ࡱ> wyrstuvq` DbjbjqPqP .L::9V7'''8'T&(, ^*^*:***s+s+s+MOOOOOOhjOM}3s+s+}3}3O**WWW}3!**MW}3MWWox*R* =-'AUwـt0w 5V 4xx ~0s+-W /4A0<s+s+s+OOMWXs+s+s+}3}3}3}3č  School of Nursing Christopher W. Blackwell, Ph.D., ARNP-C Assistant Professor, School of Nursing College of Health & Public Affairs University of Central Florida NGR 5003: Advanced Health Assessment & Diagnostic Reasoning Genitourinary System; Anus, Rectum, and Prostate: Basic assessment of the male and female genitourinary system Advanced assessment of the male and female genitourinary system - Pelvic examination - Manual examination of the prostate Assessment findings of abnormal presentations in the male and female genitourinary system Differential diagnoses of the male and female genitourinary system Advanced Clinical reasoning: A case study approach advanced assessment of genitourinary system: anus, rectum, and prostate LEARNING OBJECTIVEs 1. Conduct a history related to the female genitalia. 2. Discuss examination techniques for the female genitalia. 3. Identify normal age and condition variations of the female genitalia. 4. Recognize findings that deviate from expected findings. 5. Relate symptoms or clinical findings to common pathologic conditions. 6. Conduct a history related to the male genitalia. 7. Discuss examination techniques for the male genitalia. 8. Identify normal age and condition variations of the male genitalia. 9. Recognize findings that deviate from expected findings. 10. Relate symptoms or clinical findings to common pathologic conditions. 11. Conduct a history related to the anus, rectum, and prostate. 12. Discuss examination techniques for the anus, rectum, and prostate. 13. Identify normal age and condition variations of the anus, rectum, and prostate. 14. Recognize findings that deviate from expected findings. 15. Relate symptoms or clinical findings to common pathologic conditions. Outline for Chapter 18: Female Genitalia External Genitalia The vulva, or external female genital organs, include the mons pubis, labia majora, labia minora, clitoris, vestibular glands, vaginal vestibule, vaginal orifice, and urethral opening The symphysis pubis is covered by adipose tissue called the mons pubis or mons veneris, which is covered by coarse terminal hair. The labia majora are covered by hair in the postpubertal female. Under the majora are the hairless labia minora that divide into two lamellae. The lower pair forms the frenulum of the clitoris and the upper pair forms the prepuce. The labia minora fuse to form the fourchette. The clitoris, a small bud of erectile tissue, is a primary center of sexual excitement. In the labia minora is a vestibule containing the urethra, vagina, Skene glands for draining urethral glands, and Bartholin glands that secrete lubrication during sexual excitement. After the hymen tears, hymenal tags remain in some women. Muscles form functional sphincters for vagina, rectum, and urethra. Internal Genitalia The vagina is a musculomembranous tube that is transversely rugated during the reproductive phase of life. The anterior wall of the vagina is separated from the bladder and urethra by the vesicovaginal septum; the posterior wall is separated from the rectum by the rectovaginal septum. The uterine cervix is located at the upper end of the vagina. Pelvic organs may be palpated through pockets around the cervix called fornices. The inverted, pear-shaped uterus sits in the pelvic cavity between the bladder and the rectum. The endometrium, the lining of the uterus, is shed during menstruation. The nonpregnant uterus is usually positioned anteroposteriorly and weighs 60 to 90 g. The uterus is divided anatomically into the corpus and cervix. The uterine corpus consists of the fundus (convex upper portion between the fallopian tubes), the body (main portion), and the isthmus (constricted lower portion adjacent to the cervix). The cervix extends from the isthmus into the vagina. The uterus opens into the vagina via the external cervical os. The adnexa of the uterus are composed of the fallopian tubes and ovaries. Contractions of the tubal musculature move ovum to the uterus. Ovaries secrete estrogen and progesterone, hormones that have several functions, including controlling the menstrual cycle and supporting pregnancy. The internal genitalia are supported by the cardinal, uterosacral, round, and broad ligaments. The Bony Pelvis The bony pelvis accommodates a growing fetus during pregnancy. During pregnancy, increased levels of the circulating hormones estrogen and relaxin contribute to the strengthening and elasticity of pelvic ligaments and softening of the cartilage. Age- and Condition-Related Variations Infants and children. The female infant has fewer epithelial layers in the vagina. The cervix is two-thirds of the entire length of the uterus. Ovaries are tiny and immature. The labia minora are avascular, thin and pale; the labia majora are hairless and nonprominent. The hymen is a thin covering inside the introitus, giving the vaginal opening a crescent-shaped appearance. The clitoris is visible and small. Genitalia grow with age. During childhood the genitalia, except for the clitoris, grow incrementally at varying rates. Hormonal changes during puberty accelerate genital development. Adolescents. During puberty, the labia majora and mons pubis become prominent and hair appears. If the hymen is intact, the vaginal opening is around 1 cm. Vaginal secretions increase and become acidic. The endometrial lining thickens in preparation for the onset of menstruation (menarche), which on the average, occurs between the ages of 11 and 14 years in the United States. Just before menarche, vaginal secretions increase. Functional maturation of the reproductive organs is reached during puberty. Pregnant women. The uterus enlarges during pregnancy, resulting from increases in estrogen and progesterone secretion and from the growing fetus. Muscular walls become more elastic, and the uterus rises out of pelvis into the abdominal cavity by 12 weeks of gestation. Uterine weight at term, not including the fetus and placenta, is about 1000 g. Pelvic congestion and edema during pregnancy occur from increases in blood volume. Uterine pressure obstructs lymph and blood flow. The cervix becomes bluish, and vaginal secretions increase during pregnancy. The fundus presses on the urinary bladder. The pelvic joints separate slightly, resulting in the waddle gait. Older adults. Ovarian function diminishes around age 40, and menopause occurs between 40 and 55 years of age. The labia and clitoris become smaller as a result of decreased estrogen. Body fat is lost, and the labia majora flatten. Pubic hair becomes gray and thins. The vagina narrows and shortens, and the mucosa becomes thin, pale, and dry. The cervix becomes small and pale; uterine size decreases, and the endometrium thins. The ovaries become smaller and follicles disappear. Ovulation ceases about 1 to 2 years before menopause. Menopause is conventionally defined as 1 year with no menses. Pelvic ligaments and connective tissue lose elasticity and tone. Vaginal walls may lose structural integrity. After menopause, there is an increase in body fat and intraabdominal deposition of body fat. Also, after menopause, women experience an increased risk of cardiovascular disease. Postmenopausal hormone replacement (estrogen with or without progestin) is prescribed to reduce the impact of menopausal symptoms and sequelae. Review of Related History History of Present Illness Abnormal bleeding. If unexpected bleeding occurs, the character of periods and any amenorrhea or prolonged menses should be recorded. Changes in flow, including use of pads or tampons and presence of clots should be noted. Medications taken should also be noted. Pain. Patients experiencing pain should be asked about the temporal sequence and character of discomfort. Associated symptoms (e.g., abdominal pain or pelvic fullness) and the effect of pain on body functions and activities should be noted. Methods that aggravate or relieve discomfort should be recorded, and previous treatment should be described. Vaginal discharge. The character and occurrence of vaginal discharge should be noted, along with douching practices, clothing habits, and use of medications. Notations about associated symptoms (e.g., itching, dysuria, or cramping) should be made. Information about symptoms in sexual partner and condom use should be obtained. Information on premenstrual symptoms, menopausal symptoms, and infertility should be noted. Premenstrual symptoms complaint. The symptoms, such as headaches, weight gain, edema, breast tenderness, irritability or mood changes should be noted. How often the symptoms occur, and if they interfere with activities of daily living should also be noted. What relief measures or medications, if any, have been tried and/or successful. Menopausal symptoms complaint. The age at menopause or if the symptoms are currently occurring needs to be examined. Symptoms, postmenopausal bleeding, general feelings about menopause, the mothers experience, birth control methods, and the use of medications or alternative therapies should all be explored. Infertility. Explore length of time attempting pregnancy; sexual activity pattern; knowledge of fertile period in menstrual cycle; length of cycle; any abnormalities of the vagina, cervix, uterus, fallopian tubes, and ovaries; contributing factors; partner factors; and diagnostic evaluation to date. Urinary symptoms. The causes of dysuria, burning, frequency, or urgency should be explored. Acute or chronic characteristics should be listed with the description of urine and associated symptoms (e.g., vaginal discharge or flank pain) and medications taken. Past Medical History Menstrual history. Relevant data include age at menarche, menstrual cycle characteristics, any symptoms of dysmenorrhea, intermenstrual bleeding or pain, and premenstrual symptoms (e.g., headaches and breast tenderness). Menopausal history. Relevant data include age at menopause, associated symptoms, bleeding, birth control measures, general feeling about menopause, mothers experience with menopause, and medications taken. Obstetric history. Gravity, parity, spontaneous or induced abortions, pregnancy complications, and number of living children should be documented. Gynecologic history. Relevant data include prior Pap smears and results, recent and past pregnancies or gynecologic procedures, sexually transmitted infections, vaginal infections, diabetes, or cancer of reproductive organs or related cancers (breast, colorectal). Family History Relevant data include family history of diabetes, cancer of reproductive organs, DES (diethylstilbestrol) ingestion by mother during pregnancy, multiple pregnancies, and congenital anomalies. Personal and Social History Cleansing routines. Pertinent data include use of sprays, powders, perfume, antiseptic soap, deodorants, or ointments. Contraceptive history. Data related to current contraceptive method and previous methods should be assessed. Information on the length and duration of use, effectiveness, any known side effects, and perceived success and satisfaction with method should be collected. Douching