1. Presented by CLINICAL SKILLS USA, Inc. www.clinicalskillsusa.com

2. Guide to the Male Urogenital Examination 2011 © Clinical Skills USA All rights reserved I.Familiarize the clinical student with the male urogenital anatomy. II.Instruct the clinical student, in the appropriate physical maneuvers for conducting the comprehensive male urogenital (URO) exam. III.Instruct the clinical student, in the effective “patient-centered” communication skills associated with the male urogenital exam, including history-taking, easing patient anxiety, encouraging patient disclosure, and patient education and counseling. IV.Provide a “hands-on” practicum with a trained “Guiding Patient”, to apply these skills and increase student confidence in conducting the comprehensive male urogenital exam. Instructional Objectives

3. Introduce the purpose and process for the URO exam. Inquire about present or recent URO or sexual problems/concerns. Reassure that the exam should not be painful. Ask that they report if it is. Explain each PE exam maneuver in advance, or during the process. 5 Relax your patient by relieving anxiety and embarrassment. Support your patient by periodically asking how they are doing. Educate your patient about self-examination and recognizing abnormalities. Summarize by discussing findings and recommending healthy lifestyle practices. Encourage open discussion of questions and concerns. Thank your patient for their cooperation and schedule future exam(s). CLINICAL SKILLS USA, INC. Key Communication Elements for the Male Urogenital Exam

4. 2011 © Clinical Skills USA All rights reserved History-taking: The Male URO and Sexual History Explain the importance of this history information for the complete assessment of the patient’s health. Reassure the patient that all responses will be kept strictly confidential. Utilize gathered information as a “road map” in directing your physical exam. “I’d like to ask you some important questions about your urinary and reproductive systems, as well as, your sexual lifestyle. These are important questions that I routinely ask all of my male patients, and you should not feel embarrassed. Your responses will help me to develop a complete picture of your overall health.” Guide to the Male Urogenital Examination

5. 2011 © Clinical Skills USA All rights reserved History-taking: The Male URO and Sexual History Adapt questions to the age appropriateness of each patient. Place your emphasis accordingly. Younger males: Testicular health. Sexual practices and STDs. Middle-aged and older males: Prostate health. Sexual and urinary issues associated with dysfunction, e.g. pain, changes in urinary and/or bowel habits, erectile difficulties. Guide to the Male Urogenital Examination

6. 2011 © Clinical Skills USA All rights reserved Preparing the Patient To reduce anxiety and to establish open two-way communication. Conduct at the end of P.E. Explain the reasons for the genital and rectal exam. “Many possible health disorders in this area”. Re-assure the patient that there should be no pain associated with the exam, but it is very important that they report it if noticed. Guide to the Male Urogenital Examination

7. 2011 © Clinical Skills USA All rights reserved Positioning the Patient Position yourself on a stool facing the patient. Ask the patient to stand close to the exam table (or stable object) with feet spread to shoulder width. This may require that the patient remove his pants to minimize a loss of balance. Stay in touch with the patient, by making periodic eye contact, and frequently asking, “How are you doing?” “Are you doing okay?” Guide to the Male Urogenital Examination

8. Male Urogenital Exam Order of the Physical Examination 1)Pubic and Groin Regions 2)Hernias 3)Scrotum (sac/testes/spermatic cord/vas) 4)Penis 5)Rectum and Prostate 6)Breast (as needed, based on family history) Instructed by CLINICAL SKILLS USA, Inc. Teaching the patient-centered clinical skills required in serving the good health of men and women of all ages.

9. 2011 © Clinical Skills USA All rights reserved I. Pubic Region “At this point in the physical exam I am going to examine your pubic area, genitals, and prostate. This portion of the exam should only last five to ten minutes and is very important, because of the many disorders associated with this part of your body. In addition to multiple prostate disorders and testicular cancer, there are many other diseases and disorders of the male URO system, which if caught early, are treatable and may prevent future pain and grief for you and your family.” “I am going to look for “lumps, bumps or anything out of the ordinary”. (Avoid heightening anxiety by being too specific.) “There should be no pain associated with this portion of the exam— however, it will be important that you let me know if you do notice any pain or tenderness, as a possible sign of a medical problem.” “Feel free to ask questions as we proceed.” “ What to say”: Guide to the Male Urogenital Examination

10. 2011 © Clinical Skills USA All rights reserved I. Pubic Region Explore the base of the pubic hair for signs of skin irritation or lice/nits. Excoriations in the area may provide clues. Evaluate the amount and distribution of the pubic hair. Compare to the Tanner Stages diagrams for adolescent development. Note bulges or scars in the inguinal region consistent with past or present hernias or other surgeries. Look for skin disorders, edema, masses, ulcerations, infections, warts, or lesions. Visually Inspect: Guide to the Male Urogenital Examination

