Neurological & Genitalia

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Chapter 25

Male Genitourinary System

Male genital structures include:

External

Penis and scrotum

Internal

Testis, epididymis, and vas deferens

Glandular structures accessory to genital organs:

Prostate, seminal vesicles, and bulbourethral glands

Male Genitourinary System

Composed of three cylindric columns of erectile tissue:

Two corpora cavernosa on dorsal side

Corpus spongiosum ventrally

Glans: at distal end of shaft corpus spongiosum expands into cone of erectile tissue

Corona: shoulder where glans joins shaft

Urethra conduit for both genital and urinary systems.

Foreskin or prepuce forms hood or flap over glans.

Often removed shortly after birth by circumcision

Frenulum: fold of foreskin extending from urethral meatus ventrally

Penis

Anatomy: Penis

Scrotum

Loose protective sac; continuation of abdominal wall

Scrotal wall consists of thin skin lying in folds, or rugae, and underlying cremaster muscle.

Cremaster muscle controls size of scrotum by responding to ambient temperature.

Septum inside separates sac into halves; in each is a testis, which produces sperm.

Testes

Have a solid oval shape, suspended vertically by spermatic cord

Left testis is lower because left spermatic cord is longer.

Tunica vaginalis: double-layered membrane covers each testis and separates it from scrotal wall

Scrotum and Testes

Scrotum

Sperm

Epididymis: markedly coiled duct system and main storage site of sperm; comma-shaped structure, curved over top, and posterior surface of testis

Vas deferens: a muscular duct continuous with lower part of epididymis and with other vessels (arteries and veins, lymphatics, nerves) that forms spermatic cord

Spermatic cord

Ascends along posterior border of testis and runs through tunnel of inguinal canal into abdomen

Here, vas deferens continues back and down behind bladder, where it joins duct of seminal vesicle to form ejaculatory duct, which empties into urethra.

Sperm and Spermatic Cord

Lymphatics of penis and scrotal surface drain into inguinal lymph nodes

Lymphatics of testes drain into abdomen.

Abdominal lymph nodes are not accessible to clinical examination.

Lymphatics

Juncture of lower abdominal wall and thigh

Potential site for hernia development

Borders are the anterior superior iliac spine and symphysis pubis.

Between these landmarks lies inguinal ligament.

Inguinal canal is 4 to 6 cm long in adult.

Openings are:

Internal ring: 1 to 2 cm above midpoint of inguinal ligament

External ring: above and lateral to pubis

Inguinal Area or Groin

Inguinal Area

Infants

Prenatally, testes develop in abdominal cavity near kidneys.

At birth, testis measure 1.5 to 2 cm long and 1 cm wide.

Only a slight increase in size occurs during prepubertal years.

Adolescents

Signs of puberty are appearing earlier in boys according to research studies both in the United States and other countries.

First sign is enlargement of testes.

Next, pubic hair appears, then penis size increases.

Stages of development are documented in Tanner’s sexual maturity ratings.

Developmental Competence: Infants and Adolescents

Do not assume sexual orientation by appearance.

Be aware of definition of “sexual minority.”

Self-identify as gay, lesbian, bisexual, and transgender

Provide accepting attitude while providing factual information that is confidential in nature.

Identify and provide supportive resources.

Developmental Competence: Gender Identity

Male does not experience a definite end to fertility as female does.

Around age 40 years, production of sperm begins to decrease, although it continues into 80s and 90s.

Testosterone production declines after age 30 but continues very gradually so resulting physical changes are not evident until later in life.

Pubic hair decreases and penis size decreases.

Due to decreased tone of dartos muscle, scrotal contents hang lower, rugae decrease, and scrotum becomes pendulous.

Testes decrease in size and are less firm to palpation.

Increased connective tissue is present in tubules, so these become thickened and produce less sperm.

Developmental Competence: Adults and Aging Adults

Chronologic age by itself should not mean a halt in sexual activity; physical changes need not interfere with libido and sexual pleasure.

Older male is capable of sexual function as long as he is in reasonably good health and has an interested, willing partner.

Danger is in male misinterpreting normal age changes as a sexual failure; once this idea occurs, it may demoralize man and place undue emphasis on performance rather than on pleasure.

