Module 5 Flashcards by Myarka Williams

A cheesy whitish material, may accumulate normally under the foreskin

Smegma

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On the posterolateral surface of each testis is the softer, comma-shaped organ, consisting of tightly coiled tubules emanating from the testis that become the vas deferent

epididymis

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The parietal and visceral layers form a potential space for the abnormal fluid accumulation of a

hydrocele

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a firm muscular cord-like structure, transports sperm from the tail of the epididymis along a somewhat circular route to the urethra

VAs Deferens

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is normally separated from the testis by a palpable sulcus and provides a reservoir for storage, maturation, and transport of sperm.

the epididymis

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During ejaculation, the …, a firm muscular cord-like structure, transports sperm from the tail of the epididymis along a somewhat circular route to the urethra.

vas deferens

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protrude at the femoral canal and are more likely to present as emergencies with bowel incarceration or strangulation.

Femoral hernias

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-Most common, all ages and sexes. Often in children; may occur in adults.
-Above inguinal ligament, near its midpoint (the internal inguinal ring)
–often in the scrotum
he hernia comes down the inguinal canal and touches the fingertip.
- a bulge near the internal inguinal ring

indirect inguinal hernias

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-Less common. Usually in men older than 40 yrs; rare in women.
-Above inguinal ligament, close to the pubic tubercle (near the external inguinal ring).
-The hernia bulges anteriorly and pushes the side of the finger forward
- a bulge near the external inguinal ring

direct inguinal hernias

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-Least common. More common in women than in men.
-Below the inguinal ligament; appears more lateral than an inguinal hernia. Can be hard to differentiate from lymph nodes.
-never in the scrotum
-The inguinal canal is empty.
-Most commonly present inferior to the inguinal ligament and medial to the femoral artery

femoral hernias

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Examining finger in inguinal canal during coughing or straining

Hernia examination

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-Appearance: Single or multiple papules or plaques of variable shapes; may be round, acuminate (pointed), or thin and slender. May be raised, flat, or cauliflower-like (verrucous). -Causative organism: HPV, usually subtypes 6, 11; carcinogenic subtypes rare, approximately 5%–10% of all anogenital warts. Incubation: weeks to months; infected contact may have no visible warts.
- Can arise on penis, scrotum, groin, thighs, anus; usually asymptomatic, occasionally cause itching and pain. -May disappear without treatment.

Genital Warts (Condylomata Acuminata)

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-Appearance: Small scattered or grouped vesicles, 1–3 mm in size, on glans or shaft of penis. Appear as erosions if vesicular membrane breaks. Causative organism: Usually Herpes simplex virus 2 (90%), a double-stranded DNA virus. Incubation: 2–7 days after exposure. -Primary episode may be asymptomatic; recurrence usually less painful, of shorter duration. -Associated with fever, malaise, headache, arthralgias; local pain and edema, lymphadenopathy. -Need to distinguish from genital herpes zoster (usually in older patients with dermatomal distribution) and candidiasis.

Genital Herpes Simplex

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Appearance: Small red papule that becomes a chancre, a painless erosion up to 2 cm in diameter. Base of chancre is clean, red, smooth, and glistening; borders are raised and indurated. Chancre heals within 3–8 wks. Causative organism: Treponema pallidum, a spirochete. Incubation: 9–90 days after exposure. May develop inguinal lymphadenopathy within 7 days; lymph nodes are rubbery, nontender, mobile. 20–30% of patients develop secondary syphilis while chancre still present (suggests coinfection with HIV). Distinguish from: genital herpes simplex; chancroid; granuloma inguinale from Klebsiella granulomatis (rare in the United States; four variants, so difficult to identify).

Primary Syphilis

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Appearance: Red papule or pustule initially, then forms a painful deep ulcer with ragged nonindurated margins; contains necrotic exudate, has a friable base. Causative organism: Haemophilus ducreyi, an anaerobic bacillus. Incubation: 3–7 days after exposure. Painful inguinal adenopathy; suppurative buboes in 25% of patients. Need to distinguish from: primary syphilis; genital herpes simplex; lymphogranuloma venereum, granuloma inguinale from Klebsiella granulomatis (both rare in the United States).

