Male Examination Gender-Related Health Lisa Zaynab Killinger, DC

1. Male ExaminationGender-Related HealthLisa Zaynab Killinger, DC

2. What can you expect from this class?(Or what do you get in return?) • Fulfill the requirements of your licenses! • Learn info relevant to clinical practice • Learn info for success on boards • Have fun?

3. Let’s get started!

4. The Digital Rectal Exam Or Why do I have to know this stuff ????

5. What is a DRE? • A DRE evaluates the terminal portions of the G-I tract. • Sacrococcygeal and perianal areas • Anus • Sphincter and anal ring • Lateral and posterior rectal walls • Anterior rectal wall and prostate for males • Stool

6. DIGITAL RECTAL EXAM • Why should a DRE be performed? • How frequently should a DRE be performed? • Who can perform a DRE?

7. Why? • Yearly screening for males • Over age 50 for most; over age 40 for high risk • As part of an annual exam for females • Yearly after becoming sexually active • History-Perianal pain, problems w/urination/defecation/sexual function • Symptoms? Low Back Pain, hesitancy or dribbling of urine, other local pain, changes

8. Who? • Chiropractors---In most states • Family practitioners/General practitioners • Gynecologists • Proctologists/Urologists • Physician’s assistants

9. What do patients say that provide clues that a digital rectal exam should be done?

10. Symptoms • Changes in bowel function • number, frequency, consistency, color, blood • Changes in bladder function • hesitancy, urgency, nocturia, dysuria, dribbling, discharge, decreased caliber or force • Anal discomfort or rectal bleeding • Sexual dysfunction

11. When can’t a DRE be done? • Anal fissures---very painful • Anal fistula--very painful • Spasticity of the sphincter • Rectal prolapse

12. Important issues related to this exam: • Patient modesty • Patient culture • Dr/Pt boundary issues • Patient history of abuse, rape, incest, etc.

13. What should we do? • Take a complete history • Always have another individual in the room if you do this exam • Talk to patient about their comfort level with this exam, & with you doing this exam • If you or patient is uncomfortable refer to another health professional for this exam!

14. But, in the end… • Make sure that every patient over 50 (or over 40 with risk factors) is having this exam done annually by SOMEONE! • If you don’t, you are liable for missed diagnoses. (Failure to diagnose is one of the most common successful malpractice claims against DCs.) • Use your education to protect your patients’ health! Be a DOCTOR of Chiropractic.

15. Let’s talk about anatomy!

16. The Rectum • The rectum is approximately 12 cm long. • Proximally, it joins the sigmoid colon. • Distally, it joins the anal canal at the anorectal junction (about 2.5 to 4 cm). • The distal end is not palpable. • Folds in rectal walls may be palpable.

17. The Rectum Inferior rectal valve Internal h. plexus Crypts Columns Internal sphincter External sphincter

18. Sphincter Control • The internal sphincter is made of smooth muscle and is under involuntary autonomic control. • The external sphincter is made of striated muscle and is under voluntary control.

19. The urge to defecate occurs when the rectum fills with feces which causes reflex stimulation of the internal sphincter. • Defecation is then controlled by the striated external sphincter.

20. The lower half of the anal canal is supplied with somatic sensory nerves, which makes it sensitive to painful stimuli. • The upper half of the anal canal is under autonomic control and is not well-supplied by sensory nerves. Therefore, it is relatively insensitive to pain (lesions).

21. The Prostate • Located at the base of the bladder • Surrounds the urethra • Made of both fibromuscular and glandular tissue • How big? • Chestnut size: 4cm X 3cm X 2cm • In infants and children—small and inactive • In adolescents—enlarges and becomes active • After age 25—continues to enlarge

22. The Prostate Urethra Median lobe Ejaculatory duct

23. So, what does it do? • It is the source of much investigation. • We know that it contributes to the ejaculatory fluid. • Believed to secrete enzymes that decrease the viscosity of the ejaculatory fluid • Believed to lower acidity of the vaginal canal

24. Access to the prostate • The posterior surface of the prostate (what we palpate) is in close contact with the anterior rectal wall. • A sulcus runs through the middle of the prostate and divides it into right and left lobes.

