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Chapter 19 Male Genitalia Examination of the male genitalia is typically performed: When patient has a specific complaint As part of the newborn examination As part of an overall well child or well person examination In adults, examination of the anus, rectum, and prostate (see Chapter 20) is often performed at the same time. Physical Examination Preview Male Genitalia Inspect the pubic hair characteristics and distribution. Retract the foreskin if the patient is uncircumcised. Inspect the glans of the penis with foreskin retracted, noting the following: Color Smegma External meatus of urethra Urethral discharge Male Genitalia (Cont.) Palpate the penis, noting the following: Tenderness Induration Strip the urethra for discharge. Male Genitalia (Cont.) Inspect the scrotum and ventral surface of the penis for the following: Color Texture Asymmetry Lesions Unusual thickening Presence of hernia Transilluminate any masses in the scrotum. Male Genitalia (Cont.) Palpate the inguinal canal for a direct or indirect hernia. Palpate the testes, epididymides, and vas deferens for the following: Consistency Size Tenderness Bleeding, masses, lumpiness, or nodules Palpate for inguinal lymph nodes. Elicit the cremasteric reflex bilaterally. Anatomy and Physiology Male Genitalia Penis Testicles Epididymis Scrotum Prostate gland Seminal vesicles Male Genitalia (Cont.) Penis Corpora cavernosa Corpus spongiosum Urethra/orifice Prepuce Penis function Excretes urine Introduces sperm into vagina Male Genitalia (Cont.) Scrotum Septum Testis Epididymis Spermatic cord Muscle layer Cremasteric muscle Male Genitalia (Cont.) Testicular functions Spermatogenesis Testosterone production Epididymal functions Storage/maturation/transit of sperm Vas deferens begins at the tail of the epididymis, ascends the spermatic cord, travels through the inguinal canal, and unites with the seminal vesicle to form the ejaculatory duct Male Genitalia (Cont.) Prostate gland Approximately the size of a testis Surrounds the urethra at the bladder neck Produces the major volume of ejaculatory fluid Contains fibrinolysin, which liquefies the coagulated semen―important in sperm motility Male Genitalia (Cont.) Sexual physiology Erection of the penis occurs when the two corpora cavernosa become engorged with blood. Increased blood supply is produced by increased arterial dilation and decreased venous outflow. Autonomic nervous system Local synthesis of nitric oxide Male Genitalia (Cont.) Sexual physiology Ejaculation during orgasm consists of the emission of secretions from: Testes Vas deferens Epididymides Prostate Seminal vesicles Orgasm is followed by constriction of the vessels supplying blood to the corpora cavernosa and gradual detumescence. Infants and Children Sexual differentiation by 12 weeks’gestation During the third trimester, the testes descend from the retroperitoneal space through the inguinal canal to the scrotum Descent of testes may occur after birth. Complete separation of prepuce from the glans at about 3 to 4 years in uncircumcised males Adolescents Puberty: functional maturation of reproductive organs Increased size Penis Enlarges in length and breadth Testes Scrotal skin reddens, thins, and becomes increasingly pendulous. Development of pubic hair Older Adults Pubic hair becomes finer and less abundant. Pendulous scrotum Decreased sexual activity Slower erection Orgasm less intense Review of Related History History of Present Illness Difficulty achieving and maintaining erection Pain Constant or intermittent, with one or more sexual partners Associated with alcohol ingestion or medication Medications: diuretics, sedatives, antihypertensive agents, anxiolytics, estrogens, inhibitors of androgen synthesis, antidepressants, carbamazepine, erectile dysfunction agents History of Present Illness (Cont.) Persistent erections unrelated to sexual stimulation Curvature of penis in any direction with erection Difficulty with ejaculation Painful or premature, efforts to treat the problem Ejaculate color, consistency, odor, and amount Medications: alpha-blockers, antidepressants, antipsychotics, clonidine, methyldopa History of Present Illness (Cont.) Infertility Lifestyle factors Time attempting pregnancy Sexual activity pattern History undescended testes Diagnostic evaluation to date Medications: testosterone, glucocorticoid steroids, hypothalamic releasing hormone History of Present Illness (Cont.) Enlargement in inguinal area Intermittent or constant, association with straining or lifting, duration, presence of pain Change in size or character of mass; ability to reduce the mass Pain in groin Efforts to treat Medications: analgesics History of Present Illness (Cont.) Testicular pain or mass Change in testicular size Onset Lumps Soreness Heaviness Medications: analgesics, antibiotics Past Medical History Surgery of genitourinary tract Undescended testes, hypospadias, epispadias, hydrocele, varicocele, hernia, prostate; vasectomy STDs Single or multiple infections, specific organism (gonorrhea, syphilis, herpes, warts, Chlamydia), treatment, effectiveness, residual problems Chronic illness Testicular or prostatic cancer, neurologic or vascular impairment, diabetes mellitus, arthritis, cardiac or respiratory disease Family History Infertility in siblings History of prostate, testicular, or penile cancer Hernias Peyronie disease (contracture of penis) Personal and Social History Occupational risk of trauma to suprapubic region or genitalia, exposure to