PHYSICAL EXAM OF GUS CAMPBELL ppt pre.pptx

Physical exam

1. PHYSICAL EXAM OF GUS

2. Androgen deficiency results in decreased secretions from the prostate and seminal vesicles, causing a reduction or loss of seminal volume. Sympathectomy or extensive retroperitoneal surgery, most notably retroperitoneal lymphadenectomy for testicu lar cancer, may interfere with autonomic innervation of the prostate and seminal vesicles, resulting in absence of smooth muscle con traction and absence of seminal emission at time of orgasm

3. Phar macologic agents, particularly α-adrenergic antagonists, may interfere with bladder neck closure at time of orgasm and result in retrograde ejaculation. Similarly, previous bladder neck or prostatic urethral surgery, most commonly transurethral resection of the prostate, may interfere with bladder neck closure, resulting in ret rograde ejaculation. Finally, retrograde ejaculation may develop spontaneously in diabetic men.

4. absence of Orgasm. Anorgasmia is usually psychogenic or caused by certain medications used to treat psychiatric diseases. Sometimes, however, anorgasmia may be due to decreased penile sensation owing to impaired pudendal nerve function. Most com monly , this occurs in diabetics with peripheral neuropathy. Men who experience anorgasmia in association with decreased penile sensation should undergo vibratory testing of the penis and further neurologic evaluation as indicated.

5. premature Ejaculation . However, there are men with true premature ejaculation who reach orgasm within less than 1 minute after initiation of intercourse. This problem is almost always psychogenic and best treated by a clinical psychologist or psychiatrist who specializes in treatment of this problem and other psychological aspects of male sexual dysfunction. With counseling and appropriate modifications in sexual technique, this problem can usually be overcome. Alternatively, treatment with serotonin reuptake inhibitors such as sertraline and fluoxetine has been dem onstrated to be helpful in men with premature ejaculation

6. Hematospermia refers to the presence of blood in the seminal fluid. It almost always results from nonspecific inflammation of the prostate and/or seminal vesicles and resolves spontaneously, usually within several weeks. It frequently occurs after a prolonged period of sexual abstinence, and we have observed it several times in men whose wives are in the final weeks of pregnancy. Patients with hematospermia that persists beyond several weeks should undergo further urologic evaluation because, rarely, an underlying etiology will be identified. A genital and rectal examination should be done to exclude the presence of tuberculosis; a prostate-specific antigen (PSA) and a rectal examination done to exclude prostatic carcinoma; and a urinary cytology done to exclude the possibility of transitional cell carcinoma of the prostate It should be empha sized, however, that hematospermia almost always resolves sponta neously and rarely is associated with any significant urologic pathology

7. Pneumaturia Pneumaturia is the passage of gas in the urine. In patients who have not recently had urinary tract instrumentation or a urethral catheter placed, this is almost always due to a fistula between the intestine and the bladder. Common causes include diverticulitis, carci noma of the sigmoid colon, and regional enteritis ( Crohn disease). In rare instances, patients with diabetes mellitus may have gas-forming infections, with carbon dioxide formation from the fermentation of high concentrations of sugar in the urine.

8. General Observations The skin should be inspected for evidence of jaundice or pallor. Cachexia is a frequent sign of malignancy, and obesity may be a sign of underlying endocrinologic abnormalities. In this instance, one should search for the presence of truncal obesity, a “buffalo hump,” and abdominal skin striae , which are stigmata of hyperadrenocorticism . In contrast, debility and hyperpigmentation may be signs of hypoadrenocorticism . Gynecomastia may be a sign of endocrinologic disease and a possible indicator of alcoholism or previous hormonal therapy for prostate cancer. Edema of the genitalia and lower extremities may be associated with cardiac decompensation , renal failure, nephrotic syndrome, or pelvic and/or retroperitoneal lymphatic obstruction. Supraclavicular lymphadenopathy may be seen with any GU neoplasm, most commonly prostate and testis cancer; inguinal lymphadenopathy may occur secondary to carcinoma of the penis or urethra