Sexual Expression in Later Life (1 of 2)

In the absence of disease, withdrawal from sexual activity may be due to (any combination of)

loss of spouse, depression, preoccupation with work.

marital or family conflicts.

side effects of medication, heavy alcohol use.

lack of privacy, living with children or in a nursing home.

economic or emotional stress.

poor nutrition or fatigue.

Sexual Expression Later in Life (2 of 2)

During pregnancy or immediate neonatal period, parents may ask whether or not to circumcise male infant.

Religious and cultural as well as medical indications

American Academy of Pediatrics (AAP) health benefits outweigh risks

Circumcision:

Lowers risk for certain STIs such as HPV, herpes simplex virus, genital ulcer disease in men and decreased risk for bacterial vaginosis and trichomoniasis in females

Reduced risk for contracting HIV infection through heterosexual contact

Culture and Genetics: Circumcision

Kidney disease

Two main causes of ESRD: hypertension and diabetes

Prevalence of diabetes and hypertension is higher in some racial groups: African Americans, American Indians and Hispanics are more likely to be affected

Contributing factors: low socioeconomic status with higher proportion of at risk behaviors, presence of comorbidities, and limited access to care

Bladder cancer

4th most common cancer in men with ethnic differences

Smoking is the most common risk factor along with occupational exposure to chemicals

Assess for painless hematuria.

Culture and Genetics: Kidney Disease and Bladder Cancer

Frequency, urgency, and nocturia

Dysuria

Hesitancy and straining

Past genitourinary history

Penis—pain, lesion, discharge

Scrotum—self-care behaviors, lump

Sexual activity and contraceptive use

Sexually transmitted infection (STI) contact

Subjective Data

Frequency, urgency, and nocturia: Ask about

whether the person urinates more often than usual.

whether the person feels as if he or she cannot wait to urinate.

whether the person is awakened during the night because he or she needs to urinate, and if so how often and whether this is a recent change.

Dysuria: Ask about

any pain or burning with urinating.

Hesitancy and straining: Ask about

Any trouble starting urine stream?

Need to strain to start or maintain stream?

Has there been any change in force of stream?

Dribbling, so that you must stand closer to toilet?

Afterward, do you still feel you need to urinate?

Ever had any urinary tract infections?

Subjective Data Questions (1 of 4)

Urine color: Ask about

whether the usual urine clear or discolored, cloudy, foul-smelling, or bloody.

Genitourinary history: Ask about

any difficulty in controlling urine.

Urgency incontinence: sudden loss, as in acute cystitis

Stress incontinence: involuntary urine loss with physical strain, sneezing or coughing due to weakness of pelvic floor

Do you accidentally urinate when you sneeze, laugh, cough, or bear down?

Any history of kidney disease, kidney stones, flank pain, urinary tract infections, or prostate trouble?

Subjective Data Questions (2 of 4)

Penis: Ask about

Have you had any problem with your penis, such as pain or lesions?

Any discharge? How much? Increased or decreased since start? Color? Odor? Discharge associated with pain or urination?

Scrotum, self-care behaviors: Ask about

Any problem with scrotum or testicles?

Any lumps or swelling on testes? Change in size of scrotum? History of undescended testicle as infant? Any bulge or swelling in scrotum?

Have you ever been told you have a hernia? Have you had any dragging, heavy feeling in scrotum?

Subjective Data Questions (3 of 4)

Sexual activity and contraceptive use: Ask about

Use gender-neutral terms

Are you in a relationship involving sexual intercourse?

Are aspects of sex satisfactory to you and your partner?

Are you satisfied with the way you and your partner communicate about sex?

Occasionally a man notices a change in ability to have an erection when aroused. Have you noticed any changes?

Do you and your partner use a contraceptive? Which method? Is this satisfactory? Do you have any questions about this method?

How many sexual partners have you had in the last 6 months?

What is your sexual preference? Do you prefer a relationship with a woman, a man, or both?

Subjective Data Questions (4 of 4)

Any sexual contact with a partner having an STI, such as gonorrhea, herpes, AIDS, chlamydia, venereal warts, or syphilis?