radiation or toxins Exercise risks Concerns about genitalia Testicular self-examination practices Concerns about sexual practices Reproductive function Use of alcohol and drugs Infants and Children Maternal use of sex hormones Circumcised: complications Uncircumcised: hygiene measures Scrotal swelling with crying or bowel movement Congenital anomalies Masturbation and sexual exploration Swelling or sores on penis or scrotum Concern of sexual abuse Adolescents Knowledge of reproduction and sexual function Presence of nocturnal emissions, pubic hair, enlargement of genitalia, age at time of each occurrence Concern of sexual abuse Sexual activity, protection used for contraception and STI prevention Older Adults Change in sexual desire or activity Change in sexual response Longer time required to achieve full erection Less forceful ejaculation More rapid detumescence Longer interval between erections Prostate surgery Examination and Findings Equipment Gloves Penlight Drapes Inspection and Palpation Genital hair distribution Coarseness Abundance Penis Dorsal vein Foreskin retraction Texture Tenderness or induration Discharge Inspection and Palpation (Cont.) Urethral meatus Orifice size and location Color and moisture Scrotum Color Texture Cysts Edema Inspection and Palpation (Cont.) Hernias Inguinal Indirect Direct Femoral Testes Tenderness Texture Nodules Inspection and Palpation (Cont.) Epididymis and vas deferens Texture Tenderness Cremasteric reflex Stroke the inner thigh with a blunt instrument. Testicle and scrotum should rise on the stroked side. Prostate Detailed in Chapter 20 Infants Inspect and palpate Congenital anomalies Incomplete development Sexual ambiguity Urethral placement Retractability of foreskin Descent of testicles Masses Transilluminate scrotum if mass found Children Inspect and palpate Penis Size, lesions, swelling, inflammation, and malformation Foreskin retraction Scrotum Descent of testes Testes Masses Adolescents Examination of older children and adolescents is the same as for adults. Allay anxiety. Protect privacy. Inspect and palpate. Expected maturational changes Older Adults Examination procedure for older adults same as that for younger men Age-related changes Graying and less abundant pubic hair Pendulous scrotal sac and contents Abnormalities Abnormalities Hernia Protrusion of a peritoneal-lined sac through some defect in the abdominal wall Indirect: soft swelling in area of internal ring Direct: soft swelling that bulges anteriorly Femoral: occurs at the fossa ovalis, where the femoral artery exits the abdomen Abnormalities (Cont.) Strangulated hernia Nonreducible hernia in which the blood supply to the protruded tissue is compromised Requires prompt surgical intervention Penis Paraphimosis Inability to replace the foreskin in its usual position after it has been retracted behind the glans Hypospadias Congenital defect in which the urethral meatus is located on the ventral surface of the glans penile shaft or the base of the penis Penis (Cont.) Syphilitic chancre Skin lesion associated with primary syphilis Penis (Cont.) Herpes Genital herpes is sexually transmitted infection caused by herpes simplex virus (HSV-2) Penis (Cont.) Condyloma acuminata “Genital warts” caused by human papillomavirus (HPV) Penis (Cont.) Lymphogranuloma venereum Sexually transmitted infection of the lymphatics caused by Chlamydia trachomatis Penis (Cont.) Molluscum contagiosum Benign skin infection caused by a poxvirus that infects only the skin Penis (Cont.) Peyronie disease Fibrous band in the corpus cavernosum causing bending and/or indentation of the erection Penile cancer Squamous cell carcinoma usually originating in the glans or foreskin Scrotum Hydrocele Fluid accumulation in the scrotum Scrotum (Cont.) Spermatocele Benign cystic accumulation of sperm occurring on the epididymis Scrotum (Cont.) Varicocele Abnormal tortuosity and dilation of veins of the pampiniform plexus within the spermatic cord Scrotum (Cont.) Orchitis Acute inflammation of the testis secondary to infection Scrotum (Cont.) Epididymitis Inflammation of the epididymis often seen in association with a urinary tract infection Testicular torsion Twisting of testis on spermatic cord Surgical emergency Scrotum (Cont.) Testicular cancer Seminomas and nonseminomas arise from germ cells (sperm-producing cells). Scrotum (Cont.) Klinefelter syndrome Congenital anomaly associated with XXY chromosomal inheritance Infants Ambiguous genitalia Newborn’s genitalia are not clearly either male or female. Presence or absence of male hormones controls the development of the sex organs during fetal development. Question 1 Foreskin of the penis that cannot be retracted over the glands is called: A. Balanitis B. Balanoposthitis C. Phimosis D. Preputial ring Question 2 The greatest contribution to the volume of ejaculate comes from the: A. Prostate B. Epididymis C. Seminal vesicles D. Corpus cavernosa Question 3 A hernia that protrudes through the external inguinal ring, located in the region of Hesselbach triangle is called: A. Direct hernia B. Femoral hernia C. Indirect hernia D. Ventral hernia Question 4 Expected genitalia changes that occur as men age include: A. Ejaculatory volume decreases with age B. Erections develop more quickly C. Viability of sperm increases D. The scrotum becomes more pendulous Question 5 Dense fibrous scar tissue forms in the tunica albuginea, and results in loss of penile length and pain on erection is called: A. Balanitis B. Paraphimosis C. Peyronie disease D. Phimosis