A Guide to the Clinical Male Urogenital Examination

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

Guide to the male urogenital Examination
2011 © Clinical Skills USA
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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

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.
5Relax 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

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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.”

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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.

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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.

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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?”

Male Urogenital Exam
Order of the Physical Examination
1) Pubic and Groin Regions
2) Hernias
3) Scrotum (sac/testes/spermaticcord/vas)
4) Penis
5) Rectum and Prostate
6) Breast (asneeded,basedonfamilyhistory)
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.

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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”:

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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:

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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.”

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I. Pubic Region
 Note masses, tenderness, and enlarged or immobile
nodes. It is not uncommon to feel a few shotty nodes.

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“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”

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Examine for femoral hernias

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Detect and evaluate for inguinal hernias
Insert index finger to 2nd digital crease, or entire “pinky
finger” at an angle coinciding with the inguinal canal.

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Detect and evaluate for inguinal hernias

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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.”

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Perform as neurological exam
(eg spinal injury), or test for
testicular torsion.

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.”

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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.”

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Anatomy of the Penis
Penile Anatomy

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 Identify if pt. is circumcised
or uncircumcised.
 If uncircumcised, ask the pt .
to retract the foreskin himself.

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“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?”

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Rectum & Prostate
(A matter of examiner preference)
Note the examiner’s hand upon initial contact.
The “lateral decubitis” 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.

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Rectum & Prostate
(A matter of examiner preference)

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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.

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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.”

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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 4cm 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.
 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.
Medical Illustration Copyright  2005 Nucleus Medical Art,
All rights reserved

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Rectum & Prostate
 Lubricate the anoscope well with the obturator in place.
 Position the patient in the left 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 expose.
 Spread the buttocks and gently insert the anoscope (with obturator) into the anal canal.
Asking the patient to take a few deep, gentle breaths and to bear down slightly may make the insertion
easier
 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 clinical
symptoms
 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
 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.
 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.
ANOSCOPY

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Rectum & Prostate
 Anoscopy is a procedure
used to visualize the perianal
area, anal canal, and distal
rectum. It is used to evaluate
the patient with perianal and
anal complaints, or as part of
the routine male urogenital
exam.
 Anoscopy is performed
AFTER a digital rectal exam
(DRE).
ANOSCOPY

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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.

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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.

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.
CLINICAL SKILLS USA, Inc.
provides trained instructors as
Gynecological Teaching
Associates
and
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.

A Guide to the Clinical Male Urogenital Examination

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A Guide to the Clinical Male Urogenital Examination