Male Examination Gender-Related Health Lisa Zaynab Killinger, DC

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Male ExaminationGender-Related HealthLisa
Zaynab Killinger, DC
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What can you expect from this class?(Or what do
you get in return?)

• Fulfill the requirements of your licenses!
• Learn info relevant to clinical practice
• Learn info for success on boards
• Have fun?

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Lets get started!
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The Digital Rectal Exam

• Or
• Why do I have to know this stuff ????

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What is a DRE?

• A DRE evaluates the terminal portions of the G-I
  tract.
• Sacrococcygeal and perianal areas
• Anus
• Sphincter and anal ring
• Lateral and posterior rectal walls
• Anterior rectal wall and prostate for males
• Stool

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DIGITAL RECTAL EXAM

• Why should a DRE be performed?
• How frequently should a DRE be performed?
• Who can perform a DRE?

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Why?

• Yearly screening for males
• Over age 50 for most over age 40 for high risk
• As part of an annual exam for females
• Yearly after becoming sexually active
• History-Perianal pain, problems
  w/urination/defecation/sexual function
• Symptoms? Low Back Pain, hesitancy or dribbling
  of urine, other local pain, changes

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Who?

• Chiropractors---In most states
• Family practitioners/General practitioners
• Gynecologists
• Proctologists/Urologists
• Physicians assistants

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What do patients say that provide clues that a
digital rectal exam should be done?
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Symptoms

• Changes in bowel function
• number, frequency, consistency, color, blood
• Changes in bladder function
• hesitancy, urgency, nocturia, dysuria, dribbling,
  discharge, decreased caliber or force
• Anal discomfort or rectal bleeding
• Sexual dysfunction

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When cant a DRE be done?

• Anal fissures---very painful
• Anal fistula--very painful
• Spasticity of the sphincter
• Rectal prolapse

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Important issues related to this exam

• Patient modesty
• Patient culture
• Dr/Pt boundary issues
• Patient history of abuse, rape, incest, etc.

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What should we do?

• Take a complete history
• Always have another individual in the room if you
  do this exam
• Talk to patient about their comfort level with
  this exam, with you doing this exam
• If you or patient is uncomfortable refer to
  another health professional for this exam!

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But, in the end

• Make sure that every patient over 50 (or over 40
  with risk factors) is having this exam done
  annually by SOMEONE!
• If you dont, you are liable for missed
  diagnoses. (Failure to diagnose is one of the
  most common successful malpractice claims against
  DCs.)
• Use your education to protect your patients
  health! Be a DOCTOR of Chiropractic.

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Lets talk about anatomy!
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The Rectum

• The rectum is approximately 12 cm long.
• Proximally, it joins the sigmoid colon.
• Distally, it joins the anal canal at the
  anorectal junction (about 2.5 to 4 cm).
• The distal end is not palpable.
• Folds in rectal walls may be palpable.

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The Rectum
Inferior rectal valve
Internal h. plexus
Crypts
Columns
Internal sphincter
External sphincter
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Sphincter Control

• The internal sphincter is made of smooth muscle
  and is under involuntary autonomic control.
• The external sphincter is made of striated muscle
  and is under voluntary control.

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• The urge to defecate occurs when the rectum fills
  with feces which causes reflex stimulation of the
  internal sphincter.
• Defecation is then controlled by the striated
  external sphincter.

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• The lower half of the anal canal is supplied with
  somatic sensory nerves, which makes it sensitive
  to painful stimuli.
• The upper half of the anal canal is under
  autonomic control and is not well-supplied by
  sensory nerves. Therefore, it is relatively
  insensitive to pain (lesions).

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The Prostate

• Located at the base of the bladder
• Surrounds the urethra
• Made of both fibromuscular and glandular tissue
• How big?
• Chestnut size 4cm X 3cm X 2cm
• In infants and childrensmall and inactive
• In adolescentsenlarges and becomes active
• After age 25continues to enlarge

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The Prostate
Urethra
Median lobe
Ejaculatory duct
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So, what does it do?

• It is the source of much investigation.
• We know that it contributes to the ejaculatory
  fluid.
• Believed to secrete enzymes that decrease the
  viscosity of the ejaculatory fluid
• Believed to lower acidity of the vaginal canal

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Access to the prostate

• The posterior surface of the prostate (what we
  palpate) is in close contact with the anterior
  rectal wall.
• A sulcus runs through the middle of the prostate
  and divides it into right and left lobes.

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So, how do we evaluate the prostate?

• Size
• Contour
• Consistency
• Mobility
• Protrusion into the rectum
• Grade 1, Grade 2, Grade 3, Grade 4
• Sulcus present
• Pain with palpation

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What does it feel like?

• Pencil eraser
• Tip of your nose
• Thenar pad

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Prostate Conditions

• Benign prostatic hypertrophy
• Prostate carcinoma
• Acute prostatitis
• Chronic prostatitis
• Others Prostatic calculi or abscesses

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Benign Prostatic Hypertrophy (BPH)

• Etiology is unknown
• VERY common in males over age 50
• Symptoms rare before 40
• 50 have symptoms after age 60
• 70 to 90 have symptoms after age 70

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What happens?

• The normal tissue is replaced by collagen.
• Results in expansion of the capsule, leading to
  pressure on the urethra bladder and urinary
  symptoms (as discussed earlier).
• All or part of prostate may enlarge.

