question

Age, Sex

answer

-hemorrhoids -perianal haematomata -fissure-in-ano-(acute) -anorectal abscess -pilonidal sinus -prolapse of rectum (sex)

question

hemorrhoids

answer

-common all ages but are uncommon below the a-age of 20 years -common in both sexes

question

Perianal haematomata

answer

-occurs at all ages

question

fissure-in-ano-(acute)

answer

-quite common in children -common in men

question

anorectal abscess

answer

-common between the ages of 20 & 50 years -more common in men

question

pilonidal sinus

answer

-rare before puberty and in people over 40 years -more common in men

question

Prolapse of rectum

answer

-more common in women

question

Principal symptoms of rectal and anal conditions

answer

-bleeding -pain -tenesmus: feeling that you constantly need to pass stools -change in bowel habit -change in the stool -discharge -pruritis: itchy

question

Bleeding

answer

-can be fresh or altered: ex. of altered is melaena -black tarry stool -recognizable blood may appear in four ways - mixed with faces - on the surface of the faces - separate from the faces: after/unrelated to defaecation - on the toilet paper after cleaning

question

Anal Pain

answer

-careful history focusing on the nature of the pain and its relationship to defecation -the pattern of pain helps differentiate anal fissure from hemorrhoids and other conditions. (hemorrhoids and rectal cancer are usually not painful) -anorectal pain that begins gradually and becomes excruciating over a few days with localized are of tenderness is more likely to be abscess -a nagging, aching discomfort made worse by defecation could be due to hemorrhoids -an occasional, severe, cramp-like pain deep in the anal canal, that often occur at night, lasting about half an hour- Proctalgia fugax -pain is excruciating and may be accompanied by sweating, pallor, and tachycardia -patients experience urgency to defecate, unable to pass stool -a knife-like pain when you have your bowels open, and which may last for 10-15 minutes afterwards. often described like 'passing glass'. bright red blood on the toilet paper may be observed- anal fissure

question

Anal Pain: pain alone

answer

-fissure (pain after defaction) -proctalgia fugax (pain spontaneously at night) -anorectal abscess

question

anal pain: pain with bleeding

answer

-fissure

question

anal pain: pain with a lump

answer

-perianal haematoma -anorectal abscess

question

anal pain: pain, lump and bleeding

answer

-prolapsed haemorrhoids/ rectum -carcinoma of the anal canal

question

past health history

answer

-medical history -anorectal specific -systemic -surgical history -anorectal specific -prostate -medications -communicable diseases: ex. if they have been out of the country -allergies -injuries/accidents -childhood illnesses -anal stenosis -hirschsprung's disease

question

Past health history: family history

answer

-rectal polyps -rectal cancer -pilonidal cyst -prostate cancer

question

past health history: social history

answer

-substance use -sexual practices -work environment -hobbies/leisure -stress

question

Inspection

answer

-assess the following areas for lesions, swelling, inflammation, tenderness, color, appearance -perineum -sacrococcygeal area -anal mucosa (know where these areas are)

question

Palpation

answer

-anus & rectum -assess for masses, anal sphincter, nodules -prostate -bi-digital exam -assess for tenderness, masses, or swelling -assess posterior surface for size, shape, consistency, mobility

question

Gerontological Variations

answer

-decreased muscle elasticity in the rectum -increased risk for rectal prolapse -bowel function changes -enlarged prostate -increased risk for prostate cancer

question

anorectal examination

answer

-one of the most important examinations in a pt with abdominal disease -still its the least popular segment of the entire physical examination -should not be omitted from your examination, especially in middle-aged and older pt, why? -risks missing an asymptomatic: carcinoma -can be done in numerous positions -left lateral (Sims') position: the usual position when the patient is in bed. turn pt on to left side with pelvis vertical. ask pts to draw knees up to chest with buttocks on the side of the couch -the knee-elbow position: pt kneeling on couch, resting on elbows, of particular use when palpating the prostate and seminal -the dorsal position: this position with the pt lying on the back with right leg flexed is useful when the pt is in sever pain, and movement is contra-indicated. Enables assessment of rectovesical pouch in abdominal emergencies -Lithotomy: best position for exam but not always available

question

anorectal exam: things never to be forgotten

answer

-explain necessity of procedure and reassure the pt -explain the procedure -tell the pt that its usually uncomfortable but not painful -get informed consent -ensure adequate privacy -obtain services of chaperone, if appropriate -expose the pt from waist to knee and explain the position of examination -equipment: plastic glove + lubricating jelly + good light

question

anorectal exam: external inspection

answer

-skin tags (normal, Crohn's, hemorrhoids) -rectal prolapse -anal fissure -fistula -anal warts -carcinoma -signs of incontinence, diarrhea

question

anorectal exam: external inspection (straining)

answer

-ask pt to strain -rectal prolapse upon straining -hemorrhoid prolapse -incontinence -ask if straining is painful

question

anorectal exam: palpation

answer

-lubricate index finger -insert finger slowly, assessing external sphincter tone as enter -male: palpate prostate (anterior of rectum) -hard nodule (prostate cancer) -tender (prostatitis -female: palpate cervix (anterior of rectum) -rotate finger, palpating along left, posterior, right walls -withdraw finger -wipe lubricant off pt -ask if was significant pain during examination

question

anorectal exam: inspect withdrawn fingertip for

answer

-blood, melena -stool color -pus -mucous

question

anal rectal diseases

answer

a lot...look at slide

question

anorectal abscess

answer

-an anorectal abscess is a collection of pus in the anal or rectal region -causes: infection of an anal fissure (cleft or slit), Sexually transmitted infections, and blocked anal glands are common causes of anorectal abscesses -abscesses may occur in an area that is easily accessible for drainage, or higher in the rectum -deep rectal abscesses may be caused by intestinal disorders such as Crohn's disease or diverticulitis

question

anorectal abscess 2

answer

-high risk groups include diabetics, immunocompromised patients, people who engage in receptive anal sex, and patients with inflammatory bowel disease -the male to female ratio is approx. 2:1 -the most common organisms -E.coli (60%) -Staph. aureus (23%) -common sites of anorectal abscesses

question

anorectal abscess: symptoms and signs

answer

-pain (the most common symptom) -swelling (95% of patients) -fever (18% of patients) -discharge (12% of patients) -constipation (may occur) -rigors, sweating and tachycardia

question

anorectal abscess: complications

answer

-systemic infection -recurrence -scarring and anal fistula formation

question

anorectal abscess: tests

answer

-rectal exam -proctosigmoidoscopy

question

anorectal abscess: treatment

answer

-urgent incision and drainage (the treatment of choice) -antibiotics

question

rectal prolapse

answer

-rectal prolapse is the abnormal movement of the rectal mucosa down to or through the anal opening

