Male Exam

Question 1

Genitourinary history.

Answer 1

Urinary frequency?
-How often & what amount?
-Do you have to wake at night to urinate? (Nocturia)
Any urinary incontinence?
-With sneezing, when you have the urge to go?
Any pain with urination? (Dysuria)
Any blood in the urine? (Hematuria)
Any history of urinary tract infections?
Any history of kidney stones? (Renal calculi)
Any history of sexually transmitted infections?

Question 2

Genitourinary history (male).

Answer 2

Any testicular swelling?
Any testicular pain?
Any penile discharge?
Are you having any sexual difficulties? (Erectile dysfunction)

Question 3

Inguinal inspection.

Answer 3

Ask patient to stand with his back against exam table; legs shoulder-width apart.
Instruct him to lift his gown to his waist.
Ask about any potential abnormalities.
E.g. “Have you noticed any rashes or anything unusual on the skin in this area?”

Question 4

Inguinal palpation.

Answer 4

Talk before touch.
-Inform the patient, “I’ll be checking your groin for lymph nodes. Let me know if you feel any tenderness or discomfort.”
Start at the iliac crest and palpate down the inguinal ligament medially
Hard or immobile nodes suggest cancer
Examine the pubic hair for lice, scabies, etc.
-Note – excoriations may indicate lice or scabies

Question 5

Penile exam: inspection and palpation.

Answer 5

Talk before touch.
-Inform the patient, “I am now going to examine your penis”.
Visually inspect the penis:
-If uncircumcised, ask the patient to retract the foreskin.
Palpate both sides of the penis & inspect the urethral meatus (opening):
-Gently open the meatus using your fingers.
–Observe for erythema or discharge.

Question 6

Scrotal exam: inspection and palpation.

Answer 6

Talk before touch.
-Inform the patient, “I am now going to examine your scrotum and testicles.”
Inspect scrotal skin for moles, rash, etc.
Move scrotum to side and lift to check perineal area.
Palpate scrotal contents:
-Testes
-Epididymis
-Spermatic cord (vas deferens)

Question 7

Testicular examination.

Answer 7

Palpate each testicle between your index & middle finger and your thumb.
May discuss monthly testicular exams:
-Highest incidence of testicular cancer in 15 – 35 year-old age group.
Consistency of testicle is like a “hard-boiled egg”.
-Deviation from this requires further evaluation.

Question 8

Testicular exam: Epididymis and spermatic cord.

Answer 8

Epididymis located on top of testicle and posterolateral – feels nodular & cordlike:
-May be sensitive to touch.
-Use light palpation.
Spermatic cords:
-Bilateral firm cords that feel like the “inside of a BIC pen”.
-Palpate from the epididymis to the inguinal ring.
-Palpate between thumb and index finger.

Question 9

Hernia examination.

Answer 9

Move s..l..o..w..l..y.
Invaginate some scrotal skin when inserting index or little finger into inguinal ring.
Use “cross-handed” method:
-Right hand for patients right side & vice versa.
Insert index finger into inguinal canal:
-Use little finger for child or smaller adult.
Ask patient to, “turn your head and cough” or Valsalva.
-Feel for sudden pressure at side or tip of finger.

Question 10

Rectal and prostate exams.

Answer 10

Explain that you will be performing a rectal exam:
-Ask the patient to lean forward over the exam table, rest elbows on table, legs apart & knees slightly bent or ask patient to lie in the left lateral decubitus position.
–Consider allowing the patient to choose.
Talk before touch.
-Inform the patient, “I’m now going to examine the anal region.”
Inspect the perianal area:
-Spread cheeks of buttocks with thumbs.
-Visualize the anal opening.
-Check for hemorrhoids, fissures, skin tags and other lesions.
After inspection, apply lubricant to index finger of dominant hand.
Spread buttocks cheeks laterally with the non-dominant hand.
Inform the patient, “I’ll be inserting my lubricated finger into your rectum to perform the exam.”
–Ask the patient to try & relax or strain down (without having a bowel movement).
Do not force the exam.

Question 11

Rectal exam.

Answer 11

Press tip of dominant index finger against anal opening, palm facing downward.
May need to remind the patient to try & relax the area.
Slowly begin inserting your finger into rectum & proceed to full length of your finger.
Rotate your finger clockwise as far as possible, then counterclockwise as far as possible.
-Note any nodules, irregularities, or tenderness.

Question 12

Rectal and Prostate exam continued.

Answer 12

Palpate prostate, located at 6 o’clock.
Move finger over surface of prostate, from side to side, checking right & left lobes:
-Size: about size of a walnut.
-Shape: “almond” (with 2 lobes).
-Consistency: firm, like tip of nose or thenar area of palm.
Slowly remove finger and check stool for blood (Hemoccult/guaiac test).
-Follow guaiac test instructions.
Routine rectal exam does NOT significantly alter the Prostate Specific Antigen (PSA, protein produced by the prostate gland).
Biopsy or rigorous manipulation of prostate may elevate the PSA.

