Exam V: Pelvic & Junk

Malformations of the Penis

Abnormal location of urethral orifice along penile shaft

Hypospadias: urethra on ventra...

Kegel Exercises

benefit sexual functioning and pleasure – note that the musculature around the penis is comparable to the pelvic floor m...

Seminiferous Tubules and Interstitial Cells

Seminiferous tubules are the site of sperm production
sperm maturation occurs in the epididymus (about 20 feet long) ...

Epipdidymitis vs. Testicular Torsion

BOTH are EMERGENCIES

Testicular torsion: pain is sudden and severe; abnormal axis; acut...

Seminal Vesicles

Seminal vesicles - two pouch-like structures between the bladder and the rectum - function not completely understood – t...

Prostate

Doughnut shaped gland just below the bladder - thin alkaline secretions counteract acidity in male urethra and in the va...

Cowper’s Glands

Or bulbourethral glands
Pea-sized - lie just below prostate - connect to urethra by a duct - secrete a slippery subst...

Semen

(or seminal fluid)
one teaspoon of fluid – one ejaculation contains 200-500 million sperm which - provide only 1% of ...

Ejaculation

Two stages = emission and expulsion

Emission phase - prostate, seminal vesicles and upp...

Circumcision Sutures

Interrupted sutures in case one comes out

If continuous, if it is damaged, the whole su...

Phimosis

Extremely tight foreskin
Prepuce cannot be easily retracted over glans
May be congenital, but usually associated w...

Penis Enlargement Procedure

Detach crura to give 2-3 inches and then inject fat behind glans
The erection will be pointing straight instead of an...

Inflammatory Lesions of the Penis: STDs

Balanitis (balanoposthitis): inflammation of the glans plus prepuce associated with poor hygiene in uncircumcised men (s...

Inflammatory Lesions of the Penis: Fungal

Candidiasis
Especially in diabetics
Erosive, painful, pruritic, simple yeast
Can involve entire external male g...

Neoplasms of the Penis: Squamous Cell Carcinoma

Epidemiology: uncommon aka less than 1% of cancer in males, but mostly in uncircumcised men between 40-70 years old

<...

3 Parts to Pelvic Exam

Observation and the speculum exam
Bimanual exam

History, Inspection, and Palpate

Pubic hair-triangle pattern

Lymph nodes

Orifices

Multiparous Cervix

At least one or more children have passed through

| Bigger and not round, more linear

Bacterial Vaginosis

aka: Vulvovaginitis
General description for anything that causes symptomatic discharge (an irritant)

The Bimanual Exam

The bimanual exam is the second part of a complete pelvic exam

Necessary to evaluate th...

Uterine Fibroids

KA: myoma, leiomyoma, fibroma

Very, very common (40% of women > 40)

Uterine Fibroids Symptoms

eavy menstrual bleeding

Abdominal distortion

Pelvic pr...

Monoliasis or Candidiasis: Assessment and Management

Assessment - lab KOH wet mount NS KOH 10% 20% look for (branching Hyphae or Mycelium fungus nails).

Trichomonas Vaginitis: Signs and Symptoms

Leukorrhea, vaginal soreness, burning, pruritus, dyspareunia (pain during intercourse).
Bubbly, yellowish thick disch...