Chancroid

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A congenital displacement of the urethral meatus to the inferior surface or ventral surface of the penis. The meatus may be subcoronal, midshaft, or at the junction of the penis and scrotum (penoscrotal).

Hypospadias

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Pitting edema may make the scrotal skin taut; seen in heart failure, liver failure, or nephrotic syndrome.

scrotal edema

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Palpable, nontender, hard plaques are found just beneath the skin, usually along the dorsum of the penis. The patient complains of curved, painful erections.

Peyronie disease
On the dorsal if the penis, plaques of peyronie disease can sometimes be palpated under the skin on the right or left aspect of the shaft in the corpora cavernosa

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A nontender, fluid-filled mass within the tunica vaginalis. It transilluminates, and the examining fingers can palpate above the mass within the scrotum.

Hydrocele

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n indurated nodule or ulcer that is usually nontender. Limited almost completely to men who are not circumcised, it may be masked by the prepuce. Any persistent penile sore is suspicious.

carcinoma of the penis

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Usually an indirect inguinal hernia that comes through the external inguinal ring, so the examining fingers cannot get above it within the scrotum.

scrotal hernia

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The testis is atrophied and lies outside the scrotum in the inguinal canal, abdomen, or near the pubic tubercle; it may also be congenitally absent. There is no palpable testis or epididymis in the unfilled scrotum. Cryptorchidism, even with surgical correction, markedly raises the risk of testicular cancer.24

Cryptorchidism

Failure of one or both testes to descend.

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the testis is acutely inflamed, painful, tender, and swollen. It may be difficult to distinguish from the epididymis. The scrotum may be reddened. Seen in mumps and other viral infections; usually unilateral.

Acute Orchitis

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In adults, testicular length is usually ≤3.5 cm. Small firm testes usually ≤2 cm suggest Klinefelter syndrome. Small soft testes suggesting atrophy are seen in cirrhosis, myotonic dystrophy, use of estrogens, and hypopituitarism; may also follow severe orchitis.

small testis

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-Usually appears as a painless nodule. Any nodule within the testis warrants investigation for malignancy. -As a testicular neoplasm grows and spreads, it may seem to replace the entire organ. The testicle characteristically feels heavier than normal.

tumor of the testis

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.

Spermatocele and Cyst of the Epididymis

An acutely inflamed epididymis is indurated, swollen, and notably tender, making it difficult to distinguish from the testis. The scrotum may be reddened and the vas deferens inflamed. Causes include infection from Neisseria gonorrhoeae, Chlamydia trachomatis (younger adults), Escherichia coli, and Pseudomonas (older adults); trauma; and autoimmune disease. Barring urinary symptoms, urinalysis is often negative.

Acute Epididymitis

The chronic inflammation of tuberculosis produces a firm enlargement of the epididymis, which is sometimes tender, with thickening or beading of the vas deferens.

Tuberculous Epididymitis

... refers to gravity-mediated varicose veins of the spermatic cord, usually found on the left. It feels like a soft “bag of worms” in the spermatic cord above the testis, and if prominent, appears to distort the contours of the scrotal skin. A varicocele collapses in the supine position, so examination should be both supine and standing. If the ... does not collapse when the patient is supine, suspect a left spermatic vein obstruction within the abdomen.

Varicocele of the Spermatic Cord

Torsion, or twisting, of the testicle on its spermatic cord produces an acutely painful, tender, and swollen organ that is often retracted upward in the scrotum. The cremasteric reflex is nearly always absent on the affected side in boys or men with testicular torsion, though this can be difficult to assess during acute pain episodes. If the presentation is delayed, the scrotum becomes red and edematous. There is no associated urinary infection. Torsion is most common in neonates and adolescents but can occur at any age. It is a surgical emergency because of obstructed circulation and requires urgent surgical consultation.

Testicular Torsion

risk factors for testicular cancer

A major risk factor for testicular cancer is cryptorchidism (undescended testicle), which confers a 3- to 17-fold increased cancer risk.22 Other risk factors include family history, Klinefelter syndrome, and HIV infection

yellow penile discharge

gonorrhea

white discharge in nongonococcal urethritis

Chlamydia

patient complaining of intense pruritus with evidence of penile or pubic excoriations.

