PHYSICAL ASSESSMENT OF THE GENTIALIA

OBJECTIVES : Describe the examination of the female external genitalia. Differentiate normal and abnormal assessment findings of the female external genitalia. Describe the examination of the male genitalia. Differentiate normal and abnormal findings of the male genitalia.

 Prior to Assessment :
1. Instruct the patient to empty her bladder and then to undress from the waist to the ankles. 2. Ensure that the room is warm enough to prevent chilling, and provide additional draping material as necessary. 3. Place drape or sheep skin over the stirrups to increase comfort. 4. Warm your hands with warm water prior to gloving. 5.Ensure that the privacy will be maintained during the assessment. Provide screen and a closed door.

 After the Assessment

Assess whether the patient needs assistance in dressing. Offer tissues with which to wipe excess lubrication. After the patient is dressed, discuss the experience with her, invite questions and comments, listen carefully, and provide her with information regarding the assessment and any laboratory information that is available. Tell the patient she may experience a small amount of spotting following the pap smear.

Female Genitalia

 1. With the patient seated, place a drape over the patient's torso and thighs until positioning in completed. 2. Instruct the patient to first sit on the examination table between the stirrups, facing away from the head of the table. 3. Assist the patient in assuming a dorsal recumbent or lithotomy position on the examination table. Assist the patient in placing her heels in the stirrups, thus abducting her legs and flexing her hips.

 4. Don clean gloves. 5. Assist the patient as she moves her buttocks down to the lower end of the examination table so that the buttocks are flush with the edge of the table. If the patient desires, raise the head of the examination table slightly to elevate her head and shoulders. 6.. Readjust the drape to cover the abdomen, thighs, and knees; adjust the stirrups as necessary for patient comfort. Push the drape down between the patient's knees so you can see the patient's face.

7. Sit on a stool at the foot of the examination table facing the patient's external genitalia. 8. Adjust your lighting source and provide the patient with a mirror. Instruct her on how to hold the mirror in order to view the examination prior to touching the patient's genitalia. 9. Finally, remember to inform the patient of each step of the assessment process before it is performed, and be gentle.

Female Genitalia
Inspect External Genitalia

NORMAL FINDINGS

DEVIATION FROM NORMAL

Pubic Hair

Evenly distributed Absence, on the sides of the presence of lesions labia majora Covered with pubic hair, the folds cover the labia minora Dark pink, smooth, moist, hairless Inflammation

Labia majora

Labia minora

 With Pubic lice

NORMAL PUBIC HAIR

 A chancre appears during the primary stages of syphilis at the site where the treponema enters the body. The chancre last for 4 weeks and then disappears

 CONDYLOMA LATUM - a flat, highly contagious, moist, venereal wart with a grayish yellow discharge; found on the vulva in late secondary syphilis

Female Genitalia
NORMAL FINDINGS

DEVIATION FROM NORMAL

Enlarged

Clitoris

Introitus (Vaginal orifice)

Small, cylindrical mass on the anterior end of the minora Irregular, slit like structure NORMAL FINDINGS: The clitoris is approximately 2.0 cm in length and 0.5 cm in diameter and with out lesions

Imperforation, laceration, inflammation

Abnormal Introitus Pale color and dryness of the introitus- possible etiologies include atrophy from topical steroids and the aging process. Foul smelling discharge that is any color other than clear to slightly pale white. Malodorous white, yellow, green, or gray discharge that may be purulent are some possible findings.

An external tear or impotency of the vaginal introitus- possible causes include trauma and fissure of the introitus. An external tear may indicate trauma from sexual activity or abuse, and a fissure may indicate a congenitalmalformation or child birth trauma. CYSTOCELE- Bulging of the anterior vaginal wall- The upper two thirds of anterior vaginal wall along with the bladder push forward into the introitus due to weakened supporting tissues and ligaments.

 5. CYSTOURETHROCELEBulging of the anterior vaginal wall, bladder and urethra into the vaginal introitus. The etiology is usually a weakening of the entire anterior vaginal wall. A fissure may define the urethrocele and cystocele URETHROCELE- a prolapsed of the urethra through the meatus urinarius or a pouch like protrusion of the urethral walls into the vaginal canal.

URETHRAL MEATUS 1. Using the dominant thumb and index finger, separate the labia minora laterally to expose the urethral meatus. Do not touch the urethral meatus; this may cause pain and urethral spasm. 2. Observe the shape, color and size of the urethral meatus. NORMAL FINDINGS; 1. The urethral opening is slitlike in appearance and midline; it is free of discharge, swelling, or redness and is about the size of pea

 1. Discharge of any color from the meatus - it indicates possible urinary infection. 2. Swelling or redness around the urethral meatus- swelling indicates possible infection of the skene's gland. Urethral caruncle ( small, red growth that protrudes from the meatus

 PALPATION OF THE EXTERNAL GENITALIA 1. palpate each labium between the thumb and the index finger of your dominant hand 2. Observe for swelling, induration, pain, or discharge from a bartholin's gland duct. NORMAL FINDINGS: The labium should feel soft and uniform in structure with no swelling, pain, induration, or purulent discharge.

 ABNORMAL FINDINGS: 1. Swelling, redness, induration, or purulent discharge from the labial folds with hot, tender areas. These findings indicate a probable Bartholin's gland infection. Causative organism include gonococci and Chlamydia trachomatis. 2. A firm mass that is possibly painful in the labia majora. This might indicate an inguinal hernia. If this is suspected, re- palpate the mass with the patient in a standing position.

