Transcript Chapter_019
CHAPTER 19 Male Genitalia . an imprint of Elsevier Inc. Copyright © 2015 by Mosby, Male Genitalia • Examination of the male genitalia is typically performed: • When patient has a specific complaint • As part of the newborn examination • As part of an overall well child or well person examination • In adults, examination of the anus, rectum, and prostate (see Chapter 20) is often performed at the same time. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 2 Male Genitalia • Inspect the pubic hair characteristics and distribution. • Retract the foreskin if the patient is uncircumcised. • Inspect the glans of the penis with foreskin retracted, noting the following: • Color • Smegma • External meatus of urethra • Urethral discharge Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 3 Male Genitalia (Cont.) • Palpate the penis, noting the following: • Tenderness • Induration • Strip the urethra for discharge. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 4 Male Genitalia (Cont.) • Inspect the scrotum and ventral surface of the penis for the following: • Color • Texture • Asymmetry • Lesions • Unusual thickening • Presence of hernia • Transilluminate any masses in the scrotum. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 5 Male Genitalia (Cont.) • Palpate the inguinal canal for a direct or indirect hernia. • Palpate the testes, epididymides, and vas deferens for the following: • Consistency • Size • Tenderness • Bleeding, masses, lumpiness, or nodules • Palpate for inguinal lymph nodes. • Elicit the cremasteric reflex bilaterally. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 6 Male Genitalia • Penis • Testicles • Epididymis • Scrotum • Prostate gland • Seminal vesicles Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 7 Male Genitalia (Cont.) • Penis • Corpora cavernosa • Corpus spongiosum • Urethra/orifice • Prepuce • Penis function • Excretes urine • Introduces sperm into vagina Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 8 Male Genitalia (Cont.) • Scrotum • Septum • Testis • Epididymis • Spermatic cord • Muscle layer • Cremasteric muscle Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 9 Male Genitalia (Cont.) • Testicular functions • Spermatogenesis • Testosterone production • Epididymal functions • Storage/maturation/transit of sperm • Vas deferens begins at the tail of the epididymis, ascends the spermatic cord, travels through the inguinal canal, and unites with the seminal vesicle to form the ejaculatory duct Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 10 Male Genitalia (Cont.) • Prostate gland • Approximately the size of a testis • Surrounds the urethra at the bladder neck • Produces the major volume of ejaculatory fluid • Contains fibrinolysin, which liquefies the coagulated semen―important in sperm motility Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 11 Male Genitalia (Cont.) • Sexual physiology • Erection of the penis occurs when the two corpora cavernosa become engorged with blood. • Increased blood supply is produced by increased arterial dilation and decreased venous outflow. • Autonomic nervous system • Local synthesis of nitric oxide • Ejaculation during orgasm consists of the emission of secretions from: • Testes • Vas deferens • Epididymides • Prostate • Seminal vesicles • Orgasm is followed by constriction of the vessels supplying blood to the corpora cavernosa and gradual detumescence. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 12 Infants and Children • Sexual differentiation by 12 weeks’gestation • During the third trimester, the testes descend from the retroperitoneal space through the inguinal canal to the scrotum • Descent of testes may occur after birth. • Complete separation of prepuce from the glans at about 3 to 4 years in uncircumcised males Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 13 Adolescents • Puberty: functional maturation of reproductive organs • Increased size • Penis • Enlarges in length and breadth • Testes • Scrotal skin reddens, thins, and becomes increasingly pendulous. • Development of pubic hair Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 14 Older Adults • Pubic hair becomes finer and less abundant. • Pendulous scrotum • Decreased sexual activity • Slower erection • Orgasm less intense Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 15 History of Present Illness • Difficulty achieving and maintaining erection • Pain • Constant or intermittent, with one or more sexual partners • Associated with alcohol ingestion or medication • Medications: diuretics, sedatives, antihypertensive agents, anxiolytics, estrogens, inhibitors of androgen synthesis, antidepressants, carbamazepine, erectile dysfunction agents Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 16 History of Present Illness (Cont.) • Persistent erections unrelated to sexual stimulation • Curvature of penis in any direction with erection • Difficulty with ejaculation • Painful or premature, efforts to treat the problem • Ejaculate color, consistency, odor, and amount • Medications: alpha-blockers, antidepressants, antipsychotics, clonidine, methyldopa Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 17 History of Present Illness (Cont.) • Infertility • Lifestyle factors • Time attempting pregnancy • Sexual activity pattern • History undescended testes • Diagnostic evaluation to date • Medications: testosterone, glucocorticoid steroids, hypothalamic releasing hormone Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 18 History of Present Illness (Cont.) • Enlargement in inguinal area • Intermittent or constant, association with straining or lifting, duration, presence of pain • Change in size or character of mass; ability to reduce the mass • Pain in groin • Efforts to treat • Medications: analgesics Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 19 History of Present Illness (Cont.) • Testicular pain or mass • Change in testicular size • Onset • Lumps • Soreness • Heaviness • Medications: analgesics, antibiotics Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 20 Past Medical History • Surgery of genitourinary tract • Undescended testes, hypospadias, epispadias, hydrocele, varicocele, hernia, prostate; vasectomy • STDs • Single or multiple infections, specific organism (gonorrhea, syphilis, herpes, warts, Chlamydia), treatment, effectiveness, residual