Suspect scabies or peduculosis pubis (lice)

a tight prepuce that cannot be retracted over the glans.

Phimosis

is a tight prepuce that, once retracted, cannot be returned. Edema ensues.

Paraphymosis

inflammation of the glans

Balanitis

inflammation of the glans and prepuce

Balanoposthitis

congenital dorsal displacement

epispadias A malformation in which the urethra opens on the dorsum of the penis; frequently associated with exstrophy of the bladder.

congenital ventral displacement of the meatus on the penis

Hypospadias

Purulent, cloudy or yellow discharge sometimes signals

gonococcal urethritis

canty white or clear discharge can signal

nongonococcal urethritis

Tender painful scrotal swelling is present in

acute epididymitis, acute orchitis, testicular torsion, and strangulated inguinal hernias.

A bulge suggests

a groin hernia. Groin hernias in women often do not have a visible bulge.1

-place the tip of your dominant index finger at the anterior inferior margin of the scrotum, staying superficial to the testes, then move your finger and hand upward toward the external inguinal ring, invaginating the redundant scrotal skin beneath the peripubic fat pad next to the base of the penis. -Follow the spermatic cord upward to the inguinal ligament. Find the triangular slit-like opening of the external inguinal ring just above and lateral to the pubic tubercle. Palpate the external inguinal ring and its floor. Ask the patient to cough. Palpate for a distinct bulge or mass that moves against your stationary finger during the cough.

inguinal hernia examination (Patient should be standing)

A hernia contents that cannot be returned to the abdominal cavity.

incarcerated hernia

when the blood supply to the entrapped contents is compromised. Suspect strangulation in the presence of tenderness, nausea, and vomiting, and consider surgical intervention.17

A hernia is strangulated

may help distinguish a hydrocele from an intestine-containing hernia. Those containing blood or tissue, such as a normal testis, a tumor, or most hernias, do not transilluminate.

Transillumination of the scrotal mass

how often to screen high risk man for HIV?

One-time testing for low-risk patients is reasonable, but at least annual testing is recommended for high-risk groups,

located posteriorly on both sides of the vaginal opening but are not usually visible (Fig. 21-2). The glands themselves are situated more deeply. Just posterior and adjacent to the urethral meatus on either side lie the openings of the paraurethral (Skene) glands.

The openings of Bartholin glands

A small firm round cystic nodule in the labia suggests an.... These are yellowish in color. Look for the dark punctum marking the blocked opening of the gland.

Epidermoid Cyst

Warty lesions on the labia and within the vestibule are often condyloma acuminata from infection with human papillomavirus.

Venereal Wart (Condyloma Acuminatum)

This firm painless ulcer from primary syphilis forms ∼21 d after exposure to Treponema pallidum. It may remain hidden and undetected in the vagina and heals regardless of treatment in 3–6 wks.

syphilis Chancre

Large raised, round or oval, flat-topped gray or white lesions point to condylomata lata. These are contagious and, along with rash and mucous membrane sores in the mouth, vagina, or anus, are manifestations of secondary syphilis.

Secondary Syphilis (Condyloma Latum)

Shallow small painful ulcers on red bases are suspicious for infection from genital herpes simplex virus 1 or 2. Ulcers may take 2–4 wks to heal. Recurrent outbreaks of localized vesicles, then ulcers are common.

genital herpes

An ulcerated or raised red vulvar lesion in an elderly woman may be a vulvar carcinoma, usually a squamous cell carcinoma arising on the labia.

Carcinoma of the Vulva

a bulge of the upper two-thirds of the anterior vaginal wall, together with the bladder above it. It results from weakened anterior supporting tissues.

cystocele

is a small red benign tumor visible at the posterior urethral meatus. It occurs chiefly in postmenopausal women and usually causes no symptoms. Occasionally, a carcinoma of the urethra is mistaken for a caruncle. To check, palpate the urethra through the vagina for thickening, nodularity, or tenderness, and palpate for inguinal lymphadenopathy.