history. Information should be obtained on the frequency of douching, method and solution used, and reason for douching. Sexual history. Questions should be asked about any perceived difficulties, concerns, or problems with current and past sexual practices, as well as contraceptive methods used. The number of partners and sexual preference should be noted, as well as current or previously treated sexually transmitted infections. Care history. Note the performance of genital self-examination. The date of the last pelvic examination and pap smear, as well as the results, should be recorded. The use of prescription, over-the-counter, or street drugs should also be determined. Age- and Condition-Related Variations Infants and children. If bleeding is present, examiner should note the character of the blood, the age of mother at menarche, associated symptoms (e.g., the possibility of foreign object insertion), or suspicions of sexual abuse. If pain is suspected, the character and location of the pain, as well as associated symptoms and contributory problems (e.g., irritating soaps) should be assessed. Vaginal discharge problems should be assessed for any relationship to the use of diapers, powders, or lotions. Explore associated symptoms (e.g., pain and bleeding) and contributory problems (e.g., sexual abuse). Infants and young children should be assessed for urinary symptoms, as well as, for diarrhea, excessive crying that cannot be resolved by typical measures, loss of appetite, fever, masturbation, and nausea and vomiting. Adolescents. Ask the adolescent patient the same questions you would ask an adult woman. Talk to the adolescent without parents present. Pregnant women. Information on expected date of delivery (EDD), involuntary passage of fluid, bleeding, pain, gastrointestinal symptoms, previous obstetric history, previous birth history, previous menstrual history, surgical history, and family history should be included. Older adults. Relevant data include age at menopause, menopausal and postmenopausal symptoms (e.g., back pain, hot flashes, or bleeding), previous birth control practices, and symptoms suggesting physical changes (e.g., itching and dyspareunia). Feelings about menopause should be explored, including self-image, mothers experience with menopause, and sexual desire or behavior. See Risk Factors: Cervical Cancer (p. 590); Risk Factors: Ovarian Cancer (p. 590); and Risk Factors: Endometrial Cancer (p. 591). Examination and Findings Summary of ExaminationFemale Genitalia Preparation and Positioning Patient should have an empty bladder. Assist patient into lithotomy position. Maintain eye contact. Explain what you are doing. Ensure a comfortable room and privacy. External Inspection and Palpation Inspect and palpate external genitalia. Note hair distribution. Inspect labia majora. Inspect labia minora. Inspect clitoris. Inspect the urethral orifice. Inspect vaginal introitus. Palpate Skene and Bartholin glands. Inspect and palpate perineum. Palpate for muscle tone. Inspect anal surface. Internal Inspection and Bimanual Palpation Use speculum to inspect cervix and vaginal walls. Palpate the uterus for size, shape, and contour. Palpate ovaries. Palpate anal sphincter. Summary of Female Genitalia Findings Life Cycle VariationsNormal FindingsTypical VariationsFindings Associated with DisordersAdultsSkin is smooth. Hair is in triangular pattern. Majora are symmetric, soft, and homogenous. Minora are moist and dark pink. Clitoris is 2 cm in length and 0.5 cm in diameter. No swelling, mass, or pain is present.After hymen tears, hymenal tags may be visible. Uterus is usually flattened and anteroposterior at a 45-degree angle, but it may also be anteverted, anteflexed, retroverted, or retroflexed. Episiotomy scar may be evident. Perineum is thinner and more rigid in multiparous women and more thick and smooth in nulliparous women. Pale cervix suggests anemia. Squamous epithelium on cervical canal may be visible. Nabothian cysts may be seen around cervix. Os of nulliparous women may be small, round, or oval; os of multiparous women may be more horizontal, irregular, or stellate.External labia swelling, pain, warmth, and redness may mean Bartholin gland abscess.  Infants and children In newborns, labia majora are separate and clitoris is prominent up to 36 weeks of gestation. A newborns genitalia may be swollen with prominent minora. Hymen often protrudes and central opening is about 0.5 cm in diameter. Mucoid whitish vaginal discharge may be seen from birth to 1 month of age as a result of hormonal transfer in utero. In children, Bartholin and Skene glands and ovaries are not usually palpable.Vaginal discharge problems should be assessed for possible relationship to use of diapers, powders, or lotions. Swelling of vulvar tissues with bruising suggests sexual abuse. Enlarged clitoris in newborn suggests adrenal hyperplasia. In children, vaginal discharge may cause redness and excoriation. Perineal irritation may be related to infection or irritation. AdolescentsIn adolescents, vaginal secretions increase before menarche. By menarche, vaginal opening should be at least 1 cm wide.Menstrual cycle characteristics may include dysmenorrhea, breast tenderness, or headaches. Vaginal discharge (yellow, green, or gray) with odor suggests infection. Labia minora irritation may be caused by vaginal infection. Ulcers or vesicles may be from sexually transmitted infection. Urethral inflammation or dilation suggests repeated urinary tract infections. Discharge from Skene glands suggests infection. Pregnant women During pregnancy, there is a softening of the isthmus (the Hegar sign), bluish cervix (Chadwick sign), and cervical softening (Goodell sign). The uterus may be more anteflexed during the first 3 months, pressing more on the bladder and causing urinary frequency. Pregnancy also causes an increase in vaginal secretions and increased vascularity. The uterus deviates at 8 to 10 weeks of gestation (Piskacek sign).Deviation of cervix to right or left may mean pelvic mass, uterine adhesions, or pregnancy. Enlarged uterus suggests pregnancy or tumor.Older adultsIn older women, the labia are flatter and smaller. The clitoris is smaller, and the vagina becomes narrower and has decreased rugation. With age, the cervix becomes smaller, paler, and less mobile. The cervical os may be smaller, and uterus diminishes in size and may not be palpable.Feelings about menopause, self-image, and sexual desires should be explored. Bulging of anterior vaginal wall with urinary incontinence indicates cystocele. Bulging of posterior wall indicates rectocele. Protrusion of cervix or uterus through vaginal introitus indicates uterine prolapse. See Genital Self-Examination for Women (p. 592) and Box 18-3: Examining the Woman Who Has Had a Hysterectomy (p. 604). See Box 18-1: Evaluation of Masturbation in Children (p. 593); Box 18-4: Red Flags for Sexual Abuse (p. 611); Box 18-5: Causes of Genital Bleeding in Children (p. 612); and Box 18-6: Evaluation of Sexual Play in Adolescents (p. 613). See Box 18-7: Early Signs of Pregnancy (p. 614) and Table 18-4: Estimates of Uterine Size in Early Pregnancy (p. 617). See Differential Diagnosis: Vaginal Discharges and Infections (p. 631). Chapter Outline: Chapter 19: Male Genitalia Anatomy and Physiology The male genitalia consist of the penis, testicles, epididymides, scrotum, prostate gland, and seminal vesicles. The function of the penis is to excrete urine and to introduce semen into the vagina. The corpus spongiosum expands at its distal end to form the glans penis. The urethral orifice is a slitlike opening about 2 mm ventral to the tip of glans. The penis skin is thin, redundant to permit erection, and more darkly pigmented than the rest of the body. At birth, the foreskin covers the glans. The scrotum is also darkly pigmented and contains two pendulous sacs, each containing a testis, epididymis, spermatic cord, and muscle layer. Testicular temperature is controlled by altering the distance of the testes from the body through muscular action. Spermatogenesis requires temperatures lower than 37( C. The testicles produce spermatozoa and testosterone. The adult testis is ovoid. The epididymis provides for the storage, maturation, and transmission of the sperm. The vas deferens (spanning from the tail of the epididymis to the seminal vesicle) forms the ejaculatory duct. The prostate gland surrounds the urethra at the bladder neck. The prostate produces ejaculatory fluid, containing fibrinolysin enzyme that liquefies coagulated semen. The seminal vesicles extend from the prostate to the posterior surface of the bladder. Sexual Physiology Erection of the penis occurs when the two corpora cavernosa become engorged with 20 to 50 mL of blood in response to the autonomic nervous system. Erection is a neurovascular reflex induced by psychogenic or local reflex mechanisms. Cortical input can suppress arousal. Orgasm is the emission of secretions from the vas deferens, epididymides, prostate, and seminal vesicles. Constriction of the vessels occurs after orgasm. Age- and Condition-Related Variations Infants and children. External genitalia are the same for males and females at 8 weeks of gestation, but differentiation occurs by 12 weeks of gestation. During the third trimester, the testes descend into the scrotum. A term newborn may experience final descent of the testes during the postnatal period. Separation of the prepuce from the glans is usually incomplete at birth and may remain so until 3 to 4 years of age in uncircumcised males. Adolescents. Hormonal changes at puberty cause straight hair to appear at the base of the penis. Scrotal skin reddens and becomes increasingly pendulous. As maturation continues, pubic hair darkens and covers the pubic area, and the prostate gland enlarges. By the completion of puberty, the pubic hair is curly, dense, and coarse and forms a diamond-shaped pattern from the umbilicus to the anus. The penis is enlarged in length and breadth. Older adults. With age, pubic hair becomes finer and less abundant. The production time of mature spermatozoa does not change, although the viability of the sperm may decrease. Ejaculatory volume may increase as a result of infrequent intercourse. The scrotum becomes more pendulous. Erection may develop more slowly, and orgasm may be less intense. Review of Related History History of Present Illness Difficulty achieving or maintaining erection. Ask patients about pain with erection, pattern of erection with one or more partners, alcohol and medication ingestion, erections unrelated to sexual stimulation, and curvature of erect penis. Difficulty with ejaculation. Pertinent data include painful or premature ejaculation and color and consistency of fluids, as well as medications used on a regular basis. Discharge or lesions on the penis. Note the character of lesion (lumps, sores, rashes) or discharge (color, consistency, odor). Record any associated symptoms (e.g., itching or burning), exposure to sexually transmitted infections, and medications used. Infertility. Patients reporting problems with conceiving should be assessed for lifestyle factors (e.g., hot tub use), length of