Female & Male Genitalia, Anus, Rectum and Prostate Assessment

STRUCTURE AND FUNCTION

THE MALE GENITALIA

The male genital structures include the penis and scrotum externally and the testis, epididymis, and vas deferens internally. Glandular structures accessory to the genital organs (the prostate, seminal vesicles, and bulbourethral glands) are discussed in Chapter 25.

Penis

The penis is composed of three cylindrical columns of erectile tissue: the two corpora cavernosa on the dorsal side and the corpus spongiosum ventrally (Fig. 24—1). At the distal end of the shaft, the corpus spongiosum expands into a cone of erectile tissue, the glans. The shoulder where the glans joins the shaft is the corona. The urethra transverses the corpus spongiosum, and its meatus forms a slit at the glans tip. Over the glans, the skin folds in and back on itself forming a hood or flap. This is the foreskin or prepuce. Often, it is surgically removed shortly after birth by circumcision. The frenulum is a fold of the foreskin extending from the urethral meatus ventrally.

Scrotum

The scrotum is a loose protective sac, which is a continuation of the abdominal wall (Fig. 24-2). After adolescence, the scrotal skin is deeply pigmented and has large sebaceous follicles. The scrotal wall consists of thin skin lying in folds, or rugae, and the underlying cremaster muscle. The cremaster  muscle controls the size of the scrotum by responding to ambient temperature. This is to keep the testes at 3° C below abdominal temperature, the best temperature for producing sperm. When it is cold, the muscle contracts, raising the sac and bringing the testes closer to the body to absorb heat necessary for sperm viability. As a result, the scrotal skin looks corrugated. When it is warmer, the muscle relaxes, the scrotum lowers, and the skin looks smoother.

Inside, a septum separates the sac into two halves. In each scrotal half is a testis, which produces sperm. The testis has a solid oval shape, which is compressed laterally and measures 4 to 5 cm long by 3 cm wide in the adult. The testis is suspended vertically by the spermatic cord. The left testis is lower than the right because the left spermatic cord is longer. Each testis is covered by a double-layered membrane, the tunica vaginalis, which separates it from the scrotal wall. The two layers are lubricated by fluid so that the testis can slide a little within the scrotum; this helps prevent injury.

Sperm are transported along a series of ducts. First, the testis is capped by the epididymis, which is a markedly coiled duct system and the main storage site of sperm. It is a comma-shaped structure, curved over the top and the posterior surface of the testis. Occasionally (in 6 to 7 percent of males), the epididymis is anterior to the testis.

The lower part of the epididymis is continuous with a muscular duct, the vas deferens. This duct approximates with other vessels (arteries and veins, lymphatics, nerves) to form the spermatic cord. The spermatic cord ascends along the posterior border of the testis and runs through the tunnel of the inguinal canal into the abdomen. Here, the vas deferens continues back and down behind the bladder, where it joins the duct of the seminal vesicle to form the ejaculatory duct. This duct empties into the urethra.

The lymphatics of the penis and scrotal surface drain into the inguinal lymph nodes, whereas those of the testes drain into the abdomen. Abdominal lymph nodes are not accessible to clinical examination

Inguinal Area

The inguinal area, or groin, is the juncture of the lower abdominal wall and the thigh (Fig. 24-3). Its diagonal borders are the anterior superior iliac spine and the symphysis pubis. Between these landmarks lies the inguinal ligament (Poupart's ligament). Superior to the ligament lies the inguinal canal, a narrow tunnel passing obliquely between layers of abdominal muscle. It is 4 to 6 cm long in the adult. Its openings are an internal ring, located 1 to 2 cm above the midpoint of the inguinal ligament, and an external ring, located just above and lateral to the pubis.

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Fig. 24-3 structures of the inguinal area

Inferior to the inguinal ligament is the femoral canal. It is a potential space located 3 cm medial to and parallel with the femoral artery. You can use the artery as a landmark to find this space.

Knowledge of these anatomic areas in the groin is useful because they are potential sites for a hernia, which is a loop of bowel protruding through a weak spot in the musculature.

DEVELOPMENTAL CONSIDERATIONS

Infants

Prenatalty, the testes develop in the abdominal cavity near the kidneys. During the later months of gestation the testes migrate, pushing the abdominal wall in front of them and dragging the vas deferens, the blood vessels, and nerves behind. The 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. Only a slight increase in size occurs during the prepubertal years.

Adolescents

Puberty begins sometime between the ages of 97₂ and 13V₂. The first sign is enlargement of the testes. Next, pubic hair appears, then penis size increases. The stages of development are documented in Tanner's sexual maturity ratings (SMR) (Table 24-1).

Table 24-4 Sex Maturity Ratings (SMR) in Boys

Developmental Stage	Pubic Hair	PENIS	SCROTUM
	No pubic hair. Fine body hair on abdomen (vellus hair) continues over pubic area	Preadolescent, size, and proportion the same as during childhood	Preadolescent, size, and proportion the same as during childhood
	Few straight slightly darker hairs at base of penis. Hair is long and downy	Little or no enlargement	Testes and scrotum begin to enlarge. Scrotal skin reddens and changes in texture
	Sparse growth over entire pubis. Hair darker, coarser, and curly	Penis begins to enlarge, especially in length	Further enlarged
	Thick growth 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
	Growth spread over medial thighs, although not yet up toward umbilicus*	Adult size and shape	Adutt size and shape
After puberty, pubic hair growth continues until the mid-20s, extending up the abdomen toward the umbilicus. Adapted from Tanner JM: Growth at adolescence, Oxford, England, 1962, Blackwell Scientific Publications

The complete change in development from a preadoles-cent to an adult takes around 3 years, although the normal range is 2 to 5 years (Fig. 24-4). The chart shown in Figure 24-4 is useful in teaching a boy the expected sequence of events and in reassuring him about the wide range of normal ages when these  events are experienced.

Although Tanner's studies were based on data from post World War II British youth, Tanner's results are corroborated by the US. Health Examination Survey, which studied close to 7000 youth from 1966 to 1970 (Harlan et al., 1979). This study found concordance between Tanner's stages for pubic hair and genitalia. It also found that sexual characteristics developed similarly for black and white boys, and that development was not influenced by socioeconomic status.

Adults and Aging Adults

The level of sexual development at the end of puberty remains constant through young and middle adulthood, with no further genital growth and no change in circulating sex hormone. The male does not experience a definite end to fertility as the female does. Around age 40 years, the production of sperm begins to decrease, although it continues into the 80s and 90s. After age 55 to 60 years, testosterone production declines. This decline proceeds very gradually so that resulting physical changes are not evident until later in life. Aging changes also are due to decreased muscle tone, decreased subcutaneous fat, and decreased cellular metabolism.

In the aging male, the amount of pubic hair decreases, and the remaining hair turns gray. Penis size decreases. Due to decreased tone of the dartos muscle, the scrotal contents hang lower, the rugae decrease, and the scrotum looks pendulous. The testes decrease in size and are less firm to palpation. Increased connective tissue is present in the tubules, so these become thickened and produce less sperm.

In general, declining testosterone production leaves the older male with a slower and less intense sexual response. Although a wide range of individual differences can occur, the older male may find that an erection takes longer to develop and that it is less full or firm. Once obtained, the erection may be maintained for longer periods without ejaculation. Ejaculation is shorter and less forceful, and the volume of seminal fluid is less than when the man was younger. After ejaculation, rapid detumescence (return to the flaccid state) occurs, especially after 60 years of age. This occurs in a few seconds as compared with minutes or hours in the younger male. The refractory state (when the male is physiologically unable to ejaculate) lasts longer, from 12 to 24 hours as compared with 2 minutes in the younger male.

Sexual Expression in Later Life. Chronologic age by itself should not mean a halt in sexual activity. The above-mentioned physical changes need not interfere with the libido and pleasure from sexual intercourse. The older male is capable of sexual function as long as he is in reasonably good health and has an interested, willing partner. Even chronic illness does not mean a complete end to sexual desire or activity.

The danger is in the male misinterpreting normal age changes as a sexual failure. Once this idea occurs, it may demoralize the man and place undue emphasis on performance rather than on pleasure. In the absence of disease, a withdrawal from sexual activity may be due to

· Loss of spouse

· Depression

· Preoccupation with work

· Marital or family conflict

· Side effects of medications such as antihypertensives, psychotropics, antidepressants, antispasmodics, sedatives, tranquilizers or narcotics, and estrogens

· Heavy use of alcohol

· Lack of privacy (living with adult children or in a nursing home)

· Economic or emotional stress

· Poor nutrition

· Fatigue

TRANSCULTURAL CONSIDERATIONS

Circumcision. Occasionally, during pregnancy or the immediate neonatal period, parents will ask you about whether or not to circumcise the male infant. Indications for circumcision include cultural reasons, the prevention of phimosis and inflammation of the glans penis and foreskin, decreasing the incidence of cancer of the penis, and slightly decreasing the incidence of urinary tract infections in infancy. However, there is no difference in risk of contracting sexually transmitted diseases (STDs) between circumcised and uncircumcised men (Laumann, Masi, and Zuckerman, 1997). Circumcision carries a very small but possible risk of complications, such as sepsis, amputation of the distal edge of the glans, removal of an excessive amount of foreskin, urethrocutaneous fistula {Behrman, 2000), and significant pain, about which the parents should know.

The decision to circumcise is culturally based. In the United States, 70 to 80 percent of newborn males are circumcised, while in Canada, Great Britain, Australia, and Sweden, circumcision is considered unnecessary, and less than 20 percent of newborn boys are circumcised (Cornell, 1997). Some groups, such as Jews and Muslims, practice circumcision as part of their religious value system. Other groups, such as Native Americans and Hispanics, have no tradition to practice circumcision. However, many parents in the United States who are not part of these groups also believe in circumcision because it conforms to dominant cultural values.