problems • Chronic illness • Testicular or prostatic cancer, neurologic or vascular impairment, diabetes mellitus, arthritis, cardiac or respiratory disease Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 21 Family History • Infertility in siblings • History of prostate, testicular, or penile cancer • Hernias • Peyronie disease (contracture of penis) Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 22 Personal and Social History • Occupational risk of trauma to suprapubic region or • • • • • • genitalia, exposure to radiation or toxins Exercise risks Concerns about genitalia Testicular self-examination practices Concerns about sexual practices Reproductive function Use of alcohol and drugs Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 23 Infants and Children • Maternal use of sex hormones • Circumcised: complications • Uncircumcised: hygiene measures • Scrotal swelling with crying or bowel movement • Congenital anomalies • Masturbation and sexual exploration • Swelling or sores on penis or scrotum • Concern of sexual abuse Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 24 Adolescents • Knowledge of reproduction and sexual function • Presence of nocturnal emissions, pubic hair, enlargement of genitalia, age at time of each occurrence • Concern of sexual abuse • Sexual activity, protection used for contraception and STI prevention Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 25 Older Adults • Change in sexual desire or activity • Change in sexual response • Longer time required to achieve full erection • Less forceful ejaculation • More rapid detumescence • Longer interval between erections • Prostate surgery Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 26 Inspection and Palpation • Genital hair distribution • Coarseness • Abundance • Penis • Dorsal vein • Foreskin retraction • Texture • Tenderness or induration • Discharge Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 27 Inspection and Palpation (Cont.) • Urethral meatus • Orifice size and location • Color and moisture • Scrotum • Color • Texture • Cysts • Edema Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 28 Inspection and Palpation (Cont.) • Hernias • Inguinal • Indirect • Direct • Femoral • Testes • Tenderness • Texture • Nodules Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 29 Inspection and Palpation (Cont.) • Epididymis and vas deferens • Texture • Tenderness • Cremasteric reflex • Stroke the inner thigh with a blunt instrument. • Testicle and scrotum should rise on the stroked side. • Prostate • Detailed in Chapter 20 Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 30 Infants • Inspect and palpate • Congenital anomalies • Incomplete development • Sexual ambiguity • Urethral placement • Retractability of foreskin • Descent of testicles • Masses • Transilluminate scrotum if mass found Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 31 Children • Inspect and palpate • Penis • Size, lesions, swelling, inflammation, and malformation • Foreskin retraction • Scrotum • Descent of testes • Testes • Masses Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 32 Adolescents • Examination of older children and adolescents is the same as for adults. • Allay anxiety. • Protect privacy. • Inspect and palpate. • Expected maturational changes Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 33 Older Adults • Examination procedure for older adults same as that for younger men • Age-related changes • Graying and less abundant pubic hair • Pendulous scrotal sac and contents Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 34 Abnormalities • Hernia • Protrusion of a peritoneal-lined sac through some defect in the abdominal wall • Indirect: soft swelling in area of internal ring • Direct: soft swelling that bulges anteriorly • Femoral: occurs at the fossa ovalis, where the femoral artery exits the abdomen • Strangulated hernia • Nonreducible hernia in which the blood supply to the protruded tissue is compromised • Requires prompt surgical intervention Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 35 Abnormalities (Penis) • Syphilitic chancre • Skin lesion associated with primary syphilis • Paraphimosis • Inability to replace the foreskin in its usual position after it has been retracted behind the glans • Hypospadias • Congenital defect in which the urethral meatus is located on the ventral surface of the glans penile shaft or the base of the penis Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 36 Abnormalities (Penis) • Herpes • Genital herpes is sexually transmitted infection caused by herpes simplex virus (HSV-2) • Condyloma acuminata • “Genital warts” caused by human papillomavirus (HPV) • Lymphogranuloma venereum • Sexually transmitted infection of the lymphatics caused by Chlamydia trachomatis Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 37 Abnormalities (Penis) • Molluscum contagiosum • Benign skin infection caused by a poxvirus that infects only the skin • Peyronie disease • Fibrous band in the corpus cavernosum causing bending and/or indentation of the erection • Penile cancer • Squamous cell carcinoma usually originating in the glans or foreskin Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 38 Abnormalities (Scrotum) • Spermatocele • Benign cystic accumulation of sperm occurring on the epididymis • Hydrocele • Fluid accumulation in the scrotum • Varicocele • Abnormal tortuosity and dilation of veins of the pampiniform plexus within the spermatic cord • Orchitis • Acute inflammation of the testis secondary to infection Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 39 Abnormalities (Scrotum) • Epididymitis • Inflammation of the epididymis often seen in association with a urinary tract infection • Testicular torsion • Twisting of testis on spermatic cord • Surgical emergency Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 40 Scrotum (Cont.) • Testicular cancer • Seminomas and nonseminomas arise from germ cells (spermproducing cells). • Klinefelter syndrome • Congenital anomaly associated with XXY chromosomal inheritance Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 41 Infants • Ambiguous genitalia • Newborn’s genitalia are not clearly either male or female. • Presence or absence of male hormones controls the development of the sex organs during fetal development. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 42