The Male and Female History and Examination

The Male and Female History and Examination Hanne S. Harbison, MSPH, MSN, CRNP Alabama/North Carolina STD Prevention Training Center University of Ala...
Author: Joella Morrison
5 downloads 2 Views 1MB Size
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]