The Male and Female History and Examination Hanne S. Harbison, MSPH, MSN, CRNP Alabama/North Carolina STD Prevention Training Center University of Alabama, Birmingham Jefferson County Department of Health
Objectives Describe the elements of taking a sexual history Describe techniques for correctly performing an exam Describe common abnormalities found during male and female exams
Outline Case Study Sexual History Taking Male Examination and Common Abnormalities Female Examination and Common Abnormalities
Case Study 55 YO male HIV positive for 3 years and a regular patient in your clinic Here today for routine 3 month visit, no complaints At initial visit 3 years ago he was getting divorced form his wife and he denied any current sexual partners Denied any history of sex with men Exam today was normal Routine yearly screening for CT/GC done with urine NAAT, syphilis serology
Case Contd. NAAT comes back positive for CT Pt returns for rx and reports a new male sexual partner a month ago that he met online. Reports receptive oral and anal sex You perform oral and rectal CT/GC NAAT testing this visit
What went wrong?
Why Take a Sexual History? Directs exam and testing Recommended by many professional organizations Sexual health is integral to health
Sexual Health a state of physical, emotional, mental and social wellbeing in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. (World Health Organization)
Guidelines for Sexual History Get permission Assure confidentiality Provide rationale for questions being asked Use open-ended questions
Guidelines Contd. Conduct the interview with patient alone or with unrelated translator
Sitting and at eye level with patient Patient should be dressed
Guidelines Contd. Start with easy, less personal questions Avoid medical jargon Normalize behaviors
Treat ALL patients the same
Age
Sexual Orientation
Relationship Status
Culture
What to include: Symptoms Behaviors Prevention of pregnancy Gender Identity Sexual Dysfunction
Female Symptoms Dysuria Vaginal discharge Vaginal bleeding Vaginal itching or burning Vaginal odor Itching of the genital region Genital lesion Pain during intercourse
Abdominal pain Groin pain Rectal pain Rectal / perianal lesion Skin symptoms Rash, lesion(s)
Male Symptoms Dysuria Penile discharge Penile lesion Scrotal lesion Scrotal pain Scrotal swelling Itching of the genital region
Abdominal pain Groin pain Rectal pain Rectal / perianal lesion Rectal discharge Skin symptoms Rash, lesion(s)
Behaviors Partners Practices Prevention
Gender Identity Trans-gender: People whose gender identity and/or gender expression differs from the sex they were assigned at birth.
Trans-sexual: An older term which originated in the medical and psychological communities.
Cross-Dressing: Occasionally wear clothes traditionally associated with people of the other sex. Cross-dressers are usually comfortable with the sex they were assigned at birth and do not wish to change it. http:/www.glaad.org/reference/transgender
Sexual Dysfunction Men: Erectile dysfunction Ejaculation disorders Decreased libido
Sexual Dysfunction Women: Female orgasmic disorder
Dyspareunia Decreased libido Vulvodynia /Vulvar Vestibulitis Syndrome
Male Examination Inspection of Skin / Palms / Soles Joint (if patient complains of pain/redness)
Oral examination Eye (if patient complains of pain/redness) Genital examination Rectal inspection
Tonsillar herpes
Pharyngeal herpes
Mucosal herpes
Genital Exam Inspect and palpate for inguinal lymphadenopathy Inspect the pubic hair Inspect the penis - Retract the foreskin if present Compress the glans between your index finger and thumb to look for discharge For GC/CT testing insert the urethral swab ~1 cm into meatus, rotate 360 degrees. Roll the swab on a glass slide for gram stain.
