8. Genitalia & Rectum.pptx

Genitalia & Rectum Laura Graafland, DNP, MS, AGPCNP-BC, CBCN 7.2024 Frank Rodrigues  Anatomy Review Frank Rodrigues  Biologic Female External Genitalia (vulva) Mons pubis, a hair-covered fat pad overlying the...

Genitalia & Rectum Laura Graafland, DNP, MS, AGPCNP-BC, CBCN 7.2024 Frank Rodrigues  Anatomy Review Frank Rodrigues  Biologic Female External Genitalia (vulva) Mons pubis, a hair-covered fat pad overlying the symphysis pubis; the labia majora, rounded folds of adipose tissue labia minora, thinner folds that extend anterior to form the prepuce and clitoris vestibule – boat shaped fossa between the labia minora. Posterior portion is the vaginal opening (introitus) which may be covered by the hymen in some individuals The term perineum, refers to the tissue between the introitus and anus Urethral meatus opens into the vestibule between the clitoris and the vagina. The openings of the Bartholin’s glands are located posteriorly on either side of the vaginal opening, but are not usually visible.- secrete mucus to lubricate the vagina Frank Rodrigues 3 Biologic Female Internal Structures Vagina is a hollow tube extending upward and posteriorly between the urethra and rectum. It terminates in the cup-shaped fornix. The vaginal mucosa lies in transverse folds, or rugae. The uterus is a flattened fibromuscular structure shaped like an inverted pear. It has two parts: the body and the cervix, which are joined together by the isthmus. The upper surface of the body is called the fundus. The cervix protrudes into the vagina. Fallopian tubes extend from each side of the uterus toward the ovary. The two ovaries are almond-shaped structures that vary in size but average 3.5 x 2 x 1.5 cm. The ovaries are palpable during reproductive years but fallopian tubes are Frank Rodrigues normally not felt. The term adnexa refers to the ovaries, tubes and supporting tissues. 3 Biologic Male - Structures of Penis and Bladder shaft of the penis – 3 columns of tissue – corpus spongiosum – two corpora cavernosa The corpus spongiosum forms the bulb of the penis, ending in the cone-shaped glans with its expanded base, or corona If the penis is uncircumcised, the glans is covered by a loose, hood-like fold of skin called the prepuce (or foreskin) where smegma, or secretions of the glans, may collect The urethra opens into the vertical, slit- like urethral meatus Frank Rodrigues 5 Biologic Male - Lower Genitourinary Tract Testes –The testes are ovoid, somewhat rubbery structures approximately 4.5 cm long –The left testis usually lies somewhat lower than the right –The testes produce spermatozoa and testosterone Scrotum is a loose pouch divided into two compartments, each containing a testis –On the posterolateral surface of each testis is the softer, comma-shaped epididymis; the epididymis provides a reservoir for storage, maturation, and transport of sperm –The vas deferens, a cordlike structure, begins at the tail of the epididymis –It ascends within the scrotal sac (as the spermatic cord) and passes through the external inguinal ring on its way to the Frank Rodrigues abdomen and pelvis –Behind the bladder, it is joined by the duct from the seminal vesicle and enters the urethra within the prostate gland  Inguinal Area The basic landmarks of the groin are the anterior superior iliac spine, the pubic tubercle, and the inguinal ligament The inguinal canal, which lies above and parallel to the inguinal ligament, forms a tunnel for the vas deferens The exterior opening of the tunnel is the external inguinal ring; the internal opening of the canal is the internal inguinal ring When loops of bowel force their way through weak areas of the inguinal canal, they produce inguinal hernias Frank Rodrigues Another potential route for a herniating mass is the femoral canal. Anus and Rectum The rectum is 12 cm long distal portion of sigmoid colon. Just above the anal canal, the rectum dilates and turns forming the rectal ampulla. Frank Rodrigues 8 Anus & Rectum - Posterior View Anal canal is outlet of GI tract and is about 3.8 cm long in adult. Lined with modified skin (no hair or sebaceous glands), merges with rectal mucosa at anorectal junction. Surrounded by two layers of muscle the sphincters – Internal- involuntary control by autonomic nervous system. – External-surround the internal, under voluntary control There are anal columns, which are folds of mucosa that extend vertically down from rectum and Frank Rodrigues end in anorectal junction. Each column has artery and vein. Sometimes veins enlarge and form a hemorrhoid.  