Penis and testicles

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It is important to be aware of inguinal structures as well because _____________ are common in this area

Hernia

The main parts of the male genitalia anatomy

Penis
Scrotum
Prostate (or, if you listen to Fisher, 'Prostrate')
Glans penis
Foreskin
Bulbourethral gland
Urethra
Seminal vesicle
Corpus cavernosum
Corpus spongiosum
Inguinal area

Scrotum sac that contains the ____________

testes

Prostate produces 20% of ______________

semen

Two main functions of the penis

male sex organ
urine elimination

Glans penis is important for what?

Sexual arousal

What is the function of the Bulbourethral gland?

It secretes alkaline substance to neutralize vaginal secretions

What is the bladder?

A hollow muscular structure that holds urine - duh

Urethra is...

A passageway for urine

Ureter tubes connect the ________ to the ________

Connect the kidney to the bladder

What is the significance of the inguinal area?

It's a canal for the vas deferens from scrotum through abdominal muscles
It also contains inguinal lymph nodes

If uncircumcised, the glans penis is covered by foreskin or __________________

Prepuce (hood-like fold of skin)

Testes produce ____________ and _____________

Sperm and testosterone

Vas deferens

-- It is a duct from epididymis to the ejaculatory duct - provides passage for transporting sperm from testes to urethra for ejaculation.
-- It is longer on the left side

Spermatic cord

Protective sheath around vas deferens
Contains blood vessels and lymph

Seminal vesicles produce _______% of semen

70%

How does the scrotum help maintain the proper temp for sperm production? Should this temp be warmer or cooler than body temp?

Muscles contract when cold, drawing the scrotum and testes closer to the body, and when warm it relaxes taking the scrotum and testes away from the heat of the body. The temp should be cooler then body temperature for production of sperm.

Scrotum contains these two types of glands

Sweat & sebaceous glands

The scrotum has these skin folds on the outside called ________

Rugae

Cremaster muscle function

It is sensitive to changes in temperature, moving scrotum & testis upward for warmth when cold, and lowering scrotum to maintain cooler-than-body temp needed for sperm production (i.e. < 37 degrees Centigrade).

The __________ testis hangs lower than the ___________.

Left is lower than right

Where and why do you assess and palpate the inguinal area?

Assess and palpate above and lateral to symphysis pubis for swelling, lumps or masses (could indicate infection, hernia or cancer).

Developmental considerations - Prenatal, birth to puberty

Testes develop in the abdominal cavity near the kidneys
Testes descend along the inguinal canal into the scrotum before birth
At birth, each testis measures 1.5 to 2 cm long and 1 cm wide. Slight increase in size occurs during pre-pubescent years.

Cryptorchidism

Undescended testicle

Developmental considerations - At maturity
Testes are ovoid
~ 3.5 to 5 cm long, 2.5 cm wide, 5 cm deep
Should be equal bilaterally in size and shape

Testes are ovoid
~ 3.5 to 5 cm long, 2.5 cm wide, 5 cm deep
Should be equal bilaterally in size and shape

Testes should feel like this...

Smooth, firm, mobile, rubbery, free of nodules and tender to pressure

Tanner's Sexual Maturity Rating for Boys

Stages I - V

Stage I
Tanner's Sexual Maturity Rating for Boys

Preadolescent: no pubic hair; penis and scrotum size and proportion is the same as during childhood

Stage II
Tanner's Sexual Maturity Rating for Boys

Few straight slightly darker hairs at base of penis; little or no enlargement of penis; testes and scrotum begin to enlarge; scrotal skin reddens and changes in texture

Stage III
Tanner's Sexual Maturity Rating for Boys

Sparse growth of pubic hair over entire pubis; hair darker, coarser, and curly; penis begins to enlarge, especially length; scrotum further enlarged.