time attempting pregnancy, knowledge of fertile period of womans reproductive cycle, incidence of undescended testes, previous diagnostic studies (e.g., semen analysis or sperm antibody titers), and medications used. Enlargement in inguinal area. Questions relevant to an enlarged inguinal area address pain associated with lifting, change in size or character of mass, groin pain, use of truss or other treatment, and medications used. Testicular pain or mass. Patients should be assessed for changes in testicular size, events surrounding onset (e.g., sporting event), any irregular lumps, soreness, or heaviness of testes, and medications used. Past Medical History Pertinent data include previous genitourinary tract surgeries (e.g., surgery to correct hypospadias or hernia), sexually transmitted infections, and chronic illnesses (e.g., prostatic cancer, arthritis, or neurologic or vascular impairment). Family History Data should be collected on any infertility problems in siblings, hernias in family members, and a family history of prostate, testicular, or penile cancer. Personal and Social History Relevant data include employment risks (e.g., exposure to toxins), exercise patterns, concerns about genitalia, testicular self-examination practices, concerns about sexual practices, reproductive function (number of children, form of contraceptive use), and use of medications, alcohol, or street drugs that may interfere with sexual response. Age- and Condition-Related Variations Infants and children. Information should be gathered on maternal use of sex hormones or birth control pills during pregnancy. Circumcised infants should be assessed for any complication from the procedure. Pertinent data for uncircumcised infants include hygiene measures and retractibility of foreskin. Congenital anomalies (e.g., epispadias) and any incidence of scrotal swelling when infant is crying or having bowel movements should be recorded. Notation should also be made of any swelling, discoloration, sores on penis or scrotum, and genital pain. Questions should be asked about any concerns with masturbation, sexual exploration, or sexual abuse. Adolescents. Relevant data include knowledge of reproductive function, presence of nocturnal emissions, enlargement of genitalia, sexual activity patterns, use of contraceptives, and concerns of sexual abuse. Older adults. Relevant data include sexual activity patterns and any changes in sexual response or desire. See Risk Factors: Carcinoma of the Male Genitalia (p. 645). Examination and Findings Summary of ExaminationMale Genitalia Positioning Patient may be lying or standing. Examination of the genitalia involves inspection, palpation, and transillumination of any mass found. Inspection and Palpation Inspect and palpate external genitalia. Note hair characteristics. If foreskin is present, retract it and note penis characteristics. Palpate shaft of penis and note texture. Inspect urethra and note meatus locations. Inspect scrotum and inguinal areas for size, contour, and the presence of hernia. Palpate testes, epididymis, and vas deferens. Note size, contour, and characteristics of testes. Palpate prostate gland and seminal vesicles. Inspect and palpate for hernia with patient in knee-chest position. Inspect for the cremasteric reflex. Inspect sacrococcygeal and perianal areas. Transillumination Visualize any masses and note transillumination. Summary of Male Genitalia Findings Life Cycle VariationsNormal FindingsTypical VariationsFindings Associated with DisordersAdultsDorsal vein is apparent. No masses or abnormalities are visible.Scrotum is normally more red in red-haired persons. Scrotal lumps may be caused from sebaceous cysts.Uncircumcised males may have balanoposthitis as a result of nonretractable foreskin. Balanitis results from infection. Penile discharge suggests inflammation or infection. Pinpoint opening suggests meatal stenosis. Priapism, a prolonged and often painful penile erection, may suggest a more serious condition. Thickening of the scrotum from edema is associated with disease. Irregular testis texture is a sign of infection, cyst, or tumor. Beaded or lumpy vas deferens suggests diabetes, tuberculosis, or inflammatory changes.Infants and children Transitory penile erections are common in infants. Edema of newborn external genitalia is common, especially after breech delivery. Testicle of newborn is usually 1 cm in diameter. Newborn nonerect penis is 2 to 3 cm in length. Newborn scrotum without rugae and testes indicates preterm birth. Separation of prepuce from glans occurs between ages 3 to 4 years. Foreskin of noncircumcised males is fully retractable by 3 to 6 years of age.Small penis in infants may mean organ anomalies. A bulge in the inguinal area suggests hernia. A mass may indicate hydrocele. In children, an enlarged penis without testicular enlargement may mean precocious puberty, adrenal hyperplasia, or central nervous system lesions. Hypospadias is a congenital defect on ventral surface of glans, penile shaft, or perineal area. AdolescentsHormonal changes at puberty cause straight hair to appear at base of penis. Scrotal skin reddens and becomes increasingly pendulous. As maturation continues, pubic hair darkens and extends over entire pubic area; the prostate gland enlarges. By completion of puberty, the penis is enlarged in length and breadth. Pubic hair is curly and dense and forms a diamond pattern from the umbilicus to the anus.Varying degrees of maturation should be classified according to the Tanner stages.Groin, inguinal, or testicular pain may be associated with mass caused by sports injury or testicular cancer. Older adults With age, pubic hair becomes finer and less abundant. Viability of sperm may decrease. Erection may develop more slowly, and ejaculation may be less intense.Scrotum becomes more pendulous. See Box 19-1: Minimizing the Patients Anxiety (p. 647) and Staying Well: Genital Self-Examination for Men (p. 651). Chapter 20: Anus, Rectum, and Prostate Anatomy and Physiology The rectum and anus form the terminal portions of the gastrointestinal (GI) tract. The anal canal is about 2.5 to 4 cm long and opens onto the perineum. It is normally kept closed by internal and external sphincters. The internal smooth muscle is controlled by the involuntary autonomic system. The urge to defecate occurs when the rectum fills, causing a reflexive stimulation that relaxes the internal sphincter. Defecation is controlled by the striated external sphincter, which is under voluntary control. The lower half of the anal canal is supplied with somatic sensory nerves, allowing for pain sensation. The upper half is controlled by the autonomic system and is relatively insensitive to pain. The canal is lined with columns of mucosal tissue that fuse to form the anorectal junction. The venous plexus, located in the lower segment of the canal, drains into the inferior rectal veins. The rectum lies superior to the anus and is about 12 cm long. Its proximal end is continuous with the sigmoid colon. Above the anorectal junction, the rectum dilates and turns toward the coccyx and sacrum, forming the rectal ampulla, which stores flatus and feces. In males, the prostate gland is at the base of the bladder and surrounds the urethra. The gland is composed of muscular and glandular tissue measuring 4 ( 3 ( 2 cm. The prostate gland is convex and contains right and left lateral lobes. A third median lobe, not palpable, is composed of glandular tissue and contains active secretory alveoli that contribute to ejaculatory fluid. In females, the anterior rectal wall contacts the vagina and is kept separate by the rectovaginal septum. Age- and Condition-Related Variations Infants and children. The urogenital sinus develops into the anal opening by 8 weeks of gestation. Newborns pass meconium stool within 24 to 48 hours of age, indicating anal patency. Gastrocolic reflex occurs following feedings in infants. Internal and external sphincter control is involuntary until spinal cord myelination is complete. By the end of the first year, infants may have one to two daily stools. By 18 to 24 months, sphincter control is achieved. In males, prostate remains undeveloped until puberty and is not palpable on rectal examination. Pregnant women. Pressure in the veins increases below the enlarged uterus. Decreased gastrointestinal tract tone and motility produce constipation. With labor, protrusion and inflammation of hemorrhoids may occur. Older adults. Increased stool retention occurs with age, resulting from the degeneration of afferent neurons in the rectal wall interfering with internal sphincter relaxation. As internal sphincter tone is lost, the external sphincter cannot alone control the bowels, and fecal incontinence may occur. In men, the fibromuscular structures of the prostate atrophy, with loss of function of the secretory alveoli. Collagen replaces the muscular component of the prostate. Review of Related History History of Present Illness Changes in bowel function. Pertinent data include character of stool; onset and duration of perceived problem; medications taken; and any accompanying symptoms such as flatus, fever, or cramping. Anal discomfort (including itching, pain, stinging, and burning). Relevant data include relation to body position and defecation, straining at stool, presence of mucus or blood, interference with sleep or activities of daily living, and medications taken. Rectal bleeding. Inquire about color and amount of blood, relation to defecation, stool changes (e.g., frequency, consistency, or presence of mucus), associated symptoms (e.g., flatus, abdominal distention, or weight loss), and medications taken. Changes in urinary function (in males): Symptoms (e.g., hesitancy, urgency, or dysuria) and any history of enlarged prostate or prostatitis should be noted. Past Medical History All patients should be assessed for a history of hemorrhoids and spinal cord injury. Prostate hypertrophy or carcinoma or colorectal cancer should be noted in males. Data pertinent to females include episiotomy, fourth-degree laceration during delivery, colorectal cancer or related cancers: breast, ovarian, or endometrial. Family History Relevant data include family history of rectal polyps, colon cancer, or prostatic cancer. Personal and Social History Questions should center on bowel habits and characteristics (e.g., timing, frequency, and stool color), travel history (to determine risk of parasitic infestations), dietary patterns (inclusion of fiber foods), risk factors for colorectal or prostatic cancer, and use of alcohol. Age- and Condition-Related Variations Infants and children. Stool characteristics of newborns should be carefully recorded. Crying, straining, or rectal bleeding during defecation should be noted. Record the age at which bowel control and toilet training were achieved. Associated symptoms should be explored, such as incidence of diarrhea or constipation. Feeding habits and any history of congenital anomalies (e.g., imperforate anus) should be noted. Pregnant women. Questions regarding gestation and EDC, as well as exercise, fluid intake, dietary habits, and medications should be asked. Older adults. Relevant data