When was this contact? Did you get the disease?

How was it treated? Were there any complications?

Do you use condoms to help prevent STIs?

Do you have any questions or concerns about any of these diseases?

STI Contact Questions

Does your child have any problem urinating? Does his urine stream look straight?

Any pain with urinating, crying, or holding the genitals?

Any urinary tract infections?

Age appropriate questions:

Has toilet training started? How is it progressing?

If child is 5 years old or older, does he wet bed at night? Is this a problem for child or for parents? What have you done? How does the child feel about it?

Problems with structure and appearance:

Any problem with child’s penis or scrotum, such as sores, swelling, or discoloration?

Inappropriate behavior:

Has anyone ever touched your penis or in between your legs and you did not want them to?

Additional History: Infants and Children

Ask questions that are appropriate for age.

Start with a permission statement: “Often boys your age experience . . . ” This conveys that it is normal and all right to think or feel a certain way.

Try the ubiquity approach, “When did you . . . ” rather than “Do you . . . ” This method is less threatening because it implies that topic is normal and unexceptional.

Do not be concerned if a boy will not discuss sexuality with you or respond to offers for information.

You do well to “open the door;” adolescents may come back at a future time.

Additional History: Preadolescents and Adolescents (1 of 5)

Around age 12 to 13, but sometimes earlier, boys start to change and grow around penis and scrotum; what changes have you noticed?

Have you ever seen charts and pictures of normal growth patterns for boys? Let’s go over these now.

Who can you talk to about your body changes and about sex information? How do these talks go? What about sex education classes at school? How about your parents? Is there a favorite teacher, nurse, doctor, minister, or counselor to whom you can talk?

Additional History: Preadolescents and Adolescents (2 of 5)

Boys around age 12 to 13 have normal experience of fluid coming out of penis at night, called nocturnal emissions, or “wet dreams.”

Have you had this?

Teenage boys wonder if they are only ones who ever had them, like having an erection at embarrassing times, having sexual fantasies, or masturbating.

Boys might have thoughts about touching another boy’s genitals and wonder if he might be homosexual.

Would you like to talk about any of these things?

Additional History: Preadolescents and Adolescents (3 of 5)

Often boys your age have questions about sexual activity.

What questions do you have? How about things like birth control, or STIs such as gonorrhea or herpes? Do you have any questions about these?

Are you dating? Someone steady? Have you had intercourse? Are you using birth control?

What kind of birth control do you use?

Has a nurse or doctor ever taught you how to examine your own testicles to make sure they are healthy?

Have you had the vaccine Gardasil?

Additional History: Preadolescents and Adolescents (4 of 5)

Has anyone ever touched your genitals and you did not want them to?

Another boy, or an adult, even a relative?

Sometimes that happens to teenagers

You should remember it is not your fault and you should tell another adult about it.

Additional History: Preadolescents and Adolescents (5 of 5)

Any difficulty urinating?

Have you experienced any hesitancy or straining, a weakened force of stream, dribbling, or incomplete emptying?

Do you ever leak water or urine when you don’t want to?

Do you use pads/tissue to catch urine in your underwear?

Do you need to get up at night to urinate?

What medications are you taking? What fluids do you drink in the evening?

Additional History: Aging Adult

Preparation

Position male standing with underwear down and appropriate draping.

Concerns are similar to those experienced by female during examination of genitalia.

Take time to consider these feelings, as well as to explore your own.

Your demeanor should be confident and relaxed.

Use a firm deliberate touch, not soft, stroking one.

Equipment

Gloves: wear gloves during every male genitalia examination

Occasionally may require glass slide for urethral specimen

Materials for cytology

Flashlight

Objective Data

Skin normally looks wrinkled, hairless, and without lesions; dorsal vein may be apparent.

Glans looks smooth and without lesions; ask uncircumcised male to retract foreskin, or you retract it; it should move easily.

Some cheesy smegma may have collected under foreskin; after inspection, slide foreskin back to original position.

Urethral meatus positioned just about centrally

Compress glans anteroposteriorly between your thumb and forefinger; meatus edge should appear pink, smooth, and without discharge.