question

rectal prolapse

answer

-mucosal prolapse: is more often seen in children below 3 years of age following an attack of diarrhea or whooping cough and if it occurs in adult is usually associated with hemorrhoids -complete rectal prolapse is seen more commonly in elderly women who have a habit of excessive straining during defecation -rectal prolapse is often associated with other conditions such as -pinworms (enterobiasis) -cystic fibrosis -malnutrition and malabsorption (celiac disease) -constipation -prior trauma to the anus or pelvic area

question

rectal prolapse: symptoms

answer

the main symptom is a protrusion of a reddish mass from the anal opening, especially following a bowel movement

question

rectal prolapse: treatment

answer

*treating the underlying condition *in children conservative treatment -the rectal mass may be returned to the rectum manually -surgical correction for complete rectal prolapse

question

rectal prolapse: complications

answer

-constipation -malnutrition or malabsorption -other complications of underlying condition

question

proctitis

answer

-an inflammation of the rectum causing discomfort, bleeding, and occasionally, a discharge or mucus or pus, and the anus may also be involved -causes: *sexually-transmitted diseases (gonorrhea), herpes, syphilis, chiamydia, and lymphogranuloma venereum *non-sexually transmitted infections (beta-hemolytic streptococcus, amoebic dysentry, bilharzial dysentry) *autoimmune diseases (ulcerative colitis and crown's disease) *tuberculous proctitis *AIDS *radiation proctitis *noxious agents

question

Proctitis: symptoms

answer

-pain, discomfort -rectal bleeding -rectal discharge, pus -stools, bloody -constipation -Tenesmus

question

Proctitis: tests

answer

-proctoscopy -sigmoidoscopy -rectal culture

question

proctitis: treatment

answer

treatment of the underlying cause usually cures the problem. Proctitis caused by infection is treated with antibiotics specific for the causative organism. Corticosteroid or melamine suppositories may relieve symptoms in Crohn's disease or ulcerative colitis

question

benign tumors of the rectum (POLYPS)

answer

-a polyp is a lesion that projects into the lumen -polyps are commonly found in vascular organs -polyps bleed easily -the rectum and sigmoid colon are common sites of polyps -symptoms and signs of polyps *passage of blood and mucus PR *rarely, obstruction or intussuception *****know this- intussusception- the bowel involutes on it self, like when you take a sock and pull it back it kinda folds into it self

question

juvenile polyps

answer

-commonest form of polyps in children -are red pedunculated spheres lesion -can occur throughout large bowel but are most common in the rectum -usually present before 12 years -present with prolapsing lump or rectal bleeding -have little malignant potential -treated by local endoscopic resection

question

adenomatous polyps

answer

-are pedunculated lesions -mainly occur in the rectum and sigmoid colon -are often asymptomatic but may produce anaemia from chronic occult bleeding -may give rise to crampy pain -may secrete mucus -have malignant potential -treated by colonoscopic polypectomy

question

villous papillomas

answer

-are flat, sessile lesions within the rectum -secrete copious amount of mucus producing spurious diarrhoea -present with hypokalemia -sifnificant risk of malignant change -treated by transanal excision of complete lesion -if lesion is extensive, mucosal proctectomy and coloanal anastomosis should be done

question

familial polyposis

answer

-in an autosomal dominate syndrome diagnosed when a pt has > 100 adenomatous polyps -due to mutation on long arm of chromosome 5 -may be asymptomatic but bleeding, abdominal pain and diarrhoea are all likely symptoms -the risk of developing carcinoma is approximately 100% within 15 years -the most appropriate treatment is panproctocolectomy with ileal pouch-anal anastomosis

question

history- bleeding

answer

-diagnosis of anal conditions which present with rectal bleeding -bleeding but no pain *blood mixed with stool = ca of colon *blood streaked on stool = ca of rectum *blood after defecation = hemorrhoids *blood and mucus = colitis -bleeding + pain = fissure or carcinoma of anal canal -the most common causes of rectal bleeding in patients who visit primary care physicians are hemorrhoids, fissures, and polyps

question

risk factors for rectal cancer

answer

-age > 50 -familial history -history of adenomatous polyps, familial polyposis, endometrial or ovarian or breast cancer -diet low in fiber, high in fat

question

prostate exam

answer

-size: 2.5 cm x 4 cm wide -heart shaped with palpable central groove -consistency: elastic, rubbery -nodules -tenderness: non-tender to palpation -mobility: slightly mobile -should not protrude more than 1 cm into rectum

question

risk factors for prostate cancer

answer

-age > 50 -family history -african american -diet high in fat, oil, sugar -high levels of serum testosterone

question

the outlet of the GI tract, 3.8 cm long in the adult. lined with modified skin that merges with rectal mucosa at the anorectal junction. the canal slants forward towards the umbilicus, forming a distinct right angle with the rectum, which rests back in the hollow of the sacrum.

answer

anal canal

question

although the rectum contains only autonomic nerves,

answer

numerous somatic sensory nerves are present in the anal canal and external skin

question

having no hair or sebaceous glands

answer

modified skin

question

anal canal is surrounded by two concentric layers of muscle

answer

sphincters

question

under involuntary control by the autonomic nervous system.

answer

the internal sphincter

question

under voluntary control and surrounds the internal sphincter

answer

external sphincter

question

when are the sphincters not tightly closed

answer

passing of gas feces

question

separates the internal and external sphincters and is palpable

answer

intersphincteric groove

question

columns of morgagni. folds of mucosa

answer

anal columns

question

the anal columns extend vertically down from the rectum and end in ______________. not palpable but visible on protscopy

answer

the anorectal junction

question

each anal column contains

answer

an artery and a vein

question

hemorrhoid

answer

enlarged anal vein

question

at the lower end of each column is a small crescent fold of mucous membrane

answer

anal valve

question

the space above the anal valve is a small recess

answer

anal crypt

question

12 cm long. the distal portion of the large intestines. extends from the sigmoid colon at the level of the 3rd sacral vertebra and ends at the anal canal

answer

rectum

question

the rectal interior has three semilunar transverse folds that cross one half the circumference of the rectal lumen. their function is unclear but they may serve to hold feces at the flatus passes. the lowest is palpable usually on the person's left side and must not be mistaken for an intrarectal mass

answer

valves of houston

question

the peritoneum covers only the upper

answer

2/3 of the rectum

question

the anterior part of the peritoneum reflects down to within 7.5 cm of the anal opening in males and then covers the bladder

answer

rectovesical pouch

question

the anterior part of the peritoneum reflects down to within 5.5 cm of the anal opening and then covers the bladder in females

