Male Genital Exam
Ann A
Avery,
er MD
Cleveland Department of Public Health
MetroHealth Medical Center
Cincinnati STD/HIV Prevention Training Center
1
Penis
 Shaft
 Corpus cavernosa
 Corpus spongiosum
 Dorsal vein
 Glans
 Corona and coronal sulcus
 Prepuce (foreskin)
 Frenulum
 Urethral meatus
 Penoscrotal junction
 Median raphe
Penis Anatomy
Penis Anatomy
2
Scrotum and Testes
 Scrotal sac
 Tunica vaginalis
 Cremasteric muscle
 Testes
 Production of sperm and
testosterone
 Ovoid - 4 x 3 x 2 cm
 Smooth and rubbery in texturetexture-”hard
boiled egg”
Scrotum and Testes
 Epididymis
 Posterolateral to the testes
 Provides storage, maturation and
t
transit
it off sperm
 Vas Deferens
 Connects the epididymis and the
ejaculatory duct
 Part of the spermatic cord
3
Scrotum and Testes
Inguinal Canal
 Inguinal Canal Components
 Internal inguinal ring
 Landmark: middle of inguinal ligament
 Canal
 Canal traversed by the spermatic cord
 External inguinal ring
 Located at the pubic tubercle
 Medial and inferior to the internal inguinal ring
4
Prostate Gland
 Surrounds the urethra at the bladder
neck
 Resembles a large
g chestnut
 Approximately same size as a testes
 Produces the major volume of ejaculatory
fluid
 Milky, acidic, fluid
Taking a Sexual History




Privacy
Take history while patient is dressed
Clarify need to ask intrusive questions
Provide opportunities to ask and answer
questions
 Prioritize goals
goals--address concerns and
educate
5
Addressing Sexual
Matters
 Take the initiative
 Use language that is simple and
direct
di
 Maintain privacy and
confidentiality
Addressing Sexual
Matters
 Keep your attitude
nonjudgmental, caring and
respectful
 Provide explanations and allow
for questions
 Acknowledge and explore
responses
Common Concerns
 Symptoms of STD’s
 Premature Ejaculation
 Erectile Dysfunction
 Prostate Problems
 Infertility Problems
6
Predictors of Sexual
Dysfunction
 Daily alcohol consumption
as o
or cu
current
e S
STD’s
s
 Past
 UTI symptoms
 Emotional problems or
stress
Predictors of Sexual
Dysfunction
  economic status
 Negative sexual experiences
 Low physical or emotional
satisfaction
Risk Factor for STD/HIV
 Multiple sex partners
 New partner(s) in last 3
months
 Alcohol/drug use
 Inconsistent condom use
7
Risk Factor for STD/HIV
 Past history of STD’s
Sa e se
sex pa
partners
es
 Same
 Exchanging money/drugs
for sex
Risk Factor for STD/HIV
 Partner with HIV/AIDS
 Sharing needles
 Body piercing or tattoos
Risk Factor for STD/HIV
 Contact with blood
ou g age a
at first
s se
sexual
ua
 Young
activity
 History of sexual assault
8
Points to Remember
 Explain exam procedure
before patient undresses
 Start
St t exam from
f
less
l
invasive
i
i
to most invasive
 Examine painful areas last
Points to Remember
 Talk to the patient during the
exam, tailor language to meet
need of patient
 Encourage open discussion and
elicit questions throughout the
exam
Points to Remember
 Watch patient face for signs
of discomfort
 Take
T k light
li ht off
ff off genital
it l area
as soon as exam completed
9
Other Considerations
 Before genital exam :
 Inspect mouth (gums, tongue, tonsils,
throat soft and hard palate)
throat,
 Palpate lymph nodes ( cervical,
axillary..etc)
 Inspect skin ( face, trunk, hands/palms,
soles of feet)
Preparation For Genital
Exam
 Prepare supplies need for exam
 Label all specimens and slides
 Wash and warm hands
 Put on gloves
Preparation For Genital
Exam
 Explain what you are doing and
why
 Have client stand at end of exam
table with feet about shoulder width
apart
