Exam V: Pelvic & Junk

Question 1

Office Environment

Answer 1

ALWAYS have another person in the room while examining genital area or the female breasts.
Explain what you are going to be doing, before you do each step/maneuver
Insure patient comfort, and modesty

Question 2

Patient Comfort and Modesty

Answer 2

Use gowns AND sterile drapes over pt legs
Allow patient to wear socks, shirt- as long as access can be facilitated etc.
Foot of exam table does not face the door
Door is clearly marked to avoid interruption
Another person in the room all the time, taking notes or somehow attentive

Question 3

Male Anatomy: Penis, Root, Glans, Foreskin, Corona, and Frenulum

Answer 3

Penis - formed of three cylindrical masses of erectile tissue - enclosed in separate fibrous coverings - held together by a covering of skin

Root at base of penis, divides into crura which are attached to the pelvic bones

Glans is at the tip of the penis and is the most sensitive part for most men - covered by prepuce or foreskin which may be removed by a surgical procedure called circumcision

Corona (crown) - ridge between glans and foreskin

Frenulum - connects glans to shaft on underside of penis

Smegma - secretion that can accumulate under foreskin of penis and must wash/clean thoroughly to prevent infections

Question 4

Male Anatomy: Shaft

Answer 4

Contains spongy tissue which fills with blood when a man is aroused, leads to erection (there is no bone in the penis)
Cavernous bodies (corpus cavernosum) - on top - 2 of them
Spongy body (corpus spongiosum) underneath - 1 only - urethra runs through it

Question 5

Malformations of the Penis

Answer 5

Abnormal location of urethral orifice along penile shaft

Hypospadias: urethra on ventral aspect; most common

Epispadias: urethra on dorsal aspect

If these issues are present = congenital issues which mean problems downstream like pelvic organ abnormalities, inguinal hernias, undescended testes

Clinical Consequences: constriction of orifice, urinary tract obstruction leading to infection, impaired reproductive function

Question 6

Kegel Exercises

Answer 6

benefit sexual functioning and pleasure – note that the musculature around the penis is comparable to the pelvic floor muscles in the female

strengthening the muscles with Kegel exercises may produce benefits for men in that are similar to those produced by Kegels in women

Prevents pelvic floor prolapse
Contraction muscles that hold the urine

Question 7

Seminiferous Tubules and Interstitial Cells

Answer 7

Seminiferous tubules are the site of sperm production
sperm maturation occurs in the epididymus (about 20 feet long) on the back of each testicle

Interstitial cells are located between the seminiferous tubules and are the major producer of androgens in men

Question 8

Epipdidymitis vs. Testicular Torsion

Answer 8

BOTH are EMERGENCIES

Testicular torsion: pain is sudden and severe; abnormal axis; acute; early puberty; UA is negative; cremasteric reflex is negative; tx is surgical exploration

Epididymitis: gradual onset of pain of testis or epididymis; the testicle may be warm and/or red and swollen; axis of testicle is normal; insidious onset of symptoms; adolescents; UA can be + or -; cremasteric reflex is positive; tx is antibiotics

Question 9

Seminal Vesicles

Answer 9

Seminal vesicles - two pouch-like structures between the bladder and the rectum - function not completely understood – they secrete an alkaline fluid rich in fructose - sperm become motile here and can propel themselves (got to this point via cilia in ducts) - contribute about 70% of seminal fluid

Question 10

Prostate

Answer 10

Doughnut shaped gland just below the bladder - thin alkaline secretions counteract acidity in male urethra and in the vagina – contributes about 30% of seminal fluid

Question 11

Cowper’s Glands

Answer 11

Or bulbourethral glands
Pea-sized - lie just below prostate - connect to urethra by a duct - secrete a slippery substance when a man is sexually aroused - alkaline - helps lubricate flow of seminal fluid through urethra
can contain active sperm and cause pregnancy without ejaculation occurring

Question 12

Semen

Answer 12

(or seminal fluid)
one teaspoon of fluid – one ejaculation contains 200-500 million sperm which - provide only 1% of volume - rest from seminal vesicles (70%), prostate (30%) and Cowper’s gland (<2%)
semen of a healthy man is not harmful if swallowed – but semen can transmit HIV from an HIV-positive man