answer

recto-uterine pouch

question

lies in front of the anterior wall of the rectum and 2 cm behind the symphysis pubis. it surrounds the bladder neck and the urethra and has 15 5o 30 ducts that open in to the urethra. secretes a thin, milky, alkaline fluid that helps sperm viability. bilobed with a round or heart shape

answer

prostate gland

question

the two lateral lobes of the prostate gland are separated by a shallow groove called the

answer

median sulcus

question

project like rabbit ears above the prostate. secrete a fluid that is rich in fructose, which nourishes the sperm and contains prostaglandins

answer

seminal vesicles

question

glands that are the size of a pea and are located inferior to the prostate on either side of the urethra. they secrete a clear, viscid mucus

answer

bulbourethral (cowper) glands

question

in females this structure lies in front of the anterior rectal wall and may be palpated through it

answer

uterine cervix

question

the combined length of the anal canal and rectum in the adult

answer

16 cm

question

sigmoid colon is named for its _____. it extends from the iliac flexure of the descending colon and ends at the rectum. it is 40 cm long and is accessible to examination only through colonscope. the flexible fiberoptic scope in current use provides a view of the entire mucousal surface of the sigmoid as well as the colon

answer

s shaped course in the pelvic cavity

question

a wave of peristalsis that continues throughout life, although children and adults usually produce no more than one or two stools per day

answer

gastrocolic reflex

question

the prostate gland undergoes a very rapid increase to more than twice its size

answer

at male puberty

question

the prostate gland commonly startes to enlarge during the middle adult years. this is present in 1 of 10 males at the age of 40 years and grows larger with age. It is thought that the hypertrophy is caused by hormonal imbalance that leads to proliferation of benign adenomas. these gradually impeded urine output because they obstruct the urethra

answer

benign prostatic hypertrophy

question

more common in north america and northwestern europe. less common in central and south america, africa, and asia. the incidence is higher for african american males than an other racial group. african american males are more likely to be diagnosed at an advanced stage of the diease. family history is positively associated; men with first degree relative are 2 to 3 times more likely to develop this diease. men with BRCA2 mutations have increased risk for developing a more aggressive form at a younger age. environmental risk factors include diets high in red meat and processed meat, animal and saturated fats, an dairy products

answer

prostate cancer

question

prostate cancer screening guidelines were updated in

answer

2010 and state the ages at which men should receive health information about benefits and risks

question

men at average risk for PC should

answer

receive information at 50 years old, 5 years after men at higher risk (african americans and those that have a family history), 10 years after men at very high risk with multiple family members with PC

question

screening for prostate cancer

answer

blood test for prostate-specific antigen (PSA) and a digital rectal exam

question

can be largely prevent by removal of adenomatous polyps

answer

colorectal cancer

question

colorectal cancer guidelines

answer

average risk adults should start being tested at 50 and include health teaching about options for screening

question

colorectal screening options

answer

colonoscopy every 10 years with bowel preparation and conscious sedation and an annual guaiac based fecal occult blood test or fecal immunochemical test

question

constipation

answer

<3 stools/week and is a common concern among aging adults

question

pain due to a local condition (hemorrhoid, fissure) or constipation

answer

dyschezia

question

occur with gastroenteritis, colitis, irritable colon syndrome

answer

diarrhea

question

traveled to a foreign country during the past 6 months

answer

consider parasitic infection

question

black, tarry stool due to occult blood from GI bleeding

answer

melena

question

nontarry, black stool

answer

ingestion of iron medications

question

clay colored stool

answer

absent bile pigment

question

excessive fat in the stool as in malabsorption of fat

answer

steatorrhea

question

mucoid discharge and soiled underwear

answer

occur with prolapsed hemorrhoids

question

beans, prunes, barley, carrots, broccoli, cabbage; lower cholesterol

answer

high fiber foods of the soluble type

question

cereals, wheat germ; reduce risk for colon cancer

answer

insoluble fiber foods

question

fight obesity, stabilize blood sugar, and help with some GI disorders

answer

fiber

question

jelly like mucus shreds mixed in stool

answer

indicate inflammation

question

bright red blood on stool surface

answer

rectal bleeding

question

bright red blood mixed with feces

answer

possible colonic bleeding

question

occult bleeding

answer

usually indicates colon cancer

question

as an aging person performs the valsalva maneuver

answer

you may note relaxation of the perianal musculature and decreased sphincter control

question

sinus tract. a hair containg cyst or sinus located in the midline over the coccyx or lower sacrum. often opens as a dimple with visible tuft of hair and possibly an erythematous halo. may appear as a palpable cyst. when advanced has a palpable sinus tract. congenital disorder, the lesion is first diagnosed between the ages of 15 and 30

answer

pilonidal cyst

question

a chronically inflammed GI tract creates a abnormal passage from inner anus or recut out to skin surrounding anus. usually originates from a local abscess. the red, raised tract oepning may drain serosanguineous or purulent matter when perssure is applied.

answer

anorectal fistula

question

a painful longitudinal tear in the superficial mucosa at the anal margin below. fissures often result from trauma, or from irritant diarrheal stools. the person has itching, bleeding, and exquisite pain. a resulting spasm of the sphincters make the area painful to examine

answer

fissure

question

painless flabby papules are due to a varicose vein. external - originates below the anorectal junction and is covered by anal skin. when thrombosed it contains clotted blood and becomes a painful, swollen, shiny blue mass that itches and bleeds with defecation. internal - originates above the anorectal junction and is covered by mucous membrane

answer

hemorrhoid

question

rectal mucous membrane protrudes through the anus, appearing as a moist red donut with radiating lines. when prolapse in incomplete, only the mucosa bulges. when complete it includes the anal sphincters

answer

rectal prolapse

question

intense perianal itching manifested by red, raised, excoriated skin around the anus. common causes are pinworms in children and fungal infections in adults. the area is swollen and moist, and with a fungal infection appears dull grayish pink. the skin is dry and brittle with psychosomatic itching

answer

pruritus ani

question

localized cavity of pus from infection in a pararectal space. infection usually extends from an anal crypt. characterized by persistant throbbing rectal pain. termed by the space it occupies and appears red, hot, swollen, indurated, and tender.

answer

abscess

question

a malignant neoplasm in the rectum is asymptomatic, thus the importance of routine rectal palpation. and early lesion may be a single firm nodule. you may palpate a ulcerated center with rolled edges. as the lesion grows it has an irregular cauliflower shape and is fixed and stone hard

answer

carcinoma

question

a symmetric nontender enlargement, commonly occurs in makes beginning in the middle years, the prostate feels smooth, rubbery, or firm with the median sulcus obliterated

answer

benign prostatic hypertrophy

question

fevers, chills, malaise, urinary frequency and urgency, urethral discharge, dull, aching pain in perineal and rectal area. an exquisitely tender enlargement is acute inflammation of the prostate gland yielding a swollen slightly asymmetric gland that is quite tender to palpation

answer

prostatitis

question

What does the normal penis look like?

