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(Student) 2017-18 Male Reproductive
(Student) 2017-18 Male Reproductive
Transillumination, atechnique
in which a light source is
applied to the side of a
scrotal enlargement, is
useful in determining the
nature of a scrotal mass.
http://www.meddean.luc.edu/lumen/MedEd/uro
logy/hydrchx2.htm
Source: Jarvis, C. (2012).Physical Examination &
Health Assessment (6th ed). St. Louis: Elsevier
Scrotal disorder – Hydrocele and Varicocele
Hernia
– Inspection
• Inguinal region (no
bulge)
– Palpation
• Inguinal canal
• Femoral area
13
Digital Rectal Exam: Possible Findings
(adopted from www.brown.edu/Research/ICHP/Modules/Mod8DRE/.../DRE.ppt )
Normal prostate
• About 2.5 cm from side to side
• Prominent median sulcus (groove that separates the two lobes)
• Consistency is rubbery and smooth
• Tenderness not usual, but patients should feel urge to urinate
when you palpate
Prostate Cancer
• Asymmetric shape
• Hard consistency
• Discrete nodule may be palpable
• Median sulcus often obscured
Acute prostatitis
• Gland is swollen
• Firm consistency
• Very tender to touch
• Examine the gland carefully
• Pay attention to patient’s verbal and nonverbal cues
Concluding the Male GU Exam
• Explain your findings to the patient
• Individualize a follow-up plan for the patient
– Recommended interval for next physical exam
– Cancer screening tests—sigmoidoscopy or colonoscopy; PSA if
appropriate (ACS Recommendation)
• Address patient concerns and understanding
• 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)
Common Chief Complaints
• Scrotal pain
• Penile lesion (STIs)
• Urethral discharge (STIs)
• Testicular mass (r/o CA)
• Erectile dysfunction (ED)
History taking before physical exam
• HPI - Treatment, trauma, fertility
• PMHx – partner with STIs
• Sx of genitourinary system
• Chronic – DM, Renal, heart, hepatic disease & circulatory system
• FHx – infertility; prostate, testicular or penile CA; hernia (feel
heavy in abd)
• Personal & Social Hx – exercise, ETOH, illicit drug; do they lift a
lot?
Cont’d Hx
Sexual Hx:
• sexual practice
• Orientation – who & what do they have sex with?
• # partners (current & lifetime)
• # partners in past 6 months track exposure for follow up tx
• Form of contraception
Risk factors
DRE
Prostate Heath Index (PHI)
• http://prostatehealthindex.org/
• http://www.health.harvard.edu/blog/harvard-expert-urges-caution-
for-use-of-new-prostate-cancer-test-201207024990
Treatment for Ca Prostate
Obstructive Irritative
Weak stream Urgency
Straining Frequency
Incomplete emptying Nocturia
Prolonged voiding Urge incontinence
Hesitancy Small voided volume
Terminal dribbling
retention
Intra-operative postoperative
• Bleeding • Bladder tamponade
• Balloon compression • Infection
• TUR syndrome • Urinary retention
• Extravasation • Incontinence
• Injury of orifices • Urethral stricture
• Injury of external sphincter • Bladder neck stenosis
• Retrograde ejaculuation
• Erectile dysfunction
• Recurrent BPH
• Associated morbidity and
(Rassweiler, Teber, Kuntz & mortality
Hofmann, 2006)
TURP Syndrome (Gupta, 2009)
Table 4 :Mean maximum and average flow rate parameters in different age group (adopted from
http://www.indianjurol.com/article.asp?issn=0970-1591;year=2009;volume=25;issue=4;spage=461;epage=466;aulast=Kumar)
Urodynamic study
Controlled by
patient only
Belavic, 2010
Medical Treatments for ED
1st line treatments – Phosphodiesterase 5 (PDE5) inhibitors:
- Sidenafil (Viagra) ~ short half-lives (4-6 hrs)
- Vardenafil (Levitra) ~ short half-lives (4-6 hrs)
- Tadalafil (Cialis) ~ half-lives (16-18 hrs)
PDE5 inhibitors work by blocking PDE5 action so that cyclic
guanosine monophosphate (cGMP), a chemical produced during
sexual stimulation, continues its role in keeping the penis erect.
PDE5 inhibitors work only in the presence of sexual stimulation.
All these medications are effective 30 to 60 minutes after a dose.
Alprostadil (Caverject) (2nd line treatment) is available as both an
intracavernous injection and a transurethral formulation.
Special precautions for taking PDE5 inhibitors
Belavic, 2010
Bladder cancer
Risk factors:
Cigarette smoking
Occupations r/t dye (hair dressers) and long haul driver (limited toileting
facility)
Aromatic amine exposure (rubber and chemical industry)
Polycyclic aromatic hydrocarbon (coal and aluminum industry)
Family history
Chronic bladder infection
Chronic indwelling bladder catheter / inflammation
Signs and symptoms
Painless hematuria (occurring in 85% of patients)
Changes in urinary pattern, including frequency, the feeling of urgency, or
the inability to urinate
AS the cancer progress, the patient may begin to have frank pain, weight
loss, leg edema, pain on urination and lower back pain
Investigations
• Physical examination
• Urine cytology (sensitivity: around 60%, specificity: over 90%)
• Cystoscopy (Gold standard)
• IVP
• CT
Flexible cystoscopy