include changes in bowel habits or stool characteristics, associated symptoms (e.g., weight loss or rectal bleeding), and any dietary changes (e.g., food intolerance or change in appetite). Older males should be questioned about prostate enlargement or urinary symptoms (e.g., hesitancy or nocturia). See Risk Factors: Colorectal Cancer (p. 670) and Risk Factors: Prostate Cancer (p. 670). Examination and Findings Summary of ExaminationAnus, Rectum, and Prostate Preparation and Positioning Rectal examination can be performed with the patient in any of the following positions: knee-chest, left lateral with hips and knees flexed, or standing with the hips flexed and the upper body supported by the examining table. Drape appropriately but retain good visualization of the area being examined. Inspection Inspect sacrococcygeal (pilonidal) and perianal areas. Inspect the anus. . Look for skin lesions, skin tags or warts, external hemorrhoids, fissures, and fistulas. Ask the patient to bear down. This will make fistulas, fissures, rectal prolapse, polyps, and internal hemorrhoids more readily apparent. Palpation Palpate anal ring and rectal wall. Have the patient bear down. Feel right and left lateral surfaces. (Area should be felt using bidigital palpation.) Palpate prostate gland in males. See Box 20-1: Prostate Enlargement. Note size, contour, and characteristics. Examine fecal material. In females, a retroflexed or retroverted uterus is usually palpable through rectal examination. The cervix may be palpable through the anterior rectal wall. Summary of Anus, Rectum, and Prostate Findings Life Cycle VariationsNormal FindingsTypical VariationsFindings Associated with DisordersAdultsSkin is smooth and uninterrupted. Perianal area should be smooth and even. Skin around anus appears coarser and more darkly pigmented than the rest of the perineum. Upon palpation, prostate gland feels like a pencil eraser: firm, smooth, and slightly movable. It should be nontender, with a diameter of about 4 cm and less than 1 cm protrusion into the rectum.Internal hemorrhoids should not be felt, unless they are thrombosed. Rubbery or boggy prostate suggests benign hypertrophy. Rectal pain is indicative of local disease. Prostate enlargement is classified by the amount protruding into rectum. Stony, hard nodular prostate suggests carcinoma, calculi, or chronic fibrosis. Fluctuant softness suggests prostatic abscess. Tenderness and inflammation of perianal area suggest abscess, anorectal fistula or fissure, pilonidal cyst, or pruritus ani. Infants and childrenRectal examination is not usually done on infants and children unless there are symptoms suggesting problems. Newborns pass meconium stool within 24 to 48 hours of age, indicating anal patency.Gastrocolic reflex occurs following feedings. Internal and external sphincter control is involuntary until spinal cord myelination is complete. By 18 to 24 months, sphincter control is achieved.Lack of stool passage in newborn may indicate rectal atresia, Hirschsprung disease, or cystic fibrosis. Asymmetric gluteal creases occur with congenital hip dislocation. Sinuses, tufts of hair, dimpling in pilonidal area suggest lower spinal deformities. Lack of anal contraction to touch suggests lower spinal cord lesion. In children, shrunken buttocks suggests chronic debilitating disease. Perirectal redness suggests pinworms, candidal infection, or diaper irritation. Rectal distention occurs from chronic constipation.AdolescentsProstate becomes developed at puberty.Incidence of diarrhea or constipation should be explored.Lax sphincter may mean neurologic deficit. Tight sphincter may mean scarring, lesion, inflammation, or anxiety.Pregnant womenRectal examinations can provide relevant data about the cervix and uterus of pregnant women.Iron supplements are used during pregnancy, which can cause constipation, dark green or black stools, or diarrhea.Hemorrhoids (internal or external) are a frequent finding late in pregnancy.  Older adultsIn older adults, sphincter tone may decrease as a result of a degeneration of afferent neurons in the rectal wall, leading to incontinence. Median sulcus may or may not be obliterated. Older adults commonly experience fecal impaction resulting from constipation.Prostate may be enlarged. With age, there is a greater likelihood of polyps.Older adults have a higher risk for carcinoma.  Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc Course Lecture Content: Genitourinary System; Anus, Rectum, and Prostate: Advanced assessment of the male and female genitourinary system - Pelvic examination - Manual examination of the prostate Assessment findings of abnormal presentations in the male and female genitourinary system Differential diagnoses of the male and female genitourinary system Christopher W. Blackwell, Ph.D., ARNP-C Assistant Professor, School of Nursing College of Health & Public Affairs University of Central Florida NGR 5003: Advanced Health Assessment & Diagnostic Reasoning Advanced Assessment of the @& GU System Anatomy and Physiology: External Genitalia: Includes mons pubis, labia majora/minora, clitoris, vestibular glands, vaginal vestibule, vaginal orifice, and urethral opening Labia minora meet at anterior vulva, divides into 2 lamellae, lower joining to form frenulum of clitoris, upper pair prepuce; labia minora join posteriorly to form fourchette Vestibule contains: urethra, vagina, Bartholin glands, Skene glands Vaginal opening is hymen Internal Genitalia: Vesicovaginal septum separates vagina from urethra and bladder Pocket formed around cervix divided into ant/post and lateral fornices Uterus lies between bladder and rectum; pear-shaped, covered by peritoneum and lined by endometrium Rectouterine cul-de-sac separates uterus from rectum Uterus usually forward-sitting at 45o; can be anteverted, anteflexed, retroverted, or retroflexed Uterus divided by corpus and cervix; corpus makes up fundus, which is convex portion between fallopian tubes, isthmus is lower portion adjacent to cervix; cervix opens to vagina via cervical os Adnexa = fallopian tubes + ovaries; fallopian tubes supported via mesosalpinx, rhythmically propel ovum to uterus Ovaries secrete estrogen, prosteserone, which control menstruation and pregnancy 4 ligaments support internal genitalia: cardinal, uterosacral, round, and broad Advanced Assessment of the @& GU System Pelvic Organs/ Internal Genitalia Advanced Assessment of the @& GU System Bony Pelvis: Formed by ilium, ischium, pubis, sacrum, and coccyx 4 joints: symphysis pubis, sacrococcygeal, 2 sacroiliac, which respond to relaxin and estrogen during preg, causing stretching of pelvic bones Flared-out iliac bones make-up false pelvis; true pelvis is lower curved body canal, including the inlet, cavity, ad outlet (through which fetus passes during delivery) Infants: Vagina and uterus much smaller w/ immature, non-functional tiny ovaries Labia minora relatively avascular, thin, and pale; majora hairless and non-prominent; hymen very thin; clitoris small Adolescents: Begin to ! in size to adult proportions; clitoris becomes ! erectile and minora more vascular; labia majora/ mons pubis become more prominent and cover w/ coarse terminal pubic hair; vaginal secretions become more acidic; uterine tissue thickens and becomes more vascular; menarche between 11-14 years Advanced Assessment of the @& GU System Pregnant Women: Uterine enlargement during 1st trimester brought about by estrogen and progesterone At 12 weeks gestation, uterus grows into ABD cavity; uterine walls first thicken in 1st few months, then effaces to 1.5 cm Uterine blood and lymph flow !, softening the uterus, cervix, and isthmus, giving a blue  Cullen-sign color Uterus becomes anteflexed during 1st trimester, pressuring the bladder; vaginal secretions become more acidic; Vaginal walls thicken w/ smooth muscle cell hypertrophy Older Adults: Ovarian function ! during the 40s, menopause ( 1 year w/o menses) between 40-55 Estrogen !, thinning the clitoris and labia; pubic hair becomes gray and sparse from follicular death Vaginal introitus gradually constricts; vagina narroes, shortens, loses rugation while mucoasa becomes pale, thin, dry (dyspareunia) Uterus/ovaries ! in size; endometrium thins; pelvic musculature and bones weakenm ! opportuity for prolapse Reduction in hormones from menopause results in ! male fat pattern and intra-ABD deposition; total/LDL cholesterol !; thermoregulation altered, causing flushing; risk of CV Dz ! Advanced Assessment of the @& GU System Review of Related Hx: Abnormal bleeding: Character: !intervals between period (< 19-21 days); ! interval between periods (> 37 days); amenorrhea; ! menses (> 7 days); bleeding between periods/postmenpausal bleed Change in Flow: nature of change, # of pads/tampons used in 24h, presence of clots Temporal sequence: onset, duration, precipitating factors, course since onset Associated S/S: pain, carmping, ABD distension, pelvic fullness, change in bowel habits; wt. loss/gain Rx: Non/Rx, contraceptives, tamoxifen, HRT Pain: Temporal sequence: time/date of onset; sudden vs. gradual onset; course since duration/recurrence Character: specific location, type, intensity of pain Associated S/S: vaginal DC/bleeding; GI S/S; ABD distension/ tenderness, pelvic fullness Association w/ cycle: timing, location, duration, changes Relationship to body functions/activity: voiding, eating, defecating, flatus, exercise, walking up stairs, bending stretching, sexual activity Aggravating/relieving factors Previous medical Tx for this problem/ efforts to Tx Rx: Non/Rx Advanced Assessment of the @& GU System Vaginal DC: Character: amt, color, odor, consistency, changes in characteristics Acute vs. chronic occurrence Douching habits Clothing habits: use of cotton/ventilated underwear or hose; tight pants/jeans Sexual Hx: Presence of a DC in partner; use of condoms Associated S/S: itching, tender, inflamed, bleeding external tissues, dyspareunia, dysuria/burning when voiding, ABD pain/cramps; pelvic fullness Efforts to Tx: antifungal/vaginal creams/lotions Rx: Non/Rx, oral contraceptives, ATBx PMS: Symptoms: HA, wt gain, edema, breast tenderness, irritability or mood changes Frequency: Every period? Interference w/ ADL Relief measures, aggravating factors Rx: Non/Rx Advanced Assessment of the @& GU System Menopausal c/o: Age of menopause/current experience Symptoms: menstrual/mood changes, tension, hot flashes Postmenopausal bleeding General feelings about menopause; self-image, effect on intimacy Mother s experience w/ menopause BC measures during menses Rx: HRT (dose and duration; AE: breast tenderness, bloating, vag bleeding); serum estrogen receptor modulators (AE: hot flashes, breast tenderness); other Non/Rx; complementary TxOTC estrogen Infertility: Length of time attempting preg, sexual activity patterns, knowledge of fertility in-relation to cycle, cycle length Abnormalities of vagina, cervix, uterus, fallopian tubes, ovaries Contributing factors: stress, nutrition, chemical substances, partner Dx evaluation to date Urinary symptoms (dysuria, pyuria, frequency, urgency): Character: acute vs. chronic; frequency of occurrence (last episode: onset, course since onset); feel