Subjective Data

1. Frequency, urgency, and nocturia 2. Dysuria 3. Hesitancy and straining 4. Urine color	5. Past genitourinary history 6. Penis - pain, lesion, discharge 7. Scrotum, self-care behaviors, lump	8. Sexual activity and contraceptive use 9. STD contact
Examiner Asks			Rationale
1. Frequency, urgency, and nocturia. Urinating more often than usual? · Feel as if you cannot wait to urinate? · Awaken during the night because you need to urinate? How often? Is this a recent change?			Frequency. Average adult voids five to six times per day, varying with fluid intake, individual habits. Polyuria - excessive quantity. Oliguria—diminished quantity <400 ml/24 hours Urgency. Nocturia occurs together with frequency and urgency in urinary tract diorders. Other origins: cardiovascular, habitual, diuretic medication.
2. Dysuria. Any pain or burning with urinating?			Dysuria. Burning is common with acute cystitis, prostatitis, urethritis
3. Hesitancy and straining. Any trouble starting the urine stream? ·  Need to strain to start or maintain stream? · Any change in force of stream: narrowing, becoming weaker? · Dribbling, such that you must stand closer to the toilet? · Afterward, do you still feel you need to urinate? · Ever had any urinary tract infections?			Hesitancy. Straining. Loss of force and decreased caliber. Terminal dribbling Sense of residual urine. Recurrent episodes of acute cystitis. Above-mentioned symptoms (i.e., hesitancy, and so on) suggest progressive prostatic obstruction.
4. Urine color. Is the usual urine clear or discolored, cloudy, foul-smelling, bloody?			As in urinary tract infection. Hematuria - a danger sign that warrants further workup.
5. Past genitourinary history. Any difficulty controlling your urine? · Accidentally urinate when you sneeze, laugh, cough, or bear down? · Any history of kidney disease, kidney stones, flank pain, urinary tract in іfections, prostate trouble?			True incontinence - loss of urine without warning. Urgency incontinence - sudden loss, as with acute cystitis. Stress incontinence - loss of urine with physical strain due to weakness of sphincters.
6. Penis. Any problem with penis—pain, lesions? · Any discharge? How much? Has that increased or decreased since start? · The color? Any odor? Discharge associated with pain or with urination?			Urethral discharge occurs with infection.
7. Scrotum, self-care behaviors. Any problem with the scrotum or testicles? · Do you perform testicular self-examination? · Noticed any lump or swelling on testes? · Noted any change in size of the scrotum? · Noted any bulge or swelling in the scrotum? For how long? Ever been told you have a hernia? Any dragging, heavy feeling in scrotum?			Self-care behaviors. Possible hernia.
8. Sexual activity and contraceptive use. Are you in a relationship involving sexual intercourse now? · 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? Any questions about this method? · How many sexual partners have you had in the last 6 months? · What is your sexual preference—relationship with a woman, a man, both?			Questions about sexual activity should be routine in review of body systems for these reasons: Communicates that you accept individual's sexual activity and believe it is important Your comfort with discussion prompts person's interest and possibly relief that topic has been introduced Establishes a data base for comparisons with any future sexual activities Provides opportunity to screen sexual problems Your questions should be objective and matter-of-fact. Gay and bisexual men need to feel acceptance to discuss their health concerns.
9. STD contact. Any sexual contact with a partner having a sexually transmitted disease, such as gonorrhea, herpes, AIDS, chlamydia, venereal warts, syphilis? When was this contact? Did you get the disease? · How was it treated? Any complications? · Do you use condoms to help prevent STDs? · Any questions or concerns about any of these diseases?
*At times, phrase your questions so that it is all right for the person to acknowledge a problem
Additional History For Infants and Children
1. Does your child have any problem urinating? Urine stream look straight? · Any pain with urinating, crying, or holding the genitals? · Any urinary tract infection? 2. (If child older than 2 to 272 years of age.) Has toilet training started? How is it progressing? · Wet the bed at night? Is this a problem for child or for you (parents)? · What have you done? How does the child feel about it? 3. Any problem with child's penis or scrotum: sores, swelling, discoloration? · Told if his testes are descended? · Ever had a hernia or hydrocele? · Swelling in his scrotum during crying or coughing? 4. (Ask directly to preschooler or young school-age child.) Has anyone ever touched your penis or in between your legs and you did not want them to? Sometimes that happens to children and it's not okay. They should remember that they have not been bad. They should try to tell a big person about it. Can you tell me three different big people you trust who you could talk to?			Screen for sexual abuse. For prevention, teach the child that it's not okay for someone to look at or touch their private parts while telling them it's a secret. Naming three trusted adults will include someone outside the family— important, since most molestation is by a parent (Brown, 1997).
Additional History for Preadolescents and Adolescents
Use the following questions regarding sexual growth and development and sexual behavior. First · Ask questions that seem appropriate for boy's age but be aware that norms vary widely. When you are in doubt, it is better to ask too many questions than to omit something. Children obtain information, often misinformation, from the media and from peers at surprisingly early ages. You may be sure your information will be more thoughtful and accurate. · Ask direct, matter-of-fact questions. Avoid sounding judgmental. · 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 the topic is normal and unexceptional. · Do not be concerned if a boy will not discuss sexuality with you or respond to your offers for more information. He may not wish to let on that he needs or wants more information. You do well to "open the door." The adolescent may come back at a future time.
1. Around age 12 to 13 years, but sometimes earlier, boys start to change and grow around the penis and scrotum. What changes have you noticed? Have you ever seen charts and pictures of normal growth patterns for boys? Let us go over these now. Who can you talk to about your body changes and about sex information? How do these talks go? Do you think you get enough information? 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? 2. Boys around age 12 to 13 years (SMR3) have a normal experience of fluid coming out of the penis at night, called nocturnal emissions, or "wet dreams." Have you had this? 3. Teenage boys have other normal experiences and wonder if they are the only ones who ever had them, like having an erection at embarrassing times, having sexual fantasies, or masturbating. Also, a boy might have a thought about touching another boy's genitals and wonder if this thought means he might be homosexual. Would you like to talk about any of these things? 4. Often boys your age have questions about sexual activity. What questions do you have? How about things like birth control, or STDs such as gonorrhea or herpes? Any questions about these? · Are you dating? Someone steady? Have you had intercourse? Are you using birth control? What kind? · What kind of birth control did you use the last time you had intercourse? 5. Has a nurse or doctor ever taught you how to examine your own testicles to make sure they are healthy? 6. 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. They should remember it is not their fault. They should tell another adult about it.			An occasional boy confuses this with a sign of STD or feels guilty. A boy may feel guilty about experiencing these things if not informed that they are normal. Assess level of knowledge. Many boys will not admit they need more knowledge. Avoid the term "having sex." It is ambiguous, and teens can take it to mean anything from foreplay to intercourse. This particular question often reveals that the teen is not using any method of birth control. Assess knowledge of testicular self-examination.
Additional History for the Aging Adult
1. Any difficulty urinating? Any hesitancy and straining? A weakened force of stream? Any dribbling? Or any incomplete emptying?			Early symptoms of enlarging prostate may be tolerated or ignored. Later symptoms are more dramatic: hematuria, urinary tract infection
2. Do you need to get up at night to urinate? What medications are you taking? What fluids do you drink in the evening?			Nocturia may be due to diuretic medication, habit, or fluid ingestion 3 hours before bedtime, especially coffee and alcohol, which have a specific diuretic effect. Also, fluid retention from mild heart failure or varicose veins produces nocturia; recumbency at night mobilizes fluid.
3. A man in his 70s, 80s, or 90s may notice changes in his sexual relationship or in his sexual response and wonder if it is normal. For example, it is normal for an erection to develop slowly at this age. This is not a sign of impotence, but a man might wonder if it is.			Excluding physical illness, an older man is fully capable of sexual function. But some men assume normal changes mean that they are "old men" and voluntarily withdraw from sexual activity. The older person is not reluctant to discuss sexual activity, and most welcome the opportunity. Depressants to sexual desire and function include antihypertensives, sedatives, tranquilizers, estrogens, and alcohol. Alcohol decreases the sexual response even more dramatically in the older person.
OBJECTIVE DATA
Preparation			Equipment Needed
Position the male standing with undershorts down and appropriate draping. The examiner should be sitting. Alternatively, the male may be supine for the first part of the examination and stand to check for a hernia. It is normal for a male to feel apprehensive about having his genitalia examined, especially by a female examiner. Younger adolescents usually have more anxiety than older adolescents. But any male may have difficulty dissociating a necessary, matter-of-fact step in the physical examination from the feeling this is an invasion of his privacy. His concerns are similar to those experienced by the female during the examination of the genitalia: modesty, fear of pain, cold hands, negative judgment, or memory of previously uncomfortable examinations. Additionally, he may fear comparison to others, or fear having an erection during the examination and that this would be misinterpreted by the examiner. This normal apprehension becomes manifested in different behaviors. Many act resigned and embarrassed and avoid eye contact. An occasional man will laugh and make jokes to cover embarrassment. Also, a man may refuse examination by a female and insist on a male examiner. Take time to consider these feelings, as well as to explore your own. It is normal for you to feel embarrassed and apprehensive too. You may worry about your age, lack of clinical experience, causing pain, or even that your movements might "cause" an erection. Some examiners feel guilty when this occurs. You need to accept these feelings and work through them so that you can examine the male in a professional way. Discussing these concerns in a group with other beginning examiners works best. Your demeanor is important. Your unresolved discomfort magnifies any discomfort the man may have. Your demeanor should be confident and relaxed, unhurried yet businesslike. Do not discuss genitourinary history or sexual practices while you are performing the examination. This may be perceived as judgmental. Use a firm deliberate touch, not a soft, stroking one. If an erection does occur, do not stop the examination or leave the room. This only focuses more attention on the erection and increases embarrassment. Reassure the male that this is only a normal physiologic response to touch, just as when the pupil constricts in response to bright light. Proceed with the rest of the examination.			Gloves - Wear gloves during every male genitalia examination Occasionally: glass slide for urethral specimen Materials for cytology Flashlight
NORMAL RANGE OF FINDINGS			Abnormal Findings
INSPECT AND PALPATE THE PENIS
The skin normally looks wrinkled, hairless, and without lesions. The dorsal vein may be apparent (Fig. 24-5). The glans looks smooth and without lesions. Ask the uncircumcised male to retract the foreskin, or you retract it. It should move easily. Some cheesy smegma may have collected under the foreskin. After inspection, slide the foreskin back to the original position The urethral meatus is positioned just about centrally. At the base of the penis, pubic hair distribution is consistent with age. Hair is without pest inhabitants. Compress the glans anteroposteriorly between your thumb and forefinger (Fig. 24—6). The meatus edge should appear pink, smooth, and without discharge If you note urethral discharge, collect a smear for microscopic examination and a culture. If no discharge shows but the person gives a history of it, ask him to milk the shaft of the penis. This should produce a drop of discharge. Palpate the shaft of the penis between your thumb and first two fingers. Normally, the penis feels smooth, semifirm, and nontender			Inflammation. Lesions: nodules, solitary ulcer (chancre), grouped vesicles or superficial ulcers, wartiike papules (see Table 24-2, p. 748). Inflammation. Lesions on glans or corona. Phimosis - unable to retract the foreskin. Paraphimosis - unable to return foreskin to original position. Hypospadias - ventral location of meatus. Epispadias - dorsal location of meatus (see Table 24-3). Pubic lice or nits. Excoriated skin usually accompanies. Stricture - narrowed opening. Edges that are red, everted, edema-tous, along with purulent discharge, suggest urethritis (see Table 24-2). Nodule or induration. Tenderness
INSPECT AND PALPATE THE SCROTUM
Inspect the scrotum as male holds the penis out of the way. Alternatively, you hold the penis out of the way with the back of your hand (Fig. 24—7). Scrotal size varies with ambient room temperature. Asymmetry is normal, with the left scrotal half usually lower than the right.			Scrotal swelling (edema) may be taut and pitting. This occurs with heart failure, renal failure, or local inflammation. Lesions
Spread rugae out between your fingers. Lift the sac to inspect the posterior surface. Normally, no scrotal lesions are present, except for the commonly found sebaceous cysts. These are yellowish, 1-cm nodules and are firm, nontender, and often multiple. Palpate gently each scrotal half between your thumb and first two fingers (Fig. 24-8). The scrotal contents should slide easily. Testes normally feel oval, firm and rubbery, smooth, and equal bilaterally, and are freely movable and slightly tender to moderate pressure. Each epididymis normally feels discrete, softer than the testis, smooth, and nontender			Inflammation. Absent testis - may be a temporary migration or true crypto rch id ism (see Table 24-4). Atrophied testes - small and soft. Fixed testes. Nodules on testes or epididymides. Marked tenderness. An indurated, swollen, and tender epididymis indicates epididymitis.
Palpate each spermatic cord between your thumb and forefinger, along its length from the epididymis up to the external inguinal ring (Fig. 24-9). You should feel a smooth, nontender cord. Normally, no other scrotal contents are present. If you do find a mass, note: · Any tenderness? · Is the mass distal or proximal to testis? · Can you place your fingers over it? · Does it reduce when person lies down? · Can you auscultate bowel sounds over it? Transillumination. Perform this maneuver if you note a swelling or mass. Darken the room. Shine a strong flashlight from behind the scrotal contents. Normal scrotal contents do not transilluminate.			Thickened cord. Soft, swollen, and tortuous - see the discussion of varicocele, Table 24-4 Abnormalities in the scrotum: hernia, tumor, orchitis, epididymitis, hydrocele, spermatocele, varicocele (see Table 24-4). Serous fluid does transilluminate and shows as a red glow, e.g., hydrocele, or spermatocele. Solid tissue and blood do not transilluminate, e.g., hernia, epididymitis, or tumor (see Table 24-4).
INSPECT AND PALPATE FOR HERNIA
Inspect the inguinal region for a bulge as the person stands and as he strains down. Normally, none is present.			Bulge at external inguinal ring or at femoral canal. (A hernia may be present but easily reduced and may appear only intermittently with an increase in intraab-dominal pressure.)
Palpate the inguinal canal (Fig. 24—10). For the right side, ask the male to shift his weight onto the left (unexamined) leg. Place your right index finger low on the right scrotal half. Palpate up the length of the spermatic cord, invaginating the scrotal skin as you go, to the external inguinal ring. It feels like a triangular slitlike opening, and it may or may not admit your finger. If it will admit your finger, gently insert it into the canal and ask the person to "bear down."* Normally, you feel no change. Repeat the procedure on the left side. Palpate the femoral area for a bulge. Normally you feel none.			Palpable herniating mass bumps your fingertip or pushes against the side of your finger (see Table 24-5).
PALPATE INGUINAL LYMPH NODES
Palpate the horizontal chain along the groin inferior to the inguinal ligament and the vertical chain along the upper inner thigh. It is normal to palpate an isolated node on occasion; it then feels small (<1 cm), soft, discrete, and movable (Fig. 24—11). * Avoid the old direction, "turn your head and cough." For one thing, a brief cough does not give the steady, increased intraabdominal pressure you need. For another, the person is likely to cough right in your face.			Enlarged, hard, matted, fixed nodes.
SELF-CARE—TESTICULAR SELF-EXAMINATION (TSE)
Encourage self-care by teaching every male (from 13 to 14 years old through adulthood) how to examine his own testicles every month. The overall incidence of testicular cancer is still rare, but testicular cancer most commonly occurs in young men age 15 to 40 {American Cancer Society, 2002). Males with unde-scended testicles are at greatest risk, and white males are four times more likely to contract testicular cancer than nonwhites. This tumor has no early symptoms. If detected early by palpation and treated, the cure rate is almost 100 percent. Early detection is enhanced if the 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 changes, report changes immediately Phrase your teaching something like this: A good time to examine the testicles is during the shower or bath, when your hands are warm and soapy and the scrotum is warm. Cold hands stimulate a muscle (cremasteric) reflex, retracting the scrotal contents. The procedure is simple. Hold the scrotum in the palm of your hand and gently feel each testicle usingyour thumb and first two fingers. If it hurts, you are using too much pressure. The testicle is egg-shaped and movable. It feels rubbery with a smooth surface, like a hard-boiled egg. The epididymis is on top and behind the testicle; it feels a bit softer. If you ever notice a firm, painless lump, a hard area, or an overall enlarged testicle, call your physician for a further check
DEVELOPMENTAL CONSIDERATIONS
Infants and Children
For an infant or toddler, perform this procedure right after the abdominal examination. In a preschool-age to young school-age child (3 to 8 years of age), leave underpants on until just before the examination. In an older school-age child or adolescent, offer an extra drape, as with the adult. Reassure child and parents of normal findings. Inspect the penis and scrotum. Penis size is usually small in infants (2 to 3 cm) (Fig. 24—12) and in young boys until puberty. In the obese boy, the penis looks even smaller because of folds of skin covering the base.			Rarely, a very small penis may be an enlarged clitoris in a genetically female infant. Enlarged penis—precocious puberty. Redness, swelling, lesions.
In the circumcised infant, the glans looks smooth with the meatus centered at the tip. While the child wears diapers, the meatus may become ulcerated from ammonia irritation. This is more common in circumcised infants.			Hypospadias, epispadias (see Table 24-3). Stricture—narrowed opening. Discharge. Occasionally, ulceration may produce a stricture, shown by a pinpoint meatus and a narrow stream. This increases the risk of urine obstruction.
If possible, observe the newborn's first voiding to assess strength and direction of stream.			Poor stream is significant, because it may indicate a stricture or neurogenic bladder.
If uncircumcised, the foreskin is normally tight during the first 3 months and should not be retracted because of the risk of tearing the membrane attaching the foreskin to the shaft. This leads to scarring and, possibly, to adhesions later in life. In infants older than 3 months of age, retract the foreskin gently to check the glans and meatus. It should return to its original position easily.			Phimosis—unable to retract the foreskin. Paraphimosis—the foreskin cannot be slipped forward once it is retracted. Dirt and smegma collecting under foreskin.
The scrotum looks pink in white infants and dark brown in dark-skinned infants. Rugae are well formed in the full-term infant. Size varies with ambient temperature, but overall, the infant's scrotum looks large in relation to the penis. No bulges, either constant or intermittent, are present.
Palpate the scrotum and testes. The cremasteric reflex is strong in the infant, pulling the testes up into the inguinal canal and abdomen from exposure to cold, touch, exercise, or emotion. Take care not to elicit the reflex: {1} Keep your hands warm and palpate from the external inguinal ring down; (2) block the inguinal canals with the thumb and forefinger of your other hand to prevent the testes from retracting (Fig. 24-13).
Normally, the testes are descended and are equal in size bilaterally (1.5 to 2 cm until puberty). It is important to document that you have palpated the testes. Once palpated, they are considered descended, even if they have retracted momentarily at the next visit			Cryptorchidism: undescended testes (those that have never descended). Undescended testes are common in premature infants. They occur in 3 to 4 percent of term infants, although most have descended by 3 months of age. Age at which child should be referred differs among physicians (see Table 24-4).
If the scrotal half feels empty, search for the testes along the inguinal canal and try to milk them down. Ask the toddler or child to squat with the knees flexed up; this pressure may force the testes down. Or, have the young child sit cross-legged to relax the reflex (Fig. 24-14).
Migratory testes (physiologic cryptorchidism) are common because of the strength of the cremasteric reflex and the small mass of the prepubertal testes. Note that the affected side has a normally developed scrotum (with true cryptor chidism, the scrotum is atrophic) and that the testis can be milked down. These testes descend at puberty and are normal. Palpate the epididymis and spermatic cord as described in the adult section. A common scrotal finding in the boy under 2 years of age is a hydrocele, or fluid in the scrotum. It appears as a large scrotum and transilluminates as a faint pink glow. It usually disappears spontaneously. Inspect the inguinal area for a bulge. If you do not see a bulge but the parent gives a positive history of one, try to elicit it by increasing intraabdominal pressure. Ask the boy to hold his breath and strain down or have him blow up a balloon. If a hernia is suspected, palpate the inguinal area. Use your little finger to reach the external inguinal ring.			A hydrocele is a cystic collection of serous fluid in the tunica vaginalis, surrounding the testis. (See Table 24-4.)
The Adolescent The adolescent shows a wide variation in normal development of the genitals. Using the SMR charts, note: (1) enlargement of the testes and scrotum; (2) pubic hair growth; (3) darkening of scrotal color; (4) roughening of scrotal skin; (5) increase in penis length and width; and (6) axillary hair growth. Be familiar with the normal sequence of growth
The Aging Adult In the older male, you may note thinner, graying pubic hair and the decreased size of the penis. The size of the testes may be decreased and may feel less firm. The scrotal sac is pendulous with less rugae. The scrota) skin may become excoriated if the man continually sits on it.
Summary Checklist Male Genitalia Exam
Inspect and palpate the penis Inspect and palpate the scrotum If a mass exists, transilluminate it			Palpate for an inguinal hernia Palpate the inguinal lymph nodes

APPLICATION AND CRITICAL THINKING

SAMPLE CHARTING

Subjective

Urinates four to five times/day, clear, straw-colored. No nocturia, dysuria, or hesitancy. No pain, lesions, or discharge from penis. Does not do testicular self-examination. No history of genitourinary disease. Sexually active in a monogamous relationship. Sexual life satisfactory to self snd partner. Uses birth control via barrier method (partner uses diaphragm). No known STD contact.

Objective

No lesions, inflammation, or discharge from penis. Scrotum—testes descended, symmetric, no masses.

No inguinal hernia.

FOCUSED ASSESSMENT: CLINICAL CASE STUDY

Subjective

R.C. is a 19-year-old student who 2 days PTA noted acute onset of painful urination, frequency, and urgency. Noted some thick penile discharge. States has no side pain, no abdominal pain, no fever, or genital skin rash. R.C. is concerned he has an STP because of episode of unprotected Intercourse with a new partner 6 days PTA. Has no known allergies.

Objective

Vital signs 37° C-72-16. No lesions or Inflammation around penis or scrotum. Urethral meatus has mild edema with purulent urethral discharge. No pain on palpation of genitalia. Testes symmetric with no masses. No lymphadenopathy.

Assessment

Urethral discharge

Deficient knowledge about STP prevention R/T lack of information recall

NURSING DIAGNOSES COMMONLY ASSOCIATED WITH THE MALE GENITALIA AND RELATED DISORDERS

RELATED FACTORS (Etiology)	DEFINING CHARACTERISTICS (Symptoms and Signs)
DIAGNOSIS: Ineffective Sexuality patterns
Effects of illness or medical treatment Drugs Radiation Anomalies Extreme fatigue Obesity Pain Performance anxiety Deficient knowledge/skill about alternative responses to health-related transitions Pregnancy Surgery Recent childbirth Trauma Menopause Impaired relationship with a significant other Fear of pregnancy or of acquiring a sexually transmitted disease Conflicts with sexual orientation or variant preferences Ineffective or absent role models Loss of job or ability to work Separation from or loss of significant other	Identification of sexual difficulties, limitations, or changes
DIAGNOSIS: Urinary retention
Diminished or absent sensory and/or motor impulses Effects of medications Anesthetics Opiates Psychotropics Strong sphincter Urethral blockage associated with Fecal impaction Prostate hypertrophy Surgical swelling Postpartum edema Anxiety (fear of postoperative pain)	Bladder distention Diminished force of urinary stream Dribbling Dysuria Hesitancy High residual urine Nocturia Sensation of bladder fullness Small, frequent voiding or absence of urine output
DIAGNOSIS: Impaired Skin integrity
Infection Allergy Chemical substances on skin Autoimmune dysfunction Decreased circulation Edema Effects of aging or medications Excretions/secretions Immobility Insect bites Parasites Pressure Radiation Shearing force Stress Surgery	Blisters Chafing Disruption of skin surface or layers Lesions Pruritus Bruising Cyanosis Denuded skin Erythema Induration
OTHER RELATED NURSING DIAGNOSES
ACTUAL Anxiety Delayed Growth and devepment Incontinence Pain Rape trauma syndrome: compound reaction Rape trauma syndrome (see Chapter 26) Rape trauma syndrome: silent reaction Sexual dysfunction (see Chapter 26) Ineffective Sexuality patterns Impaired Skin integrity Impaired Urinary elimination Urinary retention	RISK/WE LLNESS Risk Risk for Infection Risk for Trauma Wellness Health-seeking behavior for instruction on testicular self-examination

ABNORMAL FINDING

TABLE 24-2: Male Genital Lesions

Herpes Progenitalis

Clusters of small vesicles with surrounding erythema, which are often painful, erupt on the glans or foreskin. These rupture to form superficial ulcers. A sexually transmitted disease (STD), the initial infection lasts 7 to 10 days. The virus remains dormant indefinitely; recurrent infections last 3 to 10 days with milder symptoms.