9. Kidney Because of the position of the liver, the right kidney is somewhat lower than the left. Palpation :In children and thin women, it may be possible to palpate the lower pole of the right kidney with deep inspiration. However, it is usually not possible to palpate either kidney in men, the left kidney is almost always impalpable unless it is abnormally enlarged because of thick muscular layers

10. The best way to palpate the kidneys is with the patient in the supine position. The kidney is lifted from behind with one hand in the costovertebral angle . On deep inspiration, the examiner’s hand is advanced firmly into the anterior abdomen just below the costal margin. At the point of maximal inspiration, the kidney may be felt as it moves downward with the diaphragm

11. Transillumination of the kidneys may be helpful in children younger than 1 year of age with a palpable flank mass. Such masses are frequently of renal origin. A flashlight or fiberoptic light source is positioned posteriorly against the costovertebral angle. Fluid-filled masses such as cysts or hydronephrosis produce a dull reddish glow in the anterior abdomen. Solid masses such as tumors do not transilluminate

12. percussion of the costovertebral angle posteriorly more often localizes the pain and tenderness more accurately. Auscultation of the upper abdomen during deep inspiration may occasionally reveal a systolic bruit associated with renal artery stenosis or an aneurysm,a large renal arteriovenous fistula.

13. Bladder A normal bladder in the adult cannot be palpated or percussed until there is at least 150 mL of urine in it. At a volume of about 500 mL, the distended bladder becomes visible in thin patients as a lower midline abdominal mass. Percussion is better than palpation for diagnosing a distended bladder. The examiner begins by percussing immediately above the symphysis pubis and continuing cephalad until there is a change in pitch from dull to resonant.

14. A careful bimanual examination, best done with the patient under anesthesia, is invaluable in assessing the regional extent of a bladder tumor or other pelvic mass. The bladder is palpated between the abdomen and the vagina in the female or the rectum in the male. In addition to defining areas of induration, the bimanual examination allows the examiner to assess the mobility of the bladder; such information cannot be obtained by radiologic techniques such as CT and MRI, which convey static images.

15. Penis If the patient has not been circumcised, the foreskin should be retracted to examine for tumor or balanoposthitis (inflammation of the prepuce and glans penis). Most penile cancers occur in uncircumcised men and arise on the prepuce or glans penis. Therefore in a patient with a bloody penile discharge in whom the foreskin cannot be withdrawn, a dorsal slit or circumcision must be performed to adequately evaluate the glans penis and urethra

16. The position of the urethral meatus should be noted. It may be located proximal to the tip of the glans on the ventral surface (hypospadias) or, much less commonly, on the dorsal surface ( epispadias ). The penile skin should be examined for the presence of superficial vesicles compatible with herpes simplex and for ulcers that may indicate either venereal infection or tumor. The presence of venereal warts ( condylomata acuminata ), which appear as irregular, papillary, velvety lesions on the male genitalia, should also be noted.

17. The urethral meatus should be separated between the thumb and the forefinger to inspect for neoplastic or inflammatory lesions within the fossa navicularis . The dorsal shaft of the penis should be palpated for the presence of fibrotic plaques or ridges typical of Peyronie disease. Tenderness along the ventral aspect of the penis is suggestive of periurethritis , often secondary to a urethral stricture.

18. Scrotum and Contents The scrotum is a loose sac containing the testes and spermatic cord structures. The scrotal wall is made up of skin and an underlying thin muscular layer. The testes are normally oval, firm, and smooth; in adults, they measure about 6 cm in length and 4 cm in width . They are suspended in the scrotum, with the right testis normally anterior to the left . The epididymis lies posterior to the testis and is palpable as a distinct ridge of tissue. The vas deferens can be palpated above each testis and feels like a piece of heavy twine.