like bladder is empty after void; pain at start throughout or end of urination Description of urine: color, presence of blood/particles; clear/cloudy Associated S/S: Vaginal DC or bleeding; ABD pain/cramping/distension, pelvic fullness, flank pain Rx: Non/Rx Advanced Assessment of the @& GU System Past Medical Hx: Menstrual Hx: age of menarche; date of L (normal) MP/ 1st day of last cycle; # of days/regularity in cycle; character or flow (amt--# of pads/tampons in 24h on heaviest days), duration, presence and size of clots; dysmenorrhea (characteristics, duration, frequencyoccurs w. each cycle?, relef measures); intermenstrual bleeding or spotting (amt., duration, frequency, timing in cycle); intermenstrual pain (severity, duration, timing, association w/ ovulation); PMS symptoms (HA, wt gain, edema, breast tenderness, irritability, frequency (occurs w/ q period?), intereference w/ ADLS, relief measures Obstetric Hx: gravida, term pregnancies, pre-term pregnancies, abortion, number of living children, complications of preg, delivery, abortion, fetus/neonate (GTPALC) Menopausal Hx: age of menopause; associated S/S (menstrual changes, mood changes, tension, hot flashes); post-menopausal bleeding; BC during menopause; general feels towards menopause (self-image, effect on intimacy; mothers experience w/ menopause); Rx: HRT (dose and duration; AE: breast tenderness, bloating, vag bleeding); serum estrogen receptor modulators (AE: hot flashes, breast tenderness); other Non/Rx; complementary TxOTC estrogen Gynecological Hx: prior Pap smaears and resultsif abnormal, how Tx and follow-up; recent OB/GYN procedures/surgery (tubal ligation, hysterectomy, oophorectomy, laparoscopy, cryosurgery, conization); STDs/PID/vag infec; DM, CA or reproductive organs or related CA (breast/colorectal) Advanced Assessment of the @& GU System Family Hx: DM, reproductive CA, mother received DES while pregnant w/ pt., multiple pregnancies, congenital anomalies Personal/Social Hx: Cleansing routines (sprays, powders, perfume, antiseptic soaps, deodorant, ointments) Contraceptive Hx: current method (length of time used, effectiveness, consistency of use, AE, satisfaction); previous methods (duration of each use, AE, reasons for DC); douching Hx (frequency, length of time since last douche, # of yrs douching, method, solution used, reasons for douching); sexual Hx (current activity, # of current/previous partners/their partners, sexual orientation, methods of contraceptioncurrent, past, satisfaction use of barriers for STDs, satistfaction w/ relationship, sexual pleasure achieved, frequency; problems pain on penetration, ! lubrication, anorgasm); performance of genital self-exam; date of last pelvic exam/Pap (results); use of ilicit Rx Advanced Assessment of the @& GU System Infants and Children: Bleeding: character (onset, duration, precipitating factors, couse since onset); age of menarche; associated S/S (pain, change in cying of infant, child fearful of parent or adults); parental suspicion of insertion of FBs/ sexual abuse; Pain: character (type of pain, onset, course, duration); specific location; associated S/S (vag DC, urinary symptoms, GI symptoms, child fearful or parent/adults); contributory problems (bubble bathing, irritating soaps/ detergents, suspicion of FB insertion/abuse) Vag DC: relationship to diapers (use of powders/ lotionsfrequency of diaper change); contributory problems-- suspicion of FB insertion/abuse Urinary symptoms in young children, excessive crying not resolved, anorexia, N/V/D, masturbation Adolescents: Poise ?s in a gentle, matter-of-fact and nojudgmental attitude Dont Assume anything about sexual activities Need to question adolescent female alone Advanced Assessment of the @& GU System Pregnant Women: Expected date of delivery; weeks gestation Previous OB/GYN Hx (GPTAL, prenatal complications, fertility Tx) Previous birth Hx: gestation length at birthl birth wt; fetal outcome, labor length, fetal presentation, type of delivery (use of forceps), LACs/ episiotomy; complications Previous menstrual Hx Surgical Hx: prior uterine surgery and scarring Family Hx: DM, multiple births, preeclampsia, genetic disorders Involuntary passage of fluidcould result from ROM determine onset, duration, color, amt. and if still leaking Bleeding: Character (onset, duration, precipitating factorsintercourse/trauma since onset/amt); associated S/S; pain (type, sharp/dull, intermittent or continuous; onset, location, duration) GI S/S: V/pyrosis Older Adults: Menopausal Hx; symptoms associated w/ aging (itching, urinary symptoms, dryness, dyspareunia); changes in sexual desire/behavior in self or partner Advanced Assessment of the @& GU System Examination and Findings: Explain procedure/ show equipment to woman and try to appease anxiety No matter the gender of APN, always have a female chaperone Have pt. void prior to procedure Positioning: Place in lithotomy position, slide buttocks to table end Drape knees and symphysis, depressing drape between knees Place light source directly to vaginal area Wash hands, don clean gloves Inform pt. youre going to begin, touch fingers to lower thigh and continuously touch to genitalia Advanced Assessment of the @& GU System Lithotomy Position Advanced Assessment of the @& GU System External Examination: Inspect and palpate external genitalia; assess hair pattern and distribution; skin of majora and mons should be smooth and clean free of nits/lice Majora may be dry or moist, gaping open or closed; tissue should be soft and homogenous, free of swelling, redness or tendernessif unilateral, suspect bartholin gland abscess; excoriation, rashes, or lesions could indicate infec; observe for discoloration, varicosities, scratching, trauma/scarring Separate minora w/ fingers of one hand and use other hands 2nd digit and thumb to palpate minora, clitoris, urethral orifice, vaginal introitus, and perineum; minora should be symmetric or asymmetricmoist and dark pinkloof for inflammation, irritation, excoriation, or DC caking; discoloration or tenderness may be traumatic bruising; feel for irregularities and nodules; ulcers or vesicles may indicate STD Clitoris: observe clitoris for inflammation, adhesions, atrophy, or enlargement (masculinizing condition) Advanced Assessment of the @& GU System Urethral opening may be irregular or slit; should be midline w/o DC, polyps, caruncles, or fistulas; S/S of UTI or FB include irritation, inflammation, or dilation Thin, vertical large opened or slit introitus should be moist, free of edema, discoloration, DC, lesions, fistulas or fissures Milk Skene glands by placing digit through medial phalynx into vaginal opening, gently push upwardassess for excessive tenderness or DC (color, consistency, odorobtain sterile cultureif present, usually goncoccal infec); palpate majora with finger and thumb, noting tenderness, heat, masses, heat, or fluctuationnote for DC and characteristics, obtain cultureswelling along majora, painful to touch, fluctuationcould indicate Bartholin gland abscessusually infected by staph or gonococcalmasses here usually pus-filled and indicate chronic Bartholin infection Assess muscle tone by asking aomen to squeeze your fingers with the vaginal openingask her to bear down and assess for bulging of ant wall and incontinenceif incontinent of urine, suspect cystocelepost wall bulging is rectoceleprotrusion of cervix w/ straining indicated uterine prolapse Perineal surface should be smooth w/ or w/o episiotomy scarring; tissue should feel thick and smooth (nulliparous) or rigid and thin (mutliparrous) if tender, look for inflammation, fistulas, lesions, or growths Anal surface more darkly pigmented w/coarse skinshould be free of scarring, lesions, inflammation, fissures, lumps, skin tags, or excoriationchange glve before touching genitalia! Advanced Assessment of the @& GU System Separation of Labia; palpation of Skene Glands Advanced Assessment of the @& GU System Bartholin/ Perineum Palpation Advanced Assessment of the @& GU System Internal Examination: Lubricate speculum w/ water-based lubricant; put index finger over top of speculum, the rest wrapped around handle Gently separate minora and slowly insert speculuminsert obliquely avoiding trauma to urethral/vaginal walls, clitoris, pubic hair, or labial skin; open speculum slowly and position until cervix is viewed, lock blades into place Cervix should be pink w/ even color distribution; bluish (Cullen) color may indicate preg; pale = anemia; be alert for patchy reddened areas or irregular borders; cervix pushed out of midline could indicate pelvic mass, adhesions, or preg; protrusion > 3cm indicate pelvic/uterine mass; enlarged cervix (>3cm) indicated cervical infec; surface should be smooth, small, white or yellow raised round areas are Nabothia cyctsexpected finding; look for friable tissue, red patchy areas, granular areas, or white patches, indicative of cervicitis, infection or CA; not any DCshould be odorless, creamy or clear, may be thick, thin or stringy (if bacterial or fungal DC, odor + w/ white-yelloe to green or gray color); os is round (nulliparous) or slit (parous); obtain specimen for Pap, culture, DNA, Cervix pointing anteriorly is retroverted Cervix pointing posteriorly is anteverted Advanced Assessment of the @& GU System Speculum Exam Advanced Assessment of the @& GU System Nulliparous, Parous (Multigravidous), Eroded, and Nabothian Cervices: Advanced Assessment of the @& GU System Anteverted, Anteflexed, Retroverted, Retroflexed, Midline Uteruses Advanced Assessment of the @& GU System Obtaining vaginal cultures and smears: Pap: 1st, collect ectocervical sample w/ spatula: insert into os and rotate 360o, remove, spread on slide, apply fixative to slide Next, insert cytobrush, rotate 180o, remove, spread on slide, apply fixative Thin Prep: Insert cervical broom devices central bristles into os while outside bristles touch ectocervix, rotate broom clockwise 5x, rinse broom in solution vial by pushing to bottom of vial 10x then swirl broom or deposit broom into collection vial Gonococcal culture: Immediately after Pap, insert sterile cotton swab into os, leave in place 20 seconds, remove and spread over medium in Z pattern rotating swab; use same procedure but separate swab for anal culture DNA Probe (Chlamydia/Gonorrhea): Only use metal or plastic handled-Dacron swab (wood interferes w/ test); insert into os and rotate for 30 seconds, remove and place in reagent tube Wet Mount: Used to assess for bacterial vaginosis, Trichomonas, or candidiasis Use cotton swab to collect DC; smear on glass slide and add 1 saline gtt, add cover slide; microscopically examine Presence of trichomonads = Trichomonas; epi (clue) cells = bacterial vaginosis Collect a 2nd sample and smear on 2nd slide, add 1 gtt KOH, add cover slide, + fish smell = bacterial vaginosis; view microscopically for mycelial fragments, hyphae, and budding yeast, indicating candidiasis Advanced Assessment of the @& GU System Instrumentation of Pap Smear Advanced Assessment of the @& GU System Unlock speculum and assess vaginal walls for color (pink consistent w/ cervix), surface moistness, and clear thin/thick secretions; red