Question 13

Ejaculation

Answer 13

Two stages = emission and expulsion

Emission phase - prostate, seminal vesicles and upper part of vas deferens (ampulla) contract - moves secretions into ejaculatory duct and prostatic urethra
internal (bladder exit) and external (below prostate) urethral sphincters close - urethral bulb balloons - leads to sensation of ejaculatory inevitability

Expulsion phase - strong rhythmic contractions of the penis expel semen – urethra contracts - external sphincter relaxes allowing semen to be expelled - internal sphincter continues to contract preventing urine from being expelled

Question 14

Circumcision Sutures

Answer 14

Interrupted sutures in case one comes out

If continuous, if it is damaged, the whole suture is at risk

Question 15

Phimosis

Answer 15

Extremely tight foreskin
Prepuce cannot be easily retracted over glans
May be congenital, but usually associated with balanoposthitis (STD) and scarring
Paraphimosis: trapped glans causing urethral constriction

Question 16

Penis Enlargement Procedure

Answer 16

Detach crura to give 2-3 inches and then inject fat behind glans
The erection will be pointing straight instead of angled dorsally so urination and ejaculation flow is different
Must wear a pole attached to the penis to prevent crura from reattaching

Gelking: some men go for the stretch method of enlargement- get ulcers if too much weight stretched the skin

Question 17

Inflammatory Lesions of the Penis: STDs

Answer 17

Balanitis (balanoposthitis): inflammation of the glans plus prepuce associated with poor hygiene in uncircumcised men (smegma); distal penis is red, swollen, tender, and with or without purulent discharge

Question 18

Inflammatory Lesions of the Penis: Fungal

Answer 18

Candidiasis
Especially in diabetics
Erosive, painful, pruritic, simple yeast
Can involve entire external male genitalia
Baby powder and air helps prevent yeast growth – they like warm, dark, and moist areas

Question 19

Neoplasms of the Penis: Squamous Cell Carcinoma

Answer 19

Epidemiology: uncommon aka less than 1% of cancer in males, but mostly in uncircumcised men between 40-70 years old

Pathogenesis: poor hygiene, smegma, smoking, HPV (16 and 18)
CIS first then progression to invasive squamous cell carcinoma

Question 20

3 Parts to Pelvic Exam

Answer 20

1. Observation and the speculum exam
2. Bimanual exam
3. Recto-Vaginal Exam (includes DRE)

Question 21

History, Inspection, and Palpate

Answer 21

Pubic hair-triangle pattern
Lymph nodes
Orifices

Palpate:
Urethral meatus-incontinence
Labia
Skene’s, then Bartholin’s glands
Perineum

Question 22

Speculum Exam

Answer 22

Performed prior to the bi-manual exam so as not to disturb the tissues/samples
Performed without lubricant jelly
Always inserted with the speculum blades warmed with warm water and closed
Inserted at a 45 degree angle posteriorly

Question 23

Visual Observation of Cervix

Answer 23

Position—is it anteverted, deviated, etc
The position of the cervix gives clues to the position of uterus
Color—should be flesh-colored, but ranges from pink to dark brown (blue or pale??); certain colors indicate pregnancy
Surface characteristics—cysts, erythema
Discharge
Size and shape of os- indication of reproductive history

Question 24

Nulliparous Cervix

Answer 24

No baby has passed through

Small and round

Question 25

Multiparous Cervix

Answer 25

At least one or more children have passed through | Bigger and not round, more linear

Question 26

Everted Cervix

Answer 26

The endothelium of canal will move out | True cervical tissues and inner cervical tissues

Question 27

Nabothian Cysts

Answer 27

aka: retention cysts | Pimple like things on the cervix

Question 28

The Papanicolaou Exam (“Pap”)

Answer 28

A minimum of two samples will be taken: Cervical cells Vaginal secretion Other tests may be done to screen for STDs The “Pap smear” evaluates the condition of the cervical cells (taken with cervical brush or spatula) SCREENS FOR CERVICAL CANCER- very accurate and decreased cancer rates Assessing “transitional zone” of the cervix