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Digital Exam of BPH

• Sizeenlarged
• Consistency boggy, squishy, smooth
• Mobilityremains fairly mobile
• ProtrusionGrade depends on stage
• Sulcusmay be obscured (vs. obliterated)
• Should be nontender

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• The degree of enlargement of the prostate may not
  be related to symptoms
• i.e., a prostate that is markedly enlarged may
  not obstruct urinary flow

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• Acute urinary retention may occur, and in
  general symptoms may be aggravated by
• Exposure to cold
• Immobilization
• Attempts to retain urine
• Anesthetics, anticholinergics
• Ingestion of alcohol

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Other complications

• Incomplete bladder emptying leads to
• Urinary stasis
• Predisposes to infection of bladder and tract
• Hydronephrosis
• Renal calculus formation

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Treatments for BPH

• Wait and see
• Drug therapy
• Herbal remedies
• Prostatectomy

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Questions about BPH?
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Prostatic Carcinoma

• 2nd leading cause of cancer death in males over
  65
• An adenocarcinoma (sarcoma is rare)
• Rare before the age of 50
• 122,000 new cases/year in the US
• Etiology is unknown

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Risk Factors

• Age??
• Race??
• History??
• Diet??

• Age over 50 years
• African-American
• Family history of CA
• High in animal fat

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Signs and Symptoms

• In the early stages, asymptomatic!!
• Late in its course
• Bladder obstruction
• Ureteral obstruction
• Hematuria
• Pyuria

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Does it metastasize?

• Carcinoma from the prostate is responsible for
  60 of all skeletal metastasis
• 25 is due to lung cancer
• Predominantly blastic mets, but may be mixed

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So, how do we detect it?

• The DRE!
• Size
• Contour
• Consistency
• Mobility
• Protrusion
• Sulcus
• Tenderness

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• SizeNormal early, enlarged later
• ContourAsymmetrical
• ConsistencyHard nodules
• MobilityMay resist movement
• ProtrusionGrade 1-4
• SulcusObliterated (advanced CA)
• PainNO- usually asymptomatic

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Important Differentials

• Prostatic CA is not the only lesion with hard
  nodules
• Prostatic calculi
• Prostatic TB
• Prostate granulomata

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But, all hard nodules in the prostate should be
considered cancerous, until everything else is
ruled out!
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PSA

• Prostate Specific Antigen
• A glycoprotein specific to the prostate, but not
  to prostate carcinoma
• Produced by both healthy and unhealthy prostate
  tissue
• Serum PSA is moderately elevated in
• 30 to 50 of patients with BPH

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PSA Levels

• Levels lt 4 ng/ml are considered normal
• 4 to 10 ng/ml are considered borderline
• Above 10 ng/ml is considered high

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• The higher the PSA level, the more likely the
  presence of prostate CA.
• However.
• Men with prostate CA can have negative or
  borderline PSA levels

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How do we prove otherwise?

• PSAis elevated in 25 to 92 of patients with
  prostate cancer
• TRUS-Trans-rectal ultrasound
• Biopsy

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Borderline PSA levels

• PSA density (PSAD) divide the PSA number by the
  prostate volume (TRUS)
• Age-specific ranges Older men have higher PSA
  levels, even without CA
• PSA velocity Serial testing that measures how
  quickly PSA levels rise over time
• Free PSA ratio Bound vs. Unbound
• low levels of free PSA are more likely CA

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TRUS

• Performed when the PSA level is borderline and
  the DRE is negative
• Visualizes the areas needed for biopsy
• Helps determine the prostate volume (PSAD)

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TRUS
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Normal TRUS Image
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Abnormal TRUS Image
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TURP
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TURP
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Pre Post Prostate Resection
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Other Prostate Conditions

• BPH and Prostatic Carcinoma are, by far, the most
  common conditions associated with the prostate.
• Other conditions include.

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Acute Prostatitis

• Due to enteric, gram-negative bacteria
• High fever, chills, flu-like symptoms
• Perineal, prostate, and low back pain
• Symptoms of urinary obstruction
• Dysuria Pain or burning with urination
• Nocturia
• Hematuria (may be gross)
• Arthralgia and myalgia

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What are the DRE results?

• Sizeenlarged and may be warm
• Contourasymmetrical (within 1 lobe)
• Consistencyindurated fluctuant mass
• Mobilitymay be fixed
• Protrusionmay be present
• Sulcususually preserved
• PainYES! Very painful!

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Prostate Abscess- (Hole)

• Develops as a complication of acute prostatitis,
  urethritis, epididymitis
• Gram-negative or Staph. Aureus
• Dysuria, frequent urination, retention
• Pyuria
• Fever is present in some
• Leukocytosis is common
• Recurrent UTIs and perineal pain should suggest
  an abscess

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DRE of an Abscess

• May palpate as a hole or a divot in the prostate.
• Findings may also be normal or a fluctuant mass
  may be present
• Tenderness is possible

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Chronic Prostatitis

• Also bacterial and assoc. with UTIs
• Some may be asymptomatic
• Most have low back and perineal pain
• Urinary urgency and frequency
• Dysuria
• Infection can spread to scrotum and epididymis

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DRE Findings

• Sizeenlarged, but not like acute
• Contourusually more symmetrical
• Consistencyirregularly indurated or boggy
• Mobilitymay be fixed
• Protrusionnot much of an issue
• Sulcuspreserved
• Tendernessonly moderately tender, if at all

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Prostatic Calculi

• Protein stones of corpora amylacea
• Theory normal secretions of the prostate are
  blocked in the ducts (i.e. due to BPH)
• These blocked secretions dry out and calcify
• May also be secondary to infection

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Symptomatic? Passable?

• Typically not symptomatic, but may be discovered
  when BPH becomes symptomatic
• Not surrounded by fluid like a kidney stone, but
  about 1 of men can pass stones in the urine

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Questions about any of the prostate conditions?