patches, lesions, pallor, cracks, ulcers, bleeding, edema, curdy, frothy, gray/green/yellow malodorous DC could indicate infec. Bimanual Examination: Inform woman of digital exam, change gloves, lubricate index and middle fingers Insert slowly into vaginal canalpalpate walls for smoothness, homogeneity, tenderness, cysts, nodules, massesavoid touching clitoris Find cervix w/ palmar surface of fingersassess for firmness if non-preg, softer if preg; nodules, hardness, roughness; move cervix side-to-side, assessing for pain (+ chandelier sign), suggests PID or tubal preg Push down on the cervix and slide other hand down ABD between umbilicus and symphysis pubis; assess fundus position (if felt, uterus is retroverted/flexed); R or L deviation indicates possible adhesions, pelvic masses, or preg; should be pear-shaped between 5.5cm-8cm long, larger than this suggests tumor; countour should be rounded, firm, and smooth; attempt to move uterus, if unmovable, suspect adhesions, PID, or ruptured tubal preg Assess adnexa by depressing ABD hand sharply downward at RLQ/LLQ and catch adnexa w/ intravaginal handovaries should be smooth, firm, ovoid w/ moderate palpable tenderness; if fallopian tubes palpable, suspect problemnote size, shape, location, consistency and tenderness of any masses; if nothing at all is palpable, assume everything is normal Advanced Assessment of the @& GU System Bimanual Palpation: Advanced Assessment of the @& GU System Rectovaginal Examination: Educate woman about feeling for need to BM and assure she will not; provide comfort Place index finger into vagina, middle finger into anus Ask pt. to tighten and loosen spincter; assess for tightness (could be anxiety about procedure, scarring, fissures, lesions, or inflammation)lax sphincter could be from neurological disorder, absent from improper healed 3rd degree lac from delivery Rotate anal finger, assess walls for masses, polyps, nodules, strictures, irregularities, tenderness; assess rectovaginal septum for thickness, tone, and nodules Repeat uterus positioning and adnexa assessment as before Scoop for stool when removing finger; hemoccult test Allow pt to clean herself w/ wipes; discuss exam findings and EDUCATE about needs, misperceptions, etc. Infants: Place legs in frog position; majora appear widely separated and full-term cover internal genitalia and are swollen; minor more prominent than majora, clitoris is prominent w/ thick, vascular, protruding hymenall disappearing in a few weeks Clittoral enlargment common but can suggest hyperplasia; assess for complete hymenincomplete could cause hydrocolpos later in life Bruising and edema of genitals common w/ breech birthany ambiguous appearance or unusual orifice in vulva/perineum must be vigorously assessed Mucoid and slightly-bloody vag DC normal for up to 4 weeks; adhesions at times bind majora and minora greatly, can obstruct urinary outflow may need to tease open Advanced Assessment of the @& GU System Children: Inspection/palpation suffices unless bleeding, trauma, DC, or abuse Bubble bath vaginitis common in children, speculum exam NOT indicated Place child in frog on parent s lap or on exam table Use labial traction (grab L/R majora firmly w/ thumb and index finger, pull apart and up) to visualize hymenassess for intactness, perforated hymen will bulge on coughing; also used to find FBs If Bartholin or Skene palpable, suspect (gonococcal) infec. Etiologic agents for vaginal DC (trichomonal, gonococcal, or monoilial) include soaps, bubble baths, detergents, and UTI; foul odor suspicious for FB Vulvar swelling w/ bruising and DC indicates possible sexual abusebicycle seats do not cause external genitalia injury Vaginal bleeding: suspect FB, abuse, ovarian tumor, cervical CA, or injury If bimanual exam indicated, pt. lies on back with bent knees to chest; cervix/ FB palpable; ovaries not Adolescents: Any sexually-active @& should have annual pap, STD assessment, and manual pelvic; if non-active, 1st exam at 21 (note surveillance of lesbian women) Perform exam w/o parents if possible also important for Hx taking; Vaginal secretions ! right before menarche Advanced Assessment of the @& GU System Pregnant Women: Follow same procedure for non-preg In early preg, isthmus begins to soften while cervix remains firm 2nd month cervix, vag, vulva acquire their blue Cullen color ! secretions and ! vascularity normal; anteflexion of uterus !, causing bladder pressure to ! along w/ ! frequency; uterine deviation to one side and irregularity of uterus normal @ 8-10 weeks (Piscacek Sign) Pelvic Size: Mostly performed in 3rd trimester Insert fingers until tips reach sacral promontory, make a gun w/ thumb and hand, remove and immediately measure the distance Uterine Size: Describe in cms; measure w/ fundal forceps Cervical Dilation and Length: 10cm is complete dilated os; effacement occurs before dilation Overall cervix ! in length; shortening in midpregnancy = risk for preterm delivery Station: Relation of presenting part to the ischial spines of mom s pelvis; 0 measurement is at the spines, 1+ through 5+ 1-5cm below spines; -1 through -5 1-5 cm above spines Fetal Head Position: Assess w/ fingers, feeling for midline saggital suture, follow to anterior/ posterior fontanels Advanced Assessment of the @& GU System Pregnancy-Specific Techniques Advanced Assessment of the @& GU System Older Adults: May need assistance to hold legs in stirrups during exam Elevate head and chest for pts w/ orthopnea May need smaller speculum due to age-related constriction Labia appear flatter and smaller, more pale w/ drier skin; clitoris is smaller and pubic hair sparse and gray Urinary meatus may alter positions and be an irregular slit Vagina is narrower and shorter w/o rugation Cervix is smaller and paler; os is smaller Older women more likely to have atrophic vaginitis Women w/ Disabilities: See Seidel, et. al (2006), p. 620-622 Abnormal Presentations: @& GU PMS: Edema, HA, wt. gain, irritability, nervousness 5-7 days pre-menses Infertility: Inability to conceive after 1 year unprotected intercourse; caused by gynecological diseases, stress, nutrition, chemical substances, chromosomal Dz, immunologic problems, relationship difficulties Endometriosis: Growth of endometrial tissue outside of the uterus; causes pain, dysmenorrhea, and heavy or prolonged flow nodules palpable along uterosacral ligaments Abnormal Presentations: @& GU Endometriosis Abnormal Presentations: @& GU Sexually-Transmitted Infections (STIs): Condylomata acuminatum: Genital warts on genital/ perianal region caused by HPV infection Abnormal Presentations: @& GU Molluscum contagiosum: Caused by poxvirus, 2-7 weeks s/p exposure dome-shaped, flesh-colored papules Abnormal Presentations: @& GU Syphilitic Chancre (Primary Syphilis): firm, painless ulcer; often go undetected Condyloma latum: lesions of secondary syphilis flat, round, papules covered by gray exudate Abnormal Presentations: @& GU Herpes Lesions: Small, red vesicules; PAINFUL; original infection diffuse, then localized Abnormal Presentations: @& GU Vulva and Vagina: Bartholin Gland Inflammation: usually caused by gonococcal infectionhot, red, tender, fluctuant swelling that may drain pus Abnormal Presentations: @& GU Cystocele: herniated protrusion of bladder through anterior vaginal wall greater seen w/ bearing down Abnormal Presentations: @& GU Rectocele: hernial protrusion of rectum through vagina Abnormal Presentations: @& GU Vaginal CA: Can be r/t in utereo DES exposure; findings include DC, lesions, and masses w/ Hx of spotting, pain and urinary habit change seen as a raised red lesion on vulva Abnormal Presentations: @& GU Urethral Caruncle: No symptoms other than red polypoid growth protruding from urethral meatus Vaginal Infections: Caused by different pathogens; trichomoniasis seen w/ strawberry cervix Abnormal Presentations: @& GU Cervix: Later transverse, bilteral transverse, or stellate scarring cause by trauma Cervical Polyps: Bright, red, soft and fragile arising from endocervical canal Cervical CA: Hard, granular surface at os; assessed early w/ pap Ectropion: shiny red tissue around os that may bleed easily pap immediately Abnormal Presentations: @& GU Cervical CA: Abnormal Presentations: @& GU Uterus: Prolapse Abnormal Presentations: @& GU Differential Dx: Uterine Bleeding: Abnormal Presentations: @& GU Myomas (Fibroids): Common, benign, uterine tumors appearing as firm irregular nodules in the contour of the uterus Endometrial CA: Occurs most often in post-menopausal womenpost menopausal bleeding initial sign Adnexa: Ovarian cysts: growths which occur uni or bilaterally; smooth and sometimes compressible; ruptured mimics ruptured tubal Ovarian CA: Enlarged ovary often 1st finding; often similar to GI c/o: generalized ABD discomfort, pain, gas, indigestion, pressure, edema, bloating, cramps, feeling of fullness Ruptured tubal preg: pelvic tenderness w/ rigidity of lower ABD; + chandeliers sign; tachycardia w/ shock and hemorrhage into peritoneal cavity---EMERGENCY; confirm w. HCG test PID: often caused by gonococcal or chlamydial infection tender, biltaeral, tender, iregular, fixed adnexal area (salpingitis) Abnormal Presentations: @& GU Infants and Children: Ambiguous genitalia Abnormal Presentations: @& GU Hydrocolpos: Collection of infectious vaginal secretions behind an imperforated hymen Vulvovaginitis: warm, erythematous, and swollen vulvar tissues caused by sexual abuse, trichomonas, monoilial or gonococcal infection or FB, bubble baths, diaper, irritation, urethritis, injury Pregnant Women: PROM: passage of fluid from vagina; asses w/ nitrazine paper (turns turqoise from pH of 7.15 of amniotic fluid, forms fern patter when dried) Prolapse of umbilical cord: can be caused by many etiologies; need to relieve compression or fetal death could result Bleeding: Multiple etiologies; need to make sure placenta previa or abruption has not occurred before speculum exam Vulvar varicosities: common Older Adults: Atrophic vaginitis (dry/pale mucosa w/ possible erosions and petechiae w/ a white, gray, yellow, green, or blood-tinged thick or watery DC; Urinary Incontinence Differential Dx: Gynecological Problems Advanced Assessment of the B& GU System Anatomy and Physiology: Male genitalia = penis, testes, scrotum, prostate gland, seminal vesicles Penis: contains 2 cavernosas and 1 spongiosum, fill w/ blood during an erection; prepuce covers glans unless cicrumsized, covered in smegma, secreted by sebaceous glands Testes produce testosterone and spermatozoa Epididymis overrides testes, w/ storage, maturation, and transit of sperm( vas deferens ( spermatic cord + seminal vesicle = ejaculatory duct Prostate surrounds bladder neck, forms enzyme fibrinolysin, which liquefies semen Erections occur as a result of autonomic nervous system input, which can be either psychogenic or local reflex mechanisms Infants and Children, Adolescents, and Older Adults: Fetal insult @ 8-9 weeks can cause serious genital formation problems 1st sign of sexual maturity is testicular growth, w/ reddening scrotum, thins and becomes pendulous; penis and prostate enlarge and pubic hairs forms diamond With age, pubic hair becomes sparse; rate of conception ! w/ age; intercourse ! Advanced Assessment