penis
shaft and glans
external anatomy
-darker than other skin/hairless
-visible dorsal vein
-urethra at tip of glans
-Glans (covered by foreskin if uncircumsized)
internal anatomy
-Corpus cavernosa (dorsum [top] & sides)
-Corpus spongiosum (ventral/underneath)
circumsised
surgical removal of foreskin (becoming less popular)
-Common in the U.S. among caucasians and those of Jewish
descent
-Less common in African Americans & Hispanics
-Slight risk of surgical complications (infection, ischemia, necrosis of penis)
-May have a
uncircumsised
-Increased risk of some STIs (syphilis, genital herpes,
chlamydia), penile cancer & cervical cancer in female partners
smegma
white cheesy material on glans in uncircumsized male
-formed from sebaceous material (from glans) & desquamation of epithelial cells (from foreskin)
corpus spongiosum
(ventral/underneath) - contains urethra
bulbourethral gland
(Cowper's gland) produces pre-ejaculate fluid (parallels
Bartholin's gland in females), lubricates the urethra for sperm to pass through and neutralizes acidic urine
scrotum
-darker than other skin/scant hair
-Rugae (folds) with deeply pigmented skin & large sebaceous follicles
-Scrotal sac divided by a septum - each section contains a testis
testes
produce sperm & testosterone
-4 x 3 x 2 cm/ left is lower than right
-Epididymis (on posterior side of testes) - collects and provides transit for sperm
-Sperm travels through the vas deferens, spermatic cord, seminal vesicles (secretes a fluid that nouri
epididymis
(on posterior side of testes) - collects and provides transit for sperm
cremaster muscle
(raises & lowers the testes) - regulates temp
seminal vesicles
secretes a fluid that nourishes sperm
prostate
-2.5 cm x 4 cm
-Surrounds the urethra at the bladder neck
-Secretes ejaculatory fluid to help sperm motility
-2 lobes, separated by a median sulcus
prenatal development
-Testes located in the ABD & descend down inguinal canal to the scrotum
-later in life, if the external inguinal ring enlarges the intestines may prolapse into the scrotal sac causing an inguina hernia
puberty
(begins between the ages of 9 & 13) - usually takes 3 yrs
Tanner's Stages
-Enlargement of the testes (testosterone produced)
-Pubic hair growth
-Enlargement of the penis
-Prostate doubles in size
adult development
Prostate enlarges throughout life
-Benign Prostatic Hypertrophy (BPH)/Prostatism
-May gradually impede urine flow
-symptoms are uncommon before age 50
Testosterone production gradually declines after age 60
-Leads to a lower sperm count (fertility may dec
urinary symptoms (subjective data)
-Frequency (e.g., q 15 min) - bladder irritation (UTI), urethritis (STI/chlamydia), tumor,BPH
-Urgency (UTIs, BPH) - must go "now"
-Hesitancy (BPH) - difficulty starting urine flow
-Decreased force of stream (FOS) - BPH
-Post void dribbling (BPH)
-Post vo
nocturia
awakening in night to urinate
due to:
-incomplete bladder emptying (e.g., BPH)
mobilization of fluid & increased renal blood flow in recumbant position (seen with heart failure)
dysuria
(pain or burning with urination) - UTI, STI
pyuria
(pus) - infection
polyuria
(seen with DM) - glucose causes osmotic diuresis
enuresis
(bed wetting) - nighttime incontinence after age 5 - 6 yo; may be psychologic or a structural problem with the urinary tract
overflow incontinence
due to incomplete bladder emptying, prostatism
stress incontinence
associated with rapid movement of the diaphram) - occurs
with coughing, sneezing, laughing, etc. (more common in women)
urgency incontinence
seen with infection, prostatism, neurologic disorder
hematuria
blood in urine
-always a significant finding that needs further evaluation
-macrohematuria (visible)
-microhematuria (seen with microscope)
subjective data
-urinary symptoms
-inguinal hernia
-testicular masses, heaviness, undescended testicle
-sexual history
sexual history (subjective data)
-Number of partners/time with current partner/mutually monogamous relationship
-Reproductive function, contraception (please refer to the female genitalia lecture for B.C. methods)
-Use of barrier protection (condoms)
-H/O STIs & how treated
-Please refer
physical examination
best if patient is standing/examiner sitting
mons pubis/pubic hair (PE)
-distribution (diamond pattern)
-infestations (nits [lice eggs])
lesions (PE)
-Grouped vesicles (herpes)
-Papules (condyloma accuminata/external genital warts [EGW])
-Chancre (painless sore from syphilis)
chancre
painless sore from syphilis
penis (PE)
inspect all surfaces for lesions
glans
-retract prepuce [foreskin] to inspect
-phimosis
-balanitis
-paraphimosis
shaft
-priapism
-peyronie's disease
urethral meatus
-hypospadias
-epispadias
-discharge (i.e. none, purulent, clear)
phimosis
foreskin can't be retracted (associated with poor hygiene)
balanitis
occurs in uncircumsized
-inflammation of glans (bacterial or fungal)
-associated with phimosis
paraphimosis
foreskin permanently retracted
priapism
Prolonged painful erection (serious if lasting > 4 hours)
-Occurs with leukemia, hemoglobinapathies (sickle cell trait/disease) & meds (e.g., Viagra, Cialis, Levitra, Trazodone) - may cause sterility
peyronie's disease
Corpus cavernosis develops scar tissue (etiology unknown)
-Thought to be genetic (usually occurs after age 45)
-Penis curves when erect
-Usually doesn't affect sex life or fertility
hypospadias
(urethra ventral/underneath) - most common
epispadias
(urethra dorsal/top) - rare
scrotum/testes (PE)
inspect/palpate
scrotum
-Scrotal lumps (common) - may be due to sebaceous cysts. Important to differentiate scrotal lumps from testicular lumps.
