Today we're going to go over the male genital urinary exam and we'll go through the checklist item by item. First thing of course, just like the female genital urinary exam, is taking a sexual history is very important. We need to make sure we include all those relevant aspects that we need.
to know about sexual function or response, as well as penile discharge or lesions in the past, any scrotal pain, any swellings or masses at the moment of the scrotal. So once we get the sexual history completed, remember that during this exam, we're always going to wear gloves. Most of the exam is done by inspection and palpation.
All right? So on general inspection, we're going to have our patient in this position standing in front of you. So I'm going to use the table as his legs. I'm going to expose the patient, tell him how I'm going to perform the exam, and the patient will actually be standing in front of you as you sit on the stool.
At this point, it's really about all inspection. And what I'm looking for is I'm looking, again, for the general hair distribution. If this is an adolescent, then we're going to report the tanner stage.
Good. general hair distribution. We're looking for any inguinal swelling or pulsations. We're looking for any discharge from the penis. The scrotum, the left side, typically hangs a little lower just because the vas deferens is a little shorter on this side as it descends into the pelvis.
So this will run a little bit longer on this side. There shouldn't be any nits or lice that we look for in the pelvic region. Once we finish just the general inspection, look at hair distribution, then we start talking about inspecting the penis itself.
the shaft itself, the corona, the meatus itself. We'll raise the penis up so that we can see the posterior portion of the shaft as well. So we're looking at the penis for any discharge or lesions on the penis. And then we'll look right into, I typically have the patient at that point hold his penis to one side or the other so that it exposes the scrotum. And then once I start looking at the scrotum, I'm looking on the anterior surface, and once again, I'm looking for any lesions or rashes.
rashes, swelling, erythema. You also got to make sure that you check underneath the scrotum so that you'll bring the scrotum up so that you can see the underside of the scrotum. When I'm inspecting the scrotum, I'm also looking for contour or evenness of the scrotum that there's no masses or lesions. One of the tests that we'll also perform is with our reflex hammer or whatever device we can get a sharp point, but the cremasteric reflex, right? The cremasteric is a stroke in the inner thigh.
Okay? both sides gently. And what you'll find is that the side that you are, that you pull the hammer up or stroke with a sharp end, the scrotum will actually ascend on that side and then it'll descend, right? That's a cremasteric reflex, right? And that's done bilaterally.
So we've inspected everything. Now we're going to start palpating the scrotum and the penile shaft. Remember that when you palpate the penis, the shaft of the penis, it's actually starting at the base of the penis and then you work your way down the shaft. and your fingers should actually be going all the way around the penis and to the head.
Once you get to the meatus, you're looking for any discharge, right, with general pressure. It opens the meatus, and you should be able to see any discharge at that point. The patient, again, will hold his penis to one side or the other, and that's when you'll come all the way up as high as you can up into the inguinal region, and you'll start palpating down the vas deferens, right, to the top of the scrotum.
At the top of the scrotum, you'll actually feel the... epididymitis, right? And then from the posterior aspects of the testicles down to the inferior poles of the testicles.
Just make sure that you're hitting all of the testicles at the same time and it can be done bilaterally. Typically holding your hands in this shape, your fingers can go posteriorly and then your thumbs can kind of move the testicles around in your hands so that you get all sides of the testicles. When we start talking about hernia palpation, so we've palpated the penis, the shaft, we've checked for discharge, we've looked at the scrotum, we've looked at at the testicles, the vas deferens. Now this point of the exam, it's a matter of testing or invaginating the scrotum so that we can come up to the inguinal ring.
And then that's when you have your patient turn to the opposite side and cough for you. And you're really feeling, trying to see if you can't feel maybe some abdominal content, fat, or intestine itself that'll actually tap against your finger, which would be an indication of an inguinal hernia. This model is a better way to look at the exam. So here's the gentleman.
and scrotum. As you produce, as you go about palpating, this stone doesn't invaginate, but it's a matter of coming to the side of the testicle. So my right hand, right side, advances up the side of the testicle. It invaginates, right?