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Exam V: Pelvic & Junk

Term	Definition
Office Environment	ALWAYS have another person in the room while examining genital area or the female breasts. Explain what you are going to be doing, before you do each step/maneuver Insure patient comfort, and modesty
Patient Comfort and Modesty	Use gowns AND sterile drapes over pt legs Allow patient to wear socks, shirt- as long as access can be facilitated etc. Foot of exam table does not face the door Door is clearly marked to avoid interruption Another person in the room all the time, taking notes or somehow attentive
Male Anatomy: Penis, Root, Glans, Foreskin, Corona, and Frenulum	Penis - formed of three cylindrical masses of erectile tissue - enclosed in separate fibrous coverings - held together by a covering of skin Root at base of penis, divides into crura which are attached to the pelvic bones Glans is at the tip of the penis and is the most sensitive part for most men - covered by prepuce or foreskin which may be removed by a surgical procedure called circumcision Corona (crown) - ridge between glans and foreskin Frenulum - connects glans to shaft on underside of penis Smegma - secretion that can accumulate under foreskin of penis and must wash/clean thoroughly to prevent infections
Male Anatomy: Shaft	Contains spongy tissue which fills with blood when a man is aroused, leads to erection (there is no bone in the penis) Cavernous bodies (corpus cavernosum) - on top - 2 of them Spongy body (corpus spongiosum) underneath - 1 only - urethra runs through it
Malformations of the Penis	Abnormal location of urethral orifice along penile shaft Hypospadias: urethra on ventral aspect; most common Epispadias: urethra on dorsal aspect If these issues are present = congenital issues which mean problems downstream like pelvic organ abnormalities, inguinal hernias, undescended testes Clinical Consequences: constriction of orifice, urinary tract obstruction leading to infection, impaired reproductive function
Kegel Exercises	benefit sexual functioning and pleasure – note that the musculature around the penis is comparable to the pelvic floor muscles in the female strengthening the muscles with Kegel exercises may produce benefits for men in that are similar to those produced by Kegels in women Prevents pelvic floor prolapse Contraction muscles that hold the urine
Seminiferous Tubules and Interstitial Cells	Seminiferous tubules are the site of sperm production sperm maturation occurs in the epididymus (about 20 feet long) on the back of each testicle Interstitial cells are located between the seminiferous tubules and are the major producer of androgens in men
Epipdidymitis vs. Testicular Torsion	BOTH are EMERGENCIES Testicular torsion: pain is sudden and severe; abnormal axis; acute; early puberty; UA is negative; cremasteric reflex is negative; tx is surgical exploration Epididymitis: gradual onset of pain of testis or epididymis; the testicle may be warm and/or red and swollen; axis of testicle is normal; insidious onset of symptoms; adolescents; UA can be + or -; cremasteric reflex is positive; tx is antibiotics
Seminal Vesicles	Seminal vesicles - two pouch-like structures between the bladder and the rectum - function not completely understood – they secrete an alkaline fluid rich in fructose - sperm become motile here and can propel themselves (got to this point via cilia in ducts) - contribute about 70% of seminal fluid
Prostate	Doughnut shaped gland just below the bladder - thin alkaline secretions counteract acidity in male urethra and in the vagina – contributes about 30% of seminal fluid
Cowper’s Glands	Or bulbourethral glands Pea-sized - lie just below prostate - connect to urethra by a duct - secrete a slippery substance when a man is sexually aroused - alkaline - helps lubricate flow of seminal fluid through urethra can contain active sperm and cause pregnancy without ejaculation occurring
Semen	(or seminal fluid) one teaspoon of fluid – one ejaculation contains 200-500 million sperm which - provide only 1% of volume - rest from seminal vesicles (70%), prostate (30%) and Cowper’s gland (<2%) semen of a healthy man is not harmful if swallowed – but semen can transmit HIV from an HIV-positive man
Ejaculation	Two stages = emission and expulsion Emission phase - prostate, seminal vesicles and upper part of vas deferens (ampulla) contract - moves secretions into ejaculatory duct and prostatic urethra internal (bladder exit) and external (below prostate) urethral sphincters close - urethral bulb balloons - leads to sensation of ejaculatory inevitability Expulsion phase - strong rhythmic contractions of the penis expel semen – urethra contracts - external sphincter relaxes allowing semen to be expelled - internal sphincter continues to contract preventing urine from being expelled
Circumcision Sutures	Interrupted sutures in case one comes out If continuous, if it is damaged, the whole suture is at risk