Structure of Rectum and Prostate Biologic male with a prostate: The prostate gland lies against the anterior rectal wall. – It is rounded, heart-shaped, and normally 2.5 cm long It is bi-lobed structure with a round or heart shape. The two lateral lobes are separated by a shallow groove called the median sulcus. Only the posterior, lateral lobes and median sulcus are palpable Biologic female with a cervix: In the biologic female, the uterine cervix is usually palpable through Frank Rodrigues the anterior wall of the rectum. 10 History – Subjective Data Frank Rodrigues Tips for a Culturally Sensitive Interview 1. Do not make assumptions 2. Always start by establishing what name and pronouns the patient uses (may differ from what is recorded in the chart) a. “What name and pronouns do you use?” b. If you make a mistake with language, don’t draw too much attention, simply correct the mistake and move on 3. Explore the patient’s sex and gender identity, keeping questions open ended a. ”What sex were you assigned at birth?” Frank Rodrigues b. “How would you describe your gender identity?” Tips for a Culturally Sensitive Interview 4. When taking a sexual history a. The key is to be welcoming and respectful b. Start with “are you currently sexually active” then obtain specific details regarding the kinds of sex (oral, anal, and/or vaginal) and with whom (men, women, both or other) A transgender male may still have female reproductive organs and if they’ve had vaginal receptive intercourse with a cisgender man, they may need to be screened for pregnancy. This patient may also need regular pap smears. c. Approach your questions with attention to the language your patient would like to use to refer to their body Some patient’s may be uncomfortable with the term “penis” or Frank Rodrigues “vagina” and have alternative verbiage they prefer. 5. When taking a social history d. Every patient needs to be asked about physical, sexual or emotional violence, concerns for safety, as well as depression/suicidal ideations  History Ask about history of kidney stones, incontinence, UTIs, GU related cancers Ask about prior surgeries (on bladder, uterus, ovaries, vagina, penis, prostate, testes) Can ask about gender affirming surgeries by asking “Have you pursued any changes in your appearance or body to bring it closer to your sense of self?” Sexual History – Partners & Practices, Protection and/or contraceptives, Past hx of STIs, Pregnancy Plans, Plus (satisfaction, trauma etc) Medications for erectile dysfunction, low libido, Frank Rodrigues hormone replacement therapy, gender affirming hormones, antibiotics Self care behaviors Ask as applicable: 14 Menstrual History Ask about the age of menarche (when the first menses started); in the United States the range is between the ages of 9 and 16 Ask about menstruation patterns – How often does the patient have menses? (Every 24 to 32 days is normal.) – How long are the menses? (3 to 7 days is normal.) – How heavy are the menses? (The number of pads or tampons used is an indicator.) If applicable, at what age did menopause occur? Menopause is defined as no menses for 12 Frank Rodrigues months. The average age of menopause is 51 years old in the US. 15 Review of Systems - Genitourinary Ask all patients about genitourinary symptoms – Sudden urge to urinate – Burning with urinating – Awaken at night to urinate – Frank blood or dark cloudy/foul smelling urine Biologic Females – Vaginal discharge (color, consistency, foul smell?) – Vaginal itching, dryness or pain with intercourse Biologic Males – Pain, lesions, ulcers on the penis – Discharge from the urethra (color, odor?) Frank Rodrigues – Lumps, masses or swelling of scrotum/testes – Aching/pain in the scrotum Physical Exam – Objective Data Frank Rodrigues Lithotomy Position Surgical position commonly used for gynecological, rectal and urologic surgeries, certain types of medical imaging and childbirth Patient lies supine on the exam table with buttocks at the lower edge Legs are abducted 30-45 degrees from the midline with hips and knees flexed Legs are supported stirrups or boot leg style supports Frank Rodrigues Exam Prep Allow the patient to empty