Stage IV
Tanner's Sexual Maturity Rating for Boys

Thick growth of pubic hair over pubic area but not on thighs. Hair coarse and curly as in adult; penis grows in length and diameter, with development of glans; testes almost fully grown, scrotum darker

Stage V
Tanner's Sexual Maturity Rating for Boys

Pubic hair growth spread over medial thighs, although not yet up toward umbilicus; penis and scrotum is adult size and shape.
Pubic hair growth continues until mid 20s

When does puberty begin?
What are the first things to happen?

Sometime between ages of 9½ & 13 ½
First sign is testes enlargement
Next, pubic hair appears
Then penis size increases

How long does the complete change in development from preadolescent to an adult take?

Around 3 years, although range is 2 to 5 years.

When male genitalia get old...

Amount of pubic hair decreases and remaining hair turns gray
Penis size decreases
Scrotal contents hang lower due to decreased tone of dartos muscle; rugae decrease and scrotum appears pendulous.
Testes decrease in size and are less firm
Increased connective tissue in tubules = less sperm production
Sperm production begins to decrease around age 40
Erectile dysfunction increase in frequency with age
Diabetes can also cause impotence

Transcultural considerations - is sexual development similar in black and white boys?

Yes, sexual development is similar in black and white boys

Transcultural considerations - circumcision

Decision to circumcise the male penis is culturally based
Some groups (Jews & Muslims) practice circumcision as part of religious value system
Native Americans and Hispanics have no tradition to practice circumcision
70 to 80% of newborn males are circumcised in the United States, whereas in many countries it is considered unnecessary

History

• Urinary frequency, urgency, and nocturia
• Dysuria
• Hesitancy and straining
• Urine color
• Past genitourinary history
• Penis: pain, lesions, discharge
• Scrotum: self-care behaviors (TSE)
• Sexual activity and contraceptive use
• STI contact

TSE

Testicular Self Exam
Recommend monthly self-exam of testes as important in early Dx and Rx of testicular cancer

Pain could indicate what?

May indicate hernia or inflammatory process

Lesions that itch, burn, or sting may be...

STD or Cancer

Discharge could indicate what?

May indicate infection

Lumps, swelling, or masses could indicate what?

Hernia
Cancer
Infection

Enlargement of the scrotum may indicate what?

Fluid (hydrocele); blood (hematocele); bowel (hernia); tumor (cancer)
Heavy dragging feeling in the scrotum

Difficulty urinating may indicate what?

Infection or blockage including prostatic enlargement

Urinating more then one time a night can indicate what?

Prostate abnormalities

Change in color, amount or odor of urine means what?

Infection

Blood in the urine can mean...

Can be infection, BPH, or cancer

After a prostatectomy, sometimes this happens...

Incontinence

Dribbling may be a sign of...

Overflow incontinence

Sexual dysfunction and erectile dysfunction are related to...

ETOH, depression, anti-hypertensives, age

What % of infertility occurs in males?

30%

Client with multiple sex partners is at risk for...

Contracting STD or HIV.

American Cancer Society recommendations for testicular exam by MD

Every 3 yrs for asymptomatic men between 20-39
Every year for those over 40.

Do cancers of prostate and testes have a familial tendency?

Yes

Penis inspection...mmmmmmm
Basic set up and procedure

• Sit on stool with client standing, facing you. Client raises gown or drape (no, this is not the first scene in a bad porno)
• Wear gloves during the male genitalia examination
• Note pubic hair growth pattern and any excoriation, erythema, or infestation at base of penis and within pubic hair
• Inspect skin of shaft of penis for rashes, lesions, or lumps
• Inspect foreskin by asking uncircumcised male to retract it or examiner can do so
• Observe color, location, integrity of foreskin.
• Inspect and palpate penis, scrotum, & inguinal area for infestations, lesions, & lumps
• Inspect glans for size, shape, lesions or redness. Need to retract foreskin to observe glans in uncircumcised male. Note location of urinary meatus on the glans.

What should you do if an erection occurs?