11. 2011 © Clinical Skills USA All rights reserved I. Pubic Region “ What to say”: “I am now going to gently roll the pads of my finger tips along the front of your hip and the lower abdomen to evaluate the size and number of lymph nodes in the area. I will also be “pressing” the area for masses which could be evidence of a hernia. Please let me know if you feel any tenderness.” Guide to the Male Urogenital Examination

12. 2011 © Clinical Skills USA All rights reserved I. Pubic Region Note masses, tenderness, and enlarged or immobile nodes. It is not uncommon to feel a few shotty nodes. Guide to the Male Urogenital Examination

13. 2011 © Clinical Skills USA All rights reserved “ What to say”: II. Examine for Hernias “Now I’m going to examine the internal canal which runs along your groin area, examining for a hernia. I will be inserting my finger slightly into this canal. You should feel some pressure, but no pain. Please turn your head (away from me) and cough. And again, let me know if you feel any discomfort” Guide to the Male Urogenital Examination

14. 2011 © Clinical Skills USA All rights reserved II. Examine for Hernias Examine for femoral hernias Guide to the Male Urogenital Examination

15. 2011 © Clinical Skills USA All rights reserved II. Examine for Hernias Detect and evaluate for inguinal hernias Insert index finger to 2 nd digital crease, or entire “pinky finger” at an angle coinciding with the inguinal canal. Guide to the Male Urogenital Examination

16. 2011 © Clinical Skills USA All rights reserved II. Examine for Hernias Detect and evaluate for inguinal hernias Guide to the Male Urogenital Examination

17. 2011 © Clinical Skills USA All rights reserved III. Examine the Scrotum “ What to say”: “I am going to examine your scrotum and testicles now to ensure that there is no swelling, or the presence of hard or tender nodules. I will roll my fingers gently so that you will not experience any pain.” “Have you experienced any recent pain or swelling of your scrotum?” “I am going to simultaneously instruct you in performing a Testicular Self-Exam, which I recommend that you perform once per month.” Guide to the Male Urogenital Examination

18. 2011 © Clinical Skills USA All rights reserved III. Examine the Scrotum Guide to the Male Urogenital Examination

19. 2011 © Clinical Skills USA All rights reserved III. Examine the Scrotum Guide to the Male Urogenital Examination

20. 2011 © Clinical Skills USA All rights reserved III. Examine the Scrotum Guide to the Male Urogenital Examination

21. 2011 © Clinical Skills USA All rights reserved III. Examine the Scrotum Guide to the Male Urogenital Examination

22. 2011 © Clinical Skills USA All rights reserved III. Examine the Scrotum Perform as neurological exam (eg spinal injury), or test for testicular torsion. Guide to the Male Urogenital Examination

23. Teach Testicular Self-Exam To encourage the male patient to “know his own body”. Explain how to conduct the testicular self-exam (TSE): “Gently roll the testicle between the thumb and the fingers. You may feel a soft tubular structure (epididymis) that appears on the top and back testis. It is normal, and should feel like a small deflated noodle.” “Support the testicles in one hand and feel each simultaneously with the other hand. They should feel glassy and smooth, like a hard boiled egg or olive.” “Examining during or just after a warm shower or bath is the best time, while scrotum is loose.” “ Feel for any nodules or tenderness. There may not necessarily be any pain associated with these conditions. Consult your physician if you notice any of the above.”

24. 2011 © Clinical Skills USA All rights reserved IV. Examine the Penis “ What to say”: “I am preparing to examine the penis and will attempt to determine if there are any masses present, or if there is any abnormal skin changes or discharge.” “Have you experienced any abnormalities, including any unusual discharge, or pain with urination or erections?” If patient is uncircumcised: “Please retract the foreskin for me so that I might examine all surfaces of the penis.” Guide to the Male Urogenital Examination

25. 2011 © Clinical Skills USA All rights reserved Anatomy of the Penis Penile Anatomy Guide to the Male Urogenital Examination

26. 2011 © Clinical Skills USA All rights reserved IV. Examine the Penis Identify if pt. is circumcised or uncircumcised. If uncircumcised, ask the pt. to retract the foreskin himself. Guide to the Male Urogenital Examination

27. 2011 © Clinical Skills USA All rights reserved IV. Examine the Penis Guide to the Male Urogenital Examination

28. 2011 © Clinical Skills USA All rights reserved IV. Examine the Penis Guide to the Male Urogenital Examination

29. 2011 © Clinical Skills USA All rights reserved IV. Examine the Penis Guide to the Male Urogenital Examination