their bladder Ensure the exam table is positioned so that exposed areas are not facing a door Allow the patient to undress privately Chaperone should be present Explain that the patient can say STOP at any moment should they feel discomfort May offer the patient a mirror if they want to watch (most applicable for pelvic exams) When inspecting the scrotum/testes, may ask the Frank Rodrigues patient to lift the penis If penis is uncircumcised, ask the patient to retract the foreskin Do not perform any unnecessary assessments  Biologic Female - Inspect External Genitalia Inspect the external genitalia Mons pubis – Hair distribution should be appropriate for tanner stage Labia majora – Symmetric bilaterally an well formed – Can normally appear stretched following vaginal birth – No lesions should be present except for occasional sebaceous cyst Labia minora – Darker than surrounding skin color – Symmetrical and moist Clitoris – No inflammation or swelling should be present Urethral meatus – Slit like opening, midline Introitus (vaginal opening) Frank Rodrigues – Should be open – Occasionally may be completely or partially obstructed by hymen Perineum – Should be smooth with no lesions N0450 – May note scarring if episiotomy was performed during 20 childbirth Pelvic Exam https://www.youtube.com/watch?v =AllLe3qI7uc Frank Rodrigues Biologic Male – Inspect and Palpate External Genitalia Inspection of Skin, Hair and Corona Pubic hair distributed appropriately for tanner stage No ulcerations/lesions present on shaft Dorsal vein may be visible Glans penis should be smooth without lesions Foreskin should be pulled back easily Smegma may collect under the foreskin Be sure to replace the foreskin back into it’s original position! Phimosis – Narrowed opening of prepuce, so the foreskin cannot retract Frank Rodrigues Paraphimosis – painful constriction of glans by retracted foreskin 22 Biologic Male - Inspection of Urethra – Note the location of the urethral meatus Hypospadias – Ventral location of meatus Epispadias – Dorsal location of meatus – Compress the glans gently between your index finger above and thumb below to open the urethral meatus and allow inspection Frank Rodrigues for discharge (normally there is none) 23 Biologic Male - Palpation of the Scrotum and Testes Ask the patient to hold the penis up Lift the scrotum to inspect the posterior aspect – should be no lesions aside from occasional sebaceous cyst Palpate each testicle and epididymis – note size, shape, consistency, tenderness and any nodules – Epididymis is a soft, nodular, cordlike structure at the back of the testicle Palpate each spermatic cord – note Frank Rodrigues nodules or swelling Contents of the scrotum should slide around easily with palpation 24 Abnormal - Varicocele Patient may report a dull/ aching pain like a constant dragging feeling or may be asymptomatic On palpation while the patient is standing, will feel Frank Rodrigues Dilated, torturous internal like a bag of spermatic varicose vein worms. If severe, caused by incompetent valves which permit reflux the testes may feel of blood smaller due to lack  Abnormal – Testicular Torsion Sudden twisting of the spermatic cord, usually due to direct trauma Blood supply is cut off resulting in ischemia and engorgement Pt reports: Excruciating unilateral pain, usually sudden onset May also have lower abdominal pain and nausea/vomiting with Frank Rodrigues no fever Scrotum is red and swollen, one testicle is higher than EMERGENCY and requires immediate surgery the other due to rotation and shortening Abnormal – Testicular Cancer Firm, painless lump and associative swelling found on exam – may have a family history Usually a solitary mass Most cancers occur between ages 18 and 35 Most common in white AMAB patients Frank Rodrigues Undescended testis (even if surgically corrected) is a known  Hernias Inspection – Sit comfortably in front of the standing patient – Note any areas of bulging or asymmetry – Ask the patient to strain and bear down, making it easier to detect any hernias Palpation Frank Rodrigues – Inguinal and femoral hernias 28  Hernias sk factors: Biologic males are 8x more likely, but biologic females may also develop Age (muscles weaken with age) Frequent straining (Valsalva or due to lifting heavy weights) Obesity Pregnancy Previous abdominal surgeries Frank Rodrigues 29 Transgender Patient