Circumcised
Uncircumcised
Laboratory Testing
Genital Exam Contd. Inspect the scrotum Palpate each testis and epididymis between your thumb and first two fingers Inspect anus if exposed For CT/GC cultures- insert swab 2-3 cm, rotate 360 degrees. Inoculate onto culture media or test kit
Anal / Rectal Area
Abnormal Conditions Hypospadius Epispadius Priapism Urethral strictures Testicular Torsion Epididymitis-Orchitis
Hypospadius/Epispadius Hypospadius: Congenital disorder where urethra opens on ventral surface of the penis Occurs in 1/300 births Epispadius: Urethra exits on dorsal surface of the penis Epispadius is less common Both treated with surgical correction
Priapism Definition: Painful, persistent erection >4 hours
Involves impaired venous drainage from corpus cavernosa
Causes: sickle cell disease, anticoagulant therapy, DM, Leukemia, some antidepressant meds, unknown Treatment: Decongestant medications, ice packs, surgical ligation, injection of medication, surgical shunt, aspiration of fluid
Testicular Torsion
Definition: Twisting of the testicle & spermatic cord Occurs usually in prepubertal boys Can result in arterial ischemia & infarction; often assoc with scrotal trauma
Symptoms: Severe testicular pain, N&V, elevation of the testis on the affected side
Testicular Torsion Confirmed with US or Testicular nuclear scan Treatment: Surgical untwisting of the testis. Surgery must occur within 12 hours, or permanent testicular injury occurs
Epididymitis-Orchitis Definition: Inflammation of the epididymis & testicle due to trauma or infection Cause: In males > 35 yrs are E. coli & Pseudomonas, in males < 35 yrs Gonorrhea & Chlamydia Symptoms: Scrotal edema, pain, fever & urethral discharge Treatment: Scrotal support, pain meds & antibiotics
Varicocele Definition: Incompetent venous valves in internal spermatic & renal veins; May cause infertility Affects 10%-15% of males. Occurs on left side 98%, bilaterally 50%
Signs: Feels like a “bag of worms” on exam; does not trans-illuminate; diagnosis confirmed with U/S Symptoms: Asymptomatic or characterized by feeling of scrotal “fullness” Treatment: Surgery
Female Examination Inspection of Skin / Palms / Soles Joints (if patient complains of pain or redness) Oral examination Eye (if patient complains of pain or redness) Pelvic examination - External and Bimanual Rectal inspection
Basic Female Anatomy
Genital Exam Palpate inguinal nodes Inspect pubic hair Inspect external genitalia Palpate Bartholin’s Glands if edema present– insert one finger into vagina and palpate both sides
Speculum Exam Inspect vaginal walls for lesions Note characteristic and amount of vaginal discharge Inspect cervix for cysts, bleeding, lesions, discharge Collect specimen for Wet prep Collect swab for CT/GC – insert into os and hold for 10 seconds Collect Pap smear
pH Paper
Aptima for GC / Chlamydia Yellow (unisex; urine)
Purple (unisex; urethral / cervical)
Thin Prep PAP
Normal Cervix
Exam Contd. Inspect anus if exposed Collect Swabs for CT/GC by inserting the collection swab 2-3 cm and rotating 360° Perform Bimanual exam Assess for CMT, uterine/adenexal masses and tenderness
Abnormal Conditions Bartholin’s Cysts Cervical Polyp Nabothian Cysts Pelvic Inflammatory Disease Uterine Myomas Ovarian Cysts
Bartholin’s Cysts Definition: Infection of Bartholin’s Gland Symptoms: painful swelling of labia minora and/or vaginal wall unilaterally Treatment: Antibiotics, warm compress, I&D
Cervical Polyps Definition: Finger-like growths on cervix Symptoms: Abnormal bleeding, bleeding with sex, abnormal discharge Treatment: Surgical removal Most are benign, but some may be cancerous
Cervical Polyp
Nabothian Cysts Blocked mucous glands Appear as “yellow-white” bumps/pimples No treatment necessary
Nabothian Cyst
Pelvic Inflammatory Disease Definition: Ascension of bacteria into uterine cavity, tubes, ovaries Symptoms: Dyspareunia, lower abdominal/pelvic pain, N/V, fever, chills Treatment: Antibiotics for CT/GC +/Metronidazole May lead to infertility
Pelvic Inflammatory Disease
Uterine Fibroids Definiton: Round muscle growths within the uterus Symptoms: Irregular bleeding, heavy/painful periods, pelvic “fullness”, frequent urination, dyspareunia Treatment: Medications and/or surgery
Uterine Fibroids
Ovarian Cysts Definition: Fluid-filled sac on ovary Functional (Follicular or Corpus Luteum) Symptoms: Pressure, swelling, or pain in the abdomen/ pelvis, dyspareunia, weight gain, painful periods, abnormal bleeding, N/V Treatment: watchfull waiting; BCPs; surgery
Ovarian Cysts
For more information www.justaskstd.com www.mpaetc.org www.cdc.gov www.nnptc.org www.aidsetc.org www.asha.org www.nva.org www.arhp.org
Questions? Hanne Harbison, MSPH, MSN, CRNP Department of Medicine/ Division of Infectious Diseases University of Alabama Birmingham Email:
[email protected]