Question 29

Three Most Common STDs in Women

Answer 29

HPV, Herpes, Chlamydia, (Now 10’s of millions of existing cases) In women, often no visible symptoms

Question 30

Bacterial Vaginosis

Answer 30

aka: Vulvovaginitis General description for anything that causes symptomatic discharge (an irritant) May be due to bacteria, viruses, fungi, or protozoans Patient may talk to you about: vaginal or vulvar itching, burning, or change in color, texture or odor of discharge

Question 31

The Bimanual Exam

Answer 31

The bimanual exam is the second part of a complete pelvic exam Necessary to evaluate the cervix, uterus, and adenexal regions (ovaries, fallopian tubes, surrounding areas) Move the cervix to assess for PID/Endometriosis Important even if patient is not sexually active

Question 32

Recto-Vaginal Exam

Answer 32

DRE The Recto-Vaginal exam is the 3rd and final part of the pelvic exam May help evaluate the posterior aspect of the uterus (esp. if retroverted) Allows exam of rectal walls (initial screen for colo-rectal cancer or polyps)

Question 33

Uterine Fibroids

Answer 33

``` AKA: myoma, leiomyoma, fibroma Very, very common (40% of women > 40) The most common tumor of the pelvis The most common reason for a hysterectomy Benign, benign, benign! ``` Rick Factors: Nulliparity or delayed childbearing and African American women have 2-3 times the incidence of uterine fibroids Locations: intramural, subserosal, submucosal, pedunculated (on a stalk and can twist on axis and infarct/become painful)

Question 34

Uterine Fibroids Symptoms

Answer 34

``` Heavy menstrual bleeding Abdominal distortion Pelvic pressure Low back pain; dyspareunia Infertility Frequent urination Constipation Miscarriage or premature labor Can cause negative effects of fetus like distortion because only so much space for baby to grow ```

Question 35

Uterine Fibroid Treatment Options

Answer 35

“Wait and see” Drug therapy (GnRH agonists)- to alter tumor growth Uterine Artery Embolization (UAE) to cut blood supply; insert catheter and inject particles and fill up and implode blood supply so fibroid becomes necrotic and dies Myomectomy Hysterectomy

Question 36

Vaginitis

Answer 36

``` Inflammation of the vagina caused by: Candidiasis Trichomonas Gardnerella Bartholin’s abscess ```

Question 37

Monoliasis or Candidiasis: Signs and Symptoms

Answer 37

Marked leukorrhea, marked redness of vulva, extreme pruritus. White, creamy, cheesy, sweet smelling discharge, thrush patches. Commonly seen in pregnancy, diabetics, women on BCP or antibiotics (ampicillin).

Question 38

Monoliasis or Candidiasis: Assessment and Management

Answer 38

Assessment - lab KOH wet mount NS KOH 10% 20% look for (branching Hyphae or Mycelium fungus nails). Management - Nystatin--intravaginal adult tabs 0.1 to 0.2 million units daily times 7 to 10 days

Question 39

Trichomonas Vaginitis: Signs and Symptoms

Answer 39

Leukorrhea, vaginal soreness, burning, pruritus, dyspareunia (pain during intercourse). Bubbly, yellowish thick discharge, foul smelling. Strawberry appearance of cervix

Question 40

Trichomonas Vaginitis: Assessment and Management

Answer 40

Assessment - lab wet prep, microscopic exam reveals pear shaped parasite with long flagella and undulated (wavy outline in appearance) cell membrane. Management: Metronidazole (Flagyl) anti protozoal 250 mg TID to 500 mg BID orally for 5 days. Patient education of feminine hygiene, douching. Management based on culture results

Question 41

Bacterial Vaginitis: Signs and Symptoms

Answer 41

also called Gardnerella Vaginitis Leukorrhea, pruritus, dyspareunia. Turbid, chalky, white/gray or yellowish discharge; malodorous ("fishy").

Question 42

Bacterial Vaginitis: Assessment

Answer 42

Assessment: gram-positive nonmotile coccobacillus that normally inhabits the vagina that just overgrows Wet smears of this nonspecific vaginitis yields vaginal desquamated epithelial cells covered with many bacteria

Question 43

Bacterial Vaginitis: Management

Answer 43

Management: Metronidazole (Flagyl) 250 mg TID to 500 mg BID orally for 7 10 days. Ampicillin 500 mg QID x 7 days. Douching with povidone iodine solution. About 25% of the patients have recurrence and require treatment in 2 3 months. Management based on culture results

Question 44

Perineal Pain: Bartholin's Abscess

Answer 44

Definition and etiology - acute or chronic infection of the Bartholin's gland (streptococci, staphylococci, E. coli, anaerobes; may result in infection). History - recent intercourse, venereal disease, trauma, spontaneous abortion, wiping from rectum to vagina Signs and symptoms: Mass in perineum that is hot, tender, and fluctuant. Pus draining from Bartholin's duct

Question 45

Bartholin's Abscess: Management

Answer 45

Management: I & D Sitz bath: fill tube up quarter way and hot but not too hot; helps with healing and keeps area clean Broad-spectrum antibiotics which cover gram-positive organisms and some common vaginal gram-negative organisms

Question 46

Endometriosis

Answer 46

Normal endometrium found in abnormal places Therefore, “ectopic tissue” responds to hormone levels just like the inner layer of the uterus Retrograde menstrual flow, fallopian tubes, abdomen Lymphatic or circulatory systems cause spread

Question 47

Endometriosis: Risk Factors

Answer 47

