1. Professional Skills Urology Core Module
Trustin Domes

2. Outline Brief Anatomy of Scrotum and Prostate
Physical Examination: CVA, Scrotum and DRE
Case Scenarios
LUTS
Hematuria
Upper and lower urinary tract obstruction
Scrotal Masses/Pain

3. Anatomy of Scrotal Contents
Vessels:
Testicle has 3 arterial blood supplies:
Testicular artery
Cremasteric artery
Deferential artery
Pampiniform venous plexus
Lymphatics
Nerves
Cremasteric muscle/fascia
Vas deferens

4. Anatomy of Scrotal Contents
Vas is the most posterior component of spermatic cord
Tunica vaginalis surrounds the anterior 2/3rd of the testicle and creates a potential space for hydroceles and hematoceles

5. Clinical Anatomy of the Prostate
—Schematic shown in sagittal view of prostate illustrates normal zonal description of prostatic anatomy.
Verma S , Rajesh A AJR 2011;196:S1-S10

6. Prostate Anatomy
Peripheral Zone = 85% of prostate cancer originate in this zone, therefore are detected on DRE
Transition Zone = site of benign prostatic hyperplasia

7. CVA and Ballottement If CVA tenderness think: Renal colic
Pyelonephritis
Significant renal trauma
Renal vascular occlusion
If you can ballot the kidney think:
- Large renal mass
- Polycystic kidney disease
- Severely hydronephrotic kidney

8. Physical Examination of the Scrotum
Best to examine the man in both the supine and upright positions
Helps to demonstrate conditions that change with position: hernias and varicoceles
Bimanual examination of each testicle, adenxa and spermatic cord
Testicular size, consistency, masses, tenderness
Normal testis size cc (2 x 4 cm)
Examine cord upright (+/- valsalva) to assess for presence of vas deferens, inguinal hernia and varicocele

9. Cremasteric Reflex
Reflex elicited by stroking the medial thigh causes an ipsilateral contraction of the cremasteric muscle (bringing the testicle closer to the external inguinal ring)
Reflex tests L1-L2 (genitofemoral nerve responsible for afferent and efferent limbs)
Typically absent in testicular torsion
Negative predictive value of over 90%

10. Transillumination
Important to help differentiate solid from fluid-filled masses
Hydroceles and spermatoceles will transilluminate, other scrotal masses typically WILL NOT
Hydrocele

11. Varicoceles Dilated veins of the paminiform plexus
Predominant left-sided (98%)
Isolated right-sided varicocele may be caused by a retroperitoneal
NEED abdominal imaging
Varicocele grading:
Grade I: palpable only with valsalva
Grade II: easily palpable without valsalva
Grade III: large, visible through scrotal skin
Grade III: “bag of worms”

12. Digital Rectal Examination
Comment on:
Prostate
Size
Symmetry
Consistency
Tenderness
Nodules
Rectal/Anal Masses
Rectal Tone

13. Prostate size Average prostate size is approximately 25 cc in men
older than 50 years
25 cc
150 cc
How many finger-breadths
across?
Can you get to the top (base)?