 Supine position if unsteady or unable
to stand
 Examiner: sit on low rolling stool in
front of client
10
Beginning of Exam
 General Inspection
 Sexual Maturity
 Hair patterns of mons pubis
 Look for lice, nits, folliculitis, molluscum,
scabies
 Note size and shape of penis and
testes
Beginning of Exam
 General Inspection
 Note color and texture of scrotum
 Scars or bulging in inguinal area
 Penile or scrotal abnormalities
Examination of the
Scrotum
 Inspect skin
 Assess for warts, cysts, nodules
 Lift scrotum to assess posterior
aspect
11
Palpation
 Start from least invasive area to
most invasive
 Let patient know that you will be
t
touching
hi hi
him
 Start by checking for any inguinal
lymphadenopathy
Palpation
 If erection occurs, assure patient
that this is natural and common
reaction and continue the exam
 Have
H
patient
ti t inform
i f
examiner
i
off
any discomfort during the exam
Examination of the
Scrotum
 Palpate scrotal content
 Gently compress each testes and
epididymis between your thumb and
first two fingers
 Palpate spermatic cord and vas
deferens
 Note swelling, tenderness
 Assess for varicocele
12
Inguinal Canal Exam
Checking for inguinal hernia
 With the patient standing, ask him to
bear down as if having a bowel
movement
 Inspect area for any bulging; then have
patient relax
 If bulges present
present--note size, shape and
location
Inguinal Canal Exam
Checking for inguinal hernia
 Gently insert finger into the lower
part of the scrotum and carry it
upward along the spermatic cord
 Ask patient to bear down then turn
his head and cough once
Inguinal Hernia
13
Examination of Penis
 Inspect skin
 Look for warts, ulcers, vesicles,
chancres
 Retract foreskin or have patient
retract
 Assess ease of retraction and
release
Examination of Penis
 Inspect Glans
Look for:
 warts
 ulceration
 balanitis
Examination of Penis
 Inspect Glans
 Locate urethral meatus
 Assess for hypospadias or
epispadias
 Gently compress the glans
between your thumb and
index finger to open the
urethral meatus
14
Examination of Penis
 Inspect Glans
 Locate urethral meatus
 Check for discharge, warts,
ulcers, vesicles
 If no dischargedischarge-either milk or
have patient milk the shaft
Examination of Penis
 Gently grasp the lateral aspect of the
penis and lift to inspect all sides
 Palpate
p
along
g the shaft
 Assess for any firm areas or irregularities
 Assess for any unusual curves
 Exam at the base of the shaft
 Look for warts, vesicle, or sores
Examination of Penis
 Examine the urethral meatus
 Note position and size of opening
 Gently compress the glans
between the index finger and
thumb
15
Examination of Penis
 Examine the urethral meatus
 Inspect inside the opening –
discharge inflammation
discharge,
inflammation, lesions
 Milk for discharge
 If discharge is present assess for
consistency and color of fluid
Examination of Penis
 Collect specimens as needed






Gram stainstain-usually done if discharge present
Gonorrhea culture and/or swab
Chlamydia swab
Herpes culture
Darkfield slide if indicated
Urine testing for GC, Chlamydia
Examination of Penis
 If gloves become contaminated with
body fluids
fluids, change gloves before
any further examination
16
Non--infectious Alterations
Non
 Trauma
 Testicular Torsion
 Inguinal
I
i lH
Hernia
i
 Penile shaft fracture
 Hydrocele, spermatocle, varicocele
Non--infectious Alterations
Non
 Phimosis
 Paraphimosis
 Priapism
 Neoplasm
 Lymphoma
 Testicular
 Squamous cell
Paraphimosis
17
Sexually Transmitted
Infections
 Urethritis
 Gonococcal
 NGU
NGU--(C.