Syphilitic Chancre

Begins within 2-4 weeks of infection, as a small, solitary, silvery papule that erodes to a red, round or oval, superficial ulcer with a yellowish serous discharge. Palpation reveals a nontender indurated base that can be lifted like a button between the thumb and the finger. Lymph nodes enlarge early but are nontender. This is an STD.

Reprinted from Colour Atlas of Infectious Diseases, 3rd edition, Emond, p. 173, 1995, by permission of the publisher Mosby.

Condylomata Acuminata (Genital Warts)

Soft, pointed, moist, fleshy, painless papules may be single or multiple in a cauliflowerlike patch. Color may be gray, pale yellow, or pink in white males, and black or translucent gray-black in black males. They occur on shaft of penis, behind corona, or around the anus where they may grow into large grapelike clusters.

These are caused by the human papillomavirus (HPV) and are one of the most common STDs. The HPV infection is correlated with early onset of sexual activity, infrequent use of contraception, and multiple sexual partners.

Carcinoma

Begins as red, raised warty growth or as an ulcer, with watery discharge. As it grows, may necrose and slough. Usually painless. Almost always on glans or inner lip of foreskin and following chronic inflammation. Enlarged lymph nodes are common.

Urethritis (Urethral Discharge and Dysuria)

Infection of urethra causes painful burning urination. Mea-tus edges are reddened, everted, and swollen. Purulent urethral discharge is present. Urine is cloudy with discharge and mucous shreds. Cause determined by culture: (1) gonococcal urethritis has thick, profuse, yellow or gray-brown discharge; (2) nonspecific urethritis (NSU) may have similar discharge but often has scanty, mucoid discharge. Of these, about 50 percent are caused by chlamydia infection. This is important to differentiate because antibiotic treatment is different.

TABLE 24-3: Abnormalities on the Penis

Phimosis

Foreskin is advanced and fixed so tight it is impossible to r tract over glans. May be congenital or acquired from adhesions secondary to infection. Poor hygiene leads to retained sition. Constriction impedes circulation, so glans swells. If dirt and smegma, which increases risk of inflammation or untreated, it may compromise arterial circulation, calculus formation.

Paraphimosis

Foreskin is retracted and fixed. Once retracted behind glans, a tight or inflamed foreskin cannot return to its original po

Hypospadias, Epispadias

Hypospadias Urethral meatus opens on the ventral (under-) side of gians, shaft, or at the penoscrotal junction. A groove extends from the meatus to the normal location at the tip. This is a congenital defect that is important to recognize at birth. The newborn should not be circumcised because surgical correction may use foreskin tissue to extend urethral length	Epispadias Meatus opens on the dorsal (upper) side of glans or shaft above a broad, spadelike penis. Rare; less common than hypospadias but more disabling because of associated urinary incontinence and separation of pubic bones.

Urethral Stricture (not illustrated)

Pinpoint, constricted opening at meatus or inside along urethra. Occurs congenitally or secondary to urethral injury. Gradual decrease in force and caliber of urine stream is most common symptom. Shaft feels indurated along ventral aspect at the site of the stricture.

Priapism (not illustrated)

Prolonged painful erection of penis without sexual desire. Rare condition occurs with sickle-cell trait or disease; leukemia where increased numbers of white blood cells produce engorgement; malignancy; or local trauma or spinal cord injuries with autonomic nervous system dysfunction.

Peyronie's Disease

Hard, nontender, subcutaneous plaques palpated on dorsal or lateral surface of penis. May be single or multiple and asymmetric. They are associated with painful bending of the penis during erection. Plaques are fibrosis of covering of corpora cavernosa. Usually occurs after 45 years. Its cause is unknown. Ten to 20 percent of those afflicted also have Dupuytren's contracture of the palm.

TABLE 24-4: ABNORMALITIES IN THE SCROTUM

Disorder	Clinical Findings	Discussion
Absent Testis Cryptorchidism
	S:   Empty scrotal half O: Inspection - in true maldescent, atrophic scrotum on affected side Palpation - no testis A:  Absent testis	True cryptorchidism—testes that have never descended. Incidence at birth is 3 to 4 percent, one-half of these descend in first month. Incidence with premature infants is 30 percent; in the adult 0.7 to 0.8 percent. True unde-scended testes have a histologic change by 6 years, causing decreased sper-matogenesis and infertility.
Small Testis
	S:   (None) O: Palpation—small and soft (rarely may be firm) A:   Small testis	Small and soft (<3.5 cm) indicates atrophy as with cirrhosis, hypopitu-itarism, following estrogen therapy, or as a sequelae of orchitis. Small and firm (<2 cm) occurs with Klinefelter's syndrome (hypogonadism).
Testicular Torsion
	S:   Excruciating pain in testicle of sudden onset, often during sleep or following trauma. May also have lower abdominal pain, nausea and vomiting, no fever O: Inspection—red, swollen scrotum, one testis (usually left) higher owing to rotation and shortening Palpation—cord feels thick, swollen, tender, epididymis may be anterior, cremasteric reflex is absent on side of torsion	Sudden twisting of spermatic cord. Occurs in late childhood, early adolescence, rare after age of 20 years. Torsion occurs usually on the left side. Faulty anchoring of testis on wall of scrotum allows testis to rotate. The anterior part of the testis rotates medially toward the other testis. Blood supply is cut off, resulting in ischemia and engorgement. This is an emergency requiring surgery; testis can become gangrenous in a few hours.
Epididymitis
	S:   Severe pain of sudden onset in scrotum, somewhat relieved by elevation (a positive Phren's sign); also rapid swelling, fever O: Inspection—enlarged scrotum; reddened Palpation—exquisitely tender; epididymis enlarged, indurated; may be hard to distinguish from testis. Overlying scrotal skin may be thick and edematous Laboratory—white blood cells and bacteria in urine A: Tender swelling of epididymis	Acute infection of epididymis commonly caused by prostatitis, after prostatectomy because of trauma of urethral instrumentation, or due to chlamydia, gonorrhea, or other bacterial infection. Often difficult to distinguish between epididymitis and testicular torsion.
Spermatic Cord Varicocele
	S:   Dull pain; constant pulling or dragging feeling; or may be asymptomatic O: Inspection—usually no sign. May show bluish color through light scrotal skin Palpation—when standing, feel soft, irregular mass posterior to and above testis; collapses when supine, refills when upright. Feels distinctive, like a "bag of worms" The testis on the side of the varicocele may be smaller owing to impaired circulation A:   Soft mass on spermatic cord	A varicocele is dilated, tortuous varicose veins in the spermatic cord due to incompetent valves within the vein, which permit reflux of blood. Most often on left side, perhaps because left spermatic vein is longer and inserts at a right angle into left renal vein. Common in young males. Screen at early adolescence; early treatment important to prevent potential infertility when an adult. Treatment is relatively easy; surgical ligation of spermatic vein.
Spermatocele
	S:   Painless, usually found on examination O: Inspection—does transilluminate higher in the scrotum than a hydro-cele, and the sperm may fluoresce Palpation—round, freely movable mass lying above and behind testis. If large, feels like a third testis A:   Free cystic mass on epididymis	Retention cyst in epididymis. Cause unclear but may be obstruction of tubules. Filled with thin, milky fluid that contains sperm. Most spermato-celes are small (<1 cm); occasionally, they may be larger and then mistaken for hydrocele.
Early Testicular Tumor
	S:   Painless, found on examination O: Palpation - firm nodule or harder than normal section of testicle A: Solitary nodule	Most testicular tumors occur between the ages of 18 and 35. Practically all are malignant. Occur in whites; relatively rare in blacks, Mexican-Americans, and Asians. Must biopsy to confirm. Most important risk factor is undescended testis, even those surgically corrected. Early detection important in prognosis, but practice of testicular self-examination is currently low.
Diffuse Tumor
	S:   Enlarging testis (most common symptom). When enlarges, has feel of increased weight O: Inspection - enlarged, does not transilluminate Palpation - enlarged, smooth, ovoid, firm. Important - firm palpation does not cause usual  sickening discomfort as with normal testis A:   Nontender swelling of testis	Diffuse tumor maintains shape of testis
Hydrocele
	S:   Painless swelling, although person may complain of weight and bulk in scrotum O: Inspection—enlarged, mass does transilluminate with a pink or red glow (in contrast to a hernia) Palpation—nontender mass, able to get fingers above mass (in contrast to scrotal hernia) A:  Nontender swelling of testis	Cystic. Circumscribed collection of serous fluid in tunica vaginalis, surrounding testis. May occur following epididymitis, trauma, hernia, tumor of testis, or spontaneously in the newborn
Scrotal Hernia, Orchitis
.	S:   Swelling, may have pain with straining O: Inspection—enlarged, may reduce when supine, does not transilluminate Palpation—soft mushy mass, palpating fingers cannot get above mass. Mass is distinct from testicle that is normal A:  Nontender swelling of scrotum	Scrotal hernia usually due to indirect inguinal hernia (see Table 24-5).
	S:   Acute or moderate pain of sudden onset, swollen testis, feeling of weight, fever O: Inspection—enlarged, edematous, reddened; does not transilluminate Palpation—swollen, congested, tense, and tender; hard to distinguish testis from epididymis A: Tender swelling of testis	Acute inflammation of testis. Most common cause is mumps; can occur with any infectious disease. May have associated hydrocele that does transilluminate.
Scrotal Edema
	S:   Tenderness O: Inspection—enlarged, may be reddened (with local irritation) Palpation—taut with pitting Probably unable to feel scrotal contents A: Scrotal edema	Accompanies marked edema in lower half of body, e.g., congestive heart failure, renal failure, and portal vein obstruction. Occurs with local inflammation: epididymitis, torsion of spermatic cord. Also obstruction of inguinal lymphatics produces lymph-edema of scrotum
S = subjective data; 0 = objective data; A = assessrr

TABLE 24-5: Inguinal and Femoral HerniasCourse

	Indirect Inguinal	Direct Inguinal	Femoral
Course	Sac herniates through internal inguinal ring; can remain in canal or pass into scrotum	Directly behind and through external inguinal ring, above inguinal ligament; rarely enters scrotum	Through femoral ring and canal, below inguinal ligament, more often on right side
Clinical Symptoms and Signs	Pain with straining; soft swelling that increases with increased intraabdominal pressure; may decrease when lying down	Usually painless; round swelling close to the pubis in area of internal inguinal ring; easily reduced when supine*	Pain may be severe, may become strangulated
Frequency	Most common; 60 percent of all hernias. More common in infants <1 year and in males 16 to 20 years of age	Less common, occurs most often in men >40, rare in women	Least common, 4 percent of all hernias; more common in women
Cause	Congenital or acquired	Acquired weakness; brought on by heavy lifting, muscle atrophy, obesity, chronic cough, or ascites	Acquired; due to increased abdominal pressure, muscle weakness, or frequent stooping

Reducible—contents will return to abdominal cavity by lying down or gentle pressure. Incarcerated—herniated bowel cannot be returned to abdominal cavity

Strangulated—blood supply to hernia is shut off. Accompanied by nausea, vomiting, and tenderness.

BIBLIOGRAPHY

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Allison L: Clinical effectiveness: testicular self-examination, Prof Nurse 15(ll):710-713, Aug 2000.

American Cancer Society: http://www.cancer.org/eprise/ma/ CRI_2_4_IX_What_is_testicular_cancer_41 ?sitearea=CR [Accessed 10/2002].

Behrman RE: Nelson textbook of pediatrics, ed 16, Philadelphia, 2000, WB Saunders.

Brown MS: Pediatric genital exam, Nurse Pract 22(7):160, July 1997.

Cornell S: Controversies in circumcision: examining a cultural norm, Adv Nurs Pracf5(I0):49-52,Oct 1997.

Dufour JL: Assessing and treating epididymitis. Nurse Pract 26(3):23-24, Mar 2001.

Finan SL: Promoting healthy sexuality: guidelines for infancy through preschool, Nurse Pract 22(10):79-100, Oct 1997.

Finan SL: Promoting healthy sexuality: guidelines for early through older adulthood, Nurse Pract 22( 10):54-64, Dec 1997.

Goldman BD: Common dermatoses of the male genitalia, Postgrad Med 108(4)-.89-96, Sep 15, 2000.

Harlan W et al: Secondary sex characteristics of boys 12to 17 years of age: the U.S. Health Examination Survey, / Pediatr 95:293,1979.

Klingman L: Assessing the male genitalia, Am } Nurs 99(7):47-50, July 1999.

Laumann EO, Masi CM, Zuckerman MA: Circumcision in the United States: prevalence, prophylactic effects, and sexual practice, JAMA 277(13): 1052-1057, Apr 2, 1997.

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Miller KM: Testicular torsion, Am J Nurs 99(6}:33, June 1999.

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Anus, Rectum, and Prostate

Structure and Function

Anus and Rectum

Prostate

Regional Structures

Developmental Considerations

Transcultural Considerations

Application and Critical Thinking

Sample Charting

Focused Assessment: Clinical Case Study

Nursing Diagnoses

Assessment Video Critical Thinking Question

Subjective Data

Health History Questions

Additional History for Infants and Children

Objective Data

Preparation

Inspect the Perianal Area

Palpate the Anus and Rectum

Developmental Considerations

Infants and Children

The Aging Adult

Summary Checklist: Anus, Rectum, and Prostate Exam

Abnormal Findings,

Abnormalities of the Anus and Perianal Region

Abnormalities of the Rectum

Abnormalities of the Prostate Gland

Structure and Function

ANUS AND RECTUM

The anal canal is the outlet of the gastrointestinal tract, and it is about 3.8 cm long in the adult. It is lined with modified skin (having no hair or sebaceous glands) that merges with rectal mucosa at the anorectal junction. The canal slants forward toward the umbilicus, forming a distinct right angle with the rectum, which rests back in the hollow of the sacrum. Although the rectum contains only autonomic nerves, numerous somatic sensory nerves are present in the anal canal and external skin, so a person feels sharp pain from any trauma to the anal area.

The anal canal is surrounded by two concentric layers of muscle, the sphincters (Fig. 25-1). The internal sphincter is under involuntary control by the autonomic nervous system. The external sphincter surrounds the internal sphincter but also has a small section overriding the tip of the internal sphincter at the opening. It is under voluntary control. Except for the passing of feces and gas, the sphincters keep the anal canal tightly closed. The intersphincteric groove separates the internal and external sphincters and is palpable.

The anal columns (or columns of Morgagni) are folds of mucosa. These extend vertically down from the rectum and end in the anorectal junction (also called the mucocutaneous junction, pectinate, or dentate line). This junction is not palpable, but it is visible on proctoscopy. Each anal column contains an artery and a vein. Under conditions of chronic increased venous pressure, the vein may enlarge, forming a hemorrhoid. At the lower end of each column is a small crescent fold of mucous membrane, the anal valve. The space above the anal valve (between the columns) is a small recess, the anal crypt.

The rectum, which is 12 cm long, is the distal portion of the large intestine. It extends from the sigmoid colon, at the level of the third sacral vertebra, and ends at the anal canal.

Just above the anal canal, the rectum dilates and turns posteriorly, forming the rectal ampulla. The rectal interior has three semilunar transverse folds called the valves of Houston. These cross one-half the circumference of the rectal lumen. Their function is unclear, but they may serve to hold feces as the flatus passes. The lowest is within reach of palpation, usually on the person's left side, and must not be mistaken for an intrarectal mass.

Peritoneal Reflection. The peritoneum covers only the upper two-thirds of the rectum. In the male, the anterior part of the peritoneum reflects down to within 7.5 cm of the anal opening, forming the rectovesical pouch (Fig. 25-2) and then covers the bladder. In the female, this is termed the rectouterine pouch, and extends down to within 5.5 cm of the anal opening.

PROSTATE

In the male, the prostate gland lies in front of the anterior wall of the rectum and 2 cm behind the symphysis pubis. It surrounds the bladder neck and the urethra and has 15 to 30 ducts that open into the urethra. The prostate secretes a thin, milky alkaline fluid that helps sperm viability. It is a bilobed structure with a round or heart shape. It measures 2.5 cm long and 4 cm in diameter. The two lateral lobes are separated by a shallow groove called the median sulcus.

The two seminal vesicles project like rabbit ears above the prostate. The seminal vesicles secrete a fluid that is rich in fructose, which nourishes the sperm, and contains prostaglandins. The two bulbourethral (Cowper's) glands are each the size of a pea and are located inferior to the prostate on either side of the urethra (see Fig. 25-5). They secrete a clear, viscid mucus.

