SOCM Physical Exam of the Anus, Rectum, Hernias, Male Genitalia and Prostate PFN: SOMPYL0T

Hours: 1.5

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Terminal Learning Objective  Action: Communicate knowledge of “Physical Examination of the Male Genitalia, Rectum, and Anus”

 Condition: Given a lecture in a classroom environment

 Standard: Received a minimum score of 75% IAW course standards on the formative quizzes and the Physical Exam Practical Test grade sheet JSOMTC, SWMG(A) Slide 2

References

 Essentials of Anatomy and Physiology (6th Edition; 2013; Martini; Bartholomew)  Guide to Physical Examination and History Taking, BATES' (11th Edition, 2013; Bickley)  Taber’s Cyclopedic Medical Dictionary (22th Edition; 2013; Davis)

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1 Reason

Failure to recognize a problem could result in losing a Soldier for extended periods of time or permanently. Recognizing some conditions could mean the difference between quality of life and even death (e.g., cancer, cauda equina, etc.)

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Agenda

 Define the key terms related to the physical exam of the male genitalia, anus, and rectum  Identify common or concerning symptoms found during a male genitalia, hernia, anus, rectum, and prostate exam

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Agenda

 Communicate the exam techniques and how to record pertaining to the male genitalia, anus, rectum, prostate and hernia examinations

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2 Key Terms Related to the Physical Exam of the Male Genitalia, Anus, and Rectum

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Vocabulary

 Prepuce: fold of skin covering head of penis or fold of skin covering clitoris  Tuft: short cluster of elongated strands, such as hair, attached at the base or growing close together  Copro‐: associated with feces  Cryptorchidism: failure of one or both of the testes to descend into the scrotum (cancer risk)

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Vocabulary

 Monorchism: state of having only one testicle within the scrotum  Orchis: testis  Transillumination: the shining of a light through a body cavity or organ  Occult blood: blood not visible with naked eye  Frank blood: blood visible with naked eye

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3 Vocabulary

 Dysuria: difficult or painful urination  Anuria: absence of urine formation  Autogenous: originating in the body  Heterogeneous: composed of unlike substances  Hematochezia: presence of blood in feces

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Vocabulary

 Herniotomy: operation in which the hernia is repaired  Tenesmus: spasmodic contraction of anal or bladder sphincter with pain and persistent desire to empty bowel or bladder with ineffectual straining efforts

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The Common or Concerning Male Genitalia Symptoms Found During the Exam

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4 Common or Concerning Symptoms

 Taking the sexual history (Hx)  Be aware of social environment  Tips • In a private environment • Explain to the patient:  Why you are taking the sexual history  You realize it is highly personal  Encourage Pt. to be open and direct  You gather Hx on all patients  Affirm that it is confidential

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Common or Concerning Symptoms

 Begin Hx. with a general statement  Can cover one or more of the key “tips for taking a sexual history”  Remain neutral and non‐judgmental  Continue with questions concerning sexual orientation  Heterosexuals, bisexuals, and homosexuals are in all cultures  Most new medics experience anxiety with interview (sometimes true for the patients also)

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Common or Concerning Symptoms

 Continue with sexual function questions  Direct questions  Language appropriate for the patient  Assess each phase of the sexual response  Libido (desire)  Arousal phase  Any other factors that may contribute to problems

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5 Anatomy

 Scrotum and testes  Epididymis  Vas deferens  Seminal vesicles  Ejaculatory duct

 Prostate gland  Bulbourethral glands  Urethra

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Anatomy

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Health Promotion and Counseling

 Testicular self‐examination  Conduct exam monthly (between 15‐35)  Screen for testicular cancer  Cancer risk factors include: • Cryptorchidism • Hx of carcinoma • Mumps • Orchitis • Inguinal hernia • Hydrocele in childhood

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6 Health Promotion and Counseling

 Testicular self‐examination (cont’d)  Seek medical assistance for the following: • Painless “lump” • Swelling/enlargement in either testicle • Pain/discomfort in testicle or scrotum • Feeling of “heaviness” or fluid in scrotum • Dull ache in lower abdomen or groin

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Health Promotion and Counseling

 Conducting “testicular self‐exam”  Best after warm bath or shower  Stand in front of mirror  Examine each testicle • One may be larger ‐ normal • Pain or lumps ‐ abnormal

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The Techniques of an Examination as Pertaining to the Male Genitalia

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7 Male Genitalia Exam

 Techniques of examination  Many students feel uneasy about examining a man's genitalia  Explain each step prior to examination  Occasionally, male patients have erections during the examination  May refuse to have the examination