of the B& GU System Anatomy of B& GU Advanced Assessment of the B& GU System Review of Related Hx: Hx of Present Illness: Impotence: Pain w/ erection Constant/ intermittent, prolonged, painful; w/ one or more partners Associated w/ ETOH, ingestion or Rx Non/Rx, complementary, diuretics, sedatives, anti-HTNives, tranquilizers, estrogens, antidepressants/psych meds Persistent erections unrelated to stimuli Curvature of penis w/ erection Difficulty w/ ejaculation: Painful or premature, efforts to Tx Ejaculate color, consistency, odor, amt Non/Rx, complementary Tx Penile DC/Lump: Character: lumps, sores, rash DC: Color, consistency, odor, staining of underwear Symptoms: itching, burning, stinging Exposure to STI: Multiple partners & infections of partners, condom use, STI Hx Non/Rx, complementary Tx Advanced Assessment of the B& GU System Infertility: Lifestyle factors ! scrotal temp: tight clothing, briefs, hot baths, high-temp in employment (steel mill), prolonged sitting, varicoceles Length of time attempting preg, sexual activity patterns, knowledge of womens fertility Hx of undescended testes Dx Tests: Semen analysis, PE, sperm ATB titers Non/Rx, testosterone, glucocorticoids, hypothalmic releasing hormone, alternative Tx Enlargement of Inguinal Area: Intermittent/constant, assoc w/ straining, lifting, duration, pain Change in size or character of mass, ability to reduceif not, when could it be reduced Pain in the groin: Character (tearing, sudden, searing, cutting), associated activity (lifting heavy object, coughing, straining at stool) Non/Rx, alternative Tx Testicular Mass/Pain: Change in size; events surrounding onset (noted while bathing, after trauma, during sports); irregular lumps, soreness, heaviness in testes; Non/Rx, ATBx, alternative Tx Advanced Assessment of the B& GU System Past Medical Hx: Surgery of GU system, undescended testes, hypospadias, hydrocele, hernia, prostate, sterilization STI: single or multiple infections, which organism (gonorrhea, syphilis, herpes, warts, chlamydia) Tx, effectiveness, residual problems Chronic illness: testicular/prostate CA, neuro/vascular impairment, DM, arthritis, cardiac/respiratory Dz Family Hx: Infertility in siblings; Hx of prostate/ testicular CA; hernias Personal and Social Hx: Employment risk of trauma to genitalia, radiation/toxic exposure Exercise: use of protective devices Concerns of genitalia: size, shape, surface characteristics, texture TSE practices Concerns about sexual practices: sexual partners, sexual orientation Reproductive Functions: # of children, contraception used, frequency of ejaculation (! ejaculation ! risk of prostate CA) Use of ETOH/ street Rx Advanced Assessment of the B& GU System Infants and Children: Maternal use of sex hormones, BC during preg Complications from circumcision Uncircumsized: hygeine measures, foreskin retractability, interference w/ urinary stream Scrotal edema w/ BM/crying Congenital anomalies: hypospadias, epispadias, undescended testes, ambiguous genitalia; Parental concerns w/ masturbation, sexual exploration Swelling, discoloration, sores on penis/scrotum/genitalia Concerns of sexual abuse Adolescents: Knowledge of reproductive health, source of information about sexuality Presence of nocturnal emissions, pubic hair, genitalia enlargement, age of each occurrence Concern of sexual abuse Sexual activity; contraception use Older Adults: Change in frequency of sexual activity/desire; r/t loss of spouse or other sexual partner, sexually restrictive environment; physical illness resulting in fatigue, weakness, or pain Change in sexual response: Longer time required to achieve erection, less forceful ejaculation, longer interval between erections, prostate surgery Advanced Assessment of the B& GU System Examination and Findings: Inspection and Palpation: Inspect distribution of pubic hair, should extend scrotum to anus Examine penis, dorsal vein should be apparent; ask pt. to retract foreskin and assess for smegma (phimosis common in 1st 6 yearscan be caused by recurrent infection or scarring adhesions); balanitis also seen w/ phimosis, especially in men w/ DM and candidal infection Urethral meatus should be ventral slit, just mms from tip of glans; pinch lightly and assess mucous membraneshould be pink; bright erythema = inflammation; pinpoint = stenosis Shaft should be free of tenderness, nodules, and induration; strip penis for DCmay indicate venereal infection Inspect scrotum; redness common for redheads, not others (infection); L testicle is lower due to longer L spermatic cord; small sebaceous cysts common (epidermoid cysts); fluid can collect in testes causing edema, seen in cardiac, renal, hepatic Dz Advanced Assessment of the B& GU System Insert finger into inguinal canal, ask pt. to bear down, assess for bulging; feel for herniation of bowel slap finger w/ cough; hernia is indirect if it lies in canal, direct if medial to external canal, femoral if more towards ABD Palpate 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FgdyGjIIMJdJzJ$K%KNLpL4M"NNNNN0OTOOOOPPPJQvQ & FgdyG & FgdyGgdyG & F gdyG & F gdyGvQQRaR|RR SES^S_SlSST'TJTXTUUUVLVVW & F gdyG & FgdyG & FgdyGgdyG & FgdyG & F gdyG & FgdyGgdf,y & F gdyGWXAYYT[V[[\^^^^__!_`nXm  & FgdyG & FgdyG & FgdyG & FgdyGgdyG & F gdyGk stream could indicate stenosis Inspect scrotum for size, shape, rugae; nonterm will not have rugae, or prominent testes; palpate testes lightly as w/ the adultif one of the testes is not palpable, depress ABD above inguinal canal and feel for lump in the canal; if lump moves downward to scrotum w/ depression, it is descended; if not, undescended Advanced Assessment of the B& GU System Transillumination (mostly replaced by US): Must determine presence of liquid, gas, or solid material if any mass palpated other than testicle or spermatic cord Shine penlight through mass, attempt to reduce through inguinal canal; if size of mass doesnt change, suspect liquid; if no illumination and size does change, suspect hernia; if size does not change nor mass illuminate, suspect incarcerated hernia (EMERGENCY) Children: Perform same as infant, assure modesty Inspect penis for size, lesions, swelling, and malformation Presence of penile swelling, tenderness or ecchymosis indicates possible abuse Well-formed scrotal rugae indicates descended testes even if not in scrotum; scrotum that is small, flat, or underdeveloped good indication of undescended testes (cryptorchidism) Hard, enlarged painless testicle may indicate tumor; acute edema w/ discoloration could be torsion (EMERGENCY) or orchitis Thickened nodular epididymis = epididymitis Adolescent exam same as adults Advanced Assessment of the B& GU System Tailor Position Abnormal Presentations: B& GU Hernia: Assess carefully for incarceration and strangulation Differential Dx: Abnormal Presentations: B& GU Hernia Abnormal Presentations: B& GU Penis: Paraphimosis: severe inflammation of prepuce, constricts circulation to penis, can cause necrosis Hypospadias: urethral meatus located on ventral penis; primary is at glans, secondary is at ventral shaft, tertiary at base Syphilitc Chancre: occurs 2 weeks s/p exposure, painless, indurated borders, spirochetes on microscopic exam Abnormal Presentations: B& GU Herpes: Painful vesicular lesions on glans, shaft, base Condyloma acuminatum: Genital warts from HPV infection; precursor to CA Lymphogranuloma venerum: STI caused by chlamydia; initial painless erosion near coronal sulcus Abnormal Presentations: B& GU Molluscum contagiosum: pearly gray, dome-shaped, discerete pox-virus lesions Peyronie Dz: fibrous band in the corpus cavernosa causing extreme deviation during erection Penile CA: Tends to occur in uncircumsized men w/ poor hygeineinitial lesion resembles syphilis; does not heal Abnormal Presentations: B& GU Scrotum: Hydrocele: Nontender, emooth, firm mass from fluid accumulation in tunica vaginalis should disappear by 6 mos; will not transilluminate nor shift to canal Spermatocele: cystic swelling of epididymis; no transillumination Varicocele: abnormal dilation of the veins of the spermatic cord; sack of worms in scrotumsmall palpated during valsalva, moderate palpated w/o valsalva, large visible w/o palpation Orchitis: Acute inflammation of testis; mumps in childhood, prostatic infection migration in adults Abnormal Presentations: B& GU Epididymitis: Often seen w/ UTI; epididymis is very tender w/ erythema r/o torsion immediately; systemic infections can differential Dx (torsion w/o fever, chills, sweats) Testicular Torsion: EMERGENCY w/ inter-wrapping of spermatic cord; assess for VERY tender testis, N/V, traumatic Hx (not always) Testicular Tumor: irregular, nontender mass fixed on testis; most malignant (most common 15-30 years) Klinefelter Syndrome: XXY inheritance; hypogonadism, small scrotum, female pubic hair distribution, gynecomastia Differential Dx: Testicular Disorders Advanced Assessment: Anus, Rectum, Prostate Anatomy and Physiology: Internal sphincter under autonomic control External sphincter controls defecation voluntarily Lower anus rich w/ nerves, upper not; upper problems may be painless Anal canal lined w/ columns of Morgagnispaces between columns called cryptsinflammation of the crypts results in ficcures Internal hemorrhoids result from dilated veins of the zona hemorrhoidalis; dilation of lower venous plexus results in external hemorrhoids Rectum dilates above anorectal junction and forms the ampulla at the coccyx and sacrum, storing flatus/feces; lower valve of Houston palpable Prostate gland surrounds the urethra; posterior surface in contact w/ anterior rectal wall; it is convex and divided by shallow median sulcus, separating L and R lobes; seminal vesicles extend outward from the prostate Infants: Passing of meconium w/in 1st 24-48h = anal patency Control of sphincters occurs between 18-24 months Prostate becomes functional at puberty Pregnant Women: Constipation common due to ! GI tract motility, ! risk of hemorrhoids Older Adults: Degeneration of neurons in rectal wall leads to ! sensitivity to rectal stretch, ! retention of stool; sphincter tone also !, leading to incontinence Advanced Assessment: Anus, Rectum, Prostate Anatomy of Anus, Rectum, Prostate Advanced Assessment: Anus, Rectum, Prostate Review of Related Hx: Changes in BM: Character (#, frequency, consistency of stools, presence of mucus/blood; colordark, bright red, black light/clay) Onset and duration: sudden or gradual; relation to dietary habits; relation to stressful events Accompanying S/S: incontinence, flatus, pain, fever, nausea, vomiting, cramping ABD distension Rx: Fe-, laxatives, stool softeners, Non/Rx Anal discomfort: itching, pain, stinging, burning: Relation to body position and defecation Straining at stool Presence of mucus or blood Interference w/ ADL/sleep Rx: hemorrhoids, Non/Rx Rectal Bleeding: Color: bright or dark red, black Relation to defecation Amt: spotting on toilet paper vs. active bleeding Accompanying changes in stool: color, frequency, consistency, shape, odor, presence of mucus Associated symptoms: incontinence, flatus, rectal pain, ABD pain/cramping/distention, wt. loss Rx: Fe-, Non/Rx, fiber Males: Change in urinary function: Hx of enlarged prostate Symptoms: