Exanimation of the Male Reproductive Anatomy

1. Exanimation of the Male Reproductive Anatomy By Donald G. Hudson, D.O.,FACEP/ACOEP

2. Examination • While most of the male examination is pretty straight forward the anatomy and some of the embryology is definitely important to both know and consider. • Therefore, this slide show will include a lot of details concerning anatomy and physiology that I think is important to consider in any male examination.

3. Genital Variations • As you already recognize humans come in all sizes and shapes therefore you should not be surprised to find huge variations in male genitals and breasts. • Do a good history and record your findings • Much of what you want to know has to do with recent changes and how that effects the patient

4. History • As with most things in medicine a good history is important. • Sexual history, # of partners, their medical Hx, condom use, sexual preference, etc. • Do they get up at night to urinate, how many times, is there difficulty starting or stopping the urine flow. • Is there any problems with ejaculation

5. History • Have they had any recent weightloss • Do they use alcohol & how much • Medications, any recent changes in meds? • Family Hx of problems with reproductive system • Surgical History or trauma to genitals or testes • Do they do self examinations?

9. More Anatomy

10. Blood Supply to the Testes

11. Testes Surgically Removed

12. Internal Views of a normal Testes & one injured with loss of Blood Supply

14. Normal Prostate

16. Penis & Testes Come in all Sizes & Shapes

17. And sometimes multiple

18. Almost all men masturbate some time, ask how often and how, do they use restrictive bands, vibrators, etc, & how much do you ejaculate; penis size does not relate to amount of ejaculate

19. Why is this Important • Restrictive bands (cock rings) can cause severe ischemia & major damage to the penis. • Others put rings around both penis & Scrotum to prevent ejaculation. This also causes ischemia & atrophy to the testes. The hormone production can then be inappropriate

20. Why Important • The amount of ejaculate in both volume & force can give some good indication of nerve and prostate function. • The important fact is “is it different”? • Some men cannot ejaculate with intercourse and masturbation is their only option; is this new or an old occurrence?

21. What Else is Important • There is a large number of males who are not satisfied with their genitals, size, having testicules, & you will see some self mutilation being preformed. • These range from attempts to castrate them selves with Bizzardo Clamps (for animals) to a variety of surgical attempts, & methods to cut off blood supply for 24+ hours. • For some this is erogenous event, for others it is a mental illness.

22. Emasculatome • These are placed over the scrotum after identifying the Vas deferens. It is clamped down, left for 1 min.

23. Emasculatome (#2) • This is repeated by moving the tool about ½ inch distal on the vas. Clamp again for 1 min. Repeat on the other side. • The skin remains intact, the testes atrophy, initially the scrotum bruises & the vas swells up. • The men are now scared they did something bad & it will take some good Hx taking to get the whole truth

24. Another Reason to Ask- Remember a lot of men cannot ejaculate without stimulation of the prostate

25. What about the Prostate? • What does the Prostate do? • The prostate is the analog structure to the uterus in the female • It produces most of the ejaculate, it plus the Cowper's glands produce over 98% of what the male ejaculates • It will eventually, in the majority of men have a cancer within the organ

26. The Prostate (#2) • The PSA test is important to do. It was previously thought to be a screening test for over 60 y/o males. Now it is used on much younger men. • The exact numbers of the PSA test is not as important as the changes and progressive increases

27. Prostate (#3) • The actual exam of the prostate involves doing a rectal exam. • This is easiest done with the man laying on his back. Using an exam table have him pull his knees up and across his abd. • The prostate is now up toward the penis. • Lubricate your gloved finger, enter the rectum & sweep your finger forward & side to side.

28. Prostate (#4) • You are looking for lumps, soft areas, too large to feel sides, and pain. • While you are doing this also collect a stool sample for guiac testing.

29. Penis Examination • The penis extends behind the scrotum to an area about ½ inch from the anterior portion of the rectum, it is longer than what you actually see. • Look at the urethra, examine for sores, redness, narrowing, inability to see into the opening. • If they are not circumcised make sure you can slide the foreskin back off of the glans looking for too tight & signs of infection.

30. Penis Examination (#2) • The entire length of the shaft must be palpated, looking for painful areas, deviation to the side, soft areas, or masses. • The proximal ½ of the penis is essentially under the scrotum. • Be sure you look & fell the entire length. • Many men will get an erection during this examination, do not be embarassed, it is pretty normal behavior for most men.

31. The Testicular Examination

32. Testes Exam • The preceding picture is to refresh what you are to feel • The Vas Deferens is a hard tube feeling like a piece of spegitti, & not tender. • The Epiditmus is in the back of the testes & is softer bigger and separated from the testes & moderately tender. • The testes are frequently of different sizes.

33. Testes Exam (#2) • The blood supply for the left testes comes from the renal artery. Men may have a varicose vein, usually on the left & it feels like a “bag of worms” & may be slightly tender. These are the layers you are feeling through.

34. Testes Exam (#3) • The Testes should feel smooth. Look at the attached picture.

35. Testes Examine (#4) • Note where the blood supply & nerves all run. While you are here examine the inguinal canal looking for pain, loose tissue, hernia. Pull down gently on the testes while feeling that area.

36. Self Exam

39. The development of the male & female • While we all think our genitals are special we are so similar during gestation. • Just so you can appreciate how similar the parts are I have included a comparison chart so you can relate to the various analogous parts.

42. To Summarize • While you thought the examination of the male was easy & simple I hope this makes you realize how complicated it can be. • Also there are so many components to the male that in many ways they are as complicated as the female. • Do not forget to do a breast exam on any male with sexual dysfunction.

43. Summary (#2) • There is a lot of gynecomastia, swollen breasts as well as breast cancer. • Just because they are male does not remove the possibility of cancer. • See the next pictures. The male breast has the same internal anatomy & with hormone added they look the same. The exam is the same.

45. Before & After Surgery

46. Before & After Surgery

47. Believe it or not this is a male with breast augmentation

48. What’s Important? • Bloody discharge • Painful swelling is better than painless swelling • Milk production • Skin looking like the cover of a football • New dimples • Ulcers • Any of these are REALLY important. • And remember every thing may not be as it seems so ask questions if you have any doubts.

49. The documentation • Make sure you do a good examination & keep an open mind. • Like all examinations it is important to remove the clothes & look, touch, smell & understand what you are seeing. • Document your findings well. • Notify you collaboration physician to help make a plan of correction.