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male exam notes revised

male exam notes revised - Male Examination Gender-Related...

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Unformatted text preview: Male Examination Gender-Related Health Lisa Zaynab Killinger, DC What can you expect from this class? (Or what do you get in return?) Fulfill the requirements of your licenses! Learn info relevant to clinical practice Learn info for success on boards Have fun? Let’s get started! The Digital Rectal Exam Or Why do I have to know this stuff ???? What is a DRE? A DRE evaluates the terminal portions of the G-I tract. Sacrococcygeal and perianal areas Anus Sphincter and anal ring Lateral and posterior rectal walls Anterior rectal wall and prostate for males Stool DIGITAL RECTAL EXAM Why should a DRE be performed? How frequently should a DRE be performed? Who can perform a DRE? Why? Yearly screening for males Over age 50 for most; over age 40 for high risk As part of an annual exam for females Yearly after becoming sexually active History-Perianal pain, problems w/urination/defecation/sexual function Symptoms? Low Back Pain, hesitancy or dribbling of urine, other local pain, changes Who? Chiropractors---In most states Family practitioners/General practitioners Gynecologists Proctologists/Urologists Physician’s assistants What do patients say that provide clues that a digital rectal exam should be done? Symptoms Changes in bowel function Changes in bladder function number, frequency, consistency, color, blood hesitancy, urgency, nocturia, dysuria, dribbling, discharge, decreased caliber or force Anal discomfort or rectal bleeding Sexual dysfunction When can’t a DRE be done? Anal fissures---very painful Anal fistula--very painful Spasticity of the sphincter Rectal prolapse Important issues related to this exam: Patient modesty Patient culture Dr/Pt boundary issues Patient history of abuse, rape, incest, etc. What should we do? Take a complete history Always have another individual in the room if you do this exam Talk to patient about their comfort level with this exam, & with you doing this exam If you or patient is uncomfortable refer to another health professional for this exam! But, in the end… Make sure that every patient over 50 (or over 40 with risk factors) is having this exam done annually by SOMEONE! If you don’t, you are liable for missed diagnoses. (Failure to diagnose is one of the most common successful malpractice claims against DCs.) Use your education to protect your patients’ health! Be a DOCTOR of Chiropractic. Let’s talk about anatomy! The Rectum The rectum is approximately 12 cm long. Proximally, it joins the sigmoid colon. Distally, it joins the anal canal at the anorectal junction (about 2.5 to 4 cm). The distal end is not palpable. Folds in rectal walls may be palpable. The Rectum Inferior rectal valve Internal h. plexus Internal sphincter External sphincter Crypts Columns Sphincter Control The internal sphincter is made of smooth muscle and is under involuntary autonomic control. The external sphincter is made of striated muscle and is under voluntary control. The urge to defecate occurs when the rectum fills with feces which causes reflex stimulation of the internal sphincter. Defecation is then controlled by the striated external sphincter. The lower half of the anal canal is supplied with somatic sensory nerves, which makes it sensitive to painful stimuli. The upper half of the anal canal is under autonomic control and is not well-supplied by sensory nerves. Therefore, it is relatively insensitive to pain (lesions). The Prostate Located at the base of the bladder Surrounds the urethra Made of both fibromuscular and glandular tissue How big? Chestnut size: 4cm X 3cm X 2cm In infants and children—small and inactive In adolescents—enlarges and becomes active After age 25—continues to enlarge The Prostate Urethra Median lobe Ejaculatory duct So, what does it do? It is the source of much investigation. We know that it contributes to the ejaculatory fluid. Believed to secrete enzymes that decrease the viscosity of the ejaculatory fluid Believed to lower acidity of the vaginal canal Access to the prostate The posterior surface of the prostate (what we palpate) is in close contact with the anterior rectal wall. A sulcus runs through the middle of the prostate and divides it into right and left lobes. So, how do we evaluate the prostate? Size Contour Consistency Mobility Protrusion into the rectum Grade 1, Grade 2, Grade 3, Grade 4 Sulcus present Pain with palpation What does it feel like? Pencil eraser Tip of your nose Thenar pad Prostate Conditions Benign prostatic hypertrophy Prostate carcinoma Acute prostatitis Chronic prostatitis Others: Prostatic calculi or abscesses Benign Prostatic Hypertrophy (BPH) Etiology is unknown VERY common in males over age 50 Symptoms rare before 40 50% have symptoms after age 60 70 to 90% have symptoms after age 70 What happens? The normal tissue is replaced by collagen. Results in expansion of the capsule, leading to pressure on the urethra; bladder and urinary symptoms (as discussed earlier). All or part of