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 ___
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 feel
the scrotum, which is a very distensible muscular bit of tissue and so to confirm that
somebody actually does have just what's called a hydrocele, which is fluid in the scrotum,
you could transilluminate by just shining a flashlight to the back of the scrotum. You would
see that the fluid in the scrotum is fully translucent. In contrast, if a patient has just
enlarged testicles or a varicocele, which is an essentially engorgement of the blood vessels
that go to the testes, if that's the source of the scrotal enlargement it would not
transilluminate and instead there would be opacification when you attempted to
transilluminate with the flashlight. The testes themselves "I'm going to now just touch your
testes ____and 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. 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 and so by using my finger right here on the
scrotum I can insert my finger up towards where the inguinal ring is. I'm looking for the
spermatic cord and inguinal ring should be right in the anterior wall and it really will feel like a
ring in that area. "Now I'm going to ask you Jeff to just turn your head and cough please."
"Ahahh." "Great." So, if a patient did have a hernia, "you can lower your gown now," with
evidence of an intestinal loop protruding and causing an indirect hernia into the scrotal sac,
I may feel that on my finger when he coughs and it protrudes to the inguinal ring. As
opposed to when he coughs right now, I'm feeling what I should feel which is simply a little
bit of pressure from the diaphragm, from the peritoneum as he coughs and that increased
pressure pushes against my finger.