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Male Genitalia Exam

 Prepare for the examination  For younger patients review sexual maturity ratings • Three characteristics of maturity: pubic hair, penis, and testes • Recorded as two: genitalia and pubic hair  Private room or area  Prepare any equipment needed  Exam gloves before we begin

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Male Genitalia Exam

 Prepare patient for examination  Explain procedure  Gown – expose genitalia and inguinal  Position •Standing or sitting •Standing for hernias or varicoceles

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8 Male Genitalia Exam

 Visually inspect genitals and inguinal region  Skin around genitals  Inguinal swelling or deformity  Inspect the penis  Skin on penis  Look for ulcers, scars, nodules or signs of inflammation

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Male Genitalia Exam

 Inspect the glans  Circumcised • Examine glans • Examine meatus  Uncircumcised ‐ retract prepuce • Have patient retract • Examine glans • Examine meatus • Have pt. return foreskin

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Male Genitalia Exam

 Palpation (only done if “genital complaint”)  Mostly performed with visual inspection  “Milking down” urethra  If mass or deformity noted palpate to specifically identify the mass or solid lesion • Palpate between thumb and first two fingers • Note indurations, pain, or tenderness

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9 Male Genitalia Exam

 Examination of the scrotum  Can check cremasteric response at this time  Inspect the skin  View the anterior surface  Lift testicles view posterior surface  Check contours note • Swelling or lumps • Veins • Discoloration

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Male Genitalia Exam

 Palpate the scrotum (if a “genital complaint”)  Gently knead the scrotum between your thumb and first two fingers  Check entire scrotum –use pattern  Palpate  Each testicle and epididymis  Note: size, shape, consistency, and tenderness  Each spermatic cord from epididymis to superficial ring  Note swelling or nodules

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Male Genitalia Exam Testicular cancer – this case may not be as bad as it seems

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10 Male Genitalia Exam

 Testicular masses for SOF medics  Routine exams not recommended • Except in family hx of testicular cancer  Consult your medical officer  u/s helpful (if trained)  Most common CA for 20‐39 y/o males  “Lump” or not: may be painless  Testicular CA • Highly treatable early • Highly fatal late

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The Techniques of Hernia Examination

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Hernia

 Protrusion of organ or its fascia thru wall of cavity which should contain it  Common examples:  Abdominal (usually at the navel)  Vertebral disc (“bulging” disc)  Inguinal (direct and indirect)  Hiatal  Uncal (worry about brainstem later!)

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11 Hernia Examinations  Hernias in the groin  Femoral hernia ‐ below inguinal ligament  Indirect inguinal hernia ‐ above inguinal ligament • Near midpoint/internal inguinal ring • Often in the scrotum  Direct inguinal hernia ‐ above inguinal ligament • Near pubic tubercle / external inguinal ring

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Hernia Examinations

 Preparation  Patient standing  Sit in front of patient  Inspection  Bulging / asymmetry  Have patient strain / bear down / cough

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Hernia Examinations

 Palpation for inguinal hernia  Begin with right side  Right index finger to inferior margin of scrotum  Upward along canal • Follow spermatic cord • External inguinal ring • Pt – bear down or cough  Obliquely to internal ring • Pt – bear down or cough

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12 Hernia Examinations

 Palpate for femoral hernia  Place fingers on anterior thigh at region of femoral canal  Pt. bear down or cough  Note swelling or tenderness  Possible scrotal hernia  Large mass  Have Pt. lie down and look for retraction of mass  Check mass for bowel sounds

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How to Record Male Genitalia and Hernia Exam Findings

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Recording Your Findings

 Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes descended bilaterally, smooth, without masses. Epididymis non‐tender. No inguinal or femoral hernias.”

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13 Recording Your Findings

 Record findings  29 y/o male comes into sick call. He states for the last 5 to 6 wks he has had discomfort, sometimes “dull aching pain,” in the right inguinal area and testicles.

