Assessment of the Male Genitourinary System – Advanced (Nursing)

00:00 Now we can move on with the examination of the genitourinary system. So, this particular exam is a sensitive exam and for many patients they may feel very uncomfortable at different parts of the exam so it's really important to maintain or create a good therapeutic alliance with your patient and a good connection with your patient. So, this is my patient, Jeff, and it's important for any patient to make sure that they've had this exam performed in the past. It will be rare that you'll find an adult male who has not had a genital exam, but nonetheless it's worth asking. "Have you had this genital exam performed in the past?" "Back when I was in the military." "Wonderful." Next up, we're going to talk about the different parts of the exam just very briefly. "So, I'm going to examine your scrotum, I'm going to examine your penis, I'm going to check to see if you have had a hernia or any evidence of a risk for a hernia. And then we'll perform the rectal exam and the prostate exam after that." "Okay." "Throughout the exam I'm going to respect your comfort and make sure that you're feeling comfortable as we move through that exam particularly the rectal exam can be uncomfortable for some folks. And in addition, I want to respect your modesty throughout and I'll make sure that no part of your body is exposed that does not need to be exposed as I move on to the exam." "Okay, so having described the different components of the exam, I'll now ask if it's okay with you to gown up and we'll move on with the exam." "Absolutely." "Great." We can now proceed with the genitourinary exam. It's important whenever you're doing any sensitive part of the exam to bring a chaperone into the room with you, that's particularly important when there's a gender discordance between you and the patient you're examining. So, I would normally have that in this circumstance as well. And lastly, it's useful to be at eye level with patients whenever you're examining them if it's possible.

01:42 In this case, it's just visually a little bit easier to do it from this position, but we could have had him sit on the bed here with me standing in eye level and I would have also been away to do this. But with that, we'll jump in and start with the exam. "Jeff, if you wouldn't mind lifting up your gown for me? Please. Thank you." So, first thing we would start off with is gross inspection and just taking a look at the skin, looking at the symmetry from one side to the other. You can see right off the bat this is the shaft of his penis. "And I'm going to examine your penis now." So, the shaft of the penis is symmetric from one side to the other.

02:18 I'm also looking at the glans penis itself and noticing the urethral orifice is centered in the middle of the glans penis. Patients or particularly children may have epispadias with the urethral orifice on top or hypospadias with the urethral orifice underneath. And lastly, you might see evidence of Peyronie's disease, which is an abnormal fibrous stricture on one side of the shaft of the penis that would predispose it towards curving in one way or the other when the penis is erect. Having done that and not seeing any abnormalities, you may also, if you're concerned about an infection I will just ask Jeff "If you wouldn't mind basically milking the bottom of the penis to see if any discharge comes out of the penis. Perfect.

02:58 That's great." So if somebody has gonococcal urethritis, you may see some evidence of some purulent debris would come out the urethral orifice. Okay, so now we can move on with the scrotal part of the exam. So, again, the scrotum oftentimes hangs a little bit to the left with the left testis hanging a little bit lower than the right testis. But otherwise, I'm also looking for those same sexually transmitted infections, which I would see in the skin. We're also looking at scrotal size. So patients who, for example, have heart failure or cirrhosis may have increased hydrostatic pressure, decreased oncotic pressure, and fluid can really fill the scrotum, which is a very distensible muscular bit of tissue. The testes themselves.

03:43 "I'm going to now just touch your testes in order to examine them." So, you're looking for them to be about the same size. You're looking for smooth contour on both of the testes.

03:56 It's normal to be tender when you're touching somebody's testes. They can be uncomfortable but if somebody has testicular torsion or epididymitis or orchitis, they would be exquisitely tender during that part of the exam. When I am feeling the testes, I'm also feeling the upper pole of the testes, which is where the epididymis is. The epididymis sometimes can be palpable, but oftentimes it's hard to really isolate it. "Are you okay?" "So far." "Okay." And then proximal to the epididymis is where you'll find the spermatic cord. Spermatic cord is a very firm structure on either side that's going to the testes and it includes not just the vas deferens, but also the neurovascular bundle going down to the testes as well. There are 2 particular pathologies that you might want to be looking for if a person is complaining of testicular pain, and that would be epididymitis versus testicular torsion. Patients who have epididymitis, one of the classic physical exam features, is that they'll have pain oftentimes unilateral but can be bilateral. That will be alleviated simply by lifting up the scrotum as such. And that's called Prehn's sign if the pain is alleviated somewhat when you elevate the scrotum. In contrast, a person who has testicular torsion, will have a negative Prehn's sign, but what you might find is that since the entire spermatic cord including the neurovascular bundle is being constricted and strangulated. That means that the reflex that mediates contraction of the scrotal muscle will also be compromised, and so when you attempt to perform the cremaster reflex it would be absent. "So, I'm going to just basically grace your thigh here on the inside, and we're going to be looking for evidence that the scrotum lifts up when I do so as follows." So it's very subtle but there's just a little bit of contraction of the scrotal tissue on this side. "I'm going to do the other side now." "And actually you saw it right there, it was delayed but you saw that the scrotal tissue did contract, which is normal cremasteric reflex which might be absent in the setting of testicular torsion. And the last part of the exam in this area is going to be looking for evidence of an inguinal hernia. So for the hernia exam, remember that the spermatic cord again is conveying the vas deferens and the neurovascular bundle from the scrotum, from the testis up through the inguinal ring before we'll ultimately go back towards the penis.