25. So, how do we evaluate the prostate? • Size • Contour • Consistency • Mobility • Protrusion into the rectum • Grade 1, Grade 2, Grade 3, Grade 4 • Sulcus present • Pain with palpation

26. What does it feel like? • Pencil eraser • Tip of your nose • Thenar pad

27. Prostate Conditions • Benign prostatic hypertrophy • Prostate carcinoma • Acute prostatitis • Chronic prostatitis • Others: Prostatic calculi or abscesses

28. Benign Prostatic Hypertrophy (BPH) • Etiology is unknown • VERY common in males over age 50 • Symptoms rare before 40 • 50% have symptoms after age 60 • 70 to 90% have symptoms after age 70

29. What happens? • The normal tissue is replaced by collagen. • Results in expansion of the capsule, leading to pressure on the urethra; bladder and urinary symptoms (as discussed earlier). • All or part of prostate may enlarge.

30. Digital Exam of BPH • Size—enlarged • Consistency: boggy, squishy, smooth • Mobility—remains fairly mobile • Protrusion—Grade depends on stage • Sulcus—may be obscured (vs. obliterated) • Should be nontender

31. The degree of enlargement of the prostate may not be related to symptoms • i.e., a prostate that is markedly enlarged may not obstruct urinary flow

32. “Acute urinary retention” may occur, and in general symptoms may be aggravated by: • Exposure to cold • Immobilization • Attempts to retain urine • Anesthetics, anticholinergics • Ingestion of alcohol

33. Other complications: • Incomplete bladder emptying leads to: • Urinary stasis • Predisposes to infection of bladder and tract • Hydronephrosis • Renal calculus formation

34. Treatments for BPH • “Wait and see” • Drug therapy • Herbal remedies • Prostatectomy

35. Questions about BPH?

36. Prostatic Carcinoma • 2nd leading cause of cancer death in males over 65 • An adenocarcinoma (sarcoma is rare) • Rare before the age of 50 • 122,000 new cases/year in the US • Etiology is unknown

37. Age?? Race?? History?? Diet?? Age over 50 years African-American Family history of CA High in animal fat Risk Factors

38. Signs and Symptoms • In the early stages, asymptomatic!! • Late in its course: • Bladder obstruction • Ureteral obstruction • Hematuria • Pyuria

39. Does it metastasize? • Carcinoma from the prostate is responsible for 60% of all skeletal metastasis • 25% is due to lung cancer • Predominantly blastic mets, but may be mixed

40. So, how do we detect it? • The DRE! • Size— • Contour— • Consistency— • Mobility— • Protrusion— • Sulcus— • Tenderness–

41. Size—Normal early, enlarged later • Contour—Asymmetrical • Consistency—Hard nodules* • Mobility—May resist movement • Protrusion—Grade 1-4 • Sulcus—Obliterated (advanced CA) • Pain—NO- usually asymptomatic

42. Important Differentials • Prostatic CA is not the only lesion with hard nodules: • Prostatic calculi • Prostatic TB • Prostate granulomata

43. But, all hard nodules in the prostate should be considered cancerous, until everything else is ruled out!

44. PSA • Prostate Specific Antigen • A glycoprotein specific to the prostate, but not to prostate carcinoma • Produced by both healthy and unhealthy prostate tissue • Serum PSA is moderately elevated in 30 to 50% of patients with BPH

45. PSA Levels* • Levels < 4 ng/ml are considered normal • 4 to 10 ng/ml are considered borderline • Above 10 ng/ml is considered high

46. The higher the PSA level, the more likely the presence of prostate CA…. • However……. • Men with prostate CA can have negative or borderline PSA levels

47. How do we prove otherwise? • PSA—is elevated in 25 to 92% of patients with prostate cancer • TRUS-Trans-rectal ultrasound • Biopsy

48. Borderline PSA levels • PSA density (PSAD): divide the PSA number by the prostate volume (TRUS) • Age-specific ranges: Older men have higher PSA levels, even without CA • PSA velocity: Serial testing that measures how quickly PSA levels rise over time • Free PSA ratio: Bound vs. Unbound • *low levels of free PSA are more likely CA

49. TRUS • Performed when the PSA level is borderline and the DRE is negative • Visualizes the areas needed for biopsy • Helps determine the prostate volume (PSAD)

50. TRUS