The Male Genitourinary Examination

1. The Male Genitourinary Examination Communication During the Clinical Encounter 王強庭 國軍高雄總醫院 外科部 泌尿外科

2. Learning Objectives for the GU Exam • Understanding the communication and informational needs of the male patient • Acquiring confidence and competence in your exam technique • Increasing knowledge on topics relevant to health education of male patients, including cancer screening methods, safe sexual practices and other health behaviors

3. Communication Needs of Male Patients • Reticence about GU pain, symptoms, sexual history is common • Anxiety often high and unexpressed • Anticipation of pain/discomfort • Lack of knowledge about procedures • Previous experience with the GU exam • Embarrassment can be significant barrier • Gender and age may affect interaction

4. Informational Needs of Male Patients • Males may not be socialized to recognize relevant health issues • Access to health information often limited • Media sources, including worldwide web • Physician/clinician • Family members • Health behaviors often neglected

5. Communication Skills for the GU Exam • Maintain a professional demeanor • Professionalism dispels embarrassment • Competence engenders patient trust • Acknowledge patient’s bodily responses with a matter-of-fact manner Female clinician: “Don’t worry about it. You’re healthy, and this shows that everything works correctly.”

6. Communication Skills for the GU Exam Relationship building is essential • Ask open-ended questions • Maintain non-judgmental, respectful attitude • Display tact, sensitivity, and humor when appropriate • Explain what you’re doing as you do it • Don’t rush through the exam

7. Request the Patient’s Permission Ask permission before proceeding • Patient consent essential for invasive procedures • Patient’s attitude affected by • Cultural or religious beliefs • Previous positive or negative experiences

8. Qualitative Research Data Focus group participant: “I thought it very strange that going into the ER because of the blood pressure and chest pain…the doctor did a rectal exam on me….I just felt very strange that he did a rectal exam and…I was like shocked….”

9. Talking the Patient Through the Exam • Warns patient to expect touching • Minimizes physical and emotional discomfort • Maintains rapport • Allays patient anxiety

10. Qualitative Research Data Patient: “The doctor talked to me while he was doing the exam…him talking to me helps me feel more at ease with it. It helps keep the connection between the two of us.”

11. Be Sensitive to Patient’s Comfort • Ask if patient needs privacy to remove clothing • Use a drape to limit exposure • Allow patient to cover up when exam is completed • Offer tissue for removing jelly after the exam

12. Technical Skills for the GU exam • Review anatomy and physiology • Practice a focused exam technique • Note any external abnormalities • Screening opportunity for testicular cancer if appropriate • Detection of hernias, swellings, masses • Relate findings and discuss results with the patient after exam

13. Penis Foreskin (prepuce) Glans Urethral Meatus Scrotum Testis Epididymis Spermatic Cord Inguinal area Hernias Lymph nodes Anus Rectum Prostate GU Exam: Review of Anatomy

14. Male Reproductive Organs Source: http://www.medscape.com/pjsp/features/ald/repro/

15. Anatomy of the Scrotum • Scrotum: muscular pouch containing testes • Testis: a network of tightly coiled seminiferous tubules that converge and anastamose into efferent tubules • Encapsulated by tunica albuginea • Epididymis: a structure formed from merged efferent tubules, which attaches along the posterior and upper border of the testis • Described as having head, body & tail • Vas deferens: tube arising from tail of epididymis, • Passes through inguinal canal and joins seminal vesicle duct to form ejaculatory duct, which passes into prostate gland • Spermatic cord: structure formed by vas deferens, testicular arteries, and veins

16. Before Beginning the GU Exam • Patient may be either supine or standing, but check for hernias or varicoceles when patient stands • Explain the procedure to the patient • Use models or diagrams to illustrate • Address patient’s concerns about pain • Chaperone in exam room often advisable • Always wear gloves

17. Development of penis and surrounding hair Foreskin (retract if present) Glans Urethral meatus Note any discharge Sexual maturation, rashes, scabies Phimosis (cannot be retracted over glans) Ulcers, scars, nodules or inflammation Urethritis Performing the GU Exam Inspect Possible Findings

18. Shaft of the penis Note any induration or tenderness Fibrous areas (ask if patient has “crooked” erection) Visible lesions Urethral stricture or carcinoma Peyronie’s disease Syphilis or cancer Performing the GU Exam Inspect and palpate Possible Findings Remember to replace the foreskin if retracted.

19. Skin of scrotum Contours of scrotum Rashes, inflammation Swellings or bulges (hernia or hydrocele) Cryptorchidism (undescended testis) Performing the GU Exam Inspect Possible Findings Transillumination, a technique in which a light source is applied to the side of a scrotal enlargement, is useful in determining the nature of a scrotal mass.

