Exam V: Pelvic & Junk

ALWAYS have another person in the room while examining genital area or the female breasts.
Explain what you are going to be doing, before you do each step/maneuver
Insure patient comfort, and modesty

Use gowns AND sterile drapes over pt legs
Allow patient to wear socks, shirt- as long as access can be facilitated etc.
Foot of exam table does not face the door
Door is clearly marked to avoid interruption
Another person in the room all the time, taking notes or somehow attentive

Penis - formed of three cylindrical masses of erectile tissue - enclosed in separate fibrous coverings - held together by a covering of skin

Root at base of penis, divides into crura which are attached to the pelvic bones

Glans is at the tip of the penis and is the most sensitive part for most men - covered by prepuce or foreskin which may be removed by a surgical procedure called circumcision

Corona (crown) - ridge between glans and foreskin

Frenulum - connects glans to shaft on underside of penis

Smegma - secretion that can accumulate under foreskin of penis and must wash/clean thoroughly to prevent infections

Contains spongy tissue which fills with blood when a man is aroused, leads to erection (there is no bone in the penis)

Cavernous bodies (corpus cavernosum) - on top - 2 of them

Spongy body (corpus spongiosum) underneath - 1 only - urethra runs through it

Abnormal location of urethral orifice along penile shaft

Hypospadias: urethra on ventral aspect; most common

Epispadias: urethra on dorsal aspect

If these issues are present = congenital issues which mean problems downstream like pelvic organ abnormalities, inguinal hernias, undescended testes

Clinical Consequences: constriction of orifice, urinary tract obstruction leading to infection, impaired reproductive function

benefit sexual functioning and pleasure – note that the musculature around the penis is comparable to the pelvic floor muscles in the female

strengthening the muscles with Kegel exercises may produce benefits for men in that are similar to those produced by Kegels in women

Prevents pelvic floor prolapse
Contraction muscles that hold the urine

Seminiferous tubules are the site of sperm production
sperm maturation occurs in the epididymus (about 20 feet long) on the back of each testicle

Interstitial cells are located between the seminiferous tubules and are the major producer of androgens in men

BOTH are EMERGENCIES

Testicular torsion: pain is sudden and severe; abnormal axis; acute; early puberty; UA is negative; cremasteric reflex is negative; tx is surgical exploration

Epididymitis: gradual onset of pain of testis or epididymis; the testicle may be warm and/or red and swollen; axis of testicle is normal; insidious onset of symptoms; adolescents; UA can be + or -; cremasteric reflex is positive; tx is antibiotics

Seminal vesicles - two pouch-like structures between the bladder and the rectum - function not completely understood – they secrete an alkaline fluid rich in fructose - sperm become motile here and can propel themselves (got to this point via cilia in ducts) - contribute about 70% of seminal fluid

Doughnut shaped gland just below the bladder - thin alkaline secretions counteract acidity in male urethra and in the vagina – contributes about 30% of seminal fluid

Or bulbourethral glands
Pea-sized - lie just below prostate - connect to urethra by a duct - secrete a slippery substance when a man is sexually aroused - alkaline - helps lubricate flow of seminal fluid through urethra
can contain active sperm and cause pregnancy without ejaculation occurring

(or seminal fluid)
one teaspoon of fluid – one ejaculation contains 200-500 million sperm which - provide only 1% of volume - rest from seminal vesicles (70%), prostate (30%) and Cowper’s gland (<2%)
semen of a healthy man is not harmful if swallowed – but semen can transmit HIV from an HIV-positive man

Two stages = emission and expulsion

Emission phase - prostate, seminal vesicles and upper part of vas deferens (ampulla) contract - moves secretions into ejaculatory duct and prostatic urethra
internal (bladder exit) and external (below prostate) urethral sphincters close - urethral bulb balloons - leads to sensation of ejaculatory inevitability

Expulsion phase - strong rhythmic contractions of the penis expel semen – urethra contracts - external sphincter relaxes allowing semen to be expelled - internal sphincter continues to contract preventing urine from being expelled

Interrupted sutures in case one comes out

If continuous, if it is damaged, the whole suture is at risk

Extremely tight foreskin
Prepuce cannot be easily retracted over glans
May be congenital, but usually associated with balanoposthitis (STD) and scarring
Paraphimosis: trapped glans causing urethral constriction

Detach crura to give 2-3 inches and then inject fat behind glans
The erection will be pointing straight instead of angled dorsally so urination and ejaculation flow is different
Must wear a pole attached to the penis to prevent crura from reattaching