Inspect Internal Genitalia

NORMAL FINDINGS

DEVIATION FROM NORMAL

Vagina insert gloved finger and ask client to bear down and assess presence of mass

Smooth vaginal wall, dark pink in color; bluish in pregnancy no mass, no warts,

Presence of cystocoele, rectocoele, purulent, foul smelling discharge

Use of vaginal speculum, water based lubricant and gloves are required Palpate by means of bimanual examination

Female Genitalia
Palpate Internal Genitalia NORMAL FINDINGS DEVIATION FROM NORMAL

Cervix and internal Os Locate the cervix with water based lubricant Insert water lubricated speculum

Cervix positioned posteriorly; not dilated in non pregnant women, non tender upon manipulation

Cervix located anteriorly, with pain upon moving, presence of purulent discharge

 Normal finding: The normal cervix is a glistening pink; it may be pale after menopause or blue ( CHADWICK's SIGN) during pregnancy. Normal size is 2.5 cm

 Small round yellow lesions on the cervical surface indicates NABOTHIAN CYSTS. These benign cysts result from the obstruction of cervical glands

Male Genitalia

 Preparation :
Examiner is sitting. Male client standing with undershorts down and appropiate draping. Or supine on the 1st part of the exam and then standing during hernia check. Consider Cleint s feelings and embarassment as well as your own. Maintian a confident and relaxed demeanor Do not discuss GU or sexual history during the exam Use a firm, deliberate touch, not soft and stroking If erection occurs, reassure that it is normal.

 Materials needed :
Gloves Flashlight Materials for Cytology PRN

 Objective Data : Inspect and Palpate the Penis

Skin is wrinkled, hairless, without lesions Dorsal vein maybe seen Glans smooth and without lesions Ask uncircimcised male to retract foreskin

 Inspect and Palpate penis

Urethral meatus just about centrally located At base, pubic hair distribution consistent with age Compress glans between thumb and forefinger
Edge smooth, pink without discharge.If with d/c collect smear

 Palpate shaft between thumb and 1st two fingers

Smooth, semifirm nontender

Inspect External Genitalia

NORMAL FINDINGS

DEVIATION FROM NORMAL

Penis Inspect for the development of the penis and the skin and the hair at its base Glans Penis Observe for size, shape and lesions

Hanging, freely movable, smooth, visible veins, non erect state is flaccid and non tender

Visible lesions, stricture, phimosis, warts, chancre,

Size and shape vary, Chancres, warts appearing rounded, broad or even pointed

Observe for appearance of hood like fold in uncircumcised penis

Penile Chancre Penile Wart

Male Genitalia
Inspect and Palpate External Genitalia NORMAL FINDINGS DEVIATION FROM NORMAL

Urethral Meatus Squeeze the glans between thumb and finger

Urethral opening is slit like located in the central part of the glans, free of discharge

Hypospadias, epispadias, discharges

Hypospadia Epispadia

 Inspect and Palpate the scrotum

Inspect scrotum as the client holds penis out of the way or use back of your hand Scrotal size varies with room temperature Asymetry is normal, L usually lower than R side Spread rugae out between your fingers Lift sac to inspect posterior surface
No lesion should be present

 Inspect and Palpate scrotum

Palpate gently each scrotal half between thumb and 1st two fingers Testes normally oval, firm, rubbery, smooth, equal bilaterally, freely movable Palpate each spermatic cord between thumb and forefinger from epididymis up to external inguinal ring. Should be smooth, non tender Note any masses Perform transillumination if with swelling or mass

Male Genitalia
NORMAL FINDINGS Inspect DEVIATION FROM NORMAL

Scrotum

Located on both sides of the penis, left side maybe slightly larger and hangs lower Non tender, no mass, no lesions Thin, rugated with little hair dispersion, intact skin

Contours

Enlarged scrotal sac, Rashes, lumps, tenderness, dilated veins, symmetry

Skin

Hernias
Patient is usually standing
NORMAL FINDINGS Inspect Free from bulges Inspect the inguinal and femoral areas for bulges. Ask the client to turn head and cough or to bear down as if to move bowel Bulges that appear in the external inguinal ring or at the femoral canal DEVIATION FROM NORMAL

 Inspect and Palpate for Inguinal Hernia

Inspect inguinal area for bulge as person stands and strains
Normal none present

Palpate femoral area for bulge

Normal none present

Palpate for inguinal lymph nodes

Palpate along horizontal chain along the groin Palpate vertical chain along upper thigh Normal to feel isolated node occasionally
1 cm, soft, discrete, movable

Hernias
NORMAL FINDINGS Palpate Bulging or masses Palpate for are not normally inguinal hernia palpated and inguinal nodes. Ask the client to shift his weight to the left for palpation of the right inguinal canal and vice versa. Plapate through he inguinal ring Presence of bulge or mass appears when the client coughs or bears down DEVIATION FROM NORMAL

Hernias
NORMAL FINDINGS DEVIATION FROM NORMAL

Palpate for inguinal nodes.

No mass upon bearing down

Enlarged or tender nodes may indicate an inflammatory process or lesions in the penis or scrotum

Hernias
NORMAL FINDINGS Palpate DEVIATION FROM NORMAL Presence of bulge or mass

Palpate for femoral hernia Palpate on the front of the thigh in the femoral canal area . Ask the client to cough or bear down. Feel the bulges

No mass upon bearing down

Hernias
NORMAL FINDINGS Inspect No mass upon Inguinal and femoral areas as bearing down patient bears down DEVIATION FROM NORMAL