answer

Wrinkled, hairless, without lesions (sometimes visible dorsal vein)

question

What are abnormal findings on the penis?

answer

Inflammation, lesions, chancres, ulcers, wartlike papules

question

What is a normal finding when a male pt pulls back his foreskin?

answer

Some cheesy smegma collected under the foreskin

question

What is phimosis?

answer

narrowed opening of prepuce so cannot retract the foreskin

question

What is paraphimosis?

answer

painful constriction of glans by retracted foreskin

question

What is hypospadias?

answer

ventral location of the meatus

question

What is epispadias?

answer

dorsal location of the meatus

question

What does the normal male meatus edge look like?

answer

Pink, smooth, without discharge

question

What is stricture?

answer

narrowed opening

question

What are abnormal findings in the male meatus edge?

answer

Red, everted, edematous, purulent discharge (all suggesting urethritis)

question

What does the normal scrotum look like?

answer

Asymmetric with the left scrotal half usually lower than the right

question

What are normal lesions found on the posterior surface of the scrotum?

answer

Sebaceous cysts

question

What do sebaceous cysts on the posterior surface of the scrotum look like?

answer

yellowish, 1 cm nodules, firm, nontender

question

What do the testes normally feel like?

answer

oval, firm, rubbery, smooth, equal bilaterally, freely movable, slightly tender to moderate pressure

question

What do atrophied testes feel like?

answer

Small, soft

question

What signs would indicate epididymitis?

answer

indurated, swollen, tender epididymis

question

What does a normal spermatic cord feel like?

answer

Smooth, nontender

question

What does an abnormal spermatic cord feel like?

answer

Thickened, soft, swollen, tortuous

question

What is the transillumination maneuver?

answer

1. Darken the room 2. Shine a strong flashlight from behind the scrotal contents 3. Note that scrotal contents do not transilluminate

question

When is the transillumination maneuver used?

answer

Only if you note a swelling or mass

question

What are the abnormal findings found with the transillumination maneuver?

answer

Serous fluid transilluminates as a red glow

question

What do you inspect the inguinal region for?

answer

A bulge as the pt stands & as he strains down in the external inguinal ring or the femoral canal

question

When does the incidence of testicular cancer peak?

answer

Age 20-39

question

What o should be included when teaching a testicular self-exam (TSE)?

answer

T: timing, once a month S: shower, warm water relaxes the scrotal sac E: examine, check for changes, report immediately

question

When assessing a male infant's voiding why is the strength of the stream significant?

answer

A poor stream may indicate a stricture or neurogenic bladder

question

How long should you wait until you retract the prepuce in an infant? Why?

answer

3 months because of the risk for tearing the membrane attaching the foreskin to the shaft

question

What is the normal scrotum to penis relation in an infant?

answer

The scrotum looks large in relation to the penis

question

What is cryptorchidism?

answer

testes that have never descended

question

What are migratory testes?

answer

physiologic cryptorchidism

question

What is a hydrocele?

answer

cystic collection of serous fluid in the scrotum

question

Are hydroceles normal or abnormal?

answer

Normal in boys younger than 2 years

question

When would urine be blue color?

answer

medications, asparagus, dye after prostate surgery

question

When would urine be dark gray color?

answer

urine contains melanin (melanuria)

question

When would urine be tea color?

answer

liver disease, jaundice, myoglobinuria, medications, food dyes, blood in urine

question

When would urine be pink color?

answer

menses, beets, berries, food dyes, laxatives, kidney stones, UTI

question

When would urine be red color?

answer

blood in urine, nephritis, cystitis, cancer, after prostate surgery

question

When would urine be orange color?

answer

medication, foods, dyes, laxatives, dehydration, jaundice

question

When would urine be amber color?

answer

dehydration, laxatives, foods or supplements with B-complex vitamins

question

When would urine be yellow color?

answer

natural yellow: urochrome excretion bright neon yellow: vitamin supplements

question

When would urine be pale yellow?

answer

clear, acute viral hepatitis, cirrhosis

question

When would urine be cloudy?

answer

UTI, kidney stones

question

What is urethritis?

answer

infection of the urethra

question

What are the common causes of urethritis?

answer

Gonorrhea, chlamydia

question

What are the symptoms of urethritis?

answer

painful burning urination, pruritus; reddened, everted, swollen meatus edges; cloudy urine with discharge

question

What is acute urinary retention?

answer

abrupt inability to pass urine with bladder distention & lower abdominal pain

question

What is the corona of the penis?

answer

Shoulder where glans joins shaft

question

What is the frenulum of the penis?

answer

Fold of foreskin extending from urethral meatus ventrally

question

What is the function of the cremaster muscle?

answer

Controls size of the scrotum by responding to ambient temperature (contracts when cold relaxes when hot)

question

What is the purpose of the function of the cremaster muscle?

answer

Keeps testes 3 C below abdominal temperature (sperm)

question

What is the epididymis?

answer

Coiled duct system

question

What is the function of the epididymis?

answer

Main storage site of sperm

question

What are the normal variations of the epididymis?

answer

6% to 7% of epididymis are anterior to testis

question

What is the order of the structures by which sperm travels?

answer

Testis > epididymis > vas deferens > spermatic cord > vas deferens > ejaculatory duct > urethra

question

Where do the penis and scrotal surface drain lymphatics?

answer

inguinal lymph nodes

question

Where do the testes drain lymphatics?

answer

abdomen

question

Where are potential sites for hernia in inguinal area?

answer

inguinal canal, femoral canal

question

What are the health pros of circumcision?

answer

prevent phimosis & inflammation of glans penis/foreskin, decreased incidence of penis cancer, decreased incidence of UTI in infancy, reduces HIV acquisition and transfer to women, reduces HPV & HSV-2

question

What are the health cons of circumcision?

answer

pain, bleeding, swelling, inadequate skin removal, excess bleeding, infection, urinary retention

question

What are symptoms of progressive prostatic obstruction?

answer

hesitancy, straining, loss of force & decrease caliber, terminal dribbling, sense of residual urine, recurrent episodes of acute cystitis

question

When should a pt seek care if color change is seen in urine?

answer

If it lasts longer than a day

question

What is the average number of adult voids a day?

answer

5-6 (varies with fluid intake)

question

What's oliguria?

answer

decreased urine (<400 mL/24hr)

question

What conditions have nocturia as an associated symptom?

answer

UT disorders, mild heart failure, varicose veins

question

What's dysuria?

answer

painful and burning urination

question

What is dysuria common with?

answer

acute cystitis, prostatis,urethritis

question

What is tinea cruris?

answer

Fungal infection in the crural fold

question

What are genital herpes (HSV-2)?