Phimosis	Extremely tight foreskin Prepuce cannot be easily retracted over glans May be congenital, but usually associated with balanoposthitis (STD) and scarring Paraphimosis: trapped glans causing urethral constriction
Penis Enlargement Procedure	Detach crura to give 2-3 inches and then inject fat behind glans The erection will be pointing straight instead of angled dorsally so urination and ejaculation flow is different Must wear a pole attached to the penis to prevent crura from reattaching Gelking: some men go for the stretch method of enlargement- get ulcers if too much weight stretched the skin
Inflammatory Lesions of the Penis: STDs	Balanitis (balanoposthitis): inflammation of the glans plus prepuce associated with poor hygiene in uncircumcised men (smegma); distal penis is red, swollen, tender, and with or without purulent discharge
Inflammatory Lesions of the Penis: Fungal	Candidiasis Especially in diabetics Erosive, painful, pruritic, simple yeast Can involve entire external male genitalia Baby powder and air helps prevent yeast growth – they like warm, dark, and moist areas
Neoplasms of the Penis: Squamous Cell Carcinoma	Epidemiology: uncommon aka less than 1% of cancer in males, but mostly in uncircumcised men between 40-70 years old Pathogenesis: poor hygiene, smegma, smoking, HPV (16 and 18) CIS first then progression to invasive squamous cell carcinoma
3 Parts to Pelvic Exam	Observation and the speculum exam Bimanual exam Recto-Vaginal Exam (includes DRE)
History, Inspection, and Palpate	Pubic hair-triangle pattern Lymph nodes Orifices Palpate: Urethral meatus-incontinence Labia Skene’s, then Bartholin’s glands Perineum
Speculum Exam	Performed prior to the bi-manual exam so as not to disturb the tissues/samples Performed without lubricant jelly Always inserted with the speculum blades warmed with warm water and closed Inserted at a 45 degree angle posteriorly
Visual Observation of Cervix	Position—is it anteverted, deviated, etc The position of the cervix gives clues to the position of uterus Color—should be flesh-colored, but ranges from pink to dark brown (blue or pale??); certain colors indicate pregnancy Surface characteristics—cysts, erythema Discharge Size and shape of os- indication of reproductive history
Nulliparous Cervix	No baby has passed through Small and round
Multiparous Cervix	At least one or more children have passed through \| Bigger and not round, more linear
Everted Cervix	The endothelium of canal will move out \| True cervical tissues and inner cervical tissues
Nabothian Cysts	aka: retention cysts \| Pimple like things on the cervix
The Papanicolaou Exam (“Pap”)	A minimum of two samples will be taken: Cervical cells Vaginal secretion Other tests may be done to screen for STDs The “Pap smear” evaluates the condition of the cervical cells (taken with cervical brush or spatula) SCREENS FOR CERVICAL CANCER- very accurate and decreased cancer rates Assessing “transitional zone” of the cervix
Three Most Common STDs in Women	HPV, Herpes, Chlamydia, (Now 10’s of millions of existing cases) In women, often no visible symptoms
Bacterial Vaginosis	aka: Vulvovaginitis General description for anything that causes symptomatic discharge (an irritant) May be due to bacteria, viruses, fungi, or protozoans Patient may talk to you about: vaginal or vulvar itching, burning, or change in color, texture or odor of discharge
The Bimanual Exam	The bimanual exam is the second part of a complete pelvic exam Necessary to evaluate the cervix, uterus, and adenexal regions (ovaries, fallopian tubes, surrounding areas) Move the cervix to assess for PID/Endometriosis Important even if patient is not sexually active
Recto-Vaginal Exam	RE The Recto-Vaginal exam is the 3rd and final part of the pelvic exam May help evaluate the posterior aspect of the uterus (esp. if retroverted) Allows exam of rectal walls (initial screen for colo-rectal cancer or polyps)
Uterine Fibroids	KA: myoma, leiomyoma, fibroma Very, very common (40% of women > 40) The most common tumor of the pelvis The most common reason for a hysterectomy Benign, benign, benign! Rick Factors: Nulliparity or delayed childbearing and African American women have 2-3 times the incidence of uterine fibroids Locations: intramural, subserosal, submucosal, pedunculated (on a stalk and can twist on axis and infarct/become painful)
Uterine Fibroids Symptoms	eavy menstrual bleeding Abdominal distortion Pelvic pressure Low back pain; dyspareunia Infertility Frequent urination Constipation Miscarriage or premature labor Can cause negative effects of fetus like distortion because only so much space for baby to grow
Uterine Fibroid Treatment Options	“Wait and see” Drug therapy (GnRH agonists)- to alter tumor growth Uterine Artery Embolization (UAE) to cut blood supply; insert catheter and inject particles and fill up and implode blood supply so fibroid becomes necrotic and dies Myomectomy Hysterectomy
Vaginitis	Inflammation of the vagina caused by: Candidiasis Trichomonas Gardnerella Bartholin’s abscess
Monoliasis or Candidiasis: Signs and Symptoms	Marked leukorrhea, marked redness of vulva, extreme pruritus. White, creamy, cheesy, sweet smelling discharge, thrush patches. Commonly seen in pregnancy, diabetics, women on BCP or antibiotics (ampicillin).