Gelking: some men go for the stretch method of enlargement- get ulcers if too much weight stretched the skin

Balanitis (balanoposthitis): inflammation of the glans plus prepuce associated with poor hygiene in uncircumcised men (smegma); distal penis is red, swollen, tender, and with or without purulent discharge

Candidiasis
Especially in diabetics
Erosive, painful, pruritic, simple yeast
Can involve entire external male genitalia
Baby powder and air helps prevent yeast growth – they like warm, dark, and moist areas

Epidemiology: uncommon aka less than 1% of cancer in males, but mostly in uncircumcised men between 40-70 years old

Pathogenesis: poor hygiene, smegma, smoking, HPV (16 and 18)
CIS first then progression to invasive squamous cell carcinoma

1. Observation and the speculum exam

2. Bimanual exam

3. Recto-Vaginal Exam (includes DRE)

Pubic hair-triangle pattern

Lymph nodes

Orifices

Palpate:

Urethral meatus-incontinence

Labia

Skene’s, then Bartholin’s glands

Perineum

Performed prior to the bi-manual exam so as not to disturb the tissues/samples
Performed without lubricant jelly
Always inserted with the speculum blades warmed with warm water and closed
Inserted at a 45 degree angle posteriorly

Position—is it anteverted, deviated, etc
The position of the cervix gives clues to the position of uterus
Color—should be flesh-colored, but ranges from pink to dark brown (blue or pale??); certain colors indicate pregnancy
Surface characteristics—cysts, erythema
Discharge
Size and shape of os- indication of reproductive history

No baby has passed through

Small and round

At least one or more children have passed through

| Bigger and not round, more linear

The endothelium of canal will move out

| True cervical tissues and inner cervical tissues

aka: retention cysts

| Pimple like things on the cervix

A minimum of two samples will be taken:
Cervical cells
Vaginal secretion
Other tests may be done to screen for STDs

The “Pap smear” evaluates the condition of the cervical cells (taken with cervical brush or spatula)
SCREENS FOR CERVICAL CANCER- very accurate and decreased cancer rates

Assessing “transitional zone” of the cervix

HPV, Herpes, Chlamydia, (Now 10’s of millions of existing cases)
In women, often no visible symptoms

aka: Vulvovaginitis
General description for anything that causes symptomatic discharge (an irritant)

May be due to bacteria, viruses, fungi, or protozoans

Patient may talk to you about: vaginal or vulvar itching, burning, or change in color, texture or odor of discharge

The bimanual exam is the second part of a complete pelvic exam

Necessary to evaluate the cervix, uterus, and adenexal regions (ovaries, fallopian tubes, surrounding areas)

Move the cervix to assess for PID/Endometriosis

Important even if patient is not sexually active

RE
The Recto-Vaginal exam is the 3rd and final part of the pelvic exam

May help evaluate the posterior aspect of the uterus (esp. if retroverted)

Allows exam of rectal walls (initial screen for colo-rectal cancer or polyps)

KA: myoma, leiomyoma, fibroma

Very, very common (40% of women > 40)

The most common tumor of the pelvis

The most common reason for a hysterectomy

Benign, benign, benign!

Rick Factors: Nulliparity or delayed childbearing and African American women have 2-3 times the incidence of uterine fibroids

Locations: intramural, subserosal, submucosal, pedunculated (on a stalk and can twist on axis and infarct/become painful)

eavy menstrual bleeding

Abdominal distortion

Pelvic pressure

Low back pain; dyspareunia

Infertility

Frequent urination

Constipation

Miscarriage or premature labor

Can cause negative effects of fetus like distortion because only so much space for baby to grow

“Wait and see”
Drug therapy (GnRH agonists)- to alter tumor growth
Uterine Artery Embolization (UAE) to cut blood supply; insert catheter and inject particles and fill up and implode blood supply so fibroid becomes necrotic and dies
Myomectomy
Hysterectomy

Inflammation of the vagina caused by:

Candidiasis

Trichomonas

Gardnerella

Bartholin’s abscess

Marked leukorrhea, marked redness of vulva, extreme pruritus.
White, creamy, cheesy, sweet smelling discharge, thrush patches.
Commonly seen in pregnancy, diabetics, women on BCP or antibiotics (ampicillin).

Assessment - lab KOH wet mount NS KOH 10% 20% look for (branching Hyphae or Mycelium fungus nails).