(C trachomatis
trachomatis,
myco/ureaplamsa, trichomoniasis, or
other
 Epididymitis
Sexually Transmitted
Infections
 Ulcers
 Primary syphilis
 HSV
 Chancroid
 LGV
Chancroid
18
LGV primary lesion
Molluscum
Contagiousum




Central umbilication
Can be burned off
Spread by skin to skin contact
DNA pox virus
19
Lichen
Planus
 Itchy
 thickened
Psoriatic plaques
Pearly Penile papules
 Normal
 Occur on
corona
 Should not
change over
time but often
have not been
noticed
previously
20
 Pruritic
 Burrows
 Skin scraping
Reiter’s syndrome




Urethritis
Arthritis
Dry eyes
Associated
with
Chlamydia
infection
21
 Scrapings
with fungal
elements
 Responds
R
d tto
antifungals
Tinea cruris
Varicella
Zoster
Examination of the Anus
and Perineum
 Ask patient to stand and bend
forward with hands positioned in the
back to spread buttock apart
 May be performed in the kneeknee-chest
position
 Examine the external areas for
lesions, warts, rashes, sores,
fissures, discharge
22
Examination of the Anus
and Perineum
 Collect specimens as indicated by
exam
 GC,
GC herpes,
herpes darkfield (syphilis)
 Common finding include
hemorrhoids and anal tags
Rectal Exam




Done as patient history indicates
Done as last part of genital exam
Change gloves if contaminated
Position patient
 Prone position
 Sims position
23
Inspection and Insertion
 Lubricate index finger
 Separate buttocks
 Have patient bear down or take a
d
deep
breath
b th and
d inform
i f
off insertion
i
ti
 Insert index finger as they bear down
or on inspiration
 Allow a few seconds for relaxation of
muscles
Inspection and Insertion
 Rotate finger 360°
360°
 Evaluate rectal walls
 Evaluate the prostate
p
 2-4 cm long
 Triagular in shape
 Two lobes with central groove
 Guiac for occult blood
End of Exam
 Take off gloves and dispose
 Offer box of tissues to remove lubricant if
used during the exam
 Allow privacy to dress
 Either take him to your office or sit down
to discuss results of exam or questions
the patient may have
 Allow time for education
24
Case #1:
23 y.o. patient
presents with
discharge and
dysuria
Differential Diagnosis of
Urethritis
 Infectious
Neisseria gonorrhoeae
Chlamydia trachomatis
Mycoplasma genitalium
Trichomonas vaginalis
Herpes simplex virus 1 and 2
Oral flora - streptococci, anaerobes, haemophilus
species
 Non
Non--infectious
Trauma – physical, chemical (drugs), catheterization, sex
sex--play
related
Autoimmune - Reiter’s syndrome, Behcets
Neisseria gonorrhoeae
 Gram
Gram--negative diplococci
 62.2 million infections worldwide in 2005
 339,593 infections reported in U.S. in 2005
 Acute clinical infection
 Urethritis, pharyngitis, cervicitis, neonatal ophthalmia
 Increases HIV transmission by 33- to 5
5--fold
 Asymptomatic in 80% of women and at least 10% of men
 Complications include: pelvic inflammatory
disease, ectopic pregnancy, infertility, chronic
pelvic pain
25
Case 22- Non
Non--Gonococcal
Urethritis
Etiology: Chlamydia trachomatis, Mycoplasma genitalium,
Ureaplasma urealyticum, Trichomonas vaginalis (rare),
Herpes simplex virus (rare), Adenovirus, Haemophilus
vaginalis, and other organisms
Non--gonococcal Urethritis
Non
 Mucopurulent or purulent discharge
 Gram stain of urethral secretions > 5 WBC per
oil immersion field
 Positive leukocyte esterase on first void urine
or >10 WBC per high power field
Empiric treatment in those with high risk who
are unlikely to return
Non--gonococcal Urethritis
Non
Azithromycin 1 gm in a single dose
or
Doxycycline 100 mg bid x 7 days
26
Nongonococcal Urethritis
Alternative regimens
Erythromycin base 500 mg qid for 7 days
or
Erythromycin ethylsuccinate 800 mg qid for 7 days
or
Ofloxacin 300 mg twice daily for 7 days
or
Levofloxacin 500 mg daily for 7 days
Symptoms continue despite
therapy
 Recurrent/Persistent Urethritis
 Objective signs of urethritis
 ReRe-treat with initial regimen if nonnon-compliant or if rereexposure occurs
 Intraurethral culture for trichomonas
 Effective regimens not identified in those with
persistent symptoms without signs
Recurrent/Persistent
Urethritis
Metronidazole 2 gm orally single dose
or
Ti id
Tinidazole
l 2 gm orally
ll single
i l d
dose
PLUS
Azithromycin 1 gm orally single dose
(if not used for initial episode)
27
Case #3:
36 y.o. patient
presents
t with
ith
genital ulcer
Ann Avery, MD
MetroHealth Medical Center
Cleveland Department of Public Health
216--778
216
778--7828
e-mail: aavery@metrohealth.org
The Cincinnati STD/HIV Prevention Training
Center
28
Abby Hunt
FW: 02/23/12 Eflyer - Please review!!!!