REGIONAL STRUCTURES

In the female, the uterine cervix lies in front of the anterior rectal wall and may be palpated through it.

The combined length of the anal canal and the rectum is about 16 cm in the adult. The average length of the examining finger is from 6 cm to 10 cm, bringing many rectal structures within reach.

The sigmoid colon is named from its S-shaped course in the pelvic cavity. It extends from the iliac flexure of the descending colon and ends at the rectum. It is 40 cm long and is accessible to examination only through the colonoscope. The flexible fiberoptic scope in current use provides a view of the entire mucosal surface of the sigmoid, as well as the colon.

developmental considerations

The first stool passed by the newborn is dark green meconium and occurs within 24 to 48 hours of birth, indicating anal patency. From that time on, the infant usually has a stool after each feeding. This response to eating is a wave of peristalsis called the gastrocolic reflex. It continues throughout life, although children and adults usually produce no more than one or two stools per day.

The infant passes stools by reflex. Voluntary control of the external anal sphincter cannot occur until the nerves supplying the area have become fully myelinated, usually around 17₂ to 2 years of age. Toilet training usually starts after age 2 years.

At male puberty, the prostate gland undergoes a very rapid increase to more than twice its prepubertal size. During young adulthood its size remains fairly constant.

The prostate gland commonly starts to enlarge during the middle adult years. This benign prostatic hypertrophy (BPH) is present in 1 of 10 males at the age of 40 years and increases with age. It is thought that the hypertrophy is caused by hormonal imbalance that leads to the proliferation of benign adenomas. These gradually impede urine output because they obstruct the urethra.

TRANSCULTURAL CONSIDERATIONS

1.Usual bowel routine 2.Change in bowel habits 3. Rectal bleeding, blood in the stool	4. Medications (laxatives, stool softeners, iron) 5. Rectal conditions (pruritus, hemorrhoids, fissure, fistula)		6. Family history 7. Self-care behaviors (diet of high-fiber foods, most recent examinations)
Examiner Asks
1. Usual bowel routine. Bowels move regularly? How often? Usual color? Hard or soft? Pain while passing a bowel movement?		Assess usual bowel routine. Dyschezia. Pain may be due to a local condition (hemorrhoid, fissure) or constipation.
2. Change in bowel habits. Any change in usual bowel habits? Loose stools, or diarrhea? When did this start? Is the diarrhea associated with nausea and vomiting, abdominal pain, something you ate recently? •Eaten at a restaurant recently? Anyone else in your group or family have the same symptoms? •Traveled to a foreign country during the last 6 months? •Stools have a hard consistency? When did this start?		Diarrhea occurs with gastroenteritis, colitis, irritable colon syndrome. Consider food poisoning. Consider parasitic infection. Constipation.
3. Rectal bleeding, blood in the stool. Ever had black or bloody stools? When did you first notice blood in the stools? What is the color, bright red or dark red-black? How much blood: spotting on the toilet paper or out right passing of blood with the stool? Do the bloody stools have a particular smell? •Ever had clay-colored stools? •Ever had mucus or pus in stool? •Frothy stool? •Need to pass gas frequently?		Melena. Black stools may be tarry due to occult blood (melena) from gastrointestinal bleeding, or nontarry from ingestion of iron medications. Red blood in stools occurs with gastrointestinal bleeding or localized bleeding around the anus, and also with colon and rectal cancer. Clay color indicates absent bile pigment. Steatorrhea is excessive fat in the stool as in malabsorption of fat. Flatulence.
4. Medications. What medications do you take - prescription and over-the-counter? Laxatives or stool softeners? Which ones? How often? Iron pills? Do you ever use enemas to move your bowels? How often?
5. Rectal conditions. Any problems in rectal area: itching, pain or burning, hemorrhoids? How do you treat these? Any hemorrhoid preparations? Ever had a fissure, or fistula? How was this treated? • Ever had a problem controlling your bowels?		Pruritus Fecal incontinence. Mucoid discharge and soiled underwear occur with prolapsed hemorrhoids.
6. Family history. Any family history: polyps or cancer in colon or rectum, inflammatory bowel disease, prostate cancer?		Risk factors for colon cancer, rectal cancer, prostate cancer
7. Self-care behaviors. What is the usual amount of high-fiber foods in your daily diet: cereals, apples or other fruits, vegetables, whole-grain breads? How many glasses of water do you drink each day? Date last: digital rectal examination, stool blood test, colonoscopy, (for men) prostate-specific antigen blood test.		High-fiber foods of the soluble type (beans, prunes, barley, carrots, broccoli, cabbage) have been shown to lower cholesterol, while insoluble fiber foods (cereals, wheat germ) reduce the risk of colon cancer. Also, fiber foods help fight obesity, stabilize blood sugar, and may help certain gastrointestinal disorders. Early detection for cancer: digital rectal examination performed annually after age 50; fecal occult blood test annually after age 50; sigmoidoscopy every 5 years or colonoscopy every 10 years after age 50; prostate-specific antigen blood test annually for men over 50, except black men beginning at age 45 (American Cancer Society, 2002).
Additional History for Infants and Children
1. Have you ever noticed any irritation in your child's anal area: redness, raised skin, frequent itching?		In children, pinworms are a common cause of intense itching and irritated anal skin.
Objective Data
Preparation		Equipment Needed
Perform a rectal examination on all adults and particularly for those in middle and late years. Help the person assume one of the following positions (Fig. 25-3): Examine the male in the left lateral decubitus or standing position. Instruct the standing male to point his toes together; this relaxes the regional muscles, making it easier to spread the buttocks. Place the female in the lithotomy position if examining genitalia as well; use the left lateral decubitus position for the rectal area alone		Penlight Lubricating jelly Glove Guaiac test container
	Lithotomy
NORMAL RANGE OF FINDINGS		Abnormal Findings
INSPECT THE PERIANAL AREA
Spread the buttocks wide apart and observe the perianal region. The anus normally looks moist and hairless, with coarse folded skin that is more pigmented than the perianal skin. The anal opening is tightly closed. No lesions are present. Inspect the sacrococcygeal area. Normally, it appears smooth and even. Instruct the person to hold the breath and bear down by performing a Val-salva maneuver. No break in skin integrity or protrusion through the anal opening should be present. Describe any abnormality in clock-face terms, with 12:00 as the anterior point toward the symphysis pubis and 6:00 toward the coccyx.		Infiammation. Lesions or scars. Linear split—fissure. Flabby skin sac—hemorrhoid. Shiny blue skin sac—thrombosed hemorrhoid. Small round opening in anal area—fistula (see Table 25-1}. Inflammation or tenderness, swelling, tuft of hair, or dimple at tip of coccyx may indicate pilonidal cyst (see Table 25-1). Appearance of fissure, or hemorrhoids. Circular red doughnut of tissue—rectal prolapse.
Palpate The Anus And Rectum
Drop lubricating jelly onto your gloved index ringer. Instruct the person that palpation is not painful but may feel like needing to move the bowels. Place the pad of your index finger gently against the anal verge (Fig. 25-4). You will feel the sphincter tighten, then relax. As it relaxes, flex the tip of your finger and slowly insert it into the anal canal in a direction toward the umbilicus. Never approach the anus at right angles with your index finger extended. Such a jabbing motion does not promote sphincter relaxation and is painful.
Rotate your examining finger to palpate the entire muscular ring. The canal should feel smooth and even. Note the intersphincteric groove circling the canal wall. To assess tone, ask the person to tighten the muscle. The sphincter should tighten evenly around your finger with no pain to the person. Use a bidigital palpation with your thumb against the perianal tissue (Fig. 25-5). Press your examining finger towar d it. This maneuver highlights any swelling or tenderness and helps assess the bulbourethral glands		Decreased tone. Increased tone occurs with inflammation and anxiety. Tenderness.
Above the anal canal, the rectum turns posteriorly, following the curve of the coccyx and sacrum. Insert your finger farther and explore all around the rectal wall. It normally feels smooth with no nodularity. Promptly report any mass you discover for further examination		Internal hemorrhoid above anorectal junction is not palpable unless thrombosed. A soft, slightly movable mass may be a polyp. A firm or hard mass with irregular shape or rolled edges may signify carcinoma (see Table 25-2).
Prostate Gland. On the anterior wall in the male, note the elastic, bulging prostate gland (Fig. 25-6). Palpate the entire prostate in a systematic manner. Press into the gland at each location, because when a nodule occurs, it will not project into the rectal lumen. The surface should feel smooth and muscular-, search for any distinct nodule or diffuse firmness. Note these characteristics: Size—2.5 cm long by 4 cm wide; should not protrude more than 1 cm into the rectum Shape—heart shape, with palpable central groove Surface—smooth Consistency—elastic, rubbery Mobility—slightly movable Sensitivity—nontender to palpation		Enlarged, or atrophied gland. Flat with no groove. Nodular. Hard; or boggy, soft, fluctuant. Fixed. Tender. Enlarged, firm smooth gland with central groove obliterated suggests benign prostatic hypertrophy. Swollen, exquisitely tender gland accompanies prostatitis. Any stone-hard, irregular, fixed nodule indicates carcinoma (see Table 25-3).
In the female, palpate the cervix through the anterior rectal wall. It normally feels like a small round mass. You also may palpate a retroverted uterus or a tampon in the vagina. Do not mistake the cervix or a tampon for a tumor. Withdraw your examining finger; normally, no bright red blood or mucus is on the glove. To complete the examination, offer the person tissues to remove the lubricant and help the person to a more comfortable position.
Examination of Stool. Inspect any feces remaining on the glove. Normally, the color is brown and the consistency is soft		Jelly-like mucus shreds mixed in stool indicate inflammation. Bright red blood on stool surface indicates rectal bleeding. Bright red blood mixed with feces indicates possible colonic bleeding.
Test any stool on the glove for occult blood using the specimen container that your agency directs. A negative response is normal. If the stool is hematest positive, it indicates occult blood. Note that a false-positive finding may occur if the person has ingested significant amounts of red meat within 3 days of the test.		Black tarry stool with distinct malodor indicates upper gastrointestinal bleeding with blood partially digested. (Must lose more than 50 cc from upper gastrointestinal tract to be considered melena.) Black stool—also occurs with ingesting iron or bismuth preparations. Gray, tan stool—absent bile pigment, e.g., obstructive jaundice. Pale yellow, greasy stool—increased fat content (steatorrhea), as occurs with malabsorption syndrome. Occult bleeding usually indicates cancer of colon.
DEVELOPMENTAL CONSIDERATIONS
Infants and Children
For the newborn, hold the feet with one hand and flex the knees up onto the abdomen. Note the presence of the anus. Confirm a patent rectum and anus by noting the first meconium stool passed within 24 to 48 hours of birth. To assess sphincter tone, check the anal reflex. Gently stroke the anal area and note a quick contraction of the sphincter. For each infant and child, note that the buttocks are firm and rounded with no masses or lesions. Recall that the mongolian spot is a common variation of hy-perpigmentation in black, Native American, Mediterranean, and Asian new-borns (see Chapter 12).		Imperforate anus. Flattened buttocks in cystic fibrosis or celiac syndrome. Coccygeal mass. Meningocele (sac containing meninges that protrude through a defect in the bony spine). Tuft of hair or ptlonidal dimple.
The perianal skin is free of lesions. However, diaper rash is common in children younger than 1 year of age and is exhibited as a generalized reddened area with papules or vesicles.		Pustules indicate secondary infection of diaper rash. Signs of physical or sexual abuse. Fissure—common cause of constipation or rectal bleeding in child. (Painful, so the child does not defecate.)
Omit palpation unless the history or symptoms warrant. When internal palpation is needed, position the infant or child on the back with the legs flexed, and gently insert a gloved, well-lubricated finger into the rectum. Your fifth finger usually is long enough, and its smaller size is more comfortable for the infant or child. However, you may need to use the index finger because of its better control and increased tactile sensitivity. On withdrawing the ringer, scant bleeding or protruding rectal mucosa may occur. Inspect the perianal region of the school-age child and adolescent during examination of the genitalia. Internal palpation is not performed routinely.
The Aging Adult
As an aging person performs the Valsalva maneuver, you may note relaxation of the perianal musculature and decreased sphincter control. Otherwise, the full examination proceeds as that described earlier for the younger adult.
Summary Checklist: Anus, Rectum, and Prostate Exam
1 Inspect anus and perianal area 2 Inspect during Valsalva maneuver		3 Palpate anal canal and rectum on alt adults 4 Test stool for occult blood

Application and Critical Thinking

SAMPLE CHARTING

Subjective

Has one BM daily, soft, brown, no pain, no change in bowel routine, On no medications, Has no history of pruritus, hemorrhoids, fissure, or fistula. Diet Includes one to two servings daily each of fresh fruits and vegetables but no whole-grain cereals or breads.

Objective

No fissure, hemorrhoids, fistula, or skin lesions in perianal area. Sphincter tone good, no prolapse. Rectal walls smooth, no masses or tenderness. Prostate not enlarged, no masses or tenderness. Stool brown, hematest negative.

FOCUSED ASSESSMENT: CLINICAL CASE STUDY

Subjective

CM. is a 62-year-old white male with chronic obstructive pulmonary disease for 15 years, who today has "diarrhea for 3 days."

7 days PTA: CM. seen at this agency for scute respiratory infection that was diagnosed as acute bronchitis and treated with oral ampicillin, Took medication as directed.

3 days FTA: symptoms of respiratory infection improved. Ingesting usual diet. Onset of four to five loose, unformed, brown stools a day. No abdominal pain or cramping. No nausea.

Now: diarrhea continues. No blood or mucus noticed in stool. No new foods or restaurant food In past 3 days. Wife not III,

Objective

Vital signs: 37° C-58-1&. B/P 142/32.

Respiratory, Respirations unlabored. 3arre\ chest. Hyperresonant to percussion. Lung sounds c\ear but diminished. No crackles or rhonchi today.

Abdomen. Flat. Bowel sounds present. No organomegaly or tenderness to palpation.

Rectal. No lesions in perianal area. Sphincter tone good. Rectal walls smooth, no mass or tenderness. Prostate smooth and firm, no median sulcus palpable, no masses or tenderness. Stool brown, hematest negative.

Assessment

Diarrhea R/T effects of antibiotic medication

NURSING DIAGNOSES COMMONLY ASSOCIATED WITH ANAL AND RECTAL DISORDERS

RELATED FACTORS (Etiology)	DEFINING CHARACTERISTICS (Symptoms and Signs)
DIAGNOSIS: Constipation
Less than adequate dietary intake and bulk Neuromuscular or musculoskeletal impairment Pain and discomfort on defecation Effects of Diagnostic procedures Pregnancy Aging Medication Stress or anxiety Weak abdominal musculature Immobility or less than adequate physical activity Chronic use of laxatives and enemas Ignoring the urge to defecate Fear of rectal or cardiac pain Gastrointestinal lesions	Frequency less than usual pattern Hard, formed stools Palpable mass Straining at stool Less than usual amount of stool Decreased bowel sounds Gas pain and flatulence Abdominal or back pain Reported feeling of abdominal or rectal fullness or pressure Impaired appetite Headache Nausea Irritability Palpable hard stool on rectal examination
DIAGNOSIS: Bowel incontinence
Diarrhea Impaction Impairment Cognitive Neuromuscular Perceptual Large stool volume Depression Severe anxiety Physical or psychological barriers that prevent access to an acceptable toileting area Effects of medications Excessive use of laxatives	Involuntary passage of stool Lack of awareness of need to defecate Lack of awareness of passage of stool Rectal oozing of stool Urgency
THER RELATED NURSING DIAGNOSES
ACTUAL	R1SK/WELLNESS
Perceived Constipation Diarrhea (see Chapter 21) Impaired Skin integrity	Risk Risk for Constipation Risk for Fluid imbalance Wellness Health-seeking behavior for information on high-fiber diet

ABNORMAL FINDINGS

TABLE 25-1: Abnormalities of the Anus and Perianal Region

Pilonidal Cyst or Sinus

A hair-containing cyst or sinus located in the midline over the coccyx or lower sacrum. Often opens as a dimple with visible tuft of hair and, possibly, an erythematous halo. Or, may appear as a palpable cyst. When advanced, has a palpable sinus tract. Although it is a congenital disorder, the lesion is first diagnosed between the ages of 15 and 30 years

Anorectal Fistula

A chronically inflamed gastrointestinal tract creates an abnormal passage from inner anus or rectum out to skin surrounding anus. Usually originates from a local abscess. The red, raised tract opening may drain serosanguineous or purulent matter when pressure is applied. Bidigital palpation may reveal an indurated cord.

Fissure

A painful longitudinal tear in the superficial mucosa at the anal margin. Most fissures (>90%) occur in the posterior midline area. They are frequently accompanied by a papule of hyperplastic skin, called a sentinel tag, on the anal margin below. Fissures often result from trauma, e.g., passing a large, hard stool or from irritant diarrheal stools. The person has itching, bleeding, and exquisite pain. A resulting spasm in the sphincters makes the area painful to examine; local anesthesia may be indicated.

