MENNONITE COLLEGE OF NURSING AT ILLINOIS STATE UNIVERSITY Diagnostic Reasoning for Advanced Practice Nursing 431

MODULE: MALE GENITALIA, RECTUM AND HERNIAS OBJECTIVES: Upon completion of this module, the student will be able to: 1. Identify normal male anatomical structures. 2. Perform, with assistance, a complete male genito-urinary examination. 3. Perform a complete sexual history in a sensitive fashion. 4. Identify STD and AIDS risk factors. 5. Demonstrate verbal and non-verbal behaviors designed to decrease the anxiety of patients undergoing genito-urinary examination. 6. Recognize the personal biases of a provider which may impact sexual history taking. REQUIRED READINGS: 1.

Bates’ guide to physical examination and history taking, Chapter 12, Male Genitalia and Hernias, and Chapter 15, The Anus, Rectum, and Prostate.

MODULE: MALE GENITALIA RECTUM, HERNIAS STUDY QUESTIONS Define:

Benign prostatic hypertrophy /BPH Cryptorchidism Hemorrhoid Hernia (direct, indirect) Hydrocele Hypospadias Phimosis Priapism Smegma Spermatocele Torsion Varicocele

1.

What are the cardinal symptoms that most be assessed during a history regarding an acute GU problem?

2.

Describe the size and consistency of a normal adult prostate gland.

3.

What are the risk factors related to prostate cancer?

4.

What are the anatomical differences between direct and indirect hernias?

5.

Describe the self-testicular exam technique.

6.

What characteristics should be noticed about the testicles during palpation?

7.

What are the cardinal signs of colon/rectal cancer?

8.

What are some normal variations of the external male GU structures due to aging?

9.

Are anoscopic exams recommended on asymptomatic gay males who engage in oral/anal sexual activities?

10. Describe the 5 Tanner stages of pubic hair, penile, testicular and scrotal development.

ASSESSMENT OF THE MALE GU SYSTEM I. Anatomy A. scrotum-- 2 sacs B.

testes--4x3x2.5 cm

C. epididymis--located on the postero-lateral aspect of testicle D. vas deferens--through inguinal canal, posterior to bladder/joining seminal vesicles to form ejaculatory ducts E.

seminal vesicles--behind bladder, above prostate

F.

prostate--inferior to bladder, constains prostatic (post. ) urethra

II. Symptoms of GU Disease A. Frequency caused by: 1. increase volume of urine (diabetes) 2. residual urine (obstruction) 3. inflammation (cystitis) 4. anxiety B. Nocturia 1. 2. 3. 4.

renal disease increased evening fluids inflammation (cystitis) anxiety

C. Urgency D. Dysuria E. Symptoms of obstruction 1. hesitancy 2. loss of force and decreased caliber of stream 3. terminal dribbling 4. urinary retention a. chronically full bladder may result in: 1. overflow incontinence and constant dribbling 2. infection 3. renal damage F. Symptoms of urethral obstruction 1. slow, bifurcated urine stream G. Discharge 1. purulent, yellow (GC) 2. clear or mucupurulent (NSU, chlamydia) H. Hematuria 1. has broader implications for both men and women and will not be discussed in detail. some of the more common causes include: a. UTI’s, cystitis b. prostatic disease, BPH,. prostatitis c. tumors, renal or bladder d. stones e. glomerulonephritis 2. the presence or absence of pain associated with hematuria is significant

III. Hernias A. Definitions 1. hernia: a protrusion through a defect or weak spot in the lining of a body cavity 2. abdominal hernia: a protrusion of a sac lined with peritoneum through a defect in the abdominal wall 3. hernias are reducible if contents of sac can be returned to the abdominal cavity 4. hernias are irreducible if the contents of sac cannot be return to the abdominal cavity 5. hernias are strangulated if there is obstruction or interference of the blood supply to the sac contents 6. umbilical hernia: protrusion through a weak spot in the abdominal wall at the umbilicus 7. ventral hernia: protrusion through a weak spot in the abdominal wall at the umbilicus 8. incisional hernia: protrusion through a weak spot in an incision 9. inguinal/femoral hernias B. Landmarks *NAVEL when feeling the femoral artery, from the lateral aspect of the thigh to the medial aspect, the structure are: Nerve, Artery (femoral), Vein (femoral)., Empty (inguinal canal) and Lymph. 1.

Inguinal ligament runs from anterior superior iliac spine to the pubic tubercle on the symphysis pubis.

2.

Mid-inguinal point is that point equidistant from the anterior superior iliac spine to the symphysis and thus slightly medial to the midpoint of the inguinal ligament.