If erection occurs reassure the client that it is not unusual and continue the examination in an unhurried and unflappable manner

Normal findings for penis inspection
- Base & Pubic Hair
- Skin of Penal Shaft
- Foreskin
- Glans

• Base & Pubic Hair: normal pubic hair pattern in adult is hair covering entire groin area, extending to medial thighs and up abdomen toward umbilicus. No excoriation, erythema, and infestation
• Skin of Penal Shaft: free of rashes, lesions, or lumps
• Foreskin: foreskin in uncircumcised male is intact and uniform in color with penis
• Glans: size and shape vary, appearing rounded, broad, or even pointed. Free of lesions and redness. Foreskin retracts easily and a small amount of whitish material (smegma) may be present (normally accumulates under foreskin. Urinary meatus is normally found in center of glans.

Abnormal findings for penis inspection
Hardness on the ventral surface may indicate...

Cancer or stricture

Abnormal findings for penis inspection
Discoloration may indicate...

Scarring or infection

Abnormal findings for penis inspection
Rashes lesions or lumps may indicate...

STD or cancer

Abnormal findings for penis inspection
Lice or nit (eggs) infestation at base of penis is known as...

Pediculosis pubis or "crabs"

Abnormal findings for penis inspection
STIs

Cankers from syphilis, warts, and pimple like lesions from herpes are sometimes detected

Abnormal findings for penis inspection
Hypospadias

The displacement of the urinary meatus to the ventral surface of the penis

Abnormal findings for penis inspection
Epispadias

Displacement of the urinary meatus to the dorsal surface of the penis

Abnormal findings for penis inspection
Yellow discharge indicates which STI?

Ghonorrhea

What do you do if there is discharge?

All discharge should be cultured

Phimosis

A tight foreskin that cannot be retracted

Palpation of the penis

• Palpate the shaft of the penis paying particular attention to palpate any abnormalities noted during inspection - note any hardened or tender areas
• Palpate for urethral discharge by squeezing glans between index finger and thumb

Normal findings for palpation of penis

• Penis in a nonerect state is usually soft, flaccid, and nontender
• Urinary meatus is normally free of discharge

Inspection of scrotum

• Inspect size, shape, and position of scrotum by having client hold penis out of the way - observe for swelling, lumps, or bulges
• Inspect scrotal skin and observe color, integrity, lesions or rashes. To perform an accurate inspection, examiner must spread out the scrotal folds (rugae) - lift scrotal sac to inspect posterior skin

Normal findings of scrotum inspection

• Scrotum varies in size (according to temperature) and shape. Scrotal sac hangs below or at level of penis. Left side of scrotal sac usually hangs lower than the right.
• Scrotal skin is thin and rugated (crinkled) with little hair dispersion. Its color is slightly darker than penis. Lesions and rashes not normally present. However, sebaceous cysts (small, yellowish, firm, non-tender, benign nodules) are a normal finding.

Palpation of scrotum - scrotal contents, spermatic cord, vas deferens

• Palpate scrotal contents by palpating each testis and epididymis between thumb and first two fingers - note size, shape, consistency, nodules, and tenderness
• Palpate each spermatic cord and vas deferens from the epididymis to the inguinal ring. Spermatic cord will lie between thumb and finger - note any nodules, swelling, or tenderness.
• Do not apply too much pressure to the testes it may cause pain

Abnormal findings of scrotum palpation
Absence of a testis suggests...

Cryptorchidism (undescended testicle)

Abnormal findings of scrotum palpation
Tenderness and swelling may indicate...

Orchitis(swelling of the testes), torsion of the cord, or a strangulated hernia

Abnormal findings of scrotum palpation
Palpable, tortuous veins suggest...

Varicocele

Normal findings of scrotum palpation

• Testes are ovoid, approximately 3.5 to 5 cm long, 2.5 cm wide, and 2.5 cm deep, and equal bilaterally in size and shape. They are smooth, firm, rubbery, mobile, free of nodules, and rather tender to pressure
• The epididymis is non-tender, smooth, and softer than testes.
• Spermatic cord and vas deferens should feel uniform on both sides. Cord is smooth, non-tender, and ropelike.

Abnormal findings of scrotum palpation
Epididymitis

Usually presents as a sudden onset of bilateral scrotal pain associated with an infection or inflammatory process. The scrotum is reddened, swollen, and enlarged. The epididymis is tender to the touch.