Question 13

Current guidelines for testicular exams.

ACS.

Answer 13

testicular exam by a healthcare provider as part of a routine cancer-related check-up:

• Men should be aware of testicular cancer & see a healthcare provider right away if a lump is found.
• No recommendation about regular self-testicular exams but recommended by some doctors.
• Men with risk factors, such as an undescended testicle (cryptorchidism), previous testicular cancer, or family history should consider monthly self-testicular exams (see handout).

Question 14

Current guidelines for testicular exams. USPSTF.

Answer 14

Recommends against routine screening for testicular cancer in asymptomatic patients (no provider or self-testicular exam):
Based on low prevalence of testicular cancer & unknown accuracy of examination for detection. Even without treatment, current treatments = favorable outcomes

Question 15

Current guidelines for evaluation for hernias.

Answer 15

-AAFP, AAP, American College of Sports Medicine, & others recommend routine male genitourinary exam, including testicular & hernia examination as part of a sports physical.
-USPSTF has no recommendation.
Some have questioned the need for the genital exam as part of a sports physical.
-Exam allows for assessment of development (necessary to safely play sports?).
-Exam warranted if history suggests a problem but an asymptomatic hernia is unlikely to affect one’s ability to play sports.
Bottom line (opinion) – exam should be discrete, refusal should not prevent child from participating in sports.

Question 16

Current guidelines for prostate exams (DRE). ACS.

Answer 16

• Men should be given the opportunity to make an informed decision about whether or not to be screened for prostate cancer – includes PSA testing & DRE.
• Current evidence suggests that annual screening with PSA & DRE detects more prostate cancer but does not lower death rate.

Question 17

Current guidelines for prostate exams (DRE). USPSTF.

Answer 17

• Recommends against PSA-based screening for prostate cancer.
• Screening methods such as DRE or transrectal US alone have not been evaluated in controlled studies.
• USPSTF Web site.
• Final Research Plan for Prostate Cancer: Screening (10-2015 with results pending).

2012 and 2017 draft:
recommends clinicians inform men ages 55-69 years about the potential benefits and harms of PSA screening. Decision should be individualized.

Question 18

Abnormalities of the penis.

Genital Herpes.

Answer 18

Caused by Herpes Simplex virus:
-Usually HSV 2.
Begins with painful vesicles that become ulcerated.
Often recurrent.

Question 19

Abnormalities of the penis.

Molluscum contagiosum.

Answer 19

Umbilicated vesicular-like lesions
Contagious, usually painless
Resolves in 6-12 months but may take as long as 4 years.

Question 20

Abnormalities of the penis.

Primary syphilitic chancre.

Answer 20

A small red macule enlarges and develops through a papular stage, becoming eroded to form a typical round, painless ulcer. If untreated, the ulcer usually heals after 4-8 weeks.

Question 21

Abnormalities of the penis. Gonococcal urethritis.

Answer 21

Caused by bacteria Neisseria gonorrhoeae. The typical purulent urethral discharge can often be demonstrated during examination by “milking” the urethra. The patient also has associated meatitis.

Question 22

Abnormalities of the penis.
Non-gonococcal urethritis.
NGU.

Answer 22

Chlamydia tracho-matis is most common cause of NGU.
Mucopurulent discharge. Although the discharge is often more watery than that in gonorrhoea, gonorrohea must always be excluded by gram stain and culture.

Question 23

Abnormalities of the penis.

Peyronie’s disease.

Answer 23

Idiopathic condition resulting in fibrosis in the corpora cavernosa.
Palpable, nontender plaques just beneath skin, usu. along the dorsum of the shaft of the penis.
May result in penile curvature, painful erections; occasionally erectile dysfunction.

Question 24

Abnormalities of the penis.

Carcinoma of Penis.

Answer 24

Begins as a firm nodule or ulcer that does not heal.
Usually nontender.
More common in uncircum-sized males.

Question 25

Indirect inguinal hernia.

Answer 25

Most common, all ages, both sexes. Often in children, may be in adults. Above inguinal ligament, near its midpoint (the internal inguinal ring). Often into the scrotum. The hernia comes down the inguinal canal and touches the fingertip. Palpable as impulse down inguinal canal.

Question 26

Direct inguinal hernia.

Answer 26

Less common. Usually in men over age 40, rare in women. Associated with heavy lifting. Above inguinal ligament, close to the pubic tubercle (near the external inguinal ring). Rarely into the scrotum. The hernia bulges anteriorly and pushes the side of the finger forward.

Question 27

Femoral hernia.

