Examining the Male Patient: Sexually Transmitted Infections April 25, 2013 Brittany Grier, M.S, PA-C The Good News Learning how to do a proper male exam can provide high yield information in formulating a diagnosis. With few exceptions, all critical reproductive organs in the male are easily accessible for inspection and palpation. The Comprehensive Approach Clinical symptoms Sexual history Risk behaviors Physical exam Laboratory tests 1
The Standard History Chief complaint ( What brings you here today? What prompted you to come in for testing? ) Symptoms Description of symptoms (Sores- Painful? Itching? Discharge- Yellow? Clear?) Duration of symptoms Onset of symptoms The Standard History Allergies to medications Current medications Medical history: medical conditions, STD history Risk assessment: last sexual encounter; number of partners (new steady, casual); use of drugs; partner behaviors Sexual behaviors: exposure sites; condom usage, sexual preferences Other Helpful Historical Data MSM activity in self or partner 2
So Why Head to Toe? Signs of STDs can occur anywhere on the body- not just in the genitals Promote primary care; many of your patients may only seek care at the STD clinic and may need to be referred for care. Signs and Symptoms: Primary HIV Infection Fever 96% Adenopathy 74% Pharyngitis 70% Rash 70% Myalgias 54% Diarrhea 32% Headache 32% Nausea & vomiting 27% Hepatosplenomegaly 14% Weight loss 13% Thrush 12% Neurologic symptoms 12% Bartlett & Gallant, 2004 Other considerations: Any part of the body can be involved in STDs. Test results may not always corroborate your clinical diagnosis. Timing of the patient s last void (between 2-4 hours prior to exam is best). Did the patient attempt any self-treatment that may affect your findings (apply ointment to their sores, take unprescribed antibiotics)? 3
The Genital Examination An Overview of the Male Anatomy The Male Anatomy Penis: urethra, glans, corona, shaft Testes: responsible for sperm, testorone production; approximately 2X3X4 cm in size Epididymis: comma-shaped organ overlying the testes responsible for sperm maturation, storage, and transport Spermatic cord: Houses the vas deferens which eventually ends to form the ejaculatory duct The Standard Examination Check for inguinal lymphadenopathy. Evaluate the pubic hair for pubic lice (may need to change the lighting to see nits). Thoroughly inspect the surfaces of the penis, scrotum, groin for hidden lesions, retract the foreskin if necessary. Palpate the scrotum, testes, and epididymis. Check the opening of the urethra pointing it away from you; obtain the swab. Perform a rectal inspection and swab if history of exposure. 4
Urethral Specimen Collection Gently milk the penis from the base to the glans to obtain discharge. Depress the glans at 6 and 12 o clock to open the urethra. Remember that the urethra is on the ventral surface of the shaft. Special Considerations: The Uncircumcised Patient Special Considerations: The Uncircumcised Patient Phimosis Inability to retract foreskin due to excessive swelling Paraphimosis Inability to replace foreskin due to excessive swelling behind the corona 5
Other Considerations: Position of the Urethra Hypospadias Urethral meatus located towards ventral aspect of penis. Balanitis Occurs commonly in uncircumcised patients and diabetics Appears as ulcerations with white coating to outer glans in candidal infections Epididymitis Inflammation of the epididymis Usually caused by STDs in patients younger than 35 (N. gonorrhea, C. trachomatis) Painful swelling of the scrotum, unilateral testicular pain, dysuria with or without a discharge. May be complicated by orchitis (inflammation of the ipsilateral testis), must rule out testicular torsion. 6
Other findings pertinent to the male examination Hernias Other findings pertinent to the male examination Hernias Varicocele 7
Hydrocele Hydrocele Transillumination allows differentiation between solid mass or cyst vs. hydrocele Testicular Torsion Presents as unilateral testicular pain Occurs more commonly in younger, athletic patients. Surgical emergency 8