It invaginates the scrotum to the point of the inguinal ring, right? The testicles have fallen to the side, the opposite side. So again, it's on the side of the testicle.
It's not center. That's not correct. It's not on the testicle.
It's just to the side. Let the testicle fall to the side. Then we invaginate the scrotum. So this tissue will actually ascend with your finger to the inguinal ring.
Once I feel the ring here, I have my patient turn his head to the opposite side and he'll cough. Right? And then I'll do the same thing on this side. And it's a matter of moving your stool. So I would just kind of move my stool around to this side.
My hand is on their hip to support them. And it's the same thing. Invaginate the skin up to the ring. Your patient.
patient turns that way and then coughs. That's testing for peritoneal palpation through the scrotum. So once that exam is complete, pretty much the male genitourinary exam is complete. The one thing that we do add to this exam is the rectal exam, just that it's easier. There are various ways that we can do the exam, but for safety purposes, I like to put my patient in the left lateral cubitus position.
So once he's done with this exam, I'll have him come back up on the bed and lay down. leg opposite to me. With your leg that's in a hip flexion and knee flexion on the left side so that his bottom, his rectum, and the angle opening is facing this way. And I stand to the side.
I have set out my occult blood test which are cards that we'll use both on the male and female. And what we do is we open the side. This side will have an open side.
We tear open. There's a side A and a side B. Once we grab our stool sample, it's a matter of smearing a small sample on both window A and window B. We close the card. get rid of our soil gloves.
On the back side, we flip open the card. And on the opposite side of the paper is our sample. So this side is clean. We'll use a occult blood developer and test. our card to make sure that our developer and our card works.
This will turn black, which tells me that it's a good card. And then I'll just put two drops, two or three drops, on top of both of my samples. If they immediately turn black, that is a sign that we have small traces of blood in the stool.
And then this is sent off to the lab. We have our lubricating jelly. This is medical-grade lubricating jelly. The problem with KY jelly, unless it's specifically...
designed for a hospital setting is that it can actually cause false negatives, false positives, or actually distort the findings on our cytology slides. So we always want to make sure that we're using a latex-free lubricating jelly. We have, of course, drapes for our patient, which are very important.
Drapes are extremely important for our patients protecting modesty. First, again, you remember all of our exam starts with inspection. So I'm inspecting the gluteal cleavage. I'm looking for any sebaceous cysts or lesions, abscesses that are going on. I'm looking for fissures.
I'm inspecting for hemorrhoids. both external or bleeding or inflamed hemorrhoids. Once I see that there's nothing like that going on, it's a matter of using lubricant once again, KY jelly.
And I just advise my patient that you're going to feel me push down on your rectum, the opening of your rectum. At that point, as they feel me push down, they're supposed to gently valve salve or bear down, which relaxes the sphincter muscle. And then I can advance my finger into the rectum.
And once I've got my finger into the rectum, it's a matter of sweeping motion through the rectum, knowing that I'm getting a 360-degree rotation of my finger all the way around so that I'm hitting all the walls of the rectum. Once I get to this portion... I know that anteriorly to my finger lies the prostate gland. I'll actually start applying pressure to the prostate.
I'm looking for the sulcus that belongs in the prostate. I'm looking for any nodules or hardness and asking my patient if it's tender. So this is relatively a quick exam.
At this point, we would actually perform our Stilgoiac test, right, once we finish this exam. The patient will roll back over. We'll keep them covered up.
And then the sample that I've got on my finger is what I would apply to the squares that we talked about in the previous exam, right? So it's a simple smear here and here. Notice this finger stays out of the way of the card.
I close it. I'll put that down, and then I get rid of my gloves, right, where it folds in. The back of my card, I open my card so I can apply the developer. So this side is not contaminated. I test this side for positive.
It should turn black. And I test this side. That's what it should turn, which would be zero.
It takes just a second for it to develop. You can see how it's starting to change color. These are very old cards, too, but it changes color to let you know that it's a positive.
That's what a positive looks like. And then I'll put two drops. over my samples. And if it's positive, then I'll get these black smears where my finger actually sampled the card. And that would complete the MEL-GU electrical example.