answer

Clusters of small vesicles with surrounding erythema that are painful and can lead to ulcers

question

What are genital warts?

answer

Soft, pointed, moist, fleshly, painless papules in a cauliflower-like patch

question

What is a syphilitic chancre?

answer

Small solitary silvery papule that erodes to a red round or oval superficial ulcer with a yellowish serous discharge

question

What is priapism?

answer

Prolonged painful erection without sexual stimulation and unrelieved by intercourse or masturbation

question

What is peyronie disease?

answer

Painful bending of the penis during erection caused by hard, nontender, subcutaneous plaques on dorsal or lateral surface

question

What is testicular torsion?

answer

Sudden twisting of spermatic cord

question

What is a varicocele?

answer

Dilated tortuous varicose veins in the spermatic cord due to incompetent valves

question

What is a spermatocele?

answer

Retention cyst in epididymis

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What is orchitis?

answer

acute inflammation of testis

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What are the external genitalia termed

answer

Vulva (Pudendum)

question

Is a round, firm pad of adipose tissue covering the symphysis pubis

answer

Mons pubis Note: After puberty it is covered with hair in the pattern of an inverted triangle

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Are two rounded folds of adipose tissue extending from the mons pubis down and around to the perineum

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Labia Majora Note: After puberty hair covers the outer surfaces of the labia whereas the inner folds are smooth and moist and contain sebaceous follicles

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Darker smaller folds of skin inside the labia majora

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Labia Minora Note: These are joined anterior at the clitoris where they form a hood or prepuce. They joined posteriorly by a transverse fold , the Frenulum

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Is a small pea-shaped erectile body, homologous with the male penis and highly sensitive to tactile stimulation

answer

Clitoris

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The labia structures encircle a boat-shaped space, or cleft termed

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Vestibule

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Appears as dimple 2.5 cm posterior to the clitoris

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Urethral Meatus

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tiny multiple glands surrounding the urethral meatus

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Paraurethral (Skene's) glands Note: Their ducts are not visible but open posterior to the urethra at 5 and 7 o clock positions

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It appears either as a thin median slit or as a large opening with irregular edges. It is posterior to the urethral meatus

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Vaginal orifice

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Is a thin circular or crescent-shaped fold that may cover part of the vaginal orifice or may be absent completely

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Hymen

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Secrete lubricating mucus during intercourse

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Vestibular (Bartholin's) gland Note: Their ducts are not visible but open at the glove between the labia minora and the hymen

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a flatten, tubular canal extending from the orifice up and backward into the pelvis. It is 9cm long and sits between the rectum posteriorly and the bladder and urethra anteriorly.

answer

Vagina

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The vagina walls are in thick traverse folds termed ______ enabling the vagina to dilate widely during childbirth

answer

Rugae

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At the end of the canal (vagina) the urterine ______ projects into the vagina. Appears as a smooth doughnut-shaped area with a small circular hole (os)

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Cervix

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After childbirth the _____ is slightly enlarged and irregular

answer

Os

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The ____ and the ______ are covered with smooth, pink, stratified squamous epithelium

answer

Vagina & Cervix

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Inside the Os, the endocervical canal is lined with _________ that looks red and rough

answer

Columnar Epithelium

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The point where the two tissues (stratified squamous epithelium & Columnar Epithelium) meet and is not visible

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Squamacolumnar junction

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A continuous recess present around and in front of the cervix

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Anterior fonix

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A continuous recess present around and in back of the cervix

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Posterior fonix

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Behind the posterior fonix another deep recess is formed by the peritoneum. It dips down between the rectum and cervix to form __________

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Rectouterine Pouch (cul-de-sac of Douglas_

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Is a pear-shaped, thick-walled muscular organ. It is flattened anteroposteriorly, measuring 5.5 to 8 cm long by 3.5 to 4 cm wide and 2 to 2.5 cm thick. It is freely movable, not fixed, and usually tilts forward and superior to the bladder

answer

Uterus

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Are two pliable, trumpet-shaped tubes, 10cm in length, extending from the uterine fundus laterally to the brim of the pelvis. They curve posteriorly , their fimbriated ends located near the ovaries

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Fallopian tube

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Are located one on each side of the uterus at the level of the anterior superior iliac spine. Each are oval shaped, 3cm long by 2cm wide by 1cm thick, and serves to develop ova (eggs) and the female hormones

answer

Ovaries (2)

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What are the first signs of puberty?

answer

Breast and pubic hair development beginning between the ages of 8 1/2 and 13 yrs. These signs usually concurrent, but is not abnormal if they do not occur together. They take about 3 yrs to complete

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Note: With Menarche the uterine body flexes on the cervix

answer

Menarche

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Note: African American and Mexican girls had pubic hair and achieved menarche at younger ages than white girls

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The African American girls on avg enter puberty first followed by the Mexican American then white girls

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Note: Menarche is more likely to occur in preteen girls with more an elevated BMI

answer

The median age achieving menarche was 5.4 months earlier in obese preteen girls than in girls with normal BMI

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Note:The cervix softens (Goodell sign) at 4 to 6 weeks and the vaginal mucosa and cervix look cyanotic (Chadwick sign) at 8 to 12 weeks. The isthmus of the uterus softens (Hegar sign)

answer

(Pregnant Woman) These changes occur due to the increased vascularity and edema of the cervix and hypertrophy and hyperplasia of the cervical glands

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It increases by size 500 to 1000 times its non pregnant state

answer

Uterus

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The cessation of the menses. Usually occurs 48 to 51 yrs although a wide variety of ages from 35 to 60 yrs exists

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Menopause

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absent of menses

answer

Amenorrhea

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Heavy menses

answer

Menorrhagia

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internal sphincter

answer

under involuntary control by the ANS

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external sphincter

answer

under voluntary control - surrounds the internal sphincter

question

meconium

answer

- the first stool passed by the newborn w/in 24-48 hours of birth - dark green - indicated anal patency

question

benign prostatic hypertrophy

answer

- enlarged prostate gland, usually in middle adult years - 1 in 10 males at age of 40 and grow larger w/age - highest among AA S: urinary frequency, urgency, hesitancy, straining to urinate, weak stream, sensation of incomplete emptying, nocturia O: symmetric, nontender enlargement - no median sulcus

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subjective data for anus/rectum/prostate exam

answer

usual bowl routine change in bowel habits rectal bleeding, blood in the stool medications rectal conditions family history self care behaviors

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dyschezia

answer

pain or difficulty passing a bowel movement - pain due to local condition (hemorrhoid, fissure) or constipation