Hemorrhoids

These painless, flabby papules are due to a varicose vein of the hemorrhoidal plexus. An external hemorrhoid originates below the anorectal junction and is covered by anal skin. When thrombosed, it contains clotted blood and becomes a painful, swollen, shiny blue mass that itches and bleeds with defecation. When it resolves, it leaves a painless, flabby skin sac around the anal orifice. An internal hemorrhoid originates above the anorectal junction and is covered by mucous membrane. When the person performs a Valsalva maneuver, it may appear as a red mucosal mass. It is not palpable. All hemorrhoids result from increased portal venous pressure, as occurs with straining at stool, chronic constipation, pregnancy, obesity, chronic liver disease, or the low-fiber diet common in Western society

Rectal Prolapse

The rectal mucous membrane protrudes through the anus, appearing as a moist red doughnut with radiating lines. When prolapse is incomplete, only the mucosa bulges. When complete, it includes the anal sphincters. Occurs following a Valsalva maneuver, such as straining at stool, or with exercise.

Pruritus Ani

Intense perianal itching is manifested by red, raised, thickened, excoriated skin around the anus. Common causes are pinworms in children and fungal infections in adults. The area is swollen and moist, and with a fungal infection, it appears dull grayish-pink. The skin is dry and brittle with psychosomatic itching.

Abscess

A localized cavity of pus from infection in a pararectal space. Infection usually extends from an anal crypt. Characterized by persistent throbbing rectal pain. Termed by the space it occupies, e.g., a perianal abscess is superficial around the anal skin, and appears red, hot, swollen, indurated, and tender. An ischiorectal abscess is deep and tender to bidigital palpation. It occurs laterally between the anus and ischial tuberosity and is uncommon.

Rectal Polyp

A protruding growth from the rectal mucous membrane that is fairly common. The polyp may be pedunculated (on a stalk) or sessile (a mound on the surface, close to the mucosal wall). The soft nodule is difficult to palpate. Proctoscopy is needed as well as biopsy to screen for a malignant growth.

^{Fecal Impaction}

A collection of hard, desiccated feces in the rectum. The obstruction often results from decreased bowel motility, in which more water is reabsorbed from the stool. Also occurs with retained barium from gastrointestinal x-ray examination. The person may complain of constipation or of diarrhea as a fecal stream passes around the impaction.

Carcinoma

A malignant neoplasm in the rectum is asymptomatic, thus the importance of routine rectal palpation. An early lesion may be a single firm nodule. You may palpate an ulcerated center with rolled edges. As the lesion grows, it has an irregular cauliflower shape and is fixed and stone-hard. Refer a person with any rectal lesion for further study because about half are malignant.

TABLE 25-3: Abnormalities of the Prostate Gland

Benign Prostatic Hypertrophy (BPH)

S: Urinary frequency, urgency, hesitancy, straining to urinate, weak stream, intermittent stream, sensation of incomplete emptying, nocturia.

0: A symmetric nontender enlargement, commonly occurs in males beginning in the middle years. The prostate surface feels smooth, rubbery, or firm (like the consistency of the nose), with the median sulcus obliterated.

Prostatitis

S: Fever, chills, malaise, urinary frequency and urgency, dysuria, urethral discharge, dull, aching pain in perinea! and rectal area.

O: An exquisitely tender enlargement is acute inflammation of the prostate gland yielding a swollen, slightly asymmetric gland that is quite tender to palpation. With a chronic inflammation the signs can vary from tender enlargement with a boggy feel to isolated firm areas due to fibrosis. Or the gland may feel normal.

Carcinoma

S: Frequency, nocturia, hematuria, weak stream, hesitancy, pain or burning on urination, continuous pain in lower back, pelvis, thighs.

O: A malignant neoplasm often starts as a single hard nodule on the posterior surface, producing asymmetry and a change in consistency. As it invades normal tissue, multiple hard nodules appear, or the entire gland feels stone-hard and fixed. The median sulcus is obliterated.

S, Subjective data

O, objective data.

ASSESSMENT OF FEMALE REPRODUCTIVE SYSTEM

Structure And Function

External Genitalia Internal Genitalia

Developmental Considerations

Infants and Adolescents

The Pregnant Female

The Aging Female

Subjective Data

Health History Questions

Additional History for Infants and Children

Additional History for Preadolescents and Adolescents

Additional History for the Aging Adult

Objective Data

Preparation

Position

External Genitalia

Inspection

Palpation

Internal Genitalia

Speculum Examination

Bimanual Examination

Rectovaginal Examination  

Developmental Considerations

Infants and Children

The Adolescent

The Pregnant Female

The Aging Adult

Summary Checklist: Female Genitalia Exam

Application and Critical Thinking

Sample Charting

Focused Assessment: Clinical Case Study 1

Focused Assessment: Clinical Case Study 2

Nursing Diagnoses

Assessment Video Critical Thinking Questions

Abnormal Findings

Abnormalities of the External Genitalia

Abnormalities of the Pelvic Musculature

Abnormalities of the Cervix

Vulvovaginal Inflammations

Conditions of Uterine Enlargement

Adnexal Enlargement

Abnormalities in Pediatric Genitalia

Structure and Function

EXTERNAL GENITALIA

The external genitalia are called the vulva, or pudendum (Fig. 26-1). The mons pubis is a round, firm pad of adipose tissue covering the symphysis pubis. After puberty, it is covered with hair in the pattern of an inverted triangle. The labia majora are two rounded folds of adipose tissue extending from the mons pubis down and around to the perineum. After puberty, hair covers the outer surfaces of the labia, while the inner folds are smooth and moist, and contain sebaceous follicles.

Inside the labia majora are two smaller, darker folds of skin, the labia minora. These are joined anteriorly at the clitoris where they form a hood, or prepuce. The labia minora are joined posteriorly by a transverse fold, the frenulum or fourchette. The clitoris is a small, pea-shaped erectile body, homologous with the male penis and highly sensitive to tactile stimulation.

The labial structures encircle a boat-shaped space, or cleft, termed the vestibule. Within it are numerous openings. The urethral meatus appears as a dimple 2.5 cm posterior to the clitoris. Surrounding the urethral meatus are the tiny, multiple paraurethral (Skene's) glands. Their ducts are not visible but open posterior to the urethra at the 5 and 7 o'clock positions. The vaginal orifice is posterior to the urethral meatus. It appears either as a thin median slit or as a large opening with irregular edges, depending on the presentation of the membranous hymen. The hymen is a thin, circular or crescent-shaped fold that may cover part of the vaginal orifice or may be absent completely. On either side and posterior to the vaginal orifice are two vestibular (Bartholin's) glands, which secrete a clear lubricating mucus during intercourse. Their ducts are not visible but open in the groove between the labia minora and the hymen.

INTERNAL GENITALIA

The internal genitalia include the vagina, a flattened, tubular canal extending from the orifice up and backward into the pelvis (Fig. 26-2). It is 9 cm long and sits between the rectum posteriorly and the bladder and urethra anteriorly. Its walls are in thick transverse folds, or rugae, enabling the vagina to dilate widely during child birth.

At the end of the canal, the uterine cervix projects into the vagina. In the nulliparous female, the cervix appears as a smooth doughnut-shaped area with a small circular hole, or os. After childbirth, the os is slightly enlarged and irregular. The cervical epithelium is of two distinct types. The vagina and cervix are covered with smooth, pink, stratified squa-mous epithelium. Inside the os, the endocervical canal is lined with columnar epithelium that looks red and rough. The point where these two tissues meet is the squamocolum-nar junction and is not visible.

A continuous recess is present around the cervix, termed the anterior fornix in front and the posterior fornix in back. Behind the posterior fornix, another deep recess is formed by the peritoneum. It dips down between the rectum and cervix to form the rectouterine pouch, or cul-de-sac of Douglas.

The uterus is a pear-shaped, thick-walled, muscular organ. It is flattened anteroposteriorly, measuring 5.5 to 8 cm long by 3.5 to 4 cm wide and 2 to 2.5 cm thick. It is freely movable, not fixed, and usually tilts forward and superior to the bladder (a position labeled as anteverted and anteflexed, see p. 785).

The fallopian tubes are two pliable, trumpet-shaped tubes, 10 cm in length, extending from the uterine fundus laterally to the brim of the pelvis. There, they curve posteriorly,their fimbriated ends located near the ovaries. The two ovaries are located one on each side of the uterus at the level of the anterior superior iliac spine. Each is oval shaped, 3 cmlong by 2 cm wide by 1 cm thick, and serves to develop ova (eggs) as well as the female hormones.

DEVELOPMENTAL CONSIDERATIONS INFANTS AND ADOLESCENTS

Infant and Adolescents

At birth, the external genitalia are engorged because of the presence of maternal estrogen. The structures recede in a few weeks, remaining small until puberty. The ovaries are located in the abdomen during childhood. The uterus is small with a straight axis and no anteflexion.

At puberty, estrogens stimulate the growth of cells in the reproductive tract and the development of secondary sex characteristics. The first signs of puberty are breast and pubic hair development, beginning between the ages of 8V₂ and 13 years. These signs are usually concurrent, but it is not abnormal if they do not develop together. They take about 3 years to complete.

Menarche occurs during the latter half of this sequence, just after the peak of growth velocity. Irregularity of the menstrual cycle is common during adolescence because of the girl's occasional failure to ovulate. With menarche, the uterine body flexes on the cervix. The ovaries now are in the pelvic cavity.

TABLE 26-1: Sex Maturity Ratings (SMR) in Girls

Tanner's table on the five stages of pubic hair development (sex maturity rating [SMR]) is helpful in teaching girls the expected sequence of sexual development (Table 26-1).

These data are derived from Tanner's study of white British females and may not necessarily generalize to all other racial groups. For example, mature Asian women normally have fine sparse pubic hair. However, the U.S. Health Examination Survey (Harlan et al., 1980) studied girls representative of the contemporary United States population. Its findings correlate closely with Tanner's SMR results. One significant difference is that black girls tend to develop breasts and pubic hair earlier than white girls of the same age.

The Pregnant Female

Shortly after the first missed menstrual period in the pregnant female, the genitalia show signs of the growing fetus. The cervix softens (Goodell's sign) at 4 to 6 weeks, and the vaginal mucosa and cervix look cyanotic (Chadwick's sign) at 8 to 12 weeks. These changes occur because of increased vas-cularity and edema of the cervix and hypertrophy and hyper -plasia of the cervical glands. The isthmus of the uterus softens (Hegar's sign) at 6 to 8 weeks.

The greatest change is in the uterus itself. It increases in capacity by 500 to 1000 times its nonpregnant state, at first because of hormone stimulation, and then because of the increasing size of its contents (Cunningham et al., 2001). The nonpregnant uterus has a flattened pear shape. Its early growth encroaches on the space occupied by the bladder, which produces the symptom of urinary frequency. By 10 to

12 weeks' gestation, the uterus becomes globular in shape and is too large to stay in the pelvis. At 20 to 24 weeks, the uterus has an oval shape. It rises almost to the liver, displacing the intestines superiorly and laterally.

A clot of thick, tenacious mucus forms in the spaces of the cervical canal (the mucus plug), which protects the fetus from infection. The mucus plug dislodges when labor begins at the end of term, producing a sign of labor called "bloody show." Cervical and vaginal secretions increase during pregnancy and are thick, white, and more acidic. The increased acidity occurs because of the action of Lactobacil-lus acidophilus, which changes glycogen into lactic acid. The acidic pH keeps pathogenic bacteria from multiplying in the vagina, but the increase in glycogen increases the risk of candidiasis (commonly called a yeast infection) during pregnancy.

The Aging Female

In contrast to the slowly declining hormones in the aging male, the female's hormonal milieu decreases rapidly. Menopause is cessation of the menses. Usually this occurs around the ages of 48 to 51 years, although a wide normal variation of ages from 35 to 60 years exists. The stage of menopause includes the preceding 1 to 2 years of decline in ovarian function, shown by irregular menses that gradually become farther apart and produce a lighter flow than usual. The ovaries stop producing progesterone and estrogen. Since cells in the reproductive tract are estrogen dependent, decreased estrogen levels during menopause bring dramatic physical changes. The uterus shrinks in size because of its decreased myo-metrium. The ovaries atrophy to 1 to 2 cm and are not palpable after menopause. Ovulation still may occur sporadically after menopause. The sacral ligaments relax, and the pelvic musculature weakens, so the uterus droops. Sometimes it may protrude, or prolapse, into the vagina. The cervix shrinks and looks paler with a thick, glistening epithelium.

The vagina becomes shorter, narrower, and less elastic because of increased connective tissue. Without sexual activity, the vagina atrophies to one half its former length and width. The vaginal epithelium atrophies, becoming thinner, drier, and itchy. This results in a fragile mucosal surface that is at risk for bleeding and vaginitis. Decreased vaginal secretions leave the vagina dry and at risk for irritation and pain with intercourse (dyspareunia). The vaginal pH becomes more alkaline, and a decreased glycogen content occurs from the decreased estrogen. These factors also increase the risk of vaginitis because they create a suitable medium for pathogens.

Externally, the mons pubis looks smaller because the fat pad atrophies. The labia and clitoris gradually decrease in size. Pubic hair becomes thin and sparse.

Declining estrogen levels produce some physiologic changes in the female sexual response cycle (Table 26-2). However, these changes do not affect sexual pleasure and function. Sexual desire and the need for full sexual expression continue. As with the male, the older female is capable of sexual function given reasonably good health and an interested partner. The problem for many older women is finding a socially acceptable sexual partner. Aging women greatly outnumber their male counterparts, and aging women are more likely to be single while males their same age are more likely to be married.

TABLE 26-2: Aging Changes in Sexual Response Cycle

PHASE	PHYSIOLOGIC CHANGE
Excitement	Reduced amount of vaginal secretion andlubrication
Plateau	Less expansion of vagina Labia majora do not elevate against perineum No color change in labia minora (was from pink to cardinal-red or dark red) Size of clitoris decreases after age 60
Orgasm	Shorter duration
Resolution	Occurs more rapidly

Data from Masters WH, Johnson VE: Human sexual response, Boston, 1966, Little, Brown, and Company.