Exam Notes Trans male Pelvic exams may be an especially traumatic or anxiety producing procedure if they have not undergone gender affirming surgery If taking exogenous testosterone without bottom surgery, the patient may be in a hypo-estrogen state which promotes vaginal atrophy and increases vaginal pH which increases the risk for vaginitis and cervicitis  use smallest speculum Trans female If h/o vaginoplasty, use an anoscope to visualize Frank Rodrigues the walls of the neo-vagina, inspect for skin changes or scarring If no bottom surgery and patient practices prolonged tucking, they are at increased risk for Rectum and Prostate Frank Rodrigues History 1. Usual bowel routine 2. Colorectal cancer screening 3. Medications (laxatives, stool softeners, iron) 4. Rectal conditions (pruritus, hemorrhoids, fissure, fistula) 5. Family history Frank Rodrigues 6. Self-care behaviors (diet of high fiber foods, most recent examinations) 32 Review of Systems Recent changes in bowel movements Rectal bleeding/blood in the stool Itching Pain Constipation/Diarrhea Stool incontinence Frank Rodrigues  Perianal Inspection Surrounding skin should be smooth and free of lesions Anal opening - –Anus looks moist, with coarse folded skin that is more pigmented than the perianal skin –Anal opening should be tightly closed Frank Rodrigues –No lesions/masses or protrusions should be present 34 The Anus and Rectum – Palpate Palpation technique to be performed by the provider– –Gently place the index finger in the anus; palpate for hemorrhoids and masses –If needed, check for occult blood with a hemoccult test Always ask the patient to Frank Rodrigues get dressed before discussing any findings Biologic Male – Prostate Exam According to the ACS, patients with a prostate should have their first exam by age 50. During rectal exam – provider will find the median sulcus and palpate the entire prostate in a fan like motion –The only palpable parts of the prostate are posterior and part of the lateral portion Press lightly into the gland on each side – note any nodules or abnormal enlargement/tenderness Normal: –2.5cms by 4 cms, should not protrude more that 1cm into the rectum Frank Rodrigues –Heart shaped with palpable grove –Smooth, elastic and rubbery –Slightly mobile and nontender Prostate Abnormalities Prostatitis Benign Prostatic Tender, enlarged Hypertrophy (BPH) Urinary frequency, urgency, prostate with dull perineal/rectal aching hesitancy Symmetric, nontender Most often caused by enlargement bacteria spread from the Patient is usually “middle rectum aged” Fever/chills, malaise, Prostate feels smooth, urinary frequency rubbery, or firm with Prostate Cancer Frequency, nocturia, weak stream,median sulcus hematuria, obliterated hesitancy, pain or burning with urination due to swelling Continuous pain in the lower back/pelvis Frank Rodrigues Usually starts as a single hard nodule on the posterior surface (producing asymmetry on exam) and a change in prostate consistency. As cancer progresses, there are multiple hard nodules or the entire gland can feel like a stone. Prostate Cancer Risk Age – Most prostate cancers are diagnosed after age 50 – More that 60% are diagnosed after age 65 Family History – Especially if family member was diagnosed before age 60 – 5-10 of every 100 cases are related to inherited genetic factors Ethnicity – Most common in Black/African American individuals – Black/African Americans are more likely to be diagnosed late stage compared to other race/ethnicities due to Frank Rodrigues genetics (west African decent), increased testosterone exposure, less screening on average Lifestyle – Risk is increased if you are overweight, eat a high fat  Documentation Frank Rodrigues Write-up History – Genitalia. Menarche age 11. Last menstrual period April 18. Cycle usually q 28 days, duration 4 to 5 days, flow moderate, denies dysmenorrhea. Denies vaginal itching or discharge, sores, or lesions. – Sexual health. Not sexually active. Little interest in sex now. Denies STI contact. Never been tested for HIV. Past history of sexual abuse by father. Physical – Genitalia. Vulva normal. Mild cystocele on straining. Cervix parous, pink, without discharge. Uterus midline, Ø enlargement, masses, or tenderness. Adnexa without tenderness. Frank Rodrigues – Rectal. Ø hemorrhoids, fissures, lesions, masses or tenderness. Brown stool, Hematest negative.