-Scrotal edema (CHF, renal failure)
-Hydrocele (serous fluid around testicle)
testes
-Cryptorchidism (undescen
hydrocele
serous fluid around testicle
-often due to trauma (e.g., bike seat) - resolves spontaneously
-transillumination (fluid glows red as light reflects off fluid)
transillumination
fluid glows red as light reflects off fluid
cryptorchidism
(undescended testicle) - decreased spermatogenesis & decreased fertility
orchitis
(acute inflammation of testis) - seen with mumps (if not immunized)
spermatocele
retention cyst
-collection of sperm in epididymis
-most common after vasectomy
testicular torsion
-Sudden twisting of spermatic cord (more common on left)
-Rare after age 20
-May occur spontaneously (during sleep) or after trauma
-Surgical emergency due to compromised blood supply
varicocele
dilated veins of spermatic cord
-More common on left side
-May be visible when patient stands (feels like a bag of worms)
-May cause infertility due to increase venous pressure and testicular temp
Symptoms
-dull ache along spermatic cord
-scrotal pain or
lymph nodes (PE)
-Often palpated normally (should be < 1-2 cm, mobile)
-Penis drains into inguinal nodes (palpable)
-Testes drain into ABD nodes (not palpable) & left supraclavicular nodes
hernia (PE)
procedure
-Examine with patient standing (gravity effect)
-Put finger up through scrotum into inguinal canal (2 inches long)
-Ask pt to cough (should feel soft tissue of intestines if hernia is present)
types
-indirect
-direct
-femoral
-incarcerated
indirect hernia
(most common)
-herniation into inguinal canal (palpated in inguinal canal)
-more common in children & young males
direct hernia
(2nd most common)
-herniation through external inguinal ring (bulge seen over inguinal canal)
-more common in men after 40yo
femoral hernia
(least common)
-herniation through femoral ring (buldge seen in groin)
-higher incidence in women
incarcerated hernia
-non reducible; can't push back in
-may lead to compromised blood supply (surgical emergency)
anus anatomy
Terminal end of the GI tract (2.5 - 4 cm long)
-Distal end opens to perianal area
-Proximal end merges with rectal mucosa at the anorectal junction
Surrounded by 2 sphincters
-Internal sphincter (involuntary control) - when the rectum fills with stool, th
hemorrhoids
(varicose anal veins) - d/t chronic increased venous pressure
(constipation/straining with BMs)
internal sphincter
involuntary control
when the rectum fills with stool, sphincter relaxes & results in the urge to defecate
external sphincter
voluntary control of defecation
anal columns
vertical folds of mucosa containing arteries & veins
rectum
(distal portion of the GI tract) - 12 cm long
sigmoid colon
(S shaped) - 40 cm long
flexible sigmoidoscope
(visualizes up to 60 cm) but misses the proximal lesions
Anus (4 cm) + rectum (12 cm) + sigmoid (40 cm) = 56 cm
colonoscopy
scopes the entire colon; the "gold standard
newborn/infant development
-1st meconium stool 24 - 48 hours after birth
-Meconium (dark green) - substance swallowed in utero (e.g., amniotic fluid)
-Gastro-colic reflex (reflex causing increased peristalsis/BM after each feeding)
-Imperforate anus (no outlet for stools)
-No volun
older adult development (butt stuff)
Fecal incontinence
-may occur with loss of internal sphincter tone
Constipation
-occurs with degeneration of afferent rectal nerves causing poor internal sphincter relaxation in response to stool in the rectum
bowel habits (subjective data)
(there is no normal) - assess for changes
-controlled by many factors including colon size, diet, exercise, response to stress or medication side effects
-number, frequency, consistency, color of BMs; presence of blood, pungent odor
subjective data (anus and rectum)
-bowel habits
-constipation (fluids, fiber, exercise)
-diarrhea
-stool color change
-rectal symptoms (pain, burning, itching)