Subjective Data

1. Menstrual history

2. Obstetric history

3. Menopause

4. Self-care behaviors

5. Urinary symptoms

6. Vaginal discharge

7. Past history

8. Sexual activity

9. Contraceptive use

10. Sexually transmitted disease (STD) contact

11. STD risk reduction

EXAMINER ASKS	RATIONALE
1. Menstrual history.
•Tell me about your menstrual periods: •Date of your last menstrual period? •Age at first period? •How often are your periods? •How many days does your period last? •Usual amount of flow: light, medium, heavy? How many pads or tampons do you use each day or hour? •Any clotting? •Any pain or cramps before or during period? How do you treat it? Interfere with daily activities? Any other associated symptoms: bloating, cramping, breast tenderness, moodiness? Any spotting between periods?	Menstrual history is usually nonthreat-ening, thus it is a good place to start history. LMP—last menstrual period. Menarche—onset between 12 and 14 years indicates normal growth; onset between 16 and 17 years suggests an endocrine problem. Cycle—normally varies every 18 to 45 days. Amenorrhea—absent menses. Duration—average 3 to 7 days. Menorrhagia—heavy menses. Clotting indicates heavy flow or vaginal pooling. Dysmenorrhea
.2. Obstetric history.
•Have you ever been pregnant? •How many times? •How many babies have you had? •Any miscarriage or abortion? •For each pregnancy, describe: duration, any complication, labor and delivery, baby's sex, birth weight, condition. •Do you think you may be pregnant now? What symptoms have you noticed?	Obstetric history. Gravida—number of pregnancies. Para—number of births. Abortions—interrupted pregnancies, including elective abortions and spontaneous miscarriages
3. Menopause.
•Have your periods slowed down or stopped? •Any associated symptoms of menopause, e.g., hot flash, numbness and tingling, headache, palpitations, drenching sweats, mood swings, vaginal dryness, itching? Any treatment? •If hormone replacement, how much? How is it working? Any side effects? •  •How do you feel about going through menopausi	Menopause—cessation of menstruation. Perimenopausal period, from 40 to 55 years of age, has hormone shifts, resulting in vasomotor instability. Side effects of estrogen replacement therapy include fluid retention, breast pain or enlargement, vaginal bleeding. Although this is a normal life stage, reaction varies from acceptance to feelings of loss.
4. Self-care behaviors.
•How often do you have a gynecologic checkup? •Last Papanicolaou smear? Results? •Has your mother ever mentioned taking hormones while pregnant with you?	Assess self-care behaviors. Maternal ingestion of DES (diethyl-stilbestrol) causes cervical and vaginal abnormalities in female offspring requiring frequent follow-up.
5. Urinary symptoms
•Any problems with urinating? Frequently and small amounts? Cannot wait to urinate? •Any burning or pain on urinating? •Awaken during night to urinate? •      Blood in the urine? ••Urine dark, cloudy, foul smelling? •      Any difficulty controlling urine or wetting yourself? •  •  • Urinate with a sneeze, laugh, cough, bearing down?	Urinary symptoms. Frequency. Urgency. Dysuria. Nocturia. Hematuria. Bile in urine or urinary tract infection. True incontinence—loss of urine without warning. Urgency incontinence—sudden loss, as with acute cystitis. Stress incontinence—loss of urine with physical strain due to muscle weakness.
6. Vaginal discharge.
•Any unusual vaginal discharge? Increased amount? ••Character or color: white, yellow-green, gray, curdlike, foul smelling? •  •When did this begin? •Is the discharge associated with vaginal itching, rash, pain with intercourse? •  •  •Taking any medications? •  •  •  •  •  •Family history of diabetes? •What part of your menstrual cycle are you in now? •Use a vaginal douche? How often? •Use feminine hygiene spray? •Wear nonventilating underpants, pantyhose? •Treated the discharge with anything? Result?	Normal discharge is small, clear or cloudy, and always nonirritating. Suggests vaginal infection; character of discharge often suggests causative organism (see Table 26-6). Acute versus chronic problem. Occurs secondary to irritation from discharge. Dyspareunia occurs with vaginitis of any cause. Factors that increase risk of vaginitis: Oral contraceptives increase glycogen content of vaginal epithelium, providing fertile medium for some organisms. Broad-spectrum antibiotics alter balance of normal flora. Diabetes increases glycogen content. Menses, postpartum, menopause have a more alkaline vaginal pH. Frequent douching alters pH. Spray has risk of contact dermatitis. Local irritation.
7. Past history
•Any other problems in the genital area? Sores or lesions-now or in the past? How were these treated? •Any abdominal pain? •Any past surgery on uterus, ovaries, vagina?	Assess feelings. Some fear loss of sexual response following hysterectomy, which may cause problems in intimate relationships.
8. Sexual activity
•Often women have a question about their sexual relationship and how it affects their health. Do you? •Are you in a relationship involving sex now? •Are aspects of sex satisfactory to you and your partner? •Satisfied with the way you and partner communicate about sex? •Satisfied with your ability to respond sexually? •Do you have more than one sexual partner? •  •  •  •What is your sexual preference: relationship with a man, with a woman, both?	Begin with open-ended question to assess individual needs. Include appropriate questions as a routine part of history: Communicates that you accept individual's sexual activity and believe it is important. Your comfort with discussion prompts person's interest and possibly relief that the topic has been introduced. Establishes a data base for comparison with any future sexual activities. Provides opportunity to screen sexual problems. Lesbians and bisexual women need to feel acceptance to discuss their health concerns.
9. Contraceptive use.
•Currently planning a pregnancy, or avoiding pregnancy? •Do you and your partner use a contraceptive? Which method? Is this satisfactory? Do you have any questions about method? •Which methods have you used in the past? Have you and partner dis-" cussed having children? •Have you ever had any problems becoming pregnant?	If oral contraceptives are used, assess smoking history. Cigarettes increase cardiovascular side effects of oral contraceptives. Infertility is considered after 1 year of engaging in unprotected sexual intercourse without conceiving
10. Sexually transmitted disease (STD) contact.
•Any sexual contact with partner having a sexually transmitted disease, such as gonorrhea, herpes, AIDS, chlamydial infection, venereal warts, syphilis? When? How was this treated? Were there any complications?
11. STD risk reduction
Any precautions to reduce risk of STDs? Usecondoms at each episode of sexual intercourse?
Additional History for Infants and Children
•1. Does your child have any problem urinating? Pain with urinating, crying, holding genitals? Urinary tract infection? •(If the child is older than 2 to 2V2 years of age) Has toilet training started? How is it progressing? · Does the child wet bed at night? Is this a problem for child or you (parents)? What have you (parents) done?
2. Problem with genital area: itching, rash, vaginal discharge?	Occurs with poor perineal hygiene or insertion of foreign body in vagina.
3. {To child) Has anyone ever touched you in between your legs and you did not want them to? Sometimes that happens to children. They should remember they have not been bad. They should try to tell a big person about it. Can you tell me three different big people you trust who you could talk to?	Screen for sexual abuse. For prevention, teach the child that it's not okay for someone to look at or touch their private parts while telling them it's a secret. Naming three trusted adults will include someone outside the family— important since most molestation is by a parent (Brown, 1997).
Additional History for Preadolescents and Adolescents
•Use the following questions, as appropriate, to assess sexual growth and development and sexual behavior. First •Ask questions that seem appropriate for girl's age but be aware that normsvary widely. When in doubt, it is better to ask too many questions than to omit something. Children obtain information, often misinformation, from the media and from peers at surprisingly early ages. You can be sure your information will be more thoughtful and accurate. •Ask direct, matter-of-fact questions. Avoid sounding judgmental. •Start with a permission statement, "Often girls your age experience ..." This conveys that it is normal to think or feel a certain way. · Try the open-ended, "When did you ..."rather than "Do you ..." This is less threatening because it implies that the topic is normal and unexceptional
1. Around age 11, but sometimes earlier, girls start to develop breasts and pubic hair. Have you ever seen charts and pictures of normal growth patterns for girls? Let us go over these now.
2. Have your periods started? How did you feel? Were you prepared or surprised?	Assess attitude of girl and parents. Note inadequate preparation or attitude of distaste.
•3. Who in your family do you talk to about your body changes and about sex information? How do these talks go? Do you think you get enough information? What about sex education classes at school? Is there a teacher, a nurse or doctor, a minister, a counselor to whom you can talk? •Often girls your age have questions about sexual activity. Do you have questions? Are you dating? Someone steady? Do you and your boyfriend have intercourse? Are you using condoms? What method of protection did you use the last time you had sex?	Avoid the term "sexually active," which is ambiguous
4. Has anyone ever talked to you about sexually transmitted diseases, such as herpes, gonorrhea, or AIDS?	Teach STD risk reduction.
5. Sometimes it happens that a person touches a girl in a way that she does not  want them to. Has that ever happened to you? If that happens, the girl should remember it is not her fault. She should tell another adult about it.	Screen for sexual abuse.
Additional History for the Aging Aduit
• After menopause, noted any vaginal bleeding? • Any vaginal itching, discharge, pain with intercourse? • Any pressure in genital area, loss of urine with cough or sneeze, back pain, or constipation? •4. Are you in a relationship involving sex now? Are aspects of sex satisfactory to you and your partner? Is there adequate privacy for a sexual relationship?	Postmenopausal bleeding warrants further workup and referral. Associated with atrophic vaginitis. Occurs with weakened pelvic musculature and uterine prolapse.

OBJECTIVE DATA

PREPARATION

Assemble the equipment before helping the woman into position. Arrange within easy reach. Familiarize yourself with the vaginal speculum before the examination. Practice opening and closing the blades, locking them into position, and releasing them. Try both metal and plastic types. Note that the plastic speculum locks and unlocks with a resounding click that can be alarming to the uninformed woman.

EQUIPMENT NEEDED

Gloves

Protective clothing for examiner Goose-necked lamp with a strong light Vaginal speculum of appropriate size (Fig. 26-3)

Graves' speculum—useful for most adult women, available in varying lengths and widths

Pederson speculum—narrow blades, useful for young or postmenopausal women with narrowed introitus

Large cotton-tipped applicators (rectal swabs)

Materials for cytologic study:

Glass slide with frosted end

Sterile Cytobrush or cotton-tipped applicator

Ayre's spatula

Spray fixative

Specimen container for gonorrhea

culture (GCyChlamydia

Small bottle of normal saline, potassium hydroxide (KOH), and acetic acid (white vinegar)

Lubricant

POSITION

Initially, the woman should be sitting up. An equal status position is important to establish trust and rapport before the vaginal examination.

For the examination, the woman should be placed in the lithotomy position, with the examiner sitting on a stool. Help the woman into lithotomy position, with the body supine, feet in stirrups and knees apart, and buttocks at edge of examining table (Fig. 26-4). Ask the woman to lift her hips as you guide them to the edge of the table. Some women prefer to leave their shoes or socks on. Or, you can place an exam glove over each of the stirrups to warm the stirrups and keep her feet from slipping.

The arms should be at the woman's sides or across the chest, not over the head, because this position only tightens the abdominal muscles. The traditional mode is to drape the woman fully, covering the stomach and legs, exposing only the vulva to your view. Be sure to push down the drape between the woman's legs so that you can see her face.

The lithotomy position leaves many women feeling helpless and vulnerable. Indeed, many women tolerate the pelvic examination because they consider it basic for health care, yet they find it embarrassing and uncomfortable. Previous examinations may have been painful, or the previous examiner's attitude hurried and patronizing.

The examination need not be this way. You can help the woman relax, decrease her anxiety, and retain a sense of control by employing these measures:

•Have her empty the bladder before the examination.

•Position the exam table so that her perineum is not exposed to an inadvertent open door.

•Ask if she would like a friend, family member, or chaperone present. Position this person by the woman's head to maintain privacy.

•Elevate her head and shoulders to a semi-sitting position to maintain eye contact.

•Place the stirrups so the legs are not abducted too far.

•Explain each step in the examination before you do it.

•Assure the woman she can stop the examination at any point should she feel any discomfort.

•Use a gentle, firm touch, and gradual movements.

•Communicate throughout the examination. Maintain a dialogue to share information

•Use the techniques of the educational or mirror pelvic examination (Fig. 26—5). This is a routine examination with some modifications in attitude, position, and communication. First, the woman is considered an active participant, one who is interested in learning and in sharing decisions about her own health care. The woman props herself up on one elbow, or the head of the table is raised. Her other hand holds a mirror between her legs, above the examiner's hands. The woman can see all that the examiner is doing and has a full view of her genitalia.

• 

The mirror works well for teaching normal anatomy and its relation to sexual behavior. Even women who are in a sexual relationship or who have had children may be surprisingly uninformed about their own anatomy. You will find the woman's enthusiasm on seeing her own cervix is rewarding too.

The mirror pelvic examination also works well when abnormalities arise because the woman can see the rationale for treatment and can monitor progress at the next appointment. She is more willing to comply with treatment when she shares in the decision.

