shorter
S/SX of Peyronie's.
Hard, non-tender, palpable plaques located on the dorsal aspect of the penis, just below the skin. CC is a painful and crooked erection.
S/SX of syphilitic chancre.
Small red papule ? chancre (painless erosion) ﾖ heals within 3-8 wks ﾖ if secondary syphilis develops while present ﾖ suggests co-infection with HIV; Treponema pallidum (spirochete) ﾖ 9-90 days after exposure; Inguinal lymphadenopathy in 7 days ﾖ mobile, non-tender, rubbery
S/SX of penile carcinoma.
Typically found in uncircumcised men ﾖ a nontender indurated nodule or ulcer-like lesion. Penile lesions that do not resolve quickly are concerning.
Foreskin fully forward over glans and cannot be retracted
Foreskin trapped behind the glans, becoming edematous and vascular engorgement occurs of distal glans. Medical emergency.
Inflammation of the glans penis and prepuce ﾖ may be result of infection or a dermatologic cause, poor hygiene in uncircumcised male
Inflammation of the glans penis and prepuce ﾖ descriptive term and not a diagnosis
S/SX of epidermoid cyst.
Common finding ﾖ white or yellowish papule resulting from follicles filled with desquamated follicular epithelium
S/SX of scrotal edema.
Pitting edema may make the scrotal skin taut; seen in HF and nephrotic syndrome
S/SX of hydrocele.
Mass of fluid within the tunica vaginalis ﾖ discreet and palpable; transilluminates
S/SX of scrotal hernia.
Usually an indirect inguinal hernia that comes through the external inguinal ring, so examining fingers cannot get above it within the scrotum
S/SX of testicular torsion.
Surgical emergency. Twisting of the testis involving spermatic cord compromises blood supply
S/SX of cryptorchidism.
Atrophied testes; may be in inguinal canal or abdomen because they are undescended; scrotum unfilled; increased risk of testicular cancer
S/SX of acute orchitis.
Red, inflamed, tender, swollen testis ﾖ typically viral infections (mumps & others); unilateral
S/SX of acute epididymitis.
Inflamed, tender, swollen ﾖ diff to differentiate from the testis ﾖ usually found with Chlamydia infection.
S/SX of spermatocele.
Located just above testis ﾖ painless and mobile cystic mass ﾖ clinical exam canﾒt determine if sperm-filled or not
Assume cancer until proven otherwise
"Bag of worms" feeling - soft, apart from testes; usually noted on left testis. May be associated w/ infertility
Small testicular size (<2 cm); may follow orchitis
What are the 3 types of hernias?
Direct inguinal; indirect inguinal; femoral
PE findings indicating a direct inguinal hernia.
Rarely in the scrotum. The hernia (omentum or part of intestine) bulges anteriorly and pushes the side of the finger forward.
Occurrence frequency of direct inguinal hernias.
Less common than indirect inguinal hernias; more common than femoral hernias.
Age/sex of typical direct inguinal hernia patients.
Usually in men older than 40; very rare in women.
Point of origin of direct inguinal hernias.
Above inguinal ligament, close to the pubic tubercle (near the external inguinal ring); through fascia of the posterior wall of the inguinal canal; medial to the inferior epigastric vessels; Bulge near external inguinal ring
PE findings indicating a indirect inguinal hernia.
Often into scrotum. Hernia comes down the inguinal canal and touches the fingertip with coughing.
Occurrence frequency of indirect inguinal hernias.
Most common hernia in all ages.
Age/sex of typical indirect inguinal hernia patients.
Affects all ages and sexes. Often in children, and may also present in adults.
Point of origin of indirect inguinal hernias.
Bulge above inguinal ligament, near its midpoint (the internal inguinal ring, which is more lateral than the external inguinal ring). Through deep inguinal ring, lateral to the inferior epigastric vessels.
PE findings indicating a femoral hernia.
Never into the scrotum. Inguinal canal is empty.
Occurrence frequency of femoral hernias.
Least common hernia in groin.
Age/sex of typical femoral hernia patients.
More common in women.
Point of origin of femoral hernias.
Below the inguinal ligament. Appears more lateral than an inguinal hernia. Can be difficult to differentiate from lymph nodes.
Common causes of penile discharge.
Profuse yellow discharge > gonococcal urethritis; scanty white or clear discharge > nongonococcal urethritis. Definitive diagnosis requires Gram stain & culture. If pt complains of discharge or discharge is noted, ask pt to milk the shaft of the penis to obtain a sample for culture.
What information should be obtained in for a menstrual hx?
Age of menarche; # of days on menses (Usually 5 +/- 2 days); Length & regularity of interval between cycles (Usually 21 ﾖ 35 days); Start date of last menstrual period(LMP); Dates of preceding menses; Intermenstrual bleeding or pain; Color; Volume of flow; Sx associated with menses
What information should be obtained in for a basic gynecological hx?
Date of last pelvic exam; Last PAP smear & results; Hx of Abnormal PAP; STDs; Gyn procedures
What information should be obtained in for a contraceptive hx?
Current method (Type; Length of time used; Compliance; Side effects; Satisfaction); Previous methods & why discontinued; Patient education about barrier methods
Absence of menses
What are common causes of amenorrhea?
Secondary amenorrhea (physiologic) - pregnancy, lactation, menopause Secondary amenorrhea (pathologic) - low body weight; hypothalamic-pituitary-ovarian dysfunction
Primary vs. Secondary amenorrhea
Primary amenorrhea - absence of periods ever initiating. Secondary amenorrhea - Cessation of periods after they have been established.