Inspection and Palpation: Penis

Inspect scrotum as male holds penis out of the way; alternatively, you hold penis out of the way with back of your hand.

Palpate gently each scrotal half between your thumb and first two fingers.

Palpate each spermatic cord between your thumb and forefinger, along its length from epididymis up to external inguinal ring.

If you find a mass, then provide additional specific information relative to location, size, shape, and ability to reduce.

Perform transillumination if mass or swelling is detected.

Inspection and Palpation: Scrotum

Inspect inguinal region for bulge as a person stands and strains down; normally none is present.

Palpate inguinal canal.

For right side, ask male to shift his weight onto left leg.

Use technique: NAVEL (Nerve, Artery, Vein, Empty space, Lymphatics)

Palpate femoral area for a bulge.

Normally you feel none.

Inspection and Palpation: Hernia

Inspect and palpate for hernia

Palpate horizontal chain along groin inferior to inguinal ligament and vertical chain along upper inner thigh.

Normal to palpate an isolated node on occasion; it then feels small, 1 cm, soft, discrete, and movable

Enlarged, hard, matted, fixed nodes are abnormal findings.

Palpation of Inguinal Lymph Nodes

Encourage self-care by teaching every male from 13 to 14 years old through adulthood how to examine his own testicles.

Early detection of cancer enhanced if male is familiar with his normal consistency.

Points to include during health teaching are:

T—timing, once a month

S—shower, warm water relaxes scrotal sac

E—examine, check for, and report changes immediately

Self-Care: Testicular Self-Examination (TSE)

Observe urine color.

Note pH and specific gravity.

Serum analysis of kidney function correlates with creatinine level which is relatively stable (end product of muscle metabolism).

BUN measures urea which can vary based on several factors (end product of protein metabolism).

Assessment of Urinary Function

Perform this procedure right after abdominal examination.

Preschool-age to young school-age child, 3 to 8 years of age, leave underpants on until just before examination

Older school-age child or adolescent, offer an extra drape, as with adult; reassure child and parents of normal findings

Inspect penis and scrotum.

Palpate scrotum and testes.

Inspect and palpate inguinal area for a bulge.

Developmental Competence: Infants and Children

Adolescents show wide variation in normal development of genitals.

Using SMR charts, note

enlargement of testes and scrotum.

pubic hair growth.

darkening of scrotal color.

roughening of scrotal skin.

increase in penis length and width.

axillary hair growth.

Be familiar with normal sequence of growth.

Developmental Competence: Adolescent

May note thinner, graying pubic hair and decreased size of penis

Size of testes may be decreased and may feel less firm.

Scrotal sac pendulous with less rugae

Scrotal skin may become excoriated if man continually sits on it.

Developmental Competence: Aging Adult

Range of colors associated with specific conditions

Can also be associated with medications and/or foods or vitamin supplements

Can also be due to use of contrast dyes during surgery and/or diagnostic procedures

Abnormal Findings: Urine Color and Discoloration

Urinary problems

Urethritis (urethral discharge and dysuria)

Renal calculi

Acute urinary retention and urinary tract infection

Urethral stricture

Male genital lesions

Tinea cruris

Genital herpes—HSV-2 infection

Genital warts

Syphilitic chancre

Carcinoma

Abnormal Findings: Urinary Problems and Male Genital Lesions

Hypospadias

Priapism

Phimosis

Paraphimosis

Epispadias

Peyronie’s disease

Abnormal Findings: Penis Abnormalities

Absent testis, cryptorchidism

Small testis

Testicular torsion

Epididymitis

Varicocele

Spermatocele

Early testicular tumor

Diffuse tumor

Hydrocele

Scrotal hernia

Orchitis

Scrotal edema

Scrotum Abnormalities

Review

Course, clinical signs and symptoms, frequency and cause

Types

Indirect inguinal hernia

Direct inguinal hernia

Femoral hernia

Abnormal Findings: Inguinal and Femoral Hernias

Inspect and palpate the penis.

Inspect and palpate the scrotum.

If a mass exists, try to transilluminate it.

Palpate for an inguinal hernia.

Palpate the inguinal lymph nodes.

Summary Checklist: Male Genitourinary System

Neurological & Genitalia

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