3.

At the mid-inguinal point, the iliac artery crosses underneath and become the femoral artery. The vein lies medial to the artery. At the position of the mid-inguinal point-where the iliac artery lies-- and 1/2 inch above is the internal inguinal ring.

4.

The external inguinal ring lies 1/2 inch above and lateral to the public tubercle.

5.

At the mid-inguinal point, the inferior epigastric artery arises from the iliac artery and travels medially and upward to the rectus muscle.

6.

The medial portion of the inguinal ligament, the inferior epigastic artery, and the rectus muscle from the Hesselback triangle.

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Direct hernia is one which protrudes directly through the abdominal wall at Hesselback triangle • Indirect hernia is one which travels into the inguinal canal--through the internal inguinal ring and sometimes into the scrotal sac • The femoral canal lies inferior to the inguinal ligament and a hernia in this region is called a femoral hernia. IV. Impotence A. Etiology 1. psychological disturbances 2. organic causes: chronic debilitating diseases; endocrine, vascular, or neurologic disorders 3. drugs 4. combinations of 1-3 Although impotence is most frequently caused by psychological disturbances, a thorough evaluation must be done to exclude organic cause.

B. History 1. 2. 3. 4. 5. 6. 7. 8. 9. C. Physical 1. 2. 3. 4.

what is the problem: inability to obtain or maintain an erection? premature ejaculation? absence of emission? inability to achieve orgasm? how firm is the erection? firm enough for intercourse? previous uninterrupted period of normal function? similar degree of dysfunction under all circumstances? impairment constant or episodic? does erection occur with other partners, masturbation, during sleep, with erotic pictures or reading? associated with decrease in libido psychosocial symptomatology associated with onset? what life events were occurring when dysfunction occurred? positive drug history (ETOH) past surgical history symptoms of diabetes, peripheral europathy, prostatitis, BPH, bladder dysfunction, vascular problems exam genital exam--especially penile abnormalities, testicular size, masses evidence of feminization--gynecomastia, abnormal hair distribution evaluate all pulses, including penile pulse neurologic exam: a. erectile reflex: test anal sphinctor tone, perineal sensation, bulbocavernosus reflex b. peripheral nerves: test muscle strength, DTR’s, sensation (vibratory, position, pain, tactile)

D. Lab: limited value, hormonal studies may be done, or UA if symptoms or indications E.. Assessment--r/o various etiologies 1. psychosocial impotence a. repeated occurrence of complete erections under any circumstances-means neurologic, vascular, and endocrine systems are intact b. typical examples 1. man unable to obtain erection with wife, but can with another partner 2. unable to maintain erection during intercourse but can during foreplay 3. successful masturbation c. in depression, sexual function may go first 2. organic impotence a. lack of erection under any and all circumstances b. incomplete nocturnal emission c. lack of any significant life events d. previous erectile function normal e. sexual desire is present f. impotence may be early symptoms of diabetes g. ETOH and drugs h. in history, look for vascular, neurologic, or endocrine symptoms 3. may have combination--some of the answers to questions may be misleading: severe depression may affect erectile function under any circumstances. Masturbation may be unsuccessful due to guilt and anxiety. Therefore, the above are guidelines--someone with diabetes may still have psychological impotence. F. Management Plan (based on etiology) 1. 2. 3. 4.

Drugs: change pharmacological regimen, education, reassurance ETOH: education, counseling, referral Psychologic: education, counseling, referral Organic: start work-up or refer

DRUGS CAUSING IMPOTENCE: phenothiazines alcohol imipramine aldomet guanethidine reserpine clonidine