Abnormal findings of scrotum palpation
Elevation of the testes within the scrotal sac may indicate...

Undescended testes. Cryptorchidism is not an acute condition but rather a failure of one or both testicles to descend into the scrotum.

Abnormal findings of scrotum palpation
Hydrocele

A soft, irregular mass may be seen with a hydrocele (collection of serous fluid in the scrotum, outside testes, appears as swelling in scrotum, usually painless will transillimunitate unless there is blood in the scrotum or "hematocele")

Abnormal findings of scrotum palpation
Spermatocele

Spermatocele (sperm-filled cyctic mass located on epididymis, will be palpable as small and non-tender, movable and will appear on transillumination).

Abnormal findings of scrotum palpation
Spermatic cord torsion

Often occurs in adolescent boys and manifests as a severely painful, reddened and enlarged scrotum

Transillumination of the scrotum

• Normally, scrotal contents do not transilluminate.
• Transilluminate scrotal contents if an abnormal mass is noted in scrotum. Darken room and shine a light from the back of the scrotum through the mass. Look for a red glow.
• Swellings or masses that contain serous fluid (hydrocele, spermatocele will light up with a red glow. Swelling or scrotal masses that are solid or filled with blood, tumors, hernias or varicolcele do not light up with a red glow).

What to do if you feel a mass when palpating some guy's balls...I mean, scrotum

When palpating the scrotum for a mass, the nurse should make the client lie down to assess for the disappearance of the mass, indicating the possibility of a hydrocele. The mass should then be auscultated with a stethoscope to listen for bowel sounds, which may be heard with a hernia. Transillumination will occur if the scrotum is filled with fluid but not with solid tumors. These finding should then be reported to the health care provider.

Hernias

Need to also inspect for inguinal & femoral hernias (i.e. normally area is free from bulges when ask client to cough or bear down as if having a bowel movement).
If a bulge or mass is detected, may indicate a hernia i.e. a loop of bowel protruding into the scrotum to create what is known as an indirect inguinal hernias, which appear as swelling in the scrotum.
Will be palpable as a soft mass and fingers cannot get above the mass.
Auscultate and check for bowel sounds.
If the bulge disappears when client lies down, a scrotal hernia is present.
This is most common type of hernia, it may occur in adults but is more frequent in children.

Femoral Hernia

The bowel herniates through the femoral ring and canal, it doesn't travel into scrotum, and the inguinal canal is empty. This is the least common type of hernia. It occurs mostly in women.

Carcinoma of the penis

Appears as hardened nodule or ulcer on glans
Is painless, occurs primarily in uncircumcised men.

Abnormalities of penis - STIs (syphilis, herpes, genital warts)

-- Syphilitic Chancre: Initially syphilis produces a small, silvery-white papule that develops a red oval ulceration. They are generally painless and spontaneously regress. This chancre is the sign of primary syphilis, a sexually transmitted disease.
-- Herpes ulcers are painful. Appear as clusters of pimple-like, clear vesicles that erupt and become ulcers. Infection remains dormant for varying periods of time. Recurrences can be frequent or minimally episodic.
-- Genital warts are fleshy papules. Can be single or multiple, generally moist and painless, caused by human papillomavirus.

Testicular tumor

Starts as a small non-tender nodule
As it grows the client complains of a heavy feeling
Does not transilluminate

Testicular Cancer Stats

• Most common cancer in young men between the ages of 15 and 40 years. But it can strike any male, any time.
• Testicular cancer is almost always curable if found early.
• Most testicular cancers are found by men themselves, either as a painless lump, a hardening or change in size of testicle, or pain in testicle.
• Incidence has doubled in past 30 to 40 years.