NORMAL RANGE OF FINDINGS			ABNORMAL FINDINGS
EXTERNAL GENITALIA
Inspection
Note: · • Skin color (Fig. 26-6) · · Hair distribution is in the usual female pattern of inverted triangle, although it normally may trail up the abdomen toward the umbilicus. · Labia majora normally are symmetric, plump, and well formed. In the nulli-parous woman, labia meet in the midline; following a vaginal delivery, the labia are gaping and slightly shriveled. · No lesions should be present, except for occasional sebaceous cysts. These are yellowish, 1-cm nodules that are firm, nontender, and often multiple. · With your gloved hand, separate the labia majora to inspect: · Clitoris (Fig. 26-7). · Labia minora are dark pink and moist, usually symmetric · Urethral opening appears stellate or slitlike and is midline. · Vaginal opening, or introitus, may appear as a narrow vertical slit or as a larger opening. · Perineum is smooth. A well-healed episiotomy scar, midline or mediolateral, may be present following a vaginal birth. · Anus has coarse skin of increased pigmentation (see Chapter 25 for assessment).			Refer any suspicious pigmented lesion for biopsy Consider delayed puberty if no pubic hair or breast development has occurred by age 13. Nits or lice at the base of pubic hair. Swelling. Excoriation, nodules, rash, or lesions (see Table 26-3). Inflammation or lesions. Polyp. Foul-smelling, irritating discharge.
Palpation
Assess the urethra and Skene's glands (Fig. 26-8). Dip your gloved finger in a bowl of warm water to lubricate. Then insert your index finger into the vagina, and gently milk the urethra by applying pressure up and out. This procedure should produce no pain. If any discharge appears, culture it. Assess Bartholin's glands. Palpate the posterior parts of the labia majora with your index finger in the vagina and your thumb outside (Fig. 26-9). Normally, the labia feel soft and homogeneous. Assess the support of pelvic musculature by using these maneuvers: 1. Palpate the perineum. Normally, it feels thick, smooth, and muscular in the nulliparous woman, and thin and rigid in the multiparous woman. 2. Ask the woman to squeeze the vaginal opening around your fingers; it should feel tight in the nulliparous woman and have less tone in the multiparous woman. 3. Using your index and middle fingers, separate the vaginal orifice and ask the woman to strain down. Normally, no bulging of vaginal walls or urinary incontinence occurs			Tenderness. Induration along urethra. Urethral discharge. Swelling (see Table 26-3). Induration. Pain with palpation. 3.Erythema around or discharge from duct opening Tenderness. Paper-thin perineum. Absent or decreased tone may diminish sexual satisfaction. Bulging of the vaginal wall indicates cystocele, rectocele, or uterine prolapse (see Table 26-4). Urinary incontinence.
INTERNAL GENITALIA
Speculum Examination
Select the proper-sized speculum. Warm and lubricate the speculum under warm running water. Avoid gel lubricant at this point because it is bacteriostatic and would distort cells in the cytology specimen you will collect. A good technique is to dedicate one hand to the patient and the other hand to picking up equipment in the room. For example, hold the speculum in your left hand (the equipment hand), with the index and the middle fingers surrounding the blades and your thumb under the thumbscrew. This prevents the blades from opening painfully during insertion. With your right index and middle fingers (the patient hand), push the introitus down and open to relax thepubococcygeal muscle (Fig. 26-10). Tilt the width of the blades obliquely and insert the speculum past your right fingers, applying any pressure downward. This avoids pressure on the sensitive urethra above it Ease insertion by asking the woman to bear down. This method relaxes the perineal muscles and opens the introitus. (With experience, you can combine speculum insertion with assessing the support of the vaginal muscles.) As the blades pass your right fingers, withdraw your fingers. Now change the hand holding the speculum to your right hand and turn the width of the blades horizontally. Continue to insert in a 45-degree angle downward toward the small of the woman's back (Fig. 26-11). This matches the natural slope of the vagina. After the blades are fully inserted, open them by squeezing the handles together (Fig. 26-12). The cervix should be in full view. Sometimes this does not occur (especially with beginning examiners), because the blades are angled above the location of the cervix. Try closing the blades, withdrawing about halfway, and reinserting in a more downward plane. Then slowly sweep upward.Once you have the cervix in full view, lock the blades open by tightening the thumbscrew.
Inspect the cervix and its os
Note: · Color. Normally the cervical mucosa is pink and even. During the 2nd month of pregnancy it looks blue (Chadwick's sign), and after menopause it is pale. · Position. Midline, either anterior or posterior. Projects 1 to 3 cminto the vagina. · Size. Diameter is 2.5 cm (1 inch). · Os. This is small and round in the nulliparous woman. In the parous woman, it is a horizontal irregular slit and also may show healed lacerations on the sides (Fig. 26-13). · Surface. This is normally smooth, but cervical eversion, or ectropkm, may occur normally after vaginal deliveries. The endocervical canal is everted or "rolled out." It looks like a red, beefy halo inside the pink cervix surrounding the os. It is difficult to distinguish this normal variation from an abnormal condition (e.g., erosion, or carcinoma), and biopsy may be needed. NORMAL VARIATION OF CERVIX Nulliparous                      Parous (after childbirth) LACERATIONS Cervical eversion                                      Nabothian cysts Nabothian cysts are benign growths that commonly appear on the cervix after childbirth. They are small, smooth, yellow nodules that may be single or multiple. Less than I cm, they are retention cysts due to obstruction of cervical glands. Note the cervical secretions. Depending on the day of the menstrual cycle, secretions may be clear and thin, or thick, opaque, and stringy. Always they are odorless and nonirritating. If secretions are copious, swab the area with a thick-tipped rectal swab. Thismethod sponges away secretions, and you have a better view of the structures.			Redness, inflammation. Pallor with anemia. Cyanotic other than with pregnancy (see Table 26-5). Lateral position may be due to adhesion or tumor. Projection of more than 3 cm may be a prolapse. Hypertrophy of more than 4 cm occurs with inflammation or tumor. Surface reddened, granular, and asymmetric, particularly around os. Friable, bleeds easily. Any lesions: white patch on cervix; strawberry spot. Refer any suspicious red, white, or pig-mented lesion for biopsy (see erosion, ul-ceration, and carcinoma, Table 26-5). Cervical polyp—bright red growth protruding from the os (see Table 26-5). Foul-smelling, irritating, with yellow, green, white, or gray discharge {see Table 26-6)
Obtain cervical smears and cultures
The Papanicolaou, or Pap, smear screens for cervical cancer. Do not obtain during the woman's menses or if a heavy infectious discharge is present. Instruct the woman not to douche, have intercourse, or put anything into the vagina within 24 hours before collecting the specimens. Obtain the Pap smear before other specimens so you will not disrupt or remove cells. Laboratories may vary in method, but usually the test consists of three specimens: Vaginal Pool. Gently rub the blunt end of an Ayre spatula over the vaginal wall under and lateral to the cervix (Fig. 26-14). Wipe the specimen on a slide and spray with fixative immediately. If the mucosa is very dry (as in a post-menopausal woman), moisten a sterile swab with normal saline to collect this specimen. Cervical Scrape (Fig. 26-15). Insert the bifid end of the Ayre spatula into the vagina with the more pointed bump into the cervical os. Rotate it 360 to 720 degrees, using firm pressure. The rounded cervix fits snugly into the spatula's groove. The spatula scrapes the surface of the squamocolumnar junction and cervix as you turn the instrument. Spread the specimen from both sides of the spatula onto a glass slide. Use a single stroke to thin out the specimen, not a back-and-forth motion. This specimen is important for the adolescent whose endocervical cells have not yet migrated into the endocervical canal. Endocervical Specimen (Fig. 26-16). Insert a Cytobrush (instead of a cotton applicator) into the os. A Cytobrush gives a higher yield of endocervical cells at the squamocolumnar junction, or SCJ, and safety for use during pregnancy has been shown (Stillson, Knight, and Elswick, 1997). The woman may feel a slight pinch with the brush and scant bleeding may occur. For this reason, collect the endocervical specimen last so that bleeding will not obscure cytologic evaluation. SCJ Rotate the brush 720 degrees in ONE direction in the endocervical canal, either clockwise or counterclockwise. Then rotate the brush gently on a slide to deposit all the cells. Rotate in the opposite direction from the one in which you obtained the specimen. Avoid leaving a thick specimen that would be hard to read under the microscope. Immediately (within 2 seconds) spray the slide with fixative to avoid drying. For the woman following hysterectomy whose cervix has been removed, collect a scrape from the end of the vagina and a vaginal pool. Immediately spray the slides with fixative. The frosted ends of the slides should be labeled with the woman's name. Send these to the laboratory with the following necessary data: · Date of specimen · Woman's date of birth · Date of last menstrual period · Hormone administration if any · If pregnant, with estimated date of delivery · Known infections · Prior surgery or radiation · Prior abnormal cytology · Abnormal findings on physical examination These data are important for accurate interpretation; e.g., a specimen maybe interpreted as positive unless the laboratory technicians know the woman has had prior radiation treatment. To screen for STDs, or if you note any abnormal vaginal discharge, obtain the following samples: SALINE MOUNT, or "Wet Prep." Spread a sample of the discharge onto a glass slide and add one drop of normal saline and a coverslip. KOH Prep. To a sample of the discharge on a glass slide, add one drop potassium hydroxide and a coverslip. GONORRHEA (GC) CHLAMYDIA CULTURE. Insert a sterile cotton applicator into the os, rotate it 360 degrees, and leave it in place 10 to 20 seconds for complete saturation. Insert into specimen container and label immediately. Note that newer specimen containers from many laboratories combine the GCIChlamydia culture and do not require incubation. ANAL CULTURE. Insert a sterile cotton swab into the anal canal about 1 cm. Rotate it, and move it side to side. Leave in place 10 to 20 seconds. If the swab collects feces, discard it and begin again. Insert into specimen container. FIVE PERCENT ACETIC ACID WASH. Acetic acid (white vinegar) screens for asymptomatic human papilloma virus (HPV), which causes genital warts. After all other specimens are gathered, soak a thick-tipped cotton rectal swab with acetic acid and "paint" the cervix. Acetic acid dissolves mucus and temporarily causes intracellular dehydration and coagulation of protein. A normal response (indicating no HPV infection) is no change in the cervical epithelium.			Rapid acetowhitening or blanching, especially with irregular borders, suggests HPV infection (see Table 26-3).
Inspect the vaginal wall
Loosen the thumbscrew but continue to hold the speculum blades open. Slowly withdraw the speculum, rotating it as you go, to fully inspect the vaginal wall. Normally, the wall looks pink, deeply rugated, moist and smooth, and is free of inflammation or lesions. Normal discharge is thin and clear, or opaque and stringy, but always odorless. When the blade ends near the vaginal opening, let them close, but be careful not to pinch the mucosa or catch any hairs. Turn the blades obliquely to avoid stretching the opening. Place the metal speculum in a basin to be cleaned later and soaked in a sterilizing and disinfecting solution; discard the plastic variety. Discard your gloves and wash hands			Inflammation or lesions. Leukoplakia, appears as spot of dried white paint. Vaginal discharge: thick, white, and curd-like with candidiasis; profuse, watery, gray-green, and frothy with trichomoniasis; or any gray, green-yellow, white, or foul-smelling discharge (see Table 26-6).
Bimanual Examination
Rise to a stand, and have the woman remain in lithotomy position. Drop lubricant onto the first two fingers of your gloved intravaginal hand (Fig. 26-17). Assume the "obstetric" position with the first two fingers extended, the last two flexed onto the palm, and the thumb abducted. Insert your fingers into the vagina, with any pressure directed posteriorly. Wait until the vaginal walls relax, then insert your fingers fully. You will use both hands to palpate the internal genitalia to assess their location, size, and mobility, and to screen for any tenderness or mass. One hand is on the abdomen while the other (often the dominant, more sensitive hand) inserts two fingers into the vagina (Fig. 26-18). It does not matter which you choose as the intravaginal hand; try each way, and settle on the most comfortable method for you Palpate the vaginal wall. Normally, it feels smooth and has no area of induration or tenderness Cervix. Locate the cervix in the midline, often near the anterior vaginal wall. The cervix points in the opposite direction of the fundus of the uterus. Palpate using the palmar surface of the fingers. Note these characteristics of a normal cervix: Consistency—feels smooth and firm, as the consistency of the tip of the nose. It softens and feels velvety at 5 to 6 weeks of pregnancy (Goodell's sign). Contour—evenly rounded. Mobility—With a finger on either side, move the cervix gently from side to side. Normally, this produces no pain (Fig. 26-19). Palpate all around the fornices; the wall should feel smooth. Next, use your abdominal hand to push the pelvic organs closer for your intravaginal fingers to palpate. Place your hand midway between the umbilicus and the symphysis; push down in a slow, firm manner, fingers together and slightly flexed. Brace the elbow of your pelvic arm against your hip, and keep it horizontal. The woman must be relaxed. Uterus. With your intravaginal fingers in the anterior fornix, assess the uterus. Determine the position, or version, of the uterus (Fig. 26-20). This compares the long axis of the uterus with the long axis of the body. In many women, the uterus is anteverted; you palpate it at the level of the pubis with the cervix pointing posteriorly. Two other positions occur normally {midposition and retroverted), as well as two aspects of flexion, where the long axis of the uterus is not straight but is flexed. Anteverted Midposition Anteflexed Retroflexed Retroverted Palpate the uterine wall with your fingers in the fornices. Normally, it feels firm and smooth, with the contour of the fundus rounded. It softens during pregnancy. Bounce the uterus gently between your abdominal and intravaginal hand. It should be freely movable and nontender. Adnexa. Move both hands to the right to explore the adnexa. Place your abdominal hand on the lower quadrant just inside the anterior iliac spine and your intravaginal fingers in the lateral fornix (Fig. 26-21). Push the abdominal hand in and try to capture the ovary. Often, you cannot feel the ovary. When you can, it normally feels smooth, firm, and almond shaped, and is highly movable, sliding through the fingers. It is slightly sensitive but not painful. The fallopian tube is not palpable normally. No other mass or pulsation should be felt. A note of caution—Normal adnexal structures often are not palpable. Be careful not to mistake an abnormality for a normal structure. To be safe, consider abnormal any mass that you cannot positively identify, and refer the woman for further study. Move to the left to palpate the other side. Then, withdraw your hand and check secretions on the fingers before discarding the glove. Normal secretions are clear or cloudy and odorless.			Nodule Tenderness. Hard with malignancy. Nodular. Irregular. Immobile with malignancy. Painful with inflammation or ectopic pregnancy Enlarged uterus (see Table 26-7). Lateral displacement. Nodular mass. Irregular, asymmetric uterus. Fixed and immobile. Tendeness Enlarged adnexa. Nodules or mass in adnexa. Immobile. Markedly tender (see Table 26-8). Pulsation or palpable fallopian tube suggests ectopic pregnancy; this warrants immediate referral.
Rectovaginal Examination
Use this technique to assess the rectovaginal septum, posterior uterine wall, cul-de-sac, and rectum. Change gloves to avoid spreading any possible infection. Lubricate the first two fingers. Instruct the woman that this may feel uncomfortable and will mimic the feeling of moving her bowels. Ask her to bear down as you insert your index finger into the vagina and your middle finger gently into the rectum (Fig. 26-22). While pushing with the abdominal hand, repeat the steps of the bimanual examination. Try to keep the intravaginal finger on the cervix so the intrarectal finger does not mistake the cervix for a mass. Note: •Rectovaginal septum should feel smooth, thin, firm, and pliable. •Rectovaginal pouch, or cul-de-sac, is a potential space and usually not palpated. •Uterine wall and fundus feel firm and smooth. Rotate the intrarectal finger to check the rectal wall and anal sphincter tone. (See Chapter 25 for assessment of anus and rectum.) Check your gloved finger as you withdraw; test any adherent stool for occult blood. Give the woman tissues to wipe the area and help her up. Remind her to slide her hips back from the edge before sitting up so she will not fall			Nodular or thickened
DEVELOPMENTAL CONSIDERATIONS
Infants and Children
PREPARATION •Infant—place on examination table. •Toddler/preschooler—place on parent's lap. Frog-leg position—hips flexed, soles of feet together and up to bottom. Preschool child may want to separate her own labia. No drapes—the young girl wants to see what you are doing. •        School-age child—place on examination table, frog-leg position, no drapes. During childhood, a routine screening is limited to inspection of the external genitalia to determine that (1) the structures are intact, (2) the vagina is present, and (3) the hymen is patent The newborn's genitalia are somewhat engorged. The labia majora are swollen, the labia minora are prominent and protrude beyond the labia majora, the clitoris looks relatively large, and the hymen appears thick. Because of transient engorgement, the vaginal opening is more difficult to see now than it will be later. Place your thumbs on the labia majora. Push laterally while pushing the perineum down, and try to note the vaginal opening above the hymenal ring. Do not palpate the clitoris because it is very sensitive. A sanguineous vaginal discharge and/or leukorrhea (mucoid discharge) are normal during the first few weeks because of the maternal estrogen effect. (This also may cause transient breast engorgement and secretion.) During the early weeks, the genital engorgement resolves, and the labia minora atrophy and remain small until puberty (Fig. 26-23) Between the ages of 2 months and 7 years, the labia majora are flat, the labia minora are thin, the clitoris is relatively small, and the hymen is tissue-paper thin. Normally, no irritation or foul-smelling discharge is present. In the young school-age girl (7 to 10 years), the mons pubis thickens, the labia majora thicken, and the labia minora become slightly rounded. Pubic hair appears beginning around age 11, although sparse pubic hair may occur as early as age 8 years. Normally, the hymen is perforate. Almost always in these age groups, an external examination will suffice. If needed, an internal pelvic examination is best performed by a pediatric gynecologist using specialized instruments.			Ambiguous genitalia are rare but are suggested by a markedly enlarged clitoris, fusion of the labia (resembling scrotum), and palpable mass in fused labia (resembling testes) (see Table 26-9). Imperforate hymen warrants referral. Lesions, rash. Poor perineal hygiene. Pest inhabitants. Excoriations. During and after toddler age, foul-smelling discharge occurs with lodging of foreign body, pinworms, or infection. Absence of pubic hair by 13 years indicates delayed puberty. Amenorrhea in adolescent, together with bluish and bulging hymen, indicates imperforate hymen and warrants referral.
The Adolescent
The adolescent girl has special needs during the genitalia examination. Examine her alone, without the mother present. Assure her of privacy and confidentiality. Allow plenty of time for health education and discussion of pubertal progress. Assess her growth velocity and menstrual history, and use the SMR charts to teach breast and pubic hair development. Assure her that increased vaginal fluid (physiologic leukorrhea) is normal because of the estrogen effect A pelvic examination is indicated when contraception is desired, when the girl's sexual activity includes intercourse, or at age 18 years in virgins. Periodic Pap smears also are started when intercourse begins. Although the techniques of the examination are listed in the adult section, you will need to provide additional time and psychological support for the adolescent having her first pelvicexamination. The experience of the first pelvic examination determines how the adolescent will approach future care. Your accepting attitude and gentle, unhurried approach are important. You have a unique teaching opportunity here. Take the time to teach, using the girl's own body as illustration. Your frank discussion of anatomy and sexual behavior communicates that these topics are acceptable to discuss and not taboo with health care providers. This affirms the girl's self-concept. During the bimanual examination, note that the adnexa are not palpable in the adolescent.			Pelvic or aclnexal mass.
The Pregnant Female
Depending on the week of gestation of the pregnancy, inspection shows the enlarging abdomen (see Fig. 27-1 in the following chapter). The height of the fun-dus ascends gradually as the fetus grows. At 16 weeks, the fundus is palpable halfway between the symphysis and umbilicus; at 20 weeks, at the lower edge of the umbilicus; at 28 weeks, halfway between the umbilicus and the xiphoid; and at 34 to 36 weeks, almost to the xiphoid. Then close to term, the fundus drops as the fetal head engages in the pelvis. The external genitalia show hyperemia of the perineum and vulva because of increased vascularity. Varicose veins may be visible in the labia or legs. Hemorrhoids may show around the anus. Both are caused by interruption in venous return from the pressure of the fetus. Internally, the walls of the vagina appear violet or blue (Chadwick's sign) because of hyperemia. The vaginal walls are deeply rugated and the vaginal mucosa thickens. The cervix looks blue, feels velvety, and feels softer than in the nonpreg-nant state, making it a bit more difficult to differentiate from the vaginal walls. During bimanual examination, the isthmus of the uterus feels softer and is more easily compressed between your two hands (Hegar's sign). The fundus balloons between your two hands; it feels connected to, but distinct from, the cervix because the isthmus is so soft. Search the adnexal area carefully during early pregnancy. Normally, the ad-nexal structures are not palpable			An ectopic pregnancy has serious consequences (see Table 26-8).
The Aging Adult
Natural lubrication is decreased; to avoid a painful examination, take care to lubricate instruments and the examining hand adequately. Use the Pedersen speculum {rather than the Graves) because its narrower, flatter blades are more comfortable in women with vaginal stenosis or dryness. Menopause and the resulting decrease in estrogen production cause numerous physical changes. Pubic hair gradually decreases, becoming thin and sparse in later years. The skin is thinner and fat deposits decrease, leaving the mons pu-bis smaller and the labia flatter. Clitoris size also decreases after age 60. Internally, the rugae of the vaginal walls decrease, and the walls look pale pink because of the thinned epithelium. The cervix shrinks and looks pale and glistening. It may retract, appearing to be flush with the vaginal wall. In some, it is hard to distinguish the cervix from the surrounding vaginal mucosa. Alternately, the cervix may protrude into the vagina if the uterus has prolapsed. With the bimanual examination, you may need to insert only one gloved finger if vaginal stenosis exists. The uterus feels smaller and firmer, and the ovaries are not palpable normally. Prior surgery for hysterectomy does not preclude the need for routine gynecologic care, including the Pap smear. The Pap smear can help detect gynecologic malignancies even when the cervix has been removed. Be aware that older women may have special needs and will appreciate the following plans of care: for those with arthritis, taking a mild analgesic or antiinflammatory before the appointment may ease joint pain in positioning; schedule appointment times when joint pain or stiffness is at its least; allow extra time for positioning and "unposition-ing" after the examination; and be careful to maintain dignity and privacy.			Refer any suspicious red, white, or pig-mented lesion for biopsy. Vaginal atrophy increases the risk of infection and trauma. Refer any mass for prompt evaluation.
SUMMARY CHECKLIST: Female Genitalia Exam
1. Inspect external genitalia 2. Palpate labia, Skene's and Bartholin's glands 3. Using vaginal speculum, inspect cervix and vagina	4. Obtain specimens for cytologic study 5. Perform bimanual examination: cervix, uterus, adnexa	6. Perform rectovaginalexamination 7. Test stool for occult blood

APPLICATION AND CRITICAL THINKING

SAMPLE CHARTING

SUBJECTIVE

Menarche age 12, cycle usually o^ 2S> days, duration 5 days, flow moderate, no dysmenorrhea, LMP April 3. <3rav O/Para O/Ab O. Gyne checkups yearly. Last Pap test 1 year PTA, negative.

No urinary problems, no irritating or foul-smelling vaginal discharge, no sores or [esions, no history pelvic surgery. Satisfied with sexual relationship with husband, uses vaginal diaphragm for birth control, no plans for pregnancy at this time. Aware of no STD contact to self or husband.

OBJECTIVE

External genitalia—no swelling, lesions, or discharge. No urethral swelling or discharge, internal-walls have no bulging or lesions, cervix pink with no lesions, scant c\ear mucoid discharge.

Bimanual—no pain on moving cervix, uterus anteflexed and anteverted, no enlargement or irregularity. Adnexa—ovaries not enlarged. Rectal—no hemorrhoids, fissures or lesions, no masses or tenderness, stool brown with guaiac test negative.

FOCUSED ASSESSMENT: CLINICAL CASE STUDY 1

J.K., 27-year-old, white, married newspaper reporter, Grav O/Fara O/Ab 0. Fresents at clinic with "urinary burning, vaginal itching, and discharge X 4 days."