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diarrhea

answer

BM 3+ x a day - occurs with gastroenteritis, colitis, IBS

question

steatorrhea

answer

excessive fat in the stool due to malabsorption of fat - stool is frothy and floats in water

question

soluble fiber

answer

lowers cholesterol ex: beans, prunes, barley, carrots

question

insoluble fiber

answer

reduce risk of colon cancer ex: cereals, wheat germ

question

early detectors of cancers

answer

digital rectal exam (DRE) - annually at 50+ fecal occult blood test - annually at 50+ sigmoidoscopy - every 5 years OR colonoscopy - every 10 years after 50+ PSA: annually after 50+ or 45+ for AA

question

positioning for rectal examination

answer

MALE: left lateral decubitis or standing position FEMALE: lithotomy or left lateral decubitus

question

prostate gland

answer

normal: size: 2.5 x 4cm no more than 1 cm into rectum shape: heart shape, palpable center groove surface: smooth consistency: elastic, rubbery mobility: slightly movable sensitivity: nontender to palpation

question

anorectal fistula

answer

a chronically inflamed gi tract creates an abnormal passage from inner anus or rectum out to the skin surround the anus

question

pilonidal cyst or sinus

answer

hair-containing cyst or sinus located in the midline over the coccyx or lower sacrum - dimple with visible tuft of hair - congenital disorder but lesion first diagnosed between 15-30 y/o

question

anal fissure

answer

painful longitudinal tear in the superficial mucosa at the anal margin - pt has itching, bleeding, pain

question

hemorrhoids

answer

painless, flabby papules are do to a varicose vein of the hemorrhoidal plexus result from increased portal venous pressure (ex: straining at stool, pregnancy) - external hemorrhoid: originates below anorectal junction+is covered by anorectal skin - internal hemorrhoid: originates above the anorectal junction and is covered by mucous membrane

question

rectal prolapse

answer

the rectal mucous membrane protrudes through the anus, appearing as a moist red donut with radiating lines.

question

pruritus ani

answer

intense perianal itching manifested by red, raised, thickened, excoriated skin around the anus - caused by pinworms in children and fungal infection is adults

question

abcess

answer

a localized cavity of pus from infection in a pararectal space - red, hot, swollen, tender

question

rectal polyp

answer

a protruding growth from the rectal mucous membrane that is fairly common pedunculated - on a stalk sessile - mounted on surface close to mucosal wall biopsy to screen for malignant growth

question

fecal impaction

answer

collection of hard, desiccated feces in rectum - often caused my decreased bowel motility or retained barium for gi x-ray

question

carcinoma

answer

malignant neoplasm in the rectum - asymptomatic so must be checked for during DRE - has irregular cauliflower shape, is fixed and stone-hard

question

Normal findings during inspected of the perianal area include:

answer

anus moist and hairless, with coarse folded skin that is more pigmented than the perianal skin; anal opening is tightly closed; no lesions present.

question

Vulva

answer

-external genitalia -aka Pudendum

question

Mons Pubis

answer

-round, firm pad of adipose tissue covering the symphysis pubis -covered with hair after puberty

question

Labia Majora

answer

-two rounded folds of adipose tissue -extend from mons pubis down and around to the perineum

question

Labia minora

answer

-two smaller, darker folds of skin -joined anteriorly by the clitoris -joined posteriorly by the transverse fold, FRENULUM

question

Clitoris

answer

-small, pea shaped erectile body -homologous to the male penis, and highly sensitive to tactile stimulation

question

Vestibule

answer

-labial structures encircle this boat shaped space/cleft -within it are numerous openings: urethral meatus, vaginal orifice, hymen -contains paraurethral (SKENE'S) glands which surround the urethral meatus... ducts not visible

question

Vestibular (Bartholin's) Glands

answer

-on either side and posterior to the vaginal orifice -secrete clear lubricating mucous during intercourse -ducts are not visible

question

Internal genitalia

answer

-vagina -cervix -fallopian tubes

question

Vagina

answer

-its walls are in thick transverse folds called RUGAE, which enable to vaginal to dilate widely during childbirth

question

Cervix

answer

-at end of vaginal canal -the uterine cervix projects into the vagina -Nulliparous woman: appears as doughnut shaped area with smooth circular hole: OS -after childbirth, OS slightly enlarged and irregular

question

Smooth, pink, stratified squamous epithelium

answer

-cover the vagina and cervix

question

Squamocolumnar junction

answer

-place where the squamous epithelium of cervix meets the Columnar epithelium thats inside the OS -is not visible

question

Anterior Fornix & Posterior Fornix

answer

-a continuos recess present around cervix -this forms the rectouterine pouch/cul-de-sac of Douglas... the groove between rectum and cervix

question

Uterus

answer

-flattened, pear shaped -thick walled -muscular organ -flattened anteroposteriorly -freely moveable, not fixed -usually tilts forward and superior to the bladder: *anteverted and anteflexed

question

Fallopian tubes

answer

-pliable, trumpet-shaped tubes -from uterine fundus to brim of pelvis -curve posteriorly -their fimbriated ends located near the OVARIES

question

infants

answer

-at birth genitalia engorged due to mother's estrogen -ovaries located in abdomen during childhood -with menarche, the uterine body flexes on the cervix, so now in the pelvic cavity and no longer in the abdomen

question

Tanner's Sex Maturity Ratings (SMR): Pubic Hair

answer

STAGE 1: no pubic hair; mons and labia covered with fine vellus hair as on abdomen STAGE 2: growth sparse and mostly on labia; long, downey, hair, slightly pigmented, straight or slightly curly STAGE 3: growth sparse and spreading over mons pubis; hair is darker, coarser, curlier STAGE 4: hair is adult in type over smaller area; non on medial thigh STAGE 5: adult in type and pattern; inverse triangle, also on medial thigh surface

question

Tanner's Table on the 5 stages of pubic hair development

answer

-helpful in teaching girls the expected sequence of sexual development

question

the pregnant female Uterus

answer

-uterus is the greatest change that occurs, increases capacity by 500-1000 times... at first bc of hormonal changes, then due to changes in size of its contents -growing uterus pushes bladder, therefore urinary frequency -Uterus becomes globular in shape and too large to stay in pelvis -at 20-24 weeks, uterus becomes oval shaped; raises almost to the liver and thus displaces the intestines superiorly and laterally

question

Goodell's Sign

answer

-at 4-6 weeks -the cervix softens

question

Chadwick's Sign

answer

-vaginal mucosa and cervix look cyanotic -8-12 weeks -occurs because of increased vascularity and edema of the cervix and hypertrophy and hyperplasia of the cervical glands

question

Hegar's sign

answer

-6-18 weeks -isthmus of uterus softens

question

Mucus Plug

answer

-clot of thick, tenacious mucus -forms in spaces of the cervical canal -protects fetus from infection -this plug dislodges when labor begins, which produces a sign of labor called the "BLOODY SHOW"