A urethral caruncle

Causes of a Bartholin gland infection include trauma, gonococci, anaerobes like bacteroides and peptostreptococci, and C. trachomatis. Acutely, the gland appears as a tense, hot, very tender abscess. Look for pus emerging from the duct or erythema around the duct opening. Chronically, a nontender cyst is felt that may be large or small.

Bartholin gland infection

When the entire anterior vaginal wall, together with the bladder and urethra, produces the bulge, a... is present. A groove sometimes defines the border between the urethrocele and cystocele, but is not always present

Cystourethrocele Hernia of the urinary bladder and urethra.

Forms a swollen red ring around the urethral meatus. It usually occurs before menarche or after menopause. Identify the urethral meatus at the center of the swelling to make this diagnosis.

Prolapse of the Urethral Mucosa

a herniation of the rectum into the posterior wall of the vagina, resulting from a weakness or defect in the endopelvic fascia.

A rectocele

The vaginal surface of the cervix

ectocervix

refers to the ovaries, fallopian tubes, and their supporting tissues.

adnexa

The area behind the uterus is in the shape of a cul-de-sac. ou can palpate this area on rectovaginal examination.

rectouterine pouch (pouch of Douglas)

the pelvic organs are supported by a sling of tissues composed of muscle, ligaments, and endopelvic fascia called ..., which helps support the pelvic organs above the outlet of the lesser pelvis (Fig. 21-6). Pelvic floor muscles also aid in sexual function (orgasm), urinary and fecal continence, and stabilization of connecting joints. The pelvic floor consists of the pelvic diaphragm and the perineal membrane.

the pelvic floor

may cause pain; urinary incontinence; fecal incontinence; and prolapse of the pelvic organs that can produce a cystocele (prolapse of the bladder into the vagina), rectocele (prolapse of the rectum into the vagina), or enterocele (prolapse of the bowel into the vagina).

Weakness of the pelvic floor muscles

prolapse of the bladder into the vagina

cystocele

prolapse of the rectum into the vagina

rectocele

prolapse of the bowel into the vagina

enterocoele

innervated by the sacral nerve roots S3 to S5

pelvic diaphragm

The perineal membrane and the urogenital diaphragm are innervated by

prudential nerve

Weakness of the perineal body from childbirth predisposes to...

rectoceles and enteroceles.

absence of menses for 12 consecutive months, usually occurring between ages 48 and 55 yrs

menopause

bleeding occurring 6 mo or more after cessation of menses

Postmenopausal bleeding

results from increased prostaglandin production during the luteal phase of the menstrual cycle, when estrogen and progesterone levels decline.

Primary dysmenorrhea

Causes of secondary dysmenorrhea

endometriosis, adenomyosis (endometriosis in the muscular layers of the uterus), pelvic inflammatory disease (PID), and endometrial polyps.

bleeding or spotting in between your menstruation

(metrorrhagia)

duration of period is longer than usual

(menorrhagia

Patterns of Abnormal bleeding

Polymenorrhea, or less than 21-day intervals between menses Oligomenorrhea, or infrequent bleeding Menorrhagia, or excessive flow Metrorrhagia, or intermenstrual bleeding Postcoital bleeding

Postcoital bleeding suggests

cervical polyps or cancer or, in an older woman, atrophic vaginitis.

Causes of postmenopausal bleeding include

endometrial cancer, hormone replacement therapy (HRT), and uterine and cervical polyps.

Acute pelvic pain in menstruating adolescent girls and women warrants immediate attention. The differential diagnosis is broad but includes life-threatening conditions such as ectopic pregnancy, ovarian torsion, and appendicitis.

Acute pelvic pain

mild unilateral pain lasting for a few hours to a few days arising at midcycle from ovulation, ruptured ovarian cyst, or tubo-ovarian abscess

mittelschmerz

from retrograde menstrual flow and extension of the uterine lining outside the uterus, affects 50% to 60% of women and girls with pelvic pain.15 Other causes include PID; adenomyosis; and fibroids, which are tumors in the uterine wall or submucosal or subserosal surfaces arising from the smooth muscle cells of the myometrium.