Testicular Cancer - cultural factors

• Caucasians are more likely to get testicular cancer than Hispanics, and much more likely to get it than Blacks or Asians.
• Highest incidence is in Denmark

Testicular Cancer - risk factors

An undescended testicle (cryptorchidism). The testes form in the abdominal area during fetal development and usually descend into the scrotum before birth. Men who have a testicle that never descended are at greater risk of testicular cancer than are men whose testicles descended normally. The risk remains even if the testicle has been surgically relocated to the scrotum. Still, the majority of men who develop testicular cancer don't have a history of undescended testicles.
Abnormal testicle development. Conditions that cause testicles to develop abnormally, such as Klinefelter's syndrome, may increase your risk of testicular cancer.
Family history. If family members have had testicular cancer, you may have an increased risk.
Age. Testicular cancer affects teens and younger men, particularly those between ages 15 and 34. However, it can occur at any age.
Race. Testicular cancer is more common in white men than in black men.

Testicular Cancer - symptoms

A lump or enlargement in either testicle - typically pea-sized, but sometimes as large as a marble or an egg
Any enlargement of the testicle
Significant shrinking of testicle
Change in consistency of a testicle (hardness)
A feeling of heaviness in the scrotum
A dull ache in the abdomen or groin
A sudden collection of fluid in the scrotum
Pain or discomfort in a testicle or the scrotum
Enlargement or tenderness of the breasts
Unexplained fatigue or a general feeling of not being well

Testicular Cancer - Tests and diagnosis

Most men discover testicular cancer themselves, either unintentionally or while doing a testicular self-examination to check for lumps. In other cases, your doctor may detect a lump during a routine physical exam

To determine whether a lump is testicular cancer, your doctor may recommend:

Ultrasound. A testicular ultrasound test uses sound waves to create a picture of the scrotum and testicles. During an ultrasound you lie on your back with your legs spread. Your doctor then applies a clear gel to your scrotum. A hand-held probe is moved over your scrotum to make the ultrasound image.
An ultrasound test can help your doctor determine the nature of any testicular lumps, such as if the lumps are solid or fluid filled. Ultrasound also tells your doctor whether lumps are inside or outside of the testicle. Your doctor uses this information to determine whether a lump is likely to be testicular cancer.

Blood tests. Your doctor may order tests to determine the levels of tumor markers in your blood. Tumor markers are substances that occur normally in your blood, but the levels of these substances may be elevated in certain situations, including testicular cancer. A high level of a tumor marker in your blood doesn't mean you have cancer, but it may help your doctor in determining your diagnosis.

Surgery to remove a testicle (radical inguinal orchiectomy). If your doctor determines the lump on your testicle may be cancerous, he or she may recommend surgery to remove the testicle. Your testicle will be analyzed in a laboratory to determine if the lump is cancerous and, if so, what type of cancer.

TSE

• Once a month from age of 13 or 14 through adulthood
• During a shower or bath, when hands are warm and soapy and scrotum is warm, hold scrotum in palm of hand and gently feel each testicle using thumb and first two fingers
• If this hurts, too much pressure is being used
• Testicle is egg-shaped and moveable. It feels rubbery with a smooth surface, like a hard-boiled egg. Epididymis is on top and behind testicle; it feels a bit softer.
• Call physician if a firm, painless lump, hard area, or an overall enlarged testicle is noted.

Prostate Anatomy

Prostate: ~ 2.5 - 4 cm in diameter, surrounds neck of bladder &amp; urethra, lies between these structures and rectum. Two lobes separated by median sulcus, secretes substance that promotes sperm motility, neutralizes female acidic vaginal secretions. Described as chestnut or heart shaped which can be palpated through anterior wall of rectum.
Seminal vesicles are located on either side and above prostate gland, produce ejaculate that nourishes and protects sperm, should not be palpable.
Anal canal is final segment of the digestive system. Anal opening is distinguished from perianal skin by it hairless, moist appearance. Has 2 sphincters: 1) external (skeletal muscle under voluntary control) and 2) internal (smooth muscle of autonomic nervous system = involuntary control).
Rectum = lowest portion of large intestine ~ 12 cm long, from end of sigmoid colon.