question

Cervical and Vaginal Secretions

answer

-increase during pregnancy -thick, white, and more acidic -increased acidity occurs because of increased acidity of Lactobacillus acidophilus, which changes glycogen into lactic acid -acidic pH keeps pathogen bacteria from multiplying in the vagina -but the increase in glycogen increases the risk of candidiasis (yeast infection) during pregnancy

question

aging female: Menopause

answer

-in contrast to the slow decline of masculine hormones in the aging males... female's hormone milieu decreases rapidly -causes cessation of menses -at 48-51 years... but wide variation from 35-60 -includes the preceding 1-2 years of hormone decline in ovarian function

question

the 1-2 years preceding Menopause

answer

-irregular menses that become farther apart and produce lighter flow -ovaries stop producing progesterone and estrogen -the estrogen dependent structures atrophy (ovaries, uterus, cervix, vagina

question

Ovarian changes in Menopause

answer

-atrophy -no longer palpable -ovulation may occur sporadically after menopause

question

Uterine changes in menopause

answer

-shrinks in size because of decreased myometrium -drops because sacral ligaments relax and the pelvic musculature weakens -may protrude or prolapse into vagina

question

Cervical changes in menopause

answer

-shrinks -looks paler with a thick, glistening epithelium

question

Vaginal changes in menopause

answer

-shorter -narrower -less elastic bc increased connective tissue -without sexual activity, atrophies to 1/2 its former length and width -epithelium atrophies and becomes thinner drier and itchy -results in fragile mucosal surface at risk for bleeding and vaginitis -decreased secretions thus dry and at risk for irritation and pain -pH more alkaline and decreased glycogen content occurs from decreased estrogen -this is suitable medium for pathogens = vaginitis

question

External changes in menopause

answer

-mons pubis externally looks smaller -bc fat pads atrophies -labia and clitoris gradually decrease in size -pubic hair becomes thin and sparse

question

Declined Estrogen causes

answer

-Excitement: reduced amount of vaginal secretion and lubrication -Plateau: less expansion of vagina; labia majora do not elevate against perineum; no color change in labia minora, smaller clitoris -Orgasm: Shorter duration -Resolution: Occurs more rapidly ... but these changes do not affect sexual pleasure and function continue as long as reasonably good health and interested partner

question

Subjective Data

answer

1. Menstrual history 2. Obstetric history 3. Menopause 4. Self-Care behiaviors 5. Urinary symptoms 6. Vaginal Discharge 7. Past history 8. Sexual activity 9. Contraceptive Use 10. STD contact 11. STD risk reduction

question

Good to start with history of mensturation

answer

-non threatening -menarch -amenorrhea- absent menses -menorrhagia- heavy menses

question

associated menopause symptoms

answer

-hot flash -numbness -tingling -headaches -palpitations -drenching sweats -mood swings -vaginal dryness -itching -Treatment: hormonal replacement, side effects of such, how do you feel about menopause

question

additional history for children

answer

-trouble urinating, pain, holding genitals -bed wetting -genital rashes, itching, discharge -screen for sexual abuse

question

Additional history for adolescents

answer

-norms vary widely -asking too many questions is better than omitting something -direct, matter-of-fact questions -avoid sounding judgmental -permission statements to ask -open ended questions, "when did you" rather than "do you".. implies topic is normal and acceptable -screen for sexual abuse

question

additional history for aging adult

answer

-vaginal bleeding after menopause -itching, discharge, painful intercourse -pressure in genital area -loss or urine with cough, sneeze, back pain, constipation -sexual relationship? satisfactory? privacy?

question

Objective data/ Physical examination

answer

-inspect external genitalia -palpate external genitalia -speculum examination of internal genitalia: *inspect cervix and its Os *obtain cervical smears and cultures *inspect vaginal wall *bimanual examination -rectovaginal examination

question

preparation for physical examination

answer

-initially pt sitting up -then lithotomy position for vaginal examination (pap position): supine, feet in stirrups, knees apart, buttocks at edge of examination table -arms not on top of head because this tightens the muscles

question

help relaxation with these measures:

answer

-empty bladder before examination -privacy -ask if wants friend, family or chaperone present, position person by woman's head to maintain privacy -elevate head and shoulders to semi-sitting position to maintain eye contact -explain each step in examination -assure woman she can stop examination at any point if she feels discomfort -gentile, firm, touch, and gradual movements -communicate, dialogue throughout to share information -use educational or mirror pelvic examination technique

question

inspection of external genitalia

answer

-not skin color, hair distribution (inverted triangle), happy trail -symmetric, plump, well formed labia majora -nulliparous labia meet in midline -after vaginal delivery, labia are gaping and slightly shriveled -normal to have occasional sebaceous cysts *yellowish, nodules, firm, nontender, often multiple

question

Separate labia majora to inspect

answer

-clitoris -labia minora should be dark pink and moist, usually symmetric -urethral opening: stellate or slitlike and it midline -vaginal opening or introitus: narrow vertical slit or larger opening -perineum smooth, well healed scar may be present after birth -Anus has coarse skin of increased pigementation

question

Palpation of external genitalia

answer

-assess the urethra and skene's glands -assess Bartholin's glands -assess support of pelvic musculature

question

Palpate Urethra and Skene's Glands

answer

-dip your gloved finger in a bowl of warm water to lubricate -insert index finger into vagina -gently milk urethra by applying pressure up and out -should not= pain -if discharge appears, culture it

question

Palpate Bartholin's glands

answer

-palpate posterior parts of labia majora with index finger in vagina and thumb outside -normally, labia feel soft and homogenous

question

Assess the support of pelvic musculature by using these palpation maneuvers:

answer

1. palpate perineum: *in Nulliparous woman: feels thick, smooth and muscular *in Multiparous woman: feels thin and rigid 2. pt to squeeze vaginal opening around your fingers: *in Nulliparous woman: feels tight *in Multiparous woman: less tone 3. Use index and middle fingers to separate vaginal orifice and ask woman to strain down. Normally no bulging of vaginal walls or urinary incontinence occurs

question

Speculum Examination of internal genitalia

answer

-inspect cervix and its Os -obtain cervical smears and cultures -inspect vaginal wall -bimanual examination while still open with speculum

question

Speculum Examination

answer

-warm and lubricate speculum under warm running water -avoid gel lubricant bc it is baceteriostatic and would distort cells in the cytology specimen -one hand to pt and other hand to picking up equipment -pressure of speculum should go DOWNWARD to avoid pressure on the sensitive urethra above vagina -cervix should be in full view *if does not occur, means the blades are angled above the location of the cervix *try reinsertion in a more downward direction

question

Relax muscles for speculum insertion

answer

-pt to bear down -relaxes perineal muscles and opent the introitus -insert with downward angle toward the small of womans back... to match the NATURAL SLOPE of the vagina