-medications
ask about
-nausea, vomiting, cramping, pain, distention, flatus, unintentional weight loss
-pencil-like stools (spas
diarrhea
-fever, chills (infection)
-foreign travel (infection/parasites)
-meds
-timing of stools
psychosomatic - no nocturnal stools
physiologic - nocturnal stools
psychocomatic
diarrhea, no nocturnal stools
physiologic
diarrhea, nocturnal stools
black stools
Melena (dark tarry stools) - upper GI bleed (gastric/duodenal ulcer or cancer)
Iron, Bismuth
hematochezia
(maroon stools) - lower GI bleed (or UGI bleed with rapid motility)
BRBRP
(drips of blood in toilet or on toilet tissue) - hemorrhoids, polyps, tumor
clay colored stools
(absence of bile pigment) - biliary obstruction (liver problem, gallstones)
rectal pain
External hemorrhoids (most common cause of painful BMs)
Internal hemorrhoids
-not painful unless prolapsed, infected or thrombosed
-may result in significant bleeding
Fissures (mucosal tear d/t passage of large/hard stool)
-results primarily form constipa
pruritis ani
rectal burning/itching
-common; etiology may never be found
-r/o fungal infection, external hemorrhoids, or parasites (pinworm)
laxatives
-Bulk laxatives - add fiber (Psyllium)
-Osmotic (MOM, Magnesium citrate, Golytely, Miralax) - pulls fluid into GI tract
-Chemical stimulant (Ex-lax, Senokot) - habit forming !
constipating medicines
(especially a problem for the elderly)
-Antidepressants
-Antihistamines (e.g., Diphenhydramine [Benadryl])
-Calcium channel blocker (e.g., Verapamil)
-Iron
steatorrhea
(excessive fat in stool) - pancreatic problem, malabsorption
colorectal cancer risk
-Age > 50 years old
-High fat/low fiber diet (fiber absorbs fat & may absorb toxins/carcinogens)
-Obesity
-Smoking
-Precancerous Intestinal polyps
-Inflammatory Bowel Disease (Crohns disease, ulcerative colitis) poses an increased risk of colon cancer 10
purposes of rectal exam
-assess anorectal area
-prostate exam in males
-bimanual recto-vaginal exam in women
positioning (rectal exam)
-patient stands and leans over exam table (most common for males)
-lithotomy position (do rectal exam with pelvic exam)
-left lateral knee-chest position
inspect perianal area
-Spread buttocks (perianal skin is darker, with hair)
-Assess for lesions, warts, skin tags, parasites, abscess, scars, fissures & external hemorrhoids (thrombosed)
-Pilonidal cyst (located over coccyx/sacrum)
pilonidal cyst
located over coccyx/sacrum
caused by:
-diagnosed between 15 - 24 years old
-cyst - may be due to an ingrown hair aggravated by prolonged sitting
-sinsus tract opening - may contain hair & skin debris with surrounding erythema, swelling, & tenderness at co
anus/rectum exam
-Digital Rectal Exam - apply pressure to anal opening with lubricated gloved index finger - have patient beardown to relax external sphincter
-Insert finger & palpate anterior, lateral & posterior surfaces
-Ask patient to tighten external sphincter around
prostate exam
-Press down on anterior rectal wall
-Only posterior surface can be assessed by DRE
-Palpate both posterior lobes (vertical groove separates lobes)
Size (norm = 2.5 cm x 4 cm)
Findings
-Normal (smooth, firm, non-tender) - like tip of nose
monthly
Genital self exam (GSE) & testicular self exam (TSE)
annual
DRE (screen for prostate and colon cancer)
Digital Rectal Exam (DRE) - reaches 7-8cm
Age for Screening
? 50 years old (all men)
? 40 years old (if high risk) - i.e. African Americans, family history of prostate/colon
PSA
-A nonspecific blood test for prostate cancer; will also increase with inflammation and BPH
-PSA screening is controversial because of high false positive and false negative rate
FOBT
Fecal occult blood test (FOBT) - guaiac testing
every 5 years
Flexible sigmoidoscopy
(routine screening starting at age 50)
every 10 years
colonoscopy
(routine screening starting at age 50)