prostate may enlarge. Digital Exam of BPH Size—enlarged Consistency: boggy, squishy, smooth Mobility—remains fairly mobile Protrusion—Grade depends on stage Sulcus—may be obscured (vs. obliterated) Should be nontender The degree of enlargement of the prostate may not be related to symptoms i.e., a prostate that is markedly enlarged may not obstruct urinary flow “Acute urinary retention” may occur, and in general symptoms may be aggravated by: Exposure to cold Immobilization Attempts to retain urine Anesthetics, anticholinergics Ingestion of alcohol Other complications: Incomplete bladder emptying leads to: Urinary stasis Predisposes to infection of bladder and tract Hydronephrosis Renal calculus formation Treatments for BPH “Wait and see” Drug therapy Herbal remedies Prostatectomy Questions about BPH? Prostatic Carcinoma 2nd leading cause of cancer death in males over 65 An adenocarcinoma (sarcoma is rare) Rare before the age of 50 122,000 new cases/year in the US Etiology is unknown Risk Factors Age?? Age over 50 years Race?? African-American History?? Family history of CA Diet?? High in animal fat Signs and Symptoms In the early stages, asymptomatic!! Late in its course: Bladder obstruction Ureteral obstruction Hematuria Pyuria Does it metastasize? Carcinoma from the prostate is responsible for 60% of all skeletal metastasis 25% is due to lung cancer Predominantly blastic mets, but may be mixed So, how do we detect it? The DRE! Size— Contour— Consistency— Mobility— Protrusion— Sulcus— Tenderness– Size—Normal early, enlarged later Contour—Asymmetrical Consistency—Hard nodules* Mobility—May resist movement Protrusion—Grade 1-4 Sulcus—Obliterated (advanced CA) Pain—NO- usually asymptomatic Important Differentials Prostatic CA is not the only lesion with hard nodules: Prostatic calculi Prostatic TB Prostate granulomata But, all hard nodules in the prostate should be considered cancerous, until everything else is ruled out! PSA Prostate Specific Antigen A glycoprotein specific to the prostate, but not to prostate carcinoma Produced by both healthy and unhealthy prostate tissue Serum PSA is moderately elevated in 30 to 50% of patients with BPH PSA Levels* Levels < 4 ng/ml are considered normal 4 to 10 ng/ml are considered borderline Above 10 ng/ml is considered high The higher the PSA level, the more likely the presence of prostate CA…. However……. Men with prostate CA can have negative or borderline PSA levels How do we prove otherwise? PSA—is elevated in 25 to 92% of patients with prostate cancer TRUS-Trans-rectal ultrasound Biopsy Borderline PSA levels PSA density (PSAD): divide the PSA number by the prostate volume (TRUS) Age-specific ranges: Older men have higher PSA levels, even without CA PSA velocity: Serial testing that measures how quickly PSA levels rise over time Free PSA ratio: Bound vs. Unbound *low levels of free PSA are more likely CA TRUS Performed when the PSA level is borderline and the DRE is negative Visualizes the areas needed for biopsy Helps determine the prostate volume (PSAD) TRUS Normal TRUS Image Abnormal TRUS Image TURP TURP Pre & Post Prostate Resection Other Prostate Conditions BPH and Prostatic Carcinoma are, by far, the most common conditions associated with the prostate. Other conditions include…. Acute Prostatitis Due to enteric, gram-negative bacteria High fever, chills, flu-like symptoms Perineal, prostate, and low back pain Symptoms of urinary obstruction Dysuria: Pain or burning with urination Nocturia Hematuria (may be gross) Arthralgia and myalgia What are the DRE results? Size—enlarged and may be warm Contour—asymmetrical (within 1 lobe) Consistency—indurated; fluctuant mass Mobility—may be fixed Protrusion—may be present Sulcus—usually preserved Pain—YES! Very painful! Prostate Abscess- (Hole) Develops as a complication of acute prostatitis, urethritis, epididymitis Gram-negative or Staph. Aureus Dysuria, frequent urination, retention Pyuria Fever is present in some Leukocytosis is common Recurrent UTIs and perineal pain should suggest an abscess DRE of an Abscess May palpate as a hole or a divot in the prostate. Findings may also be normal or a fluctuant mass may be present Tenderness is possible Chronic Prostatitis Also bacterial and assoc. with UTIs Some may be asymptomatic Most have low back and perineal pain Urinary urgency and frequency Dysuria Infection can spread to scrotum and epididymis DRE Findings Size—enlarged, but not like acute Contour—usually more symmetrical Consistency—irregularly indurated or boggy Mobility—may be fixed Protrusion—not much of an issue Sulcus—preserved Tenderness—only moderately tender, if at all Prostatic Calculi Protein stones of corpora amylacea Theory: normal secretions of the prostate are blocked in the ducts (i.e. due to BPH) These blocked secretions dry out and calcify May also be secondary to infection Symptomatic? Passable? Typically not symptomatic, but may be discovered when BPH becomes symptomatic Not surrounded by fluid like a kidney stone, but about 1% of men can pass stones in the urine Questions about any of the prostate conditions? ...
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