question

Inspect cervix and its Os

answer

-Color: pink, even, blue during pregnancy, pale after menopause -Position: midline, either posterior or anterior -Size: 1 inch diameter -Os: varies -Surface: smooth, but cervical eversion/ectropion may occur after vaginal deliveries

question

variations of the Cervical Os

answer

-Nulliparous women: small, round -Parous women: horizontal, irregular slit, may show healed lacerations on sides -Lacerations may be: unilateral, bilateral transverse, stellate (like anus-ie looking)

question

Cervical Eversion/Ectropion

answer

-may occur after vaginal deliveries -endocervical canal is everted or rolled out -looks like red, beefy halo inside the pink ervix surrounding the Os -biopsy may be needed bc difficult to differentiate this normal variation from an abnormal condition such as erosion or carcinoma

question

Nabothian cycsts

answer

-benign growths -commonly appear on cervix after childbirth -small, smooth, yellow nodules -may be single or multiple -less than 1cm, retention cysts, caused by obstruction of cervical glands

question

Note cervical secretions

answer

-depending on day of menstrual cycle, may be clear and thin, or thick, opaque, and stringy -always they are odorless and nonirritating

question

obtain cervical smears and cultures

answer

-the papanicolaou smear screens for cervical cancer -do not obtain during menses or if heavy infectious discharge is present -instruct the woman not to douche, have intercourse, or put anything into vagina within 24 hours before collecting the specimen -obtain pap smear before other specimens so you will not disrupt or remove cells -usually test consists of three specimens

question

Vaginal Pool

answer

-ayre spatula over vaginal wall under and lateral to cervix -wipe specimen on a slide and spray with fixative immediately -if very dry mucous membrane, moisten a sterile swab with normal saline solution

question

Cervical Scrape

answer

-ayre spatula into vagina with more pointed bump into cervical Os -cervix fits snugly into spatulas groove -spatula scrapes surface of squamocolumnar junction -spread specimen from both sides of spatula onto glass slide **** this specimen is important for adolescent whose endocervical cells have not yet migrated into the endocervical canal

question

Endocervical Specimen

answer

-cytobrush into Os -the cytobrush gives higher yield of endocervical cells from the squamocolumnar junction -safe to use during pregnancy -slight pinch with brush and scant bleeding may ocur -so collect this specimen last

question

Data to include int the specimen slides to be sent to the lab

answer

-date of specimen -date of birth -date of last menstrual period -hormone medications? -if preg, estimated delivery date -known infections -prior surgery or radiation -prior abnormal cytology -abnormal findings on physical examination

question

screen for STD's or when you notice abnormal discharge

answer

-obtain the Gonorrhea (GC)/chlamydia culture

question

saline mount or "wet prep"

answer

-spread sample of discharge onto glass slide -moisten with normal saline, and cover with glass slide

question

KOH Prep

answer

-add drop of KOH to discharge sample on glass slide

question

Anal Culture

answer

-discard sterile swab if it collects feces -insert, rotate, leave in for 10-20 seconds

question

Acetic Acid Wash

answer

-aka white vinegar -screens for asymptomatic human papilloma virus (HPV), which causes genital warts -do this after all other specimens have been collected -soak cotton rectal swab and "paint" the cervix -acetic acid dissolves mucus and temporarily causes intracellular dehydration and coagulation or protein -NORMAL response (meaning No Infection) is no change in cervical epithelium

question

Inspect Vaginal wall

answer

-loosen thumbscrew but continue to hold the speculum blades open -withdraw slowly and rotate as you do so, so you can inspect the whole vaginal wall while withdrawing speculum -NORMAL: pink, deeply rugated, moist, smooth -normal discharge is thin and clear, or opaque and stringy -but always odorless

question

Bimanual Examination

answer

-pt remains in lithotomy position -lub onto first 2 fingers -assume obstetric position: first 2 fingers extended, the last two flexed into palm, and thumb abducted -insert and direct pressure posteriorly

question

Vaginal Wall in bimanual examination

answer

-wait until vaginal walls relax then insert fingers fully -use both hands to palpate internal genitalia -assess location, size, mobility, tenderness, mass -one hand in abdomen while other inserts the 2 fingers -palpate vaginal wall, normally smooth, no induration, nor tenderness

question

Cervix in bimanual examination

answer

-locate cervix in midline, often near anterior vaginal wall -cervix points in opposite direction of fundus of uterus -palpate using PALMAR surface of fingers -note: Consistency (smooth, firm, like tip of nose) Contour (evenly rounded) Mobility (noves from side to side with no pain)

question

Uterus in bimanual examination

answer

-with intravaginal fingers in anterior fornix, assess the uterus -this position compares the long axis of uterus with the long axis of the body -normal for uterus to be anteverted -you palpate at the level of the pubis with the cervix pointing posteriorly -uterine wall should feel firm, smooth, rounded contour of fundus... softens during pregnancy -freely movable and nontender

question

Normal uterine positions/variations

answer

-anteverted -midposition -anteflexed -retroflexed -retroverted

question

Adnexa in bimanual examination

answer

-try to capture the ovary -often you cannot feel the ovary -when you do capture it, it feels smooth, firm, and almond shaped, highly moveable, sliding through your fingers -slightly sensitive but not painful -fallopian tube is normally not palpabe -no other mass or pulsation should be felt -normal adnexal structures may not always be palpable

question

Rectovaginal examination

answer

-to assess to rectovaginal septum, posterior uterine wall, cul-de-sac, and the rectum -change gloves at this point to avoid potential infection -warn of possible discomfort -retrovaginal septum should feel smooth, thin, firm, pliable -rectovaginal pouch/cul-de-sac is a potential space and usually not palpated -Uterine wall and fundus feel firm and smooth

question

school aged child

answer

-frog legged position -no drapes -examination is limited to inspection of external genitalia to determine: 1. intact structures 2. vagina is present 3. hymen is patent

question

infant

answer

-on examination table -bc of transient engorgement due to maternal estrogen, the vaginal orifice may be difficult to inspect

question

toddler/preschooler

answer

-on parent's lap, frog legged position

question

adolescent

answer

-examination alone, without mother present -allow time for education -use SMR charts to educate -assure her or normalities

question

pregnant female

answer

-external genitalia show hyperemia of the vulva and perineum because of increased vascularity -vaginal walls appear violet or blue (chadwick's sign), deeply rugated, -cervix looks blue, feels velvety, feels softer than in nonpregnant state... making it more difficult to differentiate from the vaginal walls

question

aging adult

answer

-lubricate adequately to ensure painless examination -cervix may retract and appear flush with vaginal wall -cervix may protrude into vagina if uterus has prolapsed -even if hysterectomy, still need routine gynecologic care including the pap smear

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