Pain during intercourse
What are common causes of dyspareunia?
local inflammation, atrophic vaginitis, inadequate lubrication; pelvic disorders; pressure on a normal ovary;
Infrequent or very light menstruation
Abnormally frequent menstruation
Abnormally heavy bleeding during menstruation
What are common causes of menorrhagia?
Threatened abortion or dysfunctional uterine bleeding (if preceded by amenorrhea)
Abnormal bleeding from uterus.
What are common causes of metrorhagia.
Pregnancy; cervical/vaginal infection or cancer; cervical or endometrial polyps or hyperplasia, fibroids, bleeding disorders, hormonal contraception or replacement therapy.
Primary vs. Secondary Dysmenorrhea
Primary - without organic cause; Secondary - with an organic cause
What are common causes of dysmenorrhea?
Primary - Increased prostaglandin production during luteal phase of the menstrual cycle when estrogen and progesterone levels decline; Secondary - endometriosis; adenomyosis; PID; endometrial polyps
Painful, spasmodic contraction of the vagina in response to physical contact
What are common causes of vaginismus?
Physical or psychological
What is gravida?
# of pregnancies
What is parity?
# of deliveries & types
What information should be obtained in for an obstetrical hx?
Gravidity (# of pregnancies); Parity (# of deliveries [F]ull term; [P]reterm; [A]borions; [L]iving children); Complications (pregnancy, deliver, fetus/neonate)
How should pregnancy and birth history be noted?
Documentation: G #Births P #Full term #Preterm #Abortions #Living Ex. - G 6 P 3-2-1-4
What general questions should be asked when taking a sexual history?
# of sexual partners; Gender of partner; Sexual preferences; High risk behavior; Prior STDs; Satisfaction with relationship (Frequency, pleasure, orgasm, dyspareunia)
What structures/organs are in the female pelvic area?
External genitalia - Vulva: Mons veneris, Labia majora, Labia minora, Clitoris, Vestibule & glands (Bartholinﾒs glands), Urethral meatus Internal genitalia - Vagina, Uterus (Cervix, Fundus, Corpus(body)), Fallopian Tubes, Ovaries, hymen
What is a PAP smear?
Sample of cervical and uterine superficial cells and secretions
When should a PAP smear be utilized?
Begin at age 21; screen every 3 years if no past abnormal results
What does a PAP smear screen?
examined microscopically to detect any abnormal cell, precancerous, or cancerous cells
What are normal PAP smear results?
Negative for intraepithelial lesion or malignancy. Note: Other organisms such as Candida,Trichomonas, Actinomyces, Herpes, bacterial vaginosis may be reported with this finding.
What are abnormal PAP smear results?
Epithelial cell abnormalities (squamous cells including atypical squamous cells; glandular cells), other malignant neoplasms
PE findings associated with hernias in women.
Direct - through fascia of the posterior wall of the inguinal canal; medial to the inferior epigastric vessels Indirect - through deep inguinal ring, lateral to the inferior epigastric vessels; palpate in the labia majora and upward to just lateral to the pubic tubercles. Femoral (more common in women than men) - Below the inguinal ligament. Appears more lateral than an inguinal hernia. Can be difficult to differentiate from lymph nodes.
Common causes of vaginitis.
Trichomonia; Candida; Bacteria; Gonococcal
Characteristics of Trichomonal vaginitis.
Yellowish green or gray, possibly frothy discharge that often pools in the vaginal fornix and has a fishy smell (malodorous). Pruritus, pain on urination, and dysparunia. Vestibule and labia minora may be red; vaginal mucosa diffusely red; petechiae in posterior fornix
Characteristics of Candidal vaginitis.
White, curdy, typically thick discharge; not malodorous; pruritus, vaginal soreness, dysuria; dyspareunia; inflamed vulva; red vaginal mucosa; mucosa may bleed when patches of discharge are removed.
Characteristics of Bacterial vaginitis.
Gray or whit, thin, homogenous, malodorous discharge coating vaginal walls; not profuse, may be minimal; Vulva and mucosa have normal appearance.
Characteristics of Gonococcal vaginitis.
Greenish yellow, muco-purulent discharge that adheres to vaginal walls; erythematous vulva; pus in os
Characteristics of uterine prolapse.
falling or sliding of the uterus from its normal position into the vaginal area
Common causes of uterine prolapse.
Weakness of the supporting structures of the pelvic floor; often associated with cystocele and rectocele.
Characteristics of cystocele.
Bulge of the upper 2/3 of the anterior vaginal wall, together with the bladder above it.
Common causes of cystocele.
Weakened supporting tissues
Characteristics of rectocele.
Herniation of the rectum into the posterior wall of the vagina
Common causes of rectocele.
Weakness or defect in the endopelvic fascia
Characteristics of nabothian cyst.
Translucent nodules on cervical surface; also known as retention cysts; not pathologic
Common causes of nabothian cyst.
Metaplasia blocks secretion of columnar epithelium, resulting in benign nabothian cysts.
Characteristics of cervical polyps.
Usually arises from endocervical canal, becoming visible when it protrudes through the os. Bright red, soft, and fragile.
Common causes of cervical polyps.
Characteristics of cervicitis.
Drainage of discharge from the cervical os.
Common causes of cervicitis.
STIs - Gonorrhea; chlamydia, herpes
Characteristics of pelvic inflammatory disease.
Acute - very tender, bilateral adnexal masses; movement of cervix is painful. Without treatment, tubo-ovarian abscess and/or infertility may result. Non-STI related PID - Infection of the fallopian tubes or ovaries ay follow delivery of a baby or gynecologic surgery.
Common causes of pelvic inflammatory disease.
STI in the fallopian tubes (salpingitis) or of tubes and ovaries (salpingo-oophoritis). Specifically Gonorrhea & chlamydia.