Endometriosis

red flag for a history of sexual abuse.

chronic pelvic pain

Excoriations or itchy, small, red maculopapules suggest

pediculosis pubis (lice or “crabs”), often found at the bases of the pubic hairs.

An enlarged clitoris is seen in

masculinizing endocrine disorders.

hallmarks of PID, ectopic pregnancy, and appendicitis.

Cervical motion tenderness and/or adnexal tenderness

Nodularity, immobility, and tenderness in the fornices may result from

endometriosis.

suggests pregnancy, uterine myomas (fibroids), or malignancy.

Uterine enlargement

Nodules on the uterine surfaces suggest

myomas

Within 3 to 5 years after menopause, the ovaries become atrophic and usually nonpalpable. In postmenopausal women, investigate a palpable ovary for possible ovarian cyst or ovarian cancer. Pelvic pain, bloating, increased abdominal size, and urinary tract symptoms are more common in women with ovarian cancer.19

ovaries become atrophic and usually nonpalpable

has the following primary purposes: to palpate a retroverted uterus, the uterosacral ligaments, cul-de-sac, and adnexa; and to assess pelvic pathology.

The rectovaginal examination

refers to a tilting backward of the entire uterus, including both the body and the cervix. It is a common variant occurring in approximately 20% of women. Early clues on pelvic examination are a cervix that faces forward and a uterine body that cannot be felt by the abdominal hand.

Retroversion of the uterus

produces purulent yellow drainage from the cervical os, usually from C. trachomatis, N. gonorrhoeae, or herpes infection. These infections are sexually transmitted and may occur without symptoms or signs.

Mucopurulent Cervicitis

begins in an area of metaplasia. In its earliest stages, it cannot be distinguished from a normal cervix. In later stages, an extensive, irregular, cauliflower-like growth may develop. Early frequent intercourse, multiple partners, smoking, and infection with human papillomavirus increase the risk for cervical cancer.

Carcinoma of the Cervix

Daughters of women who took DES during pregnancy are at greatly increased risk for several abnormalities, including (1) columnar epithelium that covers most or all of the cervix, (2) vaginal adenosis (i.e., extension of this epithelium to the vaginal wall), and (3) a circular collar or ridge of tissue, of varying shapes, between the cervix and vagina. Much less common is an otherwise rare carcinoma of the upper vagina.

Fetal Exposure to Diethylstilbestrol (DES)

refers to a backward angulation of the body of the uterus in relation to the cervix. The cervix maintains its usual position. The body of the uterus is often palpable through the posterior fornix or through the rectum.

Retroflexion of the Uterus

results from weakness of the supporting structures of the pelvic floor and is often associated with a cystocele and rectocele. In progressive stages, the uterus becomes retroverted and descends down the vaginal canal to the outside: In first-degree prolapse, the cervix is still well within the vagina. In second-degree prolapse, it is at the introitus. In third-degree prolapse (procidentia), the cervix and vagina are outside the introitus.

Prolapse of the Uterus

risk factors of ectopic pregnancy

tubal damage from PID, prior ectopic pregnancy, prior tubal surgery, age older than 35 yrs, presence of an IUD, subfertility (has altered tubal integrity), and assisted reproductive techniques.

due to “spontaneous ascension of microbes from the cervix or vagina to the endometrium, fallopian tubes, and adjacent structures.”22 85% of cases involve STIs or bacterial vaginosis affecting the fallopian tubes (salpingitis) or the tubes and ovaries (salpingo-oophoritis), primarily N. gonorrhoeae and C. trachomatis. Hallmarks of acute disease are adnexal, cervical, and uterine compression tenderness

Pelvic Inflammatory Disease

the junction of hair-bearing and hairless skin at the external anus.

Anal verge

Because of its integral connection to male urinary function, the main questions for prostate health involve

urinary habits

a fairly common, probably congenital, abnormality located in the midline natal cleft. Look for the opening of a sinus tract, sometimes with a small tuft of hair surrounded by a halo of erythema. Pilonidal cysts are generally asymptomatic, except for slight drainage, but abscess formation and secondary sinus tracts may occur.