Management - Nystatin--intravaginal adult tabs 0.1 to 0.2 million units daily times 7 to 10 days

Leukorrhea, vaginal soreness, burning, pruritus, dyspareunia (pain during intercourse).
Bubbly, yellowish thick discharge, foul smelling.
Strawberry appearance of cervix

Assessment - lab wet prep, microscopic exam reveals pear shaped parasite with long flagella and undulated (wavy outline in appearance) cell membrane.

Management:
Metronidazole (Flagyl) anti protozoal 250 mg TID to 500 mg BID orally for 5 days.
Patient education of feminine hygiene, douching.
Management based on culture results

also called Gardnerella Vaginitis
Leukorrhea, pruritus, dyspareunia.
Turbid, chalky, white/gray or yellowish discharge; malodorous ("fishy").

Assessment: gram-positive nonmotile coccobacillus that normally inhabits the vagina that just overgrows
Wet smears of this nonspecific vaginitis yields vaginal desquamated epithelial cells covered with many bacteria

Management:
Metronidazole (Flagyl) 250 mg TID to 500 mg BID orally for 7 10 days.
Ampicillin 500 mg QID x 7 days.
Douching with povidone iodine solution.
About 25% of the patients have recurrence and require treatment in 2 3 months.
Management based on culture results

Definition and etiology - acute or chronic infection of the Bartholin's gland (streptococci, staphylococci, E. coli, anaerobes; may result in infection).

History - recent intercourse, venereal disease, trauma, spontaneous abortion, wiping from rectum to vagina

Signs and symptoms:
Mass in perineum that is hot, tender, and fluctuant.
Pus draining from Bartholin's duct

Management:
I & D
Sitz bath: fill tube up quarter way and hot but not too hot; helps with healing and keeps area clean
Broad-spectrum antibiotics which cover gram-positive organisms and some common vaginal gram-negative organisms

Normal endometrium found in abnormal places
Therefore, “ectopic tissue” responds to hormone levels just like the inner layer of the uterus

Retrograde menstrual flow, fallopian tubes, abdomen
Lymphatic or circulatory systems cause spread

Young age: 10-15% of women ages 25 to 44 have endometriosis

Family History (6 - 12% of cases)

Nuliparity or delayed childbearing

Asians and Caucasians are at highest risk

Pain, pain, pain (low back and pelvic)

Pelvic mass

Alterations of menses

Dysmenorrhea (pattern = pain just prior to menses)

Infertility

Dyspareunia

Pain with defecation, urination

Women with endometriosis have:

earlier onset of menses

regular cycles

shorter intervals between periods (less than 27 days)

more severe menstrual cramps

prolonged menstrual flow (> 1 week)

Endometrial deposits can occur anywhere in pelvis
Ovary—most common (75%); an ideal site for growth
Posterior cul-de-sac—70%
Between the uterus and bowel—35%
Uterosacral ligament—30%
Ureters
Uterus
Bowel
Also known to occur on appendix, gall bladder, stomach, spleen, liver, lung

Suspected by case history
Visible lesions on the vulva or cervix
Red, brown, black (remember—may bleed)
Speculum exam (“shotty nodules”)

Definitive: The definitive diagnosis can only be made by direct visualization of the lesions
Presently, confirmed by laparoscopy

Keep in mind that these patients typically suffer a prolonged course of multiple therapies/surgeries
“Leave it alone”
Drug therapy
Laparotomy
Hysterectomy
Child-bearing (or pseudo-pregnancy conditions)
Tubal ligation

Peritoneal fluid normally acts as a lubricant.
Endometriosis causes changes in the volume and cellular content of the peritoneal fluid.
Fluid level is increased
Leukocytes are increased
Prostaglandin levels are increased
Enzyme levels are increased
These all cause a localized inflammatory reaction around the lesions

The peritoneal fluid can then act as a toxin to the embryo and/or can alter the normal function of the ovaries and fallopian tubes

Uterine sarcoma (endometrial carcinoma)

Cervical carcinoma

Ovarian carcinoma

Ovarian cysts

Uterine, vaginal prolapse

regn’s Sign: physical lifting of testicles relieves pain of epididymitis but not pain caused by testicular torsion- KEY
Negative: no pain relief with lifting the affected testicle = testicular torsion = surgical emergency
Positive is epididymitis
NOT reliable for identifying other types of testicular issues from torsion