``` Young age: 10-15% of women ages 25 to 44 have endometriosis Family History (6 - 12% of cases) Nuliparity or delayed childbearing Asians and Caucasians are at highest risk ```

Question 48

Endometriosis: Signs and Symptoms

Answer 48

``` Pain, pain, pain (low back and pelvic) Pelvic mass Alterations of menses Dysmenorrhea (pattern = pain just prior to menses) Infertility Dyspareunia Pain with defecation, urination ```

Question 49

Endometriosis: Pattern of Menstruation

Answer 49

``` Women with endometriosis have: earlier onset of menses regular cycles shorter intervals between periods (less than 27 days) more severe menstrual cramps prolonged menstrual flow (> 1 week) ```

Question 50

Endometrial Lesions

Answer 50

Endometrial deposits can occur anywhere in pelvis Ovary—most common (75%); an ideal site for growth Posterior cul-de-sac—70% Between the uterus and bowel—35% Uterosacral ligament—30% Ureters Uterus Bowel Also known to occur on appendix, gall bladder, stomach, spleen, liver, lung

Question 51

Endometrial Dx Confirmation

Answer 51

Suspected by case history Visible lesions on the vulva or cervix Red, brown, black (remember—may bleed) Speculum exam (“shotty nodules”) Definitive: The definitive diagnosis can only be made by direct visualization of the lesions Presently, confirmed by laparoscopy

Question 52

Endometriosis Treatments

Answer 52

Keep in mind that these patients typically suffer a prolonged course of multiple therapies/surgeries “Leave it alone” Drug therapy Laparotomy Hysterectomy Child-bearing (or pseudo-pregnancy conditions) Tubal ligation

Question 53

Endometriosis and Infertility

Answer 53

Peritoneal fluid normally acts as a lubricant. Endometriosis causes changes in the volume and cellular content of the peritoneal fluid. Fluid level is increased Leukocytes are increased Prostaglandin levels are increased Enzyme levels are increased These all cause a localized inflammatory reaction around the lesions The peritoneal fluid can then act as a toxin to the embryo and/or can alter the normal function of the ovaries and fallopian tubes

Question 54

Other Female Pelvic Conditions

Answer 54

``` Uterine sarcoma (endometrial carcinoma) Cervical carcinoma Ovarian carcinoma Ovarian cysts Uterine, vaginal prolapse ```

Question 55

Pregn's Sign

Answer 55

Pregn’s Sign: physical lifting of testicles relieves pain of epididymitis but not pain caused by testicular torsion- KEY Negative: no pain relief with lifting the affected testicle = testicular torsion = surgical emergency Positive is epididymitis NOT reliable for identifying other types of testicular issues from torsion