20. Testis Note tenderness Epididymis Note tenderness Spermatic Cord and adjacent area Orchitis, torsion Lumps (cancer) Swelling or lumps (cysts, tumors, or epididymitis) Varicocele (“bag of worms”) Performing the GU Exam Palpate Possible Findings

21. Inguinal and femoral areas Instruct patient to cough or to bear down Palpate External inguinal ring through scrotal skin Instruct patient to cough or to bear down Lymph nodes Sudden swelling in scrotum (hernia or mass) Pain during cough or strain should be evaluated Direct hernia (felt on pad of examining finger) Indirect hernia (auscultate for bowel sounds) Enlarged nodes (infective or malignant disorders) Performing the GU Exam Inspect Possible Findings

22. The Male GU Exam The Digital Rectal Exam

23. GU Exam: Digital Rectal Exam • Assess the patient’s strength and mobility before positioning him • Common positions for the DRE • Modified lithotomy • Sims’ position • Left lateral position • Standing, hips flexed • Ask the patient if he feels stable and comfortable before proceeding

24. Performing the DRE • Make sure lighting is sufficient • Glove both hands and spread the buttocks apart • Inspect the sacrococcygeal and perianal areas • Palpate any abnormal areas, noting lumps or tenderness • Ask the patient about localized feelings of tenderness or pain

25. Performing the DRE • Lubricate the gloved index finger • Warn the patient before inserting finger • Gently press on the sphincter’s edge and wait for it to relax, then insert your finger into anal canal • Pause and allow patient to adjust to your finger, then continue to insert finger fully • Assess sphincter tone by asking the patient to squeeze anal muscles around finger

26. Examining the Rectum • Examine the posterior and lateral walls of the rectum by gently rotating the finger through 180 degrees • To palpate the entire circumference of the rectum, you should turn away from patient and hyperpronate your wrist • Sweep your finger across the anterior and anterolateral walls of the rectum • Note texture and elasticity of the rectal lining

27. Rectal Exam: Possible Findings • Normal rectal mucosa feels uniformly smooth and pliable • Polyps--may be attached by a stalk or base • Masses or irregularly shaped nodules • Areas of unusual hardness • Abscesses (perirectal sepsis) may be indicated by extreme tenderness • Hemorrhoids (internal and external)

28. Examining the Prostate • Inform the patient that you’re going to examine his prostate gland • Sweep your finger over the prostate gland (found anteriorly through rectal wall) • Identify the two lobes with a longitudinal groove (median sulcus) between them • Note the size, nodularity, consistency and tenderness of the prostate

29. Prostate Exam: Possible Findings Normal prostate • About 2.5 cm from side to side • Prominent median sulcus • Consistency is rubbery and smooth • Tenderness not usual, but patients should feel urge to urinate when you palpate

30. Prostate Exam: Possible Findings Benign Prostatic Hypertrophy (BPH) • Enlargement of gland is symmetrical • Marked protrusion into rectal lumen • Smooth with no nodularity • Median sulcus may be indistinguishable • Consistency is rubbery, ‘boggy’ or slightly elastic

31. Prostate Exam: Possible Findings Prostate Cancer • Asymmetric shape • Hard consistency • Discrete nodule may be palpable • Median sulcus often obscured Note: Hard areas of prostate are not always cancerous but may indicate conditions such as prostatic stones or chronic inflammation

32. Prostate Exam: Possible Findings Acute prostatitis • Gland is swollen • Firm consistency • Very tender to touch • Examine the gland carefully • Pay attention to patient’s verbal and nonverbal cues

33. Concluding the Exam • Inform the patient before withdrawing your finger • Note the color of any fecal matter on glove • Use fecal material for occult blood testing if this is indicated for CRC screening • Offer the patient a tissue • Allow the patient to cover up and rise to sitting position before discussing results

34. Explaining Exam Results • Explain your findings to the patient • Negotiate a follow-up plan for the patient • Recommended interval for next physical exam • Cancer screening tests—sigmoidoscopy or colonoscopy; PSA if appropriate • Address patient concerns and understanding

35. Patient Education during the GU Exam • Young adult males (<35 years) • Sexuality, including safe sexual practices • Self-care, including the testicular self-exam • Older adult males (40+ years) • Prostate and colorectal cancer screening • Sexual function • Lower urinary tracts symptoms that affect quality of life (e.g., incontinence)

36. Summary of Issues • The GU examination does not have to be an embarrassing ordeal for the clinician OR the patient if basic communication principles are followed. • Competence in exam performance comes with practice over time. • The GU exam represents an opportunity for clinicians to broach sensitive topics relating to male health concerns.