BPH

Benign Prostatic Hypertrophy

Digital Rectal Exam (DRE)

Can reveal masses, prostate enlargement or prostate nodules
American Cancer Society recommends one every year after 40

Prostate - developmental considerations

• Prostate gland commonly starts to enlarge during the middle years.
• Benign Prostatic Hypertrophy (BPH) is present in 1 of 10 males at 40 years of age and increases with age. Thought to be caused by hormonal changes due to aging. This leads to gradual impedance of urinary output as BPH obstructs urethra.
• ~ 1 in 6 men are Dx with prostate Cancer but only 3% die of the disease. Very slow growing, can be treated if found early.

Prostate Cancer - transcultural considerations

• Prostate cancer is more common in North America and Northwestern Europe and rare in Central and South America, Africa, and Asia.
• Incidence is 50% higher for black American men than rates for other racial groups.
• Mortality rates ate two times higher for black men than for white men.
• Inherited predisposition may account for 5% to 10% of prostate cancers, and dietary fat may also be a factor.

Prostate Cancer - Risk Factors

• Advanced age (over 50)
• Nationality or ethnic group
• Diet high in fat, animal products, and calcium; low in fruits, vegetables, lycopenes (in tomatoes, grapefruit, and watermelon), and selenium
• Limited or low levels of physical activity
• Possible risk factors: exposure to cadmium; tire and rubber manufacturing, farming, mechanics, sheet metal work, history of STIs.

Prostate cancer - what is it?

It is a cancer that occurs in a man's prostate — a small walnut-shaped gland that produces the seminal fluid that nourishes and transports sperm.
Prostate cancer is one of the most common types of cancer in men. Prostate cancer usually grows slowly and initially remains confined to the prostate gland, where it may not cause serious harm. While some types of prostate cancer grow slowly and may need minimal or no treatment, other types are aggressive and can spread quickly.
Prostate cancer that is detected early — when it's still confined to the prostate gland — has a better chance of successful treatment

Prostate Cancer - prevention

There is no sure way to prevent prostate cancer, but diet & lifestyle behaviors are thought to help with prevention.

Prostate Cancer - symptoms

Prostate cancer may not cause signs or symptoms in its early stage
Trouble urinating
Decreased force in the stream of urine
Blood in your urine
Blood in your semen
Swelling in your legs
Discomfort in the pelvic area
Bone pain

Prostate Exam - History

•Straining on urination
•Hesitancy in starting urine flow
•Decreased urine stream
•Post-void dribbling
•Nocturia
•Dysuria
•Blood in urine
•Urgency
•Feeling of incomplete emptying
•Self-care Behaviors: Date of last digital rectal examination and prostate-specific antigen blood test

Prostate Exam - palpation

• Can be standing and bending over or side lying (Left side) in knee chest position, squatting or lithotomy position.
• Place lubricating jelly onto gloved index finger.
• Place pad of index finger gently against anal verge. Feel the sphincter tighten and then relax.
• As sphincter relaxes, flex tip of finger and slowly insert it into anal can in direction toward umbilicus.
• Never approach anus at right angles with index finger extended. This is painful.
• On anterior wall, note the elastic, bulging prostate gland. Palpate entire prostate in a systematic manner. Press into gland at each location; when a nodule occurs, it will not project into rectal lumen.
• Surface should feel smooth and muscular.

Prostate exam - abnormal findings of palpation

• Swollen tender prostate can indicate acute prostatitis (caused by a bacterial infection).
• An enlarged smooth firm, slightly elastic prostate that may not have a median sulcus, suggest BPH. (common in men older than age 50)
• A hard area on the prostate or hard, fixed, irregular nodules on the prostate suggest cancer.