30. 2011 © Clinical Skills USA All rights reserved IV. Examine the Penis Guide to the Male Urogenital Examination

31. 2011 © Clinical Skills USA All rights reserved “ What to say”: V. Examine the Anus, Perineum, Rectum & Prostate “You’re doing great and the exam is nearly complete. I am now going to examine your rectum and prostate. First, I will be visually inspect the area—and then, I will check the prostate to evaluate it’s size, shape, firmness, and signs of nodularity.” “Have you noticed any bleeding from your rectum or in your stool, pain with bowel movements, or urinary issues?” Guide to the Male Urogenital Examination

32. 2011 © Clinical Skills USA All rights reserved V. Examine the Anus, Perineum, Rectum & Prostate Positioning the Patient (A matter of examiner preference) Note the examiner’s hand upon initial contact. The “lateral decubitus” position allows the patient to remain on the exam table. The “standing-leaning” position is ideal for simple prostate screening when the patient is not in a gown, or when an exam table is not available. Guide to the Male Urogenital Examination

33. 2011 © Clinical Skills USA All rights reserved V. Examine the Anus, Perineum, Rectum & Prostate Positioning the Patient (A matter of examiner preference) Guide to the Male Urogenital Examination

34. 2011 © Clinical Skills USA All rights reserved V. Examine the Anus, Perineum, Rectum & Prostate The anogenital (“median”) raphe is formed in the male embryo as the line of closure of the genital folds extending from the anus to the tip of the penis. It is differentiated in the adult in three regions: - perineal raphe - scrotal raphe - penile raphe, or -“penoscrotal raphe” The extent of the distinctive raphe coarseness may vary from male to male, and should not be considered symptomatic. Guide to the Male Urogenital Examination

35. 2011 © Clinical Skills USA All rights reserved V. Examine the Anus, Perineum, Rectum & Prostate Guide to the Male Urogenital Examination

36. 2011 © Clinical Skills USA All rights reserved V. Examine the Rectum & Prostate “ What to say”: “You’re doing great. I will now check your prostate and we’ll be done.” “The prostate exam will only take a few seconds.” “A regular prostate exam is an important part of good preventive healthcare.” “One in five men in the U.S. will develop prostate cancer in their lifetime.” “My touch may feel a little cold at first. You will feel some pressure, but no pain. You may feel an urge to urinate or have a bowel movement---but, you won’t. That is a normal sensation.” Guide to the Male Urogenital Examination

37. 2011 © Clinical Skills USA All rights reserved V. Examine the Anus, Perineum, Rectum & Prostate Guide to the Male Urogenital Examination

38. 2011 © Clinical Skills USA All rights reserved V. Examine the Anus, Perineum, Rectum & Prostate Guide to the Male Urogenital Examination Proper DRE Insertion: 1. Place pad of index finger on the anus at 45 degree angle. All other fingers rolled back. 2. Wait for sphincter to relax (approx. 3 seconds) 3. Roll index finger inward slowly. 4. Slide inserted finger tight along anterior rectal wall. 5. Push inserted finger deeply into rectum as far as possible. 6. Sweep finger from side-to-side until prostate is located. Ask patient to valsalva (“try to push my finger out”).

39. 2011 © Clinical Skills USA All rights reserved V. Examine the Anus, Perineum, Rectum & Prostate Guide to the Male Urogenital Examination 1. Place the pad of inserting finger on anus. 2. Wait for anal sphincter to relax (approx. 3 secs.). 3. Roll inspecting finger inward slowly. Keep tight to the rectal wall and insert fully. Proper DRE Insertion – 3 Steps

40. 2011 © Clinical Skills USA All rights reserved V. Examine the Anus, Perineum, Rectum & Prostate Patient may feel a sensation to urinate as pressure is applied, due to the course of the urethra passing through the gland. Palpate the prostate in a firm circular motion. Locate the prostate gland. The prostate lies at the base of the bladder and can be found against the anterior rectal wall. Guide to the Male Urogenital Examination

41. 2011 © Clinical Skills USA All rights reserved V. Examine the Anus, Perineum, Rectum & Prostate Note size, shape, firmness, nodularity and tenderness. The normal prostate has two lobes with a midline sulcus. Normally the size of a chestnut, about 2 to 4 cm in length and width. Should feel symmetrical, firm and rubbery. Softness may indicate infection, and hardness may indicate disease. Should feel like the flesh at the base of the thumb. A carcinoma may palpate like the bone on the side of the thumb. Medical Illustration Copyright  2005 Nucleus Medical Art, All rights reserved Guide to the Male Urogenital Examination

42. 2011 © Clinical Skills USA All rights reserved V. Examine the Anus, Perineum, Rectum & Prostate Guide to the Male Urogenital Examination Assess the rectal wall “360-degree sweep”

43. 2011 © Clinical Skills USA All rights reserved V. Examine the Anus, Perineum, Rectum & Prostate ANOSCOPY Guide to the Male Urogenital Examination A procedure to visualize the perianal area, anal canal and distal rectum. Performed with patient presenting with perianal or rectal complaints, or as a routine “well-male” or “well-woman” exam between scheduled colonoscopies. Performed following the DRE.

