Download Male Genitourinary Examination: Kidney, Ureter, Bladder, Penis and Scrotum and more Study Guides, Projects, Research Medicine in PDF only on Docsity!
MALE GENITOURINARY EXAMINATION
KIDNEY
INSPECTION: Inspect the abdomen and flank. If the renal size is large enough, a visible mass may be seen. This is usually only seen in a child or thin adult.
PALPATION: Palpate the kidney with the patient in the supine position. Push the kidney forward with the one hand in the back, and palpate the kidney with the other hand pressing the abdomen. Ask the patient to take a deep breath while trying to keep the abdomen soft. Palpate the lower pole of the kidney. The kidney is usually not palpable in a normal adult but is in children and thin adults. Causes of visible and/or palpable kidneys: hydronephrosis polycystic disease large simple cyst carcinoma
AUSCULTATION: With the patient in the supine, prone or sitting position, auscultate the epigastrium, flank and CVA (costovertebral angle) for a bruit. Causes of bruits: A-V Fistula Renal artery stenosis Vascular tumor
BACK
INSPECTION: With the patient in the supine position or in the sitting position (or both), gently percuss the CVA (angle between the paraspinal muscles and the 12 rib).
PALPATION: Note that this must be gentle as a forceful blow will elicit tenderness in normal patients. Note tenderness of the ribs, paraspinal muscles and spine. The KIDNEY tenderness is best elicited in the CVA as this causes motion of the kidney. Tenderness of the ribs or paraspinal muscles is usually NOT renal in origin. Tenderness suggests: Acute pyelonephritis Acute glomerulonephritis Renal or Perirenal abscess Acute hydronephrosis
URETER
Because of the position of the ureter deep within the retroperitoneal space, the ureter is not visible or palpable except for massive hydronephrosis in an infant or small child.
BLADDER
INSPECTION: A midline mass in the suprapubic area may be an enlarged bladder.
PALPATION: Gently palpate the suprapubic area. With palpation of a midline mass, suspect a distended bladder if the patient has the urge to void with gentle pressure on the mass. A distended bladder may be difficult to palpate if the patient is obese or is unable to relax during the exam.
PERCUSSION: Percussion of a distended bladder caused a dull sound. Percussion of a distended loop of bowel will be tympanitic.
Causes of distended bladder: Outlet obstruction: o urethral valves (child) o Prostatic hypertrophy or carcinoma o urethral stricture Decreased bladder tone: o neurogenic bladder (spinal cord injury) o myogenic (overstretched bladder) Senility or bed rest: Some patients are unable to void in the supine position.
DIFFERENTIAL
DIAGNOSIS:
Uterus: pregnancy or tumor Ovary: cyst or tumor Colon: tumor or fecal impaction
PENIS
INSPECTION: Look at the penis. Are there any lesions present? Ulcer: syphilis, herpes simplex or chancroid Bumps: condylomata acuminata, molluscum contagiosum Tumor: carcinoma Retract the foreskin. You may find: balanitis condylomata acuminata carcinoma meatal stenosis
SCROTAL CONTENTS
INSPECTION: The scrotal contents should be examined in a systematical manner, i.e.: Testicle Epididymis Cord External Ring Testis: The testis is slightly oblong or egg shaped with a smooth surface. It measures approximately 3 x 5 cm. in size and the size may vary greatly from individual to individual. Both testicles are usually the same size in the same individual unless there is a pathology present in one or both testicles. Epididymis: The epididymis is a structure typically found on the posterior surface of the testis like a crescent. It is tender when squeezed. It is soft and uniform in character with the globus major (head) slightly larger and usually cephalad in position than the globus minor (tail). Cord: The cord contains the blood vessels, vas deferens, fat and nerves. The vas is palpable as a distinct cord like structure usually present on the posterior portion of the cord.
Transilluminate: Transillumination is aided by a dark room and a bright light. This is done by placing the light source (flashlight) usually on the posterior portion of the scrotum and noting transillumination of light through the scrotum.
DIFFERENTIAL DIAGNOSIS OF SCROTAL CONTENTS
MASS: A mass in the testicle proper suggest tumor (carcinoma) or fibroma of the tunica albuginea. This does not transilluminate. It is often not tender with palpation. Mass surrounding the testicle: Hydrocele. It is often quite firm. It transilluminates well unless it is quite large and then a very strong light source is needed. Mass above the testicle: Spermatocele or hydrocele of the cord. Both of these transilluminate well. The cord is palpable above the mass. Hernia: This usually is palpable above the testis. It is often reducible. Auscultation may reveal bowel sounds. The cord is NOT palpable above the mass.
VARICOCELE: A varicocele is a dilated mass of veins like varicose veins of the leg. They are almost always on the left side. They feel like a “bag of worms.” They disappear on supine position unless they are caused by a retroperitoneal mass or tumor.
EPIDIDYMIS: Epididymitis: The epididymis is swollen and tender. Frequently the patient has an elevated temperature. The cord is usually not tender and often a normal testis is present. If the epididymitis is severe, distinction between the testis and epididymis is impossible. Fibroma: Scarring of the epididymis from previous epididymitis. This is a nontransilluminable mass, usually small (1 cm.) in the epididymis (usually the head). Spermatocele: A small or large non-tender mass of the epididymis, usually of the globus major and typically seen in older males. It transilluminates well usually.
PROSTATE: The prostate lies at the base of the bladder through which the urethra penetrates much like a hole in a doughnut. The posterior portion of the prostate is palpable through the anterior surface of the rectum. The posterior portion of the prostate is the site of origin for most prostatic carcinomas. The prostate has some landmarks:
It is small in the new born period: 1 gram Larger in the postpubertal period: 8-10 grams With hypertrophy (benign adenomatous growth) it is large: 20 grams or more.
Palpation is best done in the standing (bending at the waist) position or lateral decubitus position. The gland palpates firm like the hyperthenar eminence of the hand when tense. Palpate the size and estimate the size in centimeters: height from the rectal wall, width and depth. Consistency: The consistency is firm like the hyperthenar eminence of the hand when firm. Palpate the lateral margins, which should be distinct (with small glands it is often indistinct). Palpate the median sulcus. It is typically absent with hypertrophy. Hard masses need to be biopsied to make the diagnosis. The hard mass of a carcinoma palpates like the bone in the thumb. If carcinoma is present, it may extend outside the margins of the prostate and the lateral margin may be indistinct or the tumor may be palpable in the surrounding tissue or in the seminal vesicles.