spironolactone heroin, methadone estrogen sedatives major tranquilizers lithium

V. Cancer screening A. Prostate: not symptomatic early in disease; rectal exam is the screening B. Testicular cancer 1. young men, ages 20-40 2. less frequent in blacks 3. high mortality 4. detected by palpation 5. cryptorchism predisposes to cancer 6. teach to do self-exam VI. Gentle, Considerate Approach Sorting Through the Differential Diagnosis of Inguinal Swellings Muscle strain--onset after physical exertion; may develop into hernia Pain in groin resolves over a few weeks: no bulge or physical sign of hernia may occur at any age, but usually in younger, otherwise healthy, individuals Lymphadenitis--femoral or inguinal swelling swelling usually tender and accompanied by fever; swelling not extending into scrotum; no impulse or cough; may occur at any age Ectopic/undescended testicle--inguinal bulge often accompanied by congenital hernia, testicle high in groin, lying outside usual course of descent empty scrotum, usually evident from birth Hydrocele--sudden onset, not tender, scrotal or inguinal mass may accompany a hernia; fluid-filled mass, palpation or normal spermatic cord beyond mass possible, red on transillumination; may occur at any age, common in infants. May follow hernioraphy or incarcerated or strangulated hernia Varicocele--testicular swelling limited to testicle; no cough impulse; feels like a bog of worms, occur most in prepubescent boys 10-12 Septic arthritis--inguinal pain similar to that seen in early strangulated hernia no lump; abnormal orthopedic evaluation (limited motion of hip joint, pain on passive motion of hip joint: most common 6-10 Arthritis--groin pain pain not related to activity and usually nocturnal, no bulge; tends to occur in elderly Saphena varix--inguinal swelling, usually below inguinal ligament, unusual in any age group Groin abscess--inguinal swelling inflammation, fluctuant; no cough impulse; uncommon Aneurysm of femoral artery--swelling and pain irreducible; pulsatile; generally not tender, very unusual in any age group Neurofibroma--inguinal swelling firm, irreducible, not tender, similar to masses in other areas, rare unless have disease

ASSESSMENT OF THE ELDERLY CLIENT/GU The renal, urinary, and genital systems of the body undergo marked changes as the elderly person ages. Renal blood flow, functional nephrons, and glomerular filtration rate all decrease, and the ability of the kidney to concentrate or dilute urine and adjust to pH changes is limited. Under normal unstressed situations, the kidney is capable of carrying out its functions well; however, systemic disease or bodily insult can precipitate major fluid and electrolyte disturbances. The aged renal system does NOT respond well to stress. The bladder of the elderly pt. undergoes functional alterations as a result of CNS and MSK degeneration. Bladder capacity decreases, uninhibited bladder contractions increase, residual urine increase and the onset of the desire to misturate occurs late. Thus, urgency, nocturia, and an increase incidence of urinary tract infections are not unusual in the aged. The changes in the glomeruli and the nephron may allow mild glycosuria and prpoteinutia to occur in the absence of metabolic, systemic, or localized pathology. BUN and creatinine may also be elevated. However, the presence of disease must be ruled out prior to documenting these as “normal” processes. The male reproductive organs show evidence of the aging process as secondary sex characteristics recede. Axillary and pubic hair decreases. Although libido decreases somewhat, sexual functioning should be normal in the aged male. Orgasm is shortened in both, however, In the male, excitement takes longer and ejaculatory control is greater. penile erection may take longer and the erection may be less hard than in youth. The prostate enlarges with age--this is normal--but the enlargement can eventually cause symptomatic obstruction which necessitates intervention. Subjective c/o nocturia

Objective findings glycosuria (mild)

urgency

proteinuria

decreased axillary & pubic hair decreased penile erection

decreased axillary & pubic hair

hesitancy & diminished urinary stream

enlarged, smooth prostate

Diagnostic Reasoning for Advanced Practice Nursing 431 MALE GU & RECTAL EXAMINATION: STUDENT VALIDATION ** Branching Exam Procedure COMPONENT ACTIVITIES EXTERNAL GENITALIA – GENERAL 1. Observe skin 2. Observe hair distribution 3. Observe size of penis and scrotum PENIS 1. Observe skin, shaft contour, whether circumcised 2. Palpate shaft penis 3. Retract foreskin, if present; observe glans 4. Inspect urethral meatus 5. **Milk shaft downward to express any exudates SCROTUM 1. Observe contour and scrotal contents 2. Inspect skin on all surfaces 3. Palpate each testis 4. Locate and palpate each epididymis 5. Locate and palpate each spermatic cord 6. **Transilluminate scrotum INGUINAL and FEMORAL AREA 1.Observe inguinal and femoral area for bulges, masses above/below inguinal ligament 2.Palpate inguinal and femoral area: a. Pulses b. Lymph nodes 3. Fingers over femoral area, internal & external inguinal ring, have client cough/strain 4. Follow spermatic cord upward to external inguinal ring. (Check for hernias) RECTUM 1. Inspect sacrococcygeal and perineal areas 2. Palpate sacrococcygeal and perineal areas 3. Inspect anus 4. Assess external sphincter tone 5. Palpate 4 rectal mucosal walls PROSTATE 1. Palpate & identify lobes and median sulcus 2. Assess size of prostate 3. Assess consistency of prostate ADDITIONAL EXAM PROCEDURES 1. Guaiac stool for occult blood 2. ** Anoscopy

DONE

NOT DONE

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