Pilonidal Cyst and Sinus

dilated hemorrhoidal veins that originate below the pectinate line that are covered with skin. They seldom produce symptoms unless thrombosis occurs. Thrombosis causes acute local pain that increases with defecation and sitting. A tender, swollen, bluish, ovoid mass is visible at the anal margin.

External hemorrhoids

enlargements of the normal vascular cushions located above the pectinate line, usually not palpable. Internal hemorrhoids may cause bright-red bleeding, especially during defecation. They may also prolapse through the anal canal and appear as reddish, moist, protruding masses, typically located in one or more of the positions illustrated.

Internal Hemorrhoids (Prolapsed

On straining for a bowel movement, the rectal mucosa, with or without its muscular wall, may prolapse through the anus, telescoping through the anal verge. A prolapse involving only mucosa is relatively small and shows radiating folds, as illustrated. When the entire bowel wall is involved, the prolapse is larger and covered by concentrically circular fold

Prolapse of the Rectum

a very painful tear/ulceration of the anoderm, found most commonly in the midline posteriorly, less commonly in the midline anteriorly. Its long axis lies longitudinally. There may be a swollen “sentinel” skin tag just below it. Gentle separation of the anal margins may reveal the lower edge of the fissure. The sphincter is spastic; the examination is painful. An examination under anesthesia may be necessary to fully characterize the lesion.

An anal fissure

Polyps of the rectum are fairly common. Variable in size and number, they can develop on a stalk (pedunculated) or lie on the mucosal surface (sessile). They are soft and may be difficult or impossible to feel even when in reach of the examining finger. Endoscopy and biopsy are needed for differentiation of benign from malignant lesions.

Polyps of the Rectum (smooth)

is suggested by an area of hardness in the gland, such as a distinct hard nodule or firmness. As the cancer enlarges, it feels irregular and may extend beyond the confines of the gland. The median sulcus may be obscured. Hard areas in the prostate are not always malignant. They may also result from prostatic stones, chronic inflammation, and other conditions.

prostate cancer (firm hard mass)

nonmalignant enlargement of the prostate gland that increases with age, present in more than 50% of men by age 50 yrs. Symptoms arise both from smooth-muscle contraction in the prostate and bladder neck and from compression of the urethra by hypertrophied prostate tissue. They may be irritative (urgency, frequency, nocturia), obstructive (decreased stream, incomplete emptying, straining), or both, and are seen in more than one-third of men by age 65 yrs. The affected gland may be normal in size, or may feel symmetrically enlarged, smooth, and firm, though slightly elastic; there may be obliteration of the median sulcus and more notable protrusion into the rectal lumen. Because of the limited nature of the digital rectal examination, the severity of symptoms may not correlate with the examination findings.

Benign Prostatic Hyperplasia

Acute bacterial prostatitis, illustrated here, presents with fever and urinary tract symptoms such as frequency, urgency, dysuria, incomplete voiding, and sometimes low back pain. The gland feels tender, swollen, “boggy,” and warm. Examine it gently as it can be extremely tender and painful for the patient. More than 80% of infections are caused by gram-negative aerobes such as Escherichia coli and Enterococcus and Proteus spp. In men younger than age 35 yrs, consider sexual transmission of Neisseria gonorrhea and Chlamydia trachomatis.

Prostatitis

As palpated through the anterior rectal wall, the normal prostate is a rounded, heart-shaped structure approximately 2.5 cm long. The median sulcus can be palpated between the two lateral lobes. Only the posterior surface of the prostate is palpable. Anterior and central lesions, including those that obstruct the urethra, are not detectable by physical examination as they are not in contact with the rectal wall.

Normal Prostate Gland (soft, rubbery)

superficial reflex found in human males that is elicited when the inner part of the thigh is stroked. Stroking of the skin causes the cremaster muscle to contract and pull up the ipsilateral testicle toward the inguinal cana

The cremasteric reflex

The cremasteric reflex is absent in

Testicular torsion upper and lower motor neuron disorders spinal injury at the L1 and L2 level, or if the ilioinguinal nerve has been cut inadvertently during hernia repair

Parts of prostate that cannot be palpated as they are not in contact with the recital wall

anterior and median lives of the prostate

This part is palpable through anterior rectal wall in female

The cervix Or sometimes a retroverted uterus