PSA - Prostate-Specific Antigen

Prostate-specific antigen (PSA) is a protein produced by cells of the prostate gland. The PSA test measures the level of PSA in the blood.
It is normal for men to have a low level of PSA in their blood; however, prostate cancer or benign conditions can increase a man's PSA level. As men age, both benign prostate conditions and prostate cancer become more common. There is no evidence that prostatitis or BPH causes cancer, but it is possible for a man to have one or both of these conditions and to develop prostate cancer as well.
The U.S. Food and Drug Administration (FDA) has approved the use of the PSA test along with a digital rectal exam to help detect prostate cancer in men 50 years of age or older.
The FDA has also approved the use of the PSA test to monitor patients who have a history of prostate cancer to see if the cancer has recurred (come back). If a man's PSA level begins to rise, it may be the first sign of recurrence.
It is important to note that a man who is receiving hormone therapy for prostate cancer may have a low PSA level during, or immediately after, treatment. The low level may not be a true measure of the man's PSA level.
Recommendations for screening vary. Some encourage yearly screening for men over age 50, and some advise men who are at a higher risk for prostate cancer to begin screening at age 40 or 45. Others caution against routine screening. Although specific recommendations regarding PSA screening vary, there is general agreement that men should be informed about the potential risks and benefits of PSA screening before being tested. Currently, Medicare provides coverage for an annual PSA test for all men age 50 and older.

PSA - levels

• Highest normal value is considered to be 4 ng/mL
• Levels above 4 ng/mL but less than 10 ng/mL are suspicious, yet most men who have this level do not have prostate cancer
• As levels increase above 10 ng/mL, the probability of prostate cancer increases dramatically

PSA - research

• PSA is not to be used alone in screening for prostate cancer. It will miss 20% to 30% of all tumors.
• Suggested that normal level for men in their 40s should be lowered to 2.5 ng/mL or less for improved screening.
• PSAs should be followed for an individual person over time. If there is a rising trend, follow with prostate biopsy.
• Use of DRE with PSA increases chances of early detection of prostate cancer.

Anus & Rectum

Anal canal begins at anal sphincter, ends at anorectal junction
~ 2.5 - 4 cm long
It is the final segment of the digestive system
Anal opening is distinguished from perianal skin by it hairless, moist appearance.
Has 2 sphincters
1) external (skeletal muscle under voluntary control)
2) internal (smooth muscle of ANS = involuntary control)
Rectum = lowest portion of large intestine ~ 12 cm long, from end of sigmoid colon.

Anal and Rectum - History

• PMH: History of anal or rectal trauma/surgery/congenital deformities or hemorrhoids?
• FH: Colorectal (& prostate cancers) have a tendency to affect members of the same family.
• Bowel patterns: Changes are associated with many disorders, can be warning sign of cancer.
• Stool: Color, consistency, blood, mucus
• Rectal itching & pain: can be associated with STDs, hemorrhoids, pinworms, anal trauma.
• Lifestyle issues
• High fat, fiber foods & roughage consumed daily?
• Use of laxatives, stool softeners, enemas
• Regular Exercise?
• Engage in anal sex?
• Medications : HRT, Calcium

Constipation, Diarrhea, Fecal incontinence

Constipation can indicate bowel obstruction or need for dietary counseling.
Diarrhea can indicate need for dietary counseling or signal impaction.
Fecal incontinence occurs with neuro disorders and some GI infections.

Poop - colors, mucus and what it all means

Black: (tarry) stools can indicate GI bleeding, (also use of iron supplements or Pepto-bismol)
Red: blood in stool found with hemorrhoids, polyps, cancer or colitis
Clay colored stools = lack of bile pigment.
Mucus in stool can indicate steatorrhea = excessive fat in the stools.

Nutrition and Cancer

High fat diets are implicated in colon cancer e.g. Nurses study suggest risk of colon cancer increases with consumption of red meat and saturated & monosaturated fats, yet other studies found no association (i.e. Iowa women health Study and one by NCI).
Role of dietary fiber as protection against colon cancer also unclear.

Laxatives

Long-term use of laxatives, etc. can alter body's ability to regulate bowel functioning. Short-term use can signal need for nutrition counseling.

Physical activity and cancer

Sedentary lifestyle linked to development of colorectal cancer, and physical activity has been associated with reduction in risk. Amount of exercise needed unknown.

Calcium and estrogen - effects of cancer

-- Observational studies suggest risk of colon cancer drops with increased calcium intake, while others do not reflect any effect.
-- Use of HRT (Nurses study) indicated that postmenopausal use of estrogen reduces risk of colon CA - further studies needed.