Subject:
The Male Genitourinary Examination: Physical Examination Skills and
Technique, Diagnosing and Managing the Common Sexually
Transmitted Infections
Start Date/Time:
Thursday, February 23, 2012 1:00 pm Eastern
End Date/Time:
Thursday, February 23, 2012 4:30 pm Eastern
Project:
Title X
Description:
This course aims to provide training for participants on how to perform a male genitourinary
examination with emphasis on developing sexual history taking techniques and physical
examination skills for providers of male clients presenting with sexually transmitted infections.
This course includes a demonstration of examination techniques and proper specimen
collection.
REGISTRATION INFORMATION




The registration fee is $15.00 for Title X participants.
Registration is required by February 20, 2012. A $15 late fee will be assessed to all
registrations after February 16, 2012.
3.5 nursing contact hours may be provided for this training pending approval.
Please email Kelly Bradford at kbradford@hcet.org to register. We will need the following
information:
1.
2.
3.
4.
5.
Event Title and Date
Your Name
Your Agency Name and Address
Your Phone Number
Your Email Address
Accreditation: Continuing Education for this activity is pending. The Centers for Disease
Control and Prevention is accredited as a provider of Continuing Nursing Education by the
American Nurses Credentialing Center's Commission on Accreditation.
LOCATION
1
Cleveland/Akron, OH
TBD
AUDIENCE
Nurses, nurse practitioners, reproductive health/STD clinic staff
PRESENTER INFORMATION
Ann Avery, MD
Assistant Professor of Medicine -Case Western Reserve University School of Medicine
Physician-Division of Infectious Diseases, MetroHealth Medical Center, Cleveland, Ohio
Medical Director-Cleveland Department of Public Health
Supported by DHHS Office of Population Affairs, Title X Family Planning Grant # 6 FPTPA056010-04-01 and
Region II STD/HIV Prevention Training Center
2
The Male Genitourinary Exam Agenda
February 23, 2012
1:00-1:10-Sign in and Introductions
Dan Newman, PhD, DD
1:10-2:45-The Male Genital Exam
Ann Avery, MD
Assistant Professor of Medicine -Case Western Reserve University School of Medicine
Physician-Division of Infectious Diseases, MetroHealth Medical Center, Cleveland, Ohio Medical
Director-Cleveland Department of Public Health
2:45-3:00- Break
3:00-4:30-Practicum-Hands on Exam with Male Teaching Associates
Ann Avery and Dan Newman
PARTICIPANT EVENT EVALUATION
Workshop Title: The Male Genitourinary Exam
Date 2-23-2012
State: OH
To assist us in planning future workshops we ask that you please complete this form. This
evaluation is confidential.
1. The overall quality of the workshop.
Excellent
5
Poor
4
3
2
1
2. The objectives of this workshop are listed below. Were the objectives met?
a. State the steps, in appropriate order, for conducting
a complete routine male exam
Yes  No
b. Describe the principal normal and abnormal
findings relevant to an STD exam to be noted at
each step of the male exam.
Yes  No
c.
Yes  No
Discuss the correct technique in obtaining lab
specimens for Gonococcal and Chlamydial testing
and urethral Gram stains.
Yes  No
d.
3. Effectiveness of presenter(s)
Excellent
Poor
a. Ann Avery, MD
5
4
3
2
1
b.
5
4
3
2
1
c.
5
4
3
2
1
d.
5
4
3
2
1
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4. In what ways do you plan to apply the information and/or skills gained by participating in
this workshop?
5. Please identify potential challenges you may have in using the ideas presented in this
workshop.
6. Please list ways to improve this workshop.
7. Please feel free to write any additional comments that you would like to share, i.e. future
training topics, appropriateness of training facility and/or technology used, cultural
sensitivity of the workshop, etc.
Page 2 of 2
Participant Event Evaluation 2
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