Monoliasis or Candidiasis: Assessment and Management	Assessment - lab KOH wet mount NS KOH 10% 20% look for (branching Hyphae or Mycelium fungus nails). Management - Nystatin--intravaginal adult tabs 0.1 to 0.2 million units daily times 7 to 10 days
Trichomonas Vaginitis: Signs and Symptoms	Leukorrhea, vaginal soreness, burning, pruritus, dyspareunia (pain during intercourse). Bubbly, yellowish thick discharge, foul smelling. Strawberry appearance of cervix
Trichomonas Vaginitis: Assessment and Management	Assessment - lab wet prep, microscopic exam reveals pear shaped parasite with long flagella and undulated (wavy outline in appearance) cell membrane. Management: Metronidazole (Flagyl) anti protozoal 250 mg TID to 500 mg BID orally for 5 days. Patient education of feminine hygiene, douching. Management based on culture results
Bacterial Vaginitis: Signs and Symptoms	also called Gardnerella Vaginitis Leukorrhea, pruritus, dyspareunia. Turbid, chalky, white/gray or yellowish discharge; malodorous ("fishy").
Bacterial Vaginitis: Assessment	Assessment: gram-positive nonmotile coccobacillus that normally inhabits the vagina that just overgrows Wet smears of this nonspecific vaginitis yields vaginal desquamated epithelial cells covered with many bacteria
Bacterial Vaginitis: Management	Management: Metronidazole (Flagyl) 250 mg TID to 500 mg BID orally for 7 10 days. Ampicillin 500 mg QID x 7 days. Douching with povidone iodine solution. About 25% of the patients have recurrence and require treatment in 2 3 months. Management based on culture results
Perineal Pain: Bartholin's Abscess	Definition and etiology - acute or chronic infection of the Bartholin's gland (streptococci, staphylococci, E. coli, anaerobes; may result in infection). History - recent intercourse, venereal disease, trauma, spontaneous abortion, wiping from rectum to vagina Signs and symptoms: Mass in perineum that is hot, tender, and fluctuant. Pus draining from Bartholin's duct
Bartholin's Abscess: Management	Management: I & D Sitz bath: fill tube up quarter way and hot but not too hot; helps with healing and keeps area clean Broad-spectrum antibiotics which cover gram-positive organisms and some common vaginal gram-negative organisms
Endometriosis	Normal endometrium found in abnormal places Therefore, “ectopic tissue” responds to hormone levels just like the inner layer of the uterus Retrograde menstrual flow, fallopian tubes, abdomen Lymphatic or circulatory systems cause spread
Endometriosis: Risk Factors	Young age: 10-15% of women ages 25 to 44 have endometriosis Family History (6 - 12% of cases) Nuliparity or delayed childbearing Asians and Caucasians are at highest risk
Endometriosis: Signs and Symptoms	Pain, pain, pain (low back and pelvic) Pelvic mass Alterations of menses Dysmenorrhea (pattern = pain just prior to menses) Infertility Dyspareunia Pain with defecation, urination
Endometriosis: Pattern of Menstruation	Women with endometriosis have: earlier onset of menses regular cycles shorter intervals between periods (less than 27 days) more severe menstrual cramps prolonged menstrual flow (> 1 week)
Endometrial Lesions	Endometrial deposits can occur anywhere in pelvis Ovary—most common (75%); an ideal site for growth Posterior cul-de-sac—70% Between the uterus and bowel—35% Uterosacral ligament—30% Ureters Uterus Bowel Also known to occur on appendix, gall bladder, stomach, spleen, liver, lung
Endometrial Dx Confirmation	Suspected by case history Visible lesions on the vulva or cervix Red, brown, black (remember—may bleed) Speculum exam (“shotty nodules”) Definitive: The definitive diagnosis can only be made by direct visualization of the lesions Presently, confirmed by laparoscopy
Endometriosis Treatments	Keep in mind that these patients typically suffer a prolonged course of multiple therapies/surgeries “Leave it alone” Drug therapy Laparotomy Hysterectomy Child-bearing (or pseudo-pregnancy conditions) Tubal ligation
Endometriosis and Infertility	Peritoneal fluid normally acts as a lubricant. Endometriosis causes changes in the volume and cellular content of the peritoneal fluid. Fluid level is increased Leukocytes are increased Prostaglandin levels are increased Enzyme levels are increased These all cause a localized inflammatory reaction around the lesions The peritoneal fluid can then act as a toxin to the embryo and/or can alter the normal function of the ovaries and fallopian tubes
Other Female Pelvic Conditions	Uterine sarcoma (endometrial carcinoma) Cervical carcinoma Ovarian carcinoma Ovarian cysts Uterine, vaginal prolapse
Pregn's Sign	regn’s Sign: physical lifting of testicles relieves pain of epididymitis but not pain caused by testicular torsion- KEY Negative: no pain relief with lifting the affected testicle = testicular torsion = surgical emergency Positive is epididymitis NOT reliable for identifying other types of testicular issues from torsion

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