American Cancer Society recommends:

• Fecal occult blood testing: annually after age 50
Clinical trials determined use of FOBT have increased detection of adenomatous polyps and colorectal CA - (associated with 15-33% decline in death rates from these conditions).
• Proctosigmoidoscipic exam: every 3-5 yrs after 50
• DRE: every yr after age 40
• PSA annually after age 50.

Physical exam

• Can produce anxiety &amp; embarrassment
• Preparing the client
• Opportunity to educate about risk factors
• Any stool on examiners glove should be checked for blood (fecal occult blood test) may indicate cancer of rectum or colon.
-Rectal cancer is usually asymptomatic until quite advanced.

Physical exam - what do RNs generally do?

RNs typically are responsible for external assessment and inspection of anus; collection of specimens and education Re: risk factors for anorectal diseases.

Perianal area - inspection

-Anal opening = hairless, moist, tightly closed. Free of redness, lumps, ulcers, lesions and rashes.
Lesions can signal STDs, CA or hemorrhoids.
Perianal abscess (i.e. a cavity of pus caused by infection in skin around anus, causes throbbing pain, and is a swollen, mass that is hard and red.
Anorectal fistula, small, round opening in skin that surrounds anal opening. Suggests an inflammatory track from anus or rectum out to the skin. A previous abscess may have preceded the fistula.
Redness and excoriation can be from scratching, which can occur if area is infected by pinworms or fungi.
Thickening of the epithelium can be from repeated trauma from anal intercourse.

Hemorrhoids

•Painless papules caused by varicose veins appear as swollen skin tag that protrudes from anus
•Risk Factors
• Can be internal or external
-External ones have thrombosed i.e. contain clotted blood.
Hemorrhoids = can itch, are painful and bleed when client passes stool.

Are formed when excessive pressure affects veins in pelvis and rectal areas. Tissue surrounding inside of anus fills with blood to help control BMs, and with excessive pressure the blood in these swells, stretches the surrounding tissue.

Can be from straining or constipation, diarrhea, being overweight, last 6 mos of pregnancy, excessive standing or slitting, liver or heart disease, very rarely from tumors in the pelvic area.

Hemorrhoids - Risk Factors

poor bowel habits
pregnancy
inadequate fluid intake
inadequate fiber intake
prolonged standing or sitting
inadequate exercise.

Hemorrhoid Recommendations

avoidance of constipation & straining, go to BR when urge occurs, eat diet with moderate fiber, whole grains, F&V, drink 8-10 glasses of water daily,
Avoid caffeine, ETOH, stool softeners, laxatives, get regular exercise, avoid heavy lifting and don't hold breath when lifting. If pregnant sleep on side to reduce pressure on anal and pelvic areas.

Colorectal Cancer

•3rd most common Cancer

Colorectal Cancer -- Symptoms

-Rectal bleeding or blood in stool, cramping or steady abd pain, decreased appetite, weakness, fatigue, jaundice
-Change in bowel habits, including diarrhea, constipation narrowed stool, or feeling you need to have BM that is not relieved with a BM.

Colorectal cancer - testing recommendations, risk factors and lifestyle recommendations

•Recommendations starting at age 50:
-FOBT (fecal occult blood test) annually
-Flexible sigmoidoscopy every 5 yrs or
-Colonoscopy every 10 yrs or
-Double contrast barium enema every 5-10 yrs.

90% occurrence over age 50; hist. of rectal/colon polyps or cancer, inflammatory bowel diseases, FH of cancer or familial colorectal Cancer syndromes.
Ashkenazi Jewish descendents (Eastern Europe) or African American;
Diet high in animal sources and animal proteins, low in F&amp;V, and fiber.
Obesity, physical inactivity, moderate to health ETOH, smoking, DM.

Recommendations:
Eat diet high in fiber F&amp;V, low in fat and animal protein. Foods with adequate CA, VitD, folic acid, and magnesium
Get regular exercise

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