hesitancy, urgency, nocturia, dysuria, change in force or caliber of stream, dribbling, urethral DC Advanced Assessment: Anus, Rectum, Prostate Past Medical Hx: Hemorrhoids, SCI, BPH/CA Females: episiotomy or 4th degree lac; colorectal, breast, ovarian, endomentrial CA Family Hx: Rectal polyps; colon CA or familial CA syndromes; prostate CA Personal and Social Hx: Bowel habits and characteristics: timing, freqency, #, consistency, shape, color, odor Travel Hx: areas w/ high incidence of parasitic infection, including zones in the US Diet: inclusion of fiber foods (cereal, bread, nuts, fruits, veggies) concentrated high-fiber foods, amount of animal fat Risk factors for colorectal/prostate CA Use of ETOH Infants and Children: Newborns: characteristics of stool BM accompanied by crying, straining, bleeding Feeding habits: types of food, milk, appetite Age at which bowel and toilet control were achieved Associated S/S: episodes of diarrhea/ constipation, tenderness when cleaning after stool; perianal irritations, wt. loss, nausea, vomiting, incontinence in toilet-trained child, convulsions Congenital anomalies: imperforate anus, myelominingocele, aganglionic megacolon Pregnant Women: Weeks of gestation and estimated date of delivery; exercise; fluid intake and dietary habits; Rx (MVM, Fe); use of alternative Tx Older Adults: Changes in BM character: frequency, number, color, consistency, shape, odor Associated S/S: wt. loss, rectal/ABD pain, incontinence, flatus, epidodes of C/D, ABD distension, rectal bleeding Dietary Changes: intolerance of foods, inclusion of high-fiber foods, regularity of eating habits, appetite Males: Hx of enlarged prostate, urinary symptoms (hesitancy, urgency, nocturia, dysuria, force and caliber of stream, dribbling) Advanced Assessment: Anus, Rectum, Prostate Examination and Findings: Have male bend over exam table, female during vaginal exam in lithotomy Sacrococcygeal and Perianal Areas: Skin should be smooth and uninterrupted, free of lumps, rashes, inflammation, excoriation, scars, dilpling, and hair tufting Assess perianal area for s/s of pinworm infestation (children) or fungal infection (adults, especially those w/ DM) Tenderness should alert APN to perianal abscess, anorectal fistula, plionidal cysts, or pruritus ani Anus: Skin around anus should appear coarser and more dark; assess for lesions, tags, warts, hemorrhoids, fissures and fistulasask pt. to bear down and assess for fistulas, fissures, prolapse, polyps and hemorrhoidsdescribe by clock location Sphincter: Insert lubed finger into canal, ask pt. to tighten sphincter and note tone/discomfort; lax may indicate neuro deficit; extremely tight may be adhesions, fissures, or anxiety Anal fistula may produce so much pain, the exam cant progress w/o anesthesia Rectal pain almost always indicates Dz, loof for irritation, constipation, fissures, thrombosed hemorrhoids Advanced Assessment: Anus, Rectum, Prostate DRE Advanced Assessment: Anus, Rectum, Prostate Anal Ring: Rotate finger around ring noting for nodules or irregularities Lateral and Posterior Rectal Walls: Insert finger further and feel for nodules, masses, irregularities, tenderness, or polyps; should be smooth, even, and uninterrupted Bidigital Palpation: Use to assess for perianal abscess; depress thumb and feel skin between examining finger and thumb Anterior Rectal Wall and Prostate: As you palpate prostate, inform male he may feel need to urinate but wont Should feel like a pencil eraserfirm, smooth, and slightly movableshould be nontender Expected size is 4 cm w/ no more than 1 cm rectal protrusion Hypertrophy noted by intrusion into rectum in cms Rubbery or boggy prostate = BPH Stony hard nodularity with obliterated sulcus may indicate CA, calculi, or fibrosis; fluctuation indicates abscess ID median sulcus and lateral lobes; CA staged in Grades 1-4 Assess stool on glove for blood/discoloration and guaic PSA used for assessment: < 4 ng/ml = normal; 4-10 ng/ml = borderline; > 10 ng/ml = high Good idea to compare PSA w/ Free PSA; borderline PSA + low Free PSA = probable CA Advanced Assessment: Anus, Rectum, Prostate DRE of Prostate Differential Dx: Stool Abnormality Advanced Assessment: Anus, Rectum, Prostate Infants and Children: Do not perform unless there is a suspected problem (mass, tenderness, bladder distension, rectal or bowel abnormalities, deviation in expected stool patterns) Inspect buttocks for redness, masses, or firmness; swollen, tender, perirectal protrusion, abscess, possible fistulas (especially w/ coughing, BM, crying, etc.) Shrunken buttocks indicates hip dislocation Perirectal redness and irritation may be pinworms, candida or diaper irritants Hemorrhoids ALWAYS indicate significant pathology (rule out portal HTN) Look closely for condylomas, indicating possible syphilis infection Sinuses, hair tufts, and dimpling of pilonidal area may indicate spinal cord lesion (as does lack of anal wink) If there is no stool passage in a newborn, assess for rectal atresia, Hirschprung Dz, or CF Internal exam done w/ child lying supine w/ legs spread; transient bleeding and rectal prolapse after DRE (use 5th digit) is normal Assess sphinctershould be snug but not too tightthis could indicate stenosis; lax sphincter indicates peripheral nerve or SCI, Shigella, or impaction Perianal bruising, scars, tears, and dilitation suggestive of abuse; empty rectum in the presence of constipation suggests Hirschsprungs Dz Palpable prostate in boys could indicate precocious puberty Perform rectal exam on adolescents w/ lower GI c/o `8:tL :!  /01]K      7yz+WQS4,444829:::>@d@e@@AACӽǻӻUh2h26]h2h2h2H* h2h2h2h2>* h2>* h&>*hf,y hyGhyGhf,yhyG>*J 8:tLZ3 z  & FgdyG & FgdyG & F gdyG & FgdyGgdyG & FgdyGP:L ! b2  01]u & F gd2gd2 & FgdyG & F gdyG & F gdyG & FgdyGgdyGu-VrKap & Fgd2 & Fgd2 & Fgd2 & Fgd2gd2 & F gd2 & Fgd2C*=Xr b          , 7  & F gd2 & Fgd2gd2 & Fgd2 & Fgd27 u   9      N |  nP^  7Q & Fgd2gd2 & Fgd2 & F gd2Q9 yz"FCf & F gd2 & F gd2 & Fgd2gd2 & Fgd2 & Fgd2 Fx G*+Wgk 8e & F gd2 & Fgd2gd2 & F gd2,4<4444?5666,7Z888299O::::<=d@ & Fgd2 & Fgd2 & Fgd2gd2 & F gd2Advanced Assessment: Anus, Rectum, Prostate Pregnant Women: Stool may appear dark green or bloack due to Fe- supplementation; may also cause C/D Evaluate hemorrhoids (more common in 3rd trimester) for s/s of infection or bleeding Older Adults: May have to result to L lateral position due to functional ability to bend Sphincter tone may be ! Prostate more likely to be larger w/ obliterated sulcus; smooth, rubbery, and symmetric Polyps predispose to CA Anus, Rectum, and Prostate Diseases Pilonidal Cysts: usually indicate anomaly; sinus track w/ dimpling and tuft of hair w/ peri-erythema; may also indicate abscess, infection, or fistula Anal Warts: Condyloma resulting from HPV infection; ! risk for anal CA Anus, Rectum, and Prostate Diseases Anal Cancer: Often curable due to slow progression; typically squamos cell; pap screening test Perianal/Perirectal Abscess: Area of edema and perierythema, TENDER, unexplained fever Anorectal Fissure: Tear in the rectal mucosa from passage of hard stool; sentinel skin tag at site of tear Anus, Rectum, and Prostate Diseases Pruritus Ani: excoriation, thickening, and ! pigmentation due to chronic inflammation; parasitic or fungal etiology Hemorrhoids: Varicoise veins above (external) or below (internal) anorectal line; internal not palpable unless they prolapse through the rectum (thrombosis, infection) Polyps: adenomas or inflammatory outpouchings (pedunculated-stalked or sessile- attached to wall), bleeding common Anus, Rectum, and Prostate Diseases Rectal CA: screen w/ pap; assess for stony, irregularly contoured mass in rectum; bleeding usual symptom Intraperitoneal Mets: hard, nodular shelf at tip of examining finger Rectal Prolapse: rectum dislocates externally usually w/ stool straining; common in children w/ CF; Anus, Rectum, and Prostate Diseases Prostatitis: acute inflammation resulting in tender often asymmetric prostate; may fluctuate w/ boggy, tender areas BPH: Enlargement of the prostate w/ advanced age; prostate feels smooth, rubbery, enlarged; urinary symptoms usually occur Prostatic CA: hard, irregular nodule palpated w/ asymmetric and obliterated sulcus Anus, Rectum, and Prostate Diseases Children: Enterobiasis: Pinworm/Roundworm infestation; lays eggs while child asleep; severe pruritis ani common, especially hs; tape on anus, microscopically examine for nematodes Imperforate Anus: Anorectal malformations; several different kinds; inability to pass stool raises suspicion     PAGE 1 PAGE 6 PAGE 51 d@e@@@7AAAA6BBCC)C3CCJDLDMDODPDRDSDUDVDaD&` & FgdyG & Fgd2 & F gd2 & Fgd2gd2CC)CJDKDMDNDPDQDSDTDVDWD]D^D_D`DaDeDfDlDmDnDoDpDrDsDyDzD|D}D~DDDD׷h20JmHnHuhyGhyG0JmHnHu hyG0JjhyG0JUhojhoU h2h2h2h2>*h2"aDbDcDdDeDpDqDrD~DDDDD & FgdyG hh]h`h&`&`h]h ,1h/ =!"#$% Dd\  c 8AHorseUnivb%B UDnB UPNG  IHDR!gAMA|Q pHYs.#.#x?vӊIDATx^]uGߜ+wr[CKTQEJ)RwqwIMIvgVff7e˳˛7o P(܁G0ZIP:,P(rTQC)3@5SE Ptym01Q'6zC@1o3@z6<]| ,!(4cȇfV(a=Iu#*QzZC}Pr7a )ңBj=BP)E"+ +م{GebY0))E"+pud,m@JK\ax,"@52^w+\˾*<"@=ÊyKCm_9O-Pp=G#Zpl&@*\a%C|x-?>Pr尢@SQdvĘy "@UdrͱdيfK("sg(7C]b@B !S6ƮigI"P(@N9m#W2>_̭IHt"@5dUX \"kk1F?jQI)E";p?|sR+QaYlyQ(g8O֒dv&pJȠ]LM )܀AX:%wF9m&R(F+~!_ +O 8r*:cwWYY(%E"8aEcj3H'dϡȜ ֚i|zR(.cfM`O׌Ȭb'܂l"@pq갞|?8f '"{43)JSP)eP\ G:m/1=8u:ѿ}Y)+CaYZ'&UL(Bq+vEmNO6rߡ3C9鉑.<<x(נ` =ihE)Epz4~+T_Q6Ͽ'Eb,س2%[4NjP\9,&l{C ?^P1> P?H|%~ֿKufCP(9cVRgXۨ"g yKCFmCR8aE{^ad,Zq>_0OP\ G8}S1NM$OlsWlv@(t_2*ϴIr?;%2\ɣfQ=/)a)Lޤ)E"hҧvc)vOkpA3rI/&Te 9W_} 0pZAP_M#vA&հS^EЬ!_m~XH]h=fP!64q"@>evOqQxJ#a=xsàvGj}Q"@ȣhiWwfb܆%f@D@uo GV-yw(+ 8af?H,2R(yU$T}E?A,b(#E /#axgO 6&ƭSibVHaT8fC=t8:4 VՐަ+#b[M]b"@pqBx-$go2(E" uXٿ}ѻoeU)'P6k'0S9z !PH tX+ԶmuWE۬ސEjQAz9)t" qX~mpPsxVGO)Aa"pg-a&#Xߏ2R(y|ii3y;yp:<ElqD\["Ǔ)eO>(IM_Rm!1Xui1v"uXM`8l`$>ÔKR(`:I(7EJv^"XeP(x+k%)*O^&ܔ|ΣE@ _$uV_$0ز*;H`9WH"RAbLjJC8K$8^l_ŋ4DCH4:JE%8 i ׷}LdVCb"@ȳ`8y0}m]"F+2R(ne lOvwj`t)Br.VI),)9|@ECȍBSW"@㈈ "@p'!@&ӥlk~p|#kZJnPփ/Sej[=zIHVb9xgrTs:"@}6_.U$,T܈l{_=ɍS)ZQ C+V5]伬;gϸ+LY#ˮY.Rlc{i)1sp"V :o?G%-8zwbG/ f%gLu/0ȧgjׯ\¯߰_vMnP@sXQ}WLֲԞUdNwXWW?TB}t(/~T?)#E"{yok%וք9fk@ɹ8TIEt_*lgy3"@TA"@ Fa]PA5V]SX"&cSOƦqy Tgm1w<,JM @_1 U89`ڌ]_1' l8fA<$4BpWPVQEt췟Tx,L>AS߾_wg1R(VۊhVp?uj,CGZv6s{%.2@jE /#b)G>kr\_z^dĽzk7 f$"@Ca픺(GTnwL'wVÝ}VdJ0CH"b`N2س;vMu[=`3IPvX.bAE- 6 U|{z1o%b Ö {i &y9LJN`#n ]ڥM={ف_ӏnWDHą (E"\ְi!uG(*·41O^ v`&UA(EXhڵqX ne;k4-v J*" : ;m&tWe4"PrXnE IUl1Nܛ9+d:B@#5 㨢qi@{/5(рjK͗WNWdW*nA8C ͠ <{1,D=c2጖j]j%P~E@y!]trCаG~x''N\~Ii(yy( qĩmjVu/)`mh]D5#8]TE ﰎ۩{Q^$`cy/Is0Lzr5VAH(4dVrodѤjW v*mb(E"# "Xw38|Uok K|:=PuXѫ n[*Ҡ#W0Ќzf E@Yu6)CL-MqMuN9,6$t#Kp[V2B?f[6$~l&ktGV_{Jㆭ2PaݼϋiVP[\n&97WPꭥ;_ _9N52?+c*2+cU3`GѶ*O=?.^tm_)f FGB/#B{P0|{GVvG+Bя[/siՀSG@谢5My[{PltU~% D%|\V4CTw."!%P:K3!SL Ƀ77~@E71 Ma=9PP݂ؕl}dVH~Ou磱"2k R"@aN)֓>_f0d3d<_]b"7hu(d"@E@7{ >KVĕ'g{U!<FTx ~OO~6vlpPnLfEifa1.:g*?^E cy2ZvҫHG V JԘA ,e*sot@[',g"fb4N>w oR1cLuT$JA @ﰌ\bDf_/>}АH%GEE8t2)E;S+:`!Kfte4 XL^X3p2& zE@4*6}S~jpZ҈*(E" sX;XKl S04fGMxGX^֪mp'MZ_}Lf$դ䣢>Sg-XjD (E- q%AQ3xbB~o޺ jdu$7$ uD)Cw} E(•(PsȊ$;H526|M."~(_9:ҭwa60P)Dlo;@7^t^ESg^5M!h>ڤI-FugUA2XI'^稑*ڔ"sX?.q7W;փvT<Ǟ6KtHNmFn VOy?Z,ȜR?r.ၣcAZ- e0!;*_ /kxTg<\_z@^IU = Y%=qz{~vXAQ^)5KCz̴gX1rOB1u ȔTW4"ŏn\Z^lkR(&xka7[^ u=_`!oSjo<NXsU?:P&}_2}P,=}ʘU[-+O6q a5Y"XN M}=Fzp,82"#ն?+9ٝx-O'2<>TϺjmnCV`MNYw)'$VM`v܈l)0)1E W"-":EFPk7^rG`; 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