44. 2011 © Clinical Skills USA All rights reserved V. Examine the Anus, Perineum, Rectum & Prostate 1. Lubricate the anoscope well with the obturator in place. 2. Position the patient in the lateral decubitus position with the patient's buttocks close to the near edge of the examining table, with knees pulled up toward the chest. Drape the patient so that only the buttocks is exposed. 3. Spread the buttocks and gently insert the anoscope (with obturator) into the anal canal. Asking the patient to take a few deep, gentle breaths may make the insertion easier 4. Gently advance the instrument towards the umbilicus until the full length is inserted If the patient complains of pain during insertion, note the location and quality and correlate the pain with possible clinical symptoms. 5. Remove the obturator and visualize the anal mucosa. Any fecal matter can be removed with a large swab Note the gross appearance of mucous membranes and vasculature. Look for presence of pus, mucous, blood, ulceration, and hemorrhoidal tissue. ANOSCOPY Guide to the Male Urogenital Examination

45. 2011 © Clinical Skills USA All rights reserved V. Examine the Anus, Perineum, Rectum & Prostate Anal fissure seen through the wall of a anoscope ANOSCOPY Guide to the Male Urogenital Examination 6. Slowly rotate the anoscope (with the obturator still removed) as it is withdrawn, inspect the anal canal, looking for mass lesions, hemorrhoids or fissures. A clear plastic anoscope allows the examiner to visualize the mucosa both through the walls and opening of the anoscope. 7. Visible masses or polyps should not be sampled as the anoscope is too short to get a good perspective of the extent of the mass lesion. A sigmoidoscope, is best used here.

46. 2011 © Clinical Skills USA All rights reserved V. Examine the Anus, Perineum, Rectum & Prostate Or, provide the patient with a self-administered 3-day panel fecal collection kit. Test for occult blood, if required. Apply fecal sample to a guaiac card. Guide to the Male Urogenital Examination

47. 2011 © Clinical Skills USA All rights reserved Concluding the Exam. Guide to the Male Urogenital Examination DO NOT hand the patient the tissue box!!

48. 2011 © Clinical Skills USA All rights reserved Concluding the Exam. Thank the patient for their cooperation and reassure them by saying, “you did very well and I appreciate your assistance.” Discuss the results of all aspects of the physical exam with the patient. Address pertinent health issues, diagnostic impressions, and health maintenance recommendations. Offer praise to the patient for their participation in the exam, encourage a healthy lifestyle, invite future contact with questions or concerns, and determine a follow-up exam schedule. Guide to the Male Urogenital Examination

49. 2011 © Clinical Skills USA All rights reserved Documenting the Exam. Subjective: What the patient tells you. Male urinary: Dysuria, frequency, urgency, UTIs, hematuria, proteinuria, Nocturia (>2), nephrolithiasis, incontinence (type). Urethral d/c, groin pain (hernia) Male sexual: STIs (type, tx), # of partners in lifetime, risky sex, recent change in sexual partner(s); infertility. Impotence/ED/pre-mature ejaculation; Vaccinations against Hepatitis A&B. Objective: Documentation of examination findings Male Genitourinary: Hair distribution, nits, circumcised/uncircumcised penis w/o lesions, masses, tenderness or d/c. scrotum – lesions, nodules, tenderness (masses- varicocele, spermatocele, hydrocele). Testes (size/symmetry, nodularity, tenderness) Hernia (direct/indirect), Suprapubic tenderness. Rectal: Masses, fistulas, fissures or gross blood (hemorrhoids, skin tags), STIs, trauma, sphincter tone, tenderness. Stool color and consistency, guaiac +/-. Prostate size, uniformity, nodules, firmness, tenderness; PSA test results. Guide to the Male Urogenital Examination

50. 2011 © Clinical Skills USA All rights reserved Any Questions?. Guide to the Male Urogenital Examination

51. 2011 © Clinical Skills USA All rights reserved. CLINICAL SKILLS USA, Inc. provides trained instructors as Gynecological Teaching Associates & Male Urogenital Teaching Associates, who share their own bodies for the clinical instruction of the female breast and pelvic, and the male urogenital and rectal exams. Serving medical and nursing schools throughout the U.S. Guide to the Male Urogenital Examination