Answer 27

``` Least common. More common in women. Below the inguinal ligament, appears more lateral than an inguinal hernia and may be hard to differentiate from lymph nodes. Never into the scrotum. The inguinal canal is empty. ```

Question 28

Abnormalities of the scrotum. | Varicocele.

Answer 28

``` Varicose veins of scrotal vessels. Usually on the left. Feels like a soft “bag of worms”. May slowly collapse if scrotum elevated while patient supine. May be assoc. with infertility. ```

Question 29

Abnormalities of the scrotum. | Hydrocele.

Answer 29

Benign, nontender, fluid-filled mass within the tunica vaginalis. Transilluminates - red glow.

Question 30

Abnormalities of the scrotum. | Spermatocele.

Answer 30

Painless, mobile mass just above the testis. Usu. smaller than a hydrocele. Contains sperm. May transilluminate.

Question 31

Abnormalities of the scrotum. | Spermatocele and cyst of the epididymis.

Answer 31

A painless, movable cystic mass just above the testis suggests a spermatocele or an epididymal cyst. Both transilluminate. The former contains sperm and the latter does not, but they are clinically indistinguishable.

Question 32

Abnormalities of the scrotum. | Acute Epididymitis.

Answer 32

Infection of the epididymis. Local pain & swelling. Primarily in adults. Often assoc. with UTI or prostate infection. An acutely inflamed epididymis is tender and swollen and may be difficult to distinguish from the testis. The scrotum may be reddened, and the vas deferens may also be inflamed. Epididymitis occurs chiefly in adults. Coexisting urinary tract infection or prostatitis supports the diagnosis.

Question 33

Abnormalities of the scrotum. | Acute Orchitis.

Answer 33

Inflammation or infection of the testis. Testicular swelling & tenderness. Similar in appearance to epididymitis. Complication of mumps & other viral infections. An acutely inflamed testis is painful, tender, and swollen. The testis may be difficult to distinguish from the epididymis. The scrotum may be reddened. Look for evidence of postpubertal mumps, such as parotid swelling, or other less common infectious causes.

Question 34

Abnormalities of the scrotum. | Testicular Torsion.

Answer 34

``` Due to twisting of the spermatic cord. Intense pain. Red, swollen, tender scrotum. Testis may be pulled upwards. Surgical emergency! Torsion, or twisting, of the testicle on its spermatic cord produces an acutely painful, tender, and swollen organ that is retracted upward in the scrotum. The scrotum becomes red and edematous. There is no associated urinary infection. Torsion, most common in adolescents, is a surgical emergency because of obstructed circulation. ```

Question 35

Abnormalities of the scrotum. | Testicular Tumors.

Answer 35

Firm, painless testicular nodule. Does not transillum-inate. A tumor of the testis usually appears as a painless nodule. It does not transilluminate. Any nodule within the testis must raise the suspicion of malignancy. As testicular neoplasm grows and spreads, it may seem to replace the entire organ. The testicle characteristically feels heavier than normal.

Question 36

Abnormalities of the anus and rectum. | Internal hemorrhoids.

Answer 36

Usually painless.

Question 37

Abnormalities of the anus and rectum. | External hemorrhoids.

Answer 37

Painful.

Question 38

Abnormalities of the anus and rectum. Prolapsed Internal hemorrhoids. Thrombosed external hemorrhoids.

Answer 38

Internal hemorrhoid prolapse – protrudes from anus. | External hemorrhoid thrombosis – develops blood clot, painful.

Question 39

Abnormalities of the anus and rectum. | Anal fissure.

Answer 39

Anal fissure is a tear in the inside lining of the wall of the anus. May be caused by the passage of very hard stools. Symptoms – severe pain as stool passes. Also, itching, burning, bleeding & wet discharge. Diagnosed by history & anoscopy.

Question 40

Abnormalities of the anus and rectum. | Perirectal abscess.

Answer 40

Swelling and erythema of buttocks.

Question 41

Abnormalities of the anus and rectum. | Perianal condylomata.

Answer 41

HPV – human papillomavirus infection. | Usually sexually transmitted.

Question 42

Abnormalities of the anus and rectum. | Rectal carcinoma.

Answer 42

Not always within reach of finger during DRE.

Question 43

Abnormalities of the prostate, seminal vesicles. | Prostatitis-acute and chronic.

Answer 43

``` Enlarged, tender prostate gland. Much more tender during acute infection, often with fever & chills. Examine carefully: -Avoid spread of infection. Treat with antibiotics. ```

Question 44

Abnormalities of the prostate, seminal vesicles. | Benign prostatic hypertrophy (hyperplasia).

Answer 44

BPH more common with increasing age. Symmetrical enlargement of gland. Slowing of urine stream with difficulty starting stream. Most common in the median lobe of the prostate.

Question 45

Abnormalities of the prostate, seminal vesicles. | Carcinoma of prostate.

Answer 45

Enlarged, firm nodule or area of hardness. Irregular contour, median sulcus obscured. Usually a slow-growing tumor. Metastasizes locally and to bone. Most common in the posterior lobe of the prostate.