19. The scrotum should be examined for dermatologic abnormalities. Because the scrotum, unlike the penis, contains both hair and sweat glands, it is a frequent site of local infection and sebaceous cysts The testes should be palpated gently between the fingertips of both hands. The testes normally have a firm, rubbery consistency with a smooth surface. Abnormally small testes suggest hypogonadism or an endocrinopathy such as Klinefelter disease. A firm or hard area within the testis should be considered a malignant tumor until proved otherwise

20. The epididymis should be palpable as a ridge posterior to each testis. Masses in the epididymis ( spermatocele , cyst, and epididymitis) are almost always benign. To examine for a hernia, the physician’s index finger should be inserted gently into the scrotum and invaginated into the external inguinal ring

21. Once the external ring has been located, the physician should place the fingertips of his or her other hand over the internal inguinal ring and ask the patient to bear down ( Valsalva maneuver). A hernia will be felt as a distinct bulge that descends against the tip of the index finger in the external inguinal ring as the patient bears down.

22. The spermatic cord is also examined with the patient in the standing position. A varicocele is a dilated, tortuous spermatic vein that becomes more obvious as the patient performs a Valsalva maneuver.. Transillumination is helpful in determining whether scrotal masses are solid (tumor) or cystic (hydrocele, spermatocele ). A small flashlight or fiberoptic light cord is placed behind the mass. A cystic mass transilluminates easily, whereas light is not transmitted through a solid tumor.

23. Rectal and Prostate Examination in the Male Digital rectal examination (DRE) should be performed in every male after age 40 years and in men of any age who present for urologic evaluation. Prostate cancer is the second most common cause of male cancer deaths after age 55 years and the most common cause of cancer deaths in men older than 70 years. Many prostate cancers can be detected in an early curable stage by DRE, and about 25% of colorectal cancers can be detected by DRE in combination with a stool guaiac test. DRE should be performed at the end of the physical examination. It is done best with the patient standing and bent over the examining table or with the patient in the knee-chest position

24. The DRE itself begins by separating the buttocks and inspecting the anus for pathology, usually hemorrhoids, but, occasionally, an anal carcinoma or melanoma may be detected. The gloved, lubricated index finger is then inserted gently into the anus. Only one phalanx should be inserted initially to give the anus time to relax and to easily accommodate the finger. Estimation of anal sphincter tone is of great importance; a flaccid or spastic anal sphincter suggests similar changes in the urinary sphincter and may be a clue to the diagnosis of neurogenic disease The index finger then sweeps over the prostate; the entire posterior surface of the gland can usually be examined

25. The index finger is extended as far as possible into the rectum, and the entire circumference is examined to detect an early rectal carcinoma. The index finger is then withdrawn gently, and the stool on the glove is transferred to a guaiac-impregnated ( Hemoccult ) card for determination of occult blood

26. Neurological examination Sensory deficits in the penis, labia, scrotum, vagina, and perianal area generally indicate damage or injury to sacral roots or nerves. testing of reflexes in the genital area may also be performed The most important of these is the bulbocavernosus reflex (BCR ), which is a reflex contraction of the striated muscle of the pelvic floor that occurs in response to various stimuli in the perineum or genitalia . This reflex is most commonly tested by placing a finger in the rectum and then squeezing the glans penis or clitoris If the BCR is intact, tightening of the anal sphincter should be felt and/or observed. The BCR tests the integrity of the spinal cord–mediated reflex arc involving S2-S4 and may be absent in the presence of sacral cord or peripheral nerve abnormalities.

27. The cremasteric reflex can be elicited by lightly stroking the superior and medial thigh in a downward direction. The normal response in males is contraction of the cremasteric muscle that results in immediate elevation of the ipsilateral scrotum and testis . There is limited clinical utility for testing superficial reflexes such as the cremasteric when investigating neurologic dysfunction. However, there may be a role for testing this reflex when assessing patients with suspected testicular torsion or epididymitis. Finally, an overly active cremasteric reflex in children can lead to the mistaken diagnosis of an undescended testis in some cases.