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Common or Concerning Symptoms Found During an Anus, Rectum, and Prostate Exam

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Common or Concerning Symptoms

 The common or concerning symptoms  Change in bowel habits  Blood in stool (frank or occult blood)  Pain with defecation • Rectal bleeding or tenderness  Anal lesions, warts, fissures, and hemorrhoids  Weak urine stream  Dysuria

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14 Common or Concerning Symptoms

 Changes in bowel habits  Consistency of stool and frequency of defecation • Weak, watery stool – diarrhea • Solid hard stool – constipation  Stool changes: • Size / consistency / appearance  Stool changes: frequency / amount • Frequent defecation • Constipation • Tenesmus

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Common or Concerning Symptoms

 Blood in stool  Frank or occult blood  Upper GI bleed – dark, tarry, foul‐smelling  Lower GI bleed – bright red • Hemorrhoids • Anal fissures  Quantity / severity of bleeding

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Common or Concerning Symptoms

 Pain with defecation • Rectal bleeding or tenderness  Anal lesions, warts, fissures and hemorrhoids  Weak urine stream • Enlarged prostate  Dysuria / hematuria  Hematospermia

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15 Common or Concerning Symptoms

 Rectal tenesmus  Itching  Rectal ulcers  Anal tag

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Techniques of the Rectal Exam

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Male Rectal Exam

 Least popular part of exam  Successful exam requires  Calm demeanor  Explain what Pt may feel  Gentle/slow movement  Prepare for exam  Area / equipment  Position patient  Standing bent at waist  Lying on side

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16 Male Rectal Exam

 External examination  Inspection • Deformity, discoloration and lesions  Pectinate line (dentate line) • Divides anal canal  Upper 2/3 – lower 1/3  Hemorrhoids • Internal/external

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Male Rectal Exam

 Preparation for the internal portion of the examination  Lubricate index finger for exam  Explain what you are about to do  Position hands for examination • Inspection of anus • Check for “anal wink”

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Male Rectal Exam

 Internal digital examination  Inform Pt. – “beginning exam”  Have Pt. strain ‐ observe  Pad of index finger over anus  Inform Pt. – “some pressure”  Apply gentle pressure

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17 Male Rectal Exam

 As the Pt. relaxes  Inform Pt. – “additional pressure”  Gently insert finger tip • Finger tip towards umbilicus • Allow sphincter to relax  After entering sphincter ‐ note the following: • Sphincter tone • Tenderness • Induration • Irregularities / nodules

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Male Rectal Exam

 Occasionally severe tenderness prevents entry into the anus  Do NOT attempt to “force through”  Stop the interior digital exam  Use both hands / fingers on each side of the anus • Gently spread orifice apart • Have Pt. strain / bear down • Look for lesions, fissures or abnormalities that could cause severe tenderness

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Male Rectal Exam

 Continue to advance finger along the anal canal  Rotating finger using pattern to check canal 360°  Advance finger as far as possible • Continue 360° palpation • Check for abnormalities  Have Pt. strain/bear down to better palpate lesions  After examining anal canal – check the prostate

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18 Male Rectal Exam

 Examining the prostate  Rotate your hand • Ventral side of rectum– pad of index finger pointed down  Tell Pt. may have urge to urinate  Palpate posterior surface of prostate through rectal wall  Carefully identify and palpate both lobes and the median sulcus • Size/shape/consistency • Nodules or tenderness

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Male Rectal Exam

 Upon completing palpation of the prostate:  If possible – extend finger beyond the prostate • Palpate the region of the seminal vesicle • Note any nodules or tenderness  If not possible to examine further • Gently withdraw finger • Note any frank blood • Give Pt. tissue • Fecal occult blood test (if indicated)

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Male Rectal Exam

 Fecal occult blood test  Blue stripe card with blue lid bottle  Yellow stripe card with yellow lid bottle  Wipe finger on appropriate part of card –  Close flap  Remove gloves  Complete test – apply drops

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19 How to Record Anus, Rectum, and Prostate Exam Findings

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Record Your Findings

 Describe your findings of the physical exam  Use plain language – full sentences  Phrases – bullet comments  Abbreviations  Standard “medical” abbreviations  Standard “military” abbreviations  Standard use of abbreviations

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Record Your Findings

 Hx: 26 y/o male (team member)  Family Hx colon cancer  Rectal bleeding  Change in bowel pattern  CC: concern of colon cancer  PE:  Inspection  Palpation

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20 Questions?

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Terminal Learning Objective

 Action: Communicate knowledge of “Physical Examination of the Male Genitalia, Rectum, and Anus”

 Condition: Given a lecture in a classroom environment

 Standard: Received a minimum score of 75% on the written exam IAW course standards

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Agenda

 Define the key terms related to the physical exam of the male genitalia, anus, and rectum  Communicate common or concerning symptoms found during a male genitalia, hernia, anus, rectum, and prostate exam

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21 Agenda

 Communicate the exam techniques and how to record pertaining to the male genitalia, anus, rectum, prostate and hernia examinations