SUBJECTIVE

3 weeks PTA: treated at clinic for bronchitis with erythromycin. Improved within 5 days.

4 to 5 days PTA: noted burning on urination, Intense vaginal itching, thick, white, "smelly" discharge. Warm water douche—no relief.

No previous history vaginal infection, urinary tract infection, or pelvic surgery. Monogamous sexual relationship, has used low-estrogen birth control pills for 3 years with no side effects.

OBJECTIVE

Vulva and vagina erythematous and edematous. Thick, white, curdlike discharge clinging to vaginal walls. Cervix pink, no lesions. Bimanual examination—no pain on palpating cervix, uterus not enlarged, ovaries not enlarged.

Specimens: Pap smear, GC/Chlamydia to lab. WH prep shows mycelia and spores of Candida alblcans.

ASSESSMENT

Candida vaginitis

Fain R./T infectious process

FOCUSED ASSESSMENT: CLINICAL CASE STUDY 2

Brenda, 17-year-old, white high school student, comes to clinic for pelvic examination. SUBJECTIVE

Menarche 12 years, cycle <\ 30 days, duration & days, mild cramps relieved by acetaminophen. LMF March 10. No dysuria, vaginal discharge, vaginal itching. Relationship involving intercourse with one boyfriend for Ј> months FTA. For birth control, boyfriend uses condoms "sometimes." Wants to start birth cor\tro\ pills. Never had pelvic examination. No knowledge of breast self-examination. No knowledge of 5TPs except AIDS. Smokes cigarettes, Va FFD, started age 11.

OBJECTIVE

Breasts—symmetric, no lesions or discharge, palpation reveals no mass or tenderness.

External genitalia—no redness, lesions, or discbarge, Internal genitalia—vaginal walls and cervix pink with no lesions or discharge. Specimens obtained. Acetic acid wash shows no acetowhitening.

Bimanual—no tenderness to palpation, uterus anteverted with no enlargement, ovaries not enlarged-Rectum—no maeeee, fissure, or tenderness. Stool brown and guaiac test negative.

Specimens—GC, Chlamydia, Fap smear to lab,

ASSESSMENT

Breast and pelvic structures appear healthy.

Deficient knowledge regarding: breast self-examination; birth control measures; STD prevention; cigarette smoking R/T lack of exposure

NURSING DIAGNOSES COMMONLY ASSOCIATED WITH THE FEMALE GENITALIA AND RELATED DISORDERS

RELATED FACTORS (Etiology)	DEFINING CHARACTERISTICS(Symptoms and Signs)
DIAGNOSIS: Sexual dysfunction
Depression Disturbance in self-esteem or body image Lack of significant other Lack of privacy Effects of actual or perceived limitation imposed by disease and/or therapy Substance abuse Physical or psychosocial abuse Dysfunctional interpersonal relationships Ineffective or absent role models Failure to identify satisfactorily with same-sex parent Cultural norms regarding male/female roles Values conflict Knowledge deficit	Decreased or absent sexual desire Impotence Delayed development of secondary sex characteristics Sexual promiscuity Exhibitionism Guilt Alterations in achieving perceived sex role or sexual satisfaction Verbalization about the problem Conflicts involving values Changes in interest in self and others Seeking confirmation of desirability Voyeurism Transsexualism Transvestism Masochism/sadism
DIAGNOSIS: Functional Incontinence
Deficits Cognitive Motor Sensory Altered environment Rape event	Unpredictable voiding pattern Unrecognized signals of bladder fullness Urge to void or bladder contractions sufficiently strong to result in loss of urine before reaching an appropriate site or receptacle Acute Phase Emotional reactions Anger Crying Overcontrol Panic Denial Self-blame Emotional shock Embarrassment Fear of being alone Humiliation Fear of physical violence and death Mistrust of the opposite sex Desire for revenge Change in sexual behavior Multiple physical symptoms Muscle tension Pain Sleep pattern disturbance Gastrointestinal irritability Genitourinary discomfort Long-Term Phase Mentally reliving rape Depression Loss of self-confidence Changes in lifestyle Changes in residence Dealing with repetitive nightmares and phobias Anxiety Ambivalence about own sexuality
OTHER RELATED NURSING DIAGNOSES
ACTUAL Ineffective Sexuality patterns (see Chapter 24) Impaired Skin integrity (see Chapters 12 and 24) Pain Stress Incontinence Reflex Incontinence Total Incontinence Urge Incontinence	RISK/WELUNESS Risk Risk for urinary urge incontinence Risk for infection Risk for post-trauma syndrome Wellness Health seeking behavior for information on STD risk reduction

Abnormal Findings

TABLE 26-3: Abnormalities of the External Genitalia

Pediculosis Pubis (Crab Lice)

S:   Severe perineal itching.

O: Excoriations and erythematous areas. May see little dark spots (lice are small), nits (eggs) adherent to pubic hair near roots. Usually localized in pubic hair, occasionally in eyebrows or eyelashes.

Herpes Simplex Virus—Type 2 (Herpes Genttalis)

S:   Episodes of local pain, dysuria, fever.

O: Clusters of small, shallow vesicles with surrounding erythema; erupt on genital areas and inner thigh. AJso, inguinal adenopathy, edema. Vesicles on labia rupture in 1 to 3 days, leaving painful ulcers. Initial infection lasts 7 to 10 days. Virus remains dormant indefinitely; recurrent infections last 3 to 10 days with milder symptoms.

Syphilitic Chancre*

O: Begins as a small, solitary silvery papule that erodes to a red round or oval, superficial ulcer with a yellowish serous discharge. Palpation—nontender indurated base; can be lifted like a button between thumb and finger. Nontender inguinal lymphadenopathy

Red Rash—Contact Dermatitis

S:   History of skin contact with allergenic substance in envired,         ronment, intense pruritus.

O: Primary lesion—red, swollen, vesicles. Then may have weeping of lesions, crusts, scales, thickening of skin, excoriations from scratching. May result from reaction to feminine hygiene spray or synthetic underclothing.

Genital Human Papillomavirus (HPV, Condylomata Acuminata, Genital Warts)

S:   Painless warty growths, may be unnoticed by woman.

O: Pink or flesh-colored, soft, pointed, moist, warty papules. Single or multiple in a cauliflowerlike patch. Occur around vulva, introitus, anus, vagina, cervix.

HPV infection is common among sexually active women, especially adolescents, regardless of ethnicity or socioeco-nomic status. Risk factors include early age at menarche andmultiple sexual partners. The long incubation period (6 weeks to 8 months) makes it difficult to establish history of exposure. A strong association of HPV infection and abnormal cervical cytology exists.

Abscess of Bartholin's Gland

S: Local pain, can be severe.

O: Overlying skin red and hot. Posterior part of labia swollen; palpable fluctuant mass and tenderness. Mucosa shows red spot at site of duct opening; can express purulent discharge. Often secondary to gonococcal infection.*

Reprinted from Colour Atlas of Infectious Diseases, 3rd edition, Emond, p. 161, 1995, by permission of the publisher Mosby.

Urethritis (not illustrated)

S:   Dysuria.

O: Palpation of anterior vaginal wall shows erythema, tenderness, induration along urethra, purulent discharge from meatus. Caused by Neisseria gonorrhoeas, Chla-mydia, orStaphylococcus infection.

Urethral Caruncle

S:   Tender, painful with urination, urinary frequency, hematuria, dyspareunia, or asymptomatic. O: Small, deep red mass protruding from meatus; usually  secondary to urethritis or skenitis; lesion may bleed on contact.

"This condition is a sexually transmitted disease (STD). The classic term, venereal disease, a disease transmitted only by sexual intercourse, now is obsolete. A broader category, STDs, includes all conditions that are usually or can be transmitted during sexual intercourse or intimate sexual contact with an infected partner. Although not inclusive of all STDs, the conditions described in this table encompass more common conditions.

TABLE 26-4: Abnormalities of the Pelvic Musculature

Cystocele (with prolapse)

S:   Feeling of pressure in vagina, stress incontinence.

O: With straining or standing, note introitus widening and the presence of a soft, round anterior bulge. The bladder, covered by vaginal mucosa, prolapses into vagina, in this case with a uterine prolapse.

Rectocele

S:   Feeling of pressure in vagina, possibly constipation. O: With straining or standing, note introitus widening and the presence of a soft, round bulge from posterior. Here, part of the rectum, covered by vaginal mucosa, prolapses into vagina.

Uterine Prolapse

O: With straining or standing, uterus protrudes into vagina. Prolapse is graded: first degree, cervix appears at introitus with straining; second degree, cervix bulges outside introitus with straining; third degree (in this case), whole uterus protrudes even without straining—essentially, uterus is inside out.

TABLE 26-5: Abnormalities of the Cervix

Bluish Cervix—Cyanosis

O: Bluish discoloration of the mucosa occurs normally in pregnancy (Chadwick's sign at 6 to 8 weeks' gestation) and with any other condition causing hypoxia or venous congestion, e.g., heart failure, pelvic tumor.

Erosion

O: Cervical lips inflamed and eroded. Reddened granular surface is superficial inflammation, with no ulceration (loss of tissue). Usually secondary to purulent or muco-purulent cervical discharge. Biopsy needed to distinguish erosion from carcinoma; cannot rely on inspection.

Human Papillomavirus (HPV, Condylomata)

O: Virus can appear in various forms when affecting cervical epithelium. Here warty growth appears as abnormal thickened white epithelium. Visibility of lesion is enhanced by acetic acid (vinegar) wash, which dissolves mucus and temporarily causes intracellular dehydration and coagulation of protein.

Polyp

S:   May have mucoid discharge or bleeding.

O: Bright red, soft, pedunculated growth emerges from os. It is a benign lesion, but this must be determined by biopsy. May be lined with squamous or columnar epithelium.

Diethylstiibestroi (DES) Syndrome

S. Prenatal exposure to DES causes cervical and vaginal abnormalities.

O: Red, granular patches of columnar epithelium extend beyond normal squamocolumnar junction onto cervix and into fornices (vaginal adenosis). Also cervical abnormalities: circular groove, transverse ridge, protuberant anterior lip, "cocks-comb" formation. Warrants monitoring by physician.

Carcinoma

S: Bleeding between menstrual periods or after menopause, unusual vaginal discharge.

O: Chronic ulcer and induration are early signs of carcinoma, although the lesion may or may not show on the exocervix. (Here, lesion is mostly around the external os.)Diagnosed by Papanicolaou smear and biopsy. Risk factors for cervical cancer are early age at first intercourse, multiple sex partners, cigarette smoking, certain sexuallytransmitted diseases.

S, Subjective data;

O, objective data.

TABLE 26-6: Vulvovaginal Inflammations

Atrophic Vaginitis

S: Postmenopausal vaginal itching, dryness, burning sensation, dyspareunia, mucoid discharge (may be flecked with blood).

O: Pale mucosa with abraded areas that bleed easily; may have bloody discharge.

An opportunistic infection related to chronic estrogen deficiency.

Candidiasis (Moniliasis)

S:   Intense pruritus, thick whitish discharge.

O: Vulva and vagina are erythematous and edematous. Discharge is usually thick, white, curdy, "like cottage cheese." Diagnose by microscopic examination of discharge onpotassium hydroxide wet mount.

Predisposing causes—use of oral contraceptives or antibiotics, more alkaline vaginal pH (as with menstrual periods, postpartum, menopause), also pregnancy from increasedglycogen and diabetes.

Trichomoniasis*

S: Pruritus, watery and often malodorous vaginal discharge, urinary frequency, terminal dysuria. Symptoms are worse during menstruation when the pH becomes optimal for the organism's growth.

O: Vulva may be erythematous. Vagina diffusely red, granular, occasionally with red raised papules and petechiae ("strawberry" appearance). Frothy, yellow-green, foul-smelling discharge. Microscopic examination of saline wet mount specimen shows characteristic flagellated cells.

Bacterial Vaginosis (Gardnerella vaginalis, Haemophilus vaginalis, or Nonspecific Vaginitis)*

S: Profuse discharge, "constant wetness" with "foul, fishy, rotten" odor.

O: Thin, creamy, gray-white, malodorous discharge. No inflammation on vaginal wall or cervix because this is a surface parasite. Microscopic view of saline wet mount specimen shows typical "clue cells."

Chlamydia*

S: (Mimics gonorrhea.) Three of four infected women have no symptoms. May have urinary frequency, dysuria, or vaginal discharge, postcoital bleeding.

O: May have yellow or green mucopurulent discharge, friable cervix, cervical motion tenderness. Signs are subtle, easily mistaken for gonorrhea. The two are important todistinguish because antibiotic treatment is different; if the wrong drug is given or if the condition is untreated, chlamydia can ascend the reproductive tract to cause pelvic inflammatory disease (PID), and result in infertility. This is the most common STD in the United States; the highest prevalence is among sexually active adolescent girls, with an incidence of almost 30 percent in some settings (Burstein et al., 1998). Clinicians are urged to screen all sexually active girls every 6 months, regardless of symptoms or risk.

Gonorrhea*

S: Variable: vaginal discharge, dysuria, abnormal uterine bleeding, abscess in Bartholin's or Skene's glands; the majority of cases are asymptomatic.

O: Often no signs are apparent. May have purulent vaginal discharge. Diagnose by positive culture of organism. If the condition is untreated, it may progress to acute sal-pingitis, pelvic inflammatory disease (PID).

TABLE 26-7: Conditions of Uterine Enlargement

Pregnancy

Obviously a normal condition, pregnancy is included here for comparison.

S: Amenorrhea, fatigue, breast engorgement, nausea, change in food tolerance, weight gain.

O: Early signs: cyanosis of vaginal mucosa and cervix (Chad-wick's sign). Palpation—soft consistency of cervix, enlarging uterus with compressible fundus and isthmus(Hegar's sign at 10 to 12 weeks).

Myomas (Leiomyomas, Uterine Fibroids

S: Varies, depending on size and location. Often no symptoms. When symptoms do occur, include vague discomfort, bloating, heaviness, pelvic pressure, dyspareunia, urinary frequency, backache, or hypermenorrhea if myoma disturbs en-dometrium. Heavy bleeding produces anemia.

O: Uterus irregularly enlarged, firm, mobile, and nodular with hard, painless nodules in the uterine wall.

They are usually benign. Highest incidence between the ages of 30 and 45 years and in blacks. Myomas are estrogen dependent; after menopause, the lesions usually regress but do not disappear. Surgery may be indicated.

Carcinoma of the Endometrium

S:   Abnormal and intermenstrual bleeding before menopause; postmenopausal bleeding or mucosanguineous discharge.

Pain and weight loss occur late in the disease.

O: Uterus maybe enlarged.

The Pap smear is rarely effective in detecting endometrial cancer. Women at high risk should have an endometrial tissue sample evaluated at menopause and periodically thereafter (American Cancer Society, 1998). Risk factors for endometrial cancer are early menarche, late menopause, history of infertility, failure to ovulate, tamoxifen, unopposed estrogen therapy (which continually stimulates the endometrium, causing hyperplasia), and obesity (which increases endogenous estrogen).

Endometriosis

S: Cyclic or chronic pelvic pain, occurring as dysmenorrhea, or dyspareunia, low backache. Also may have irregular uterine bleeding or hypermenorrhea or may be asymptomatic.

O: Uterus fixed, tender to movement. Small, firm nodular masses tender to palpation on posterior aspect of fundus, uterosacral ligaments, ovaries, sigmoid colon. Ovaries often enlarged.

Masses are aberrant growths of endometrial tissue scattered throughout pelvis due to transplantation of tissue by retrograde menstruation. Ectopic tissue responds to hormone stimulation; builds up between periods, sloughs during menstruation. May cause infertility due to pelvic adhesions, tubal obstruction, decreased ovarian function.

TABLE 26-8: Adnexal Enlargement

Fallopian Tube Mass—Acute Salpingitis (Pelvic Inflammatory Disease [PID]) S: Sudden fever >38° C or 100.4° F, suprapubic pain and tenderness. O: Acute—rigid boardlike lower abdominal musculature. May have purulent discharge from cervix. Movement of uterus and cervix causes intense pain. Pain in lateral for-nices and adnexa. Bilateral adnexal masses difficult to palpate because of pain and muscle spasm. Chronic—bilateral, tender, fixed adnexal masses. Complications include ectopic pregnancy, infertility, and reinfection. PID usually caused by Neisseria gonorrhoeae and Chlatnydia trachomatis.

Fallopian Tube Mass—Ectopic Pregnancy S:   Amenorrhea or irregular vaginal bleeding, pelvic pain.  O: Softening of cervix and fundus; movement of cervix and uterus causes pain; palpable tender pelvic mass, which is solid, mobile, unilateral. This has potential for serious sequelae; seek gynecologic consultation immediately before the mass ruptures or shows signs of acute peritonitis

Fluctuant Ovarian Mass—Ovarian Cyst

S:   Usually asymptomatic.

O: Smooth, round, fluctuant, mobile, nontender mass on ovary. Some cysts resolve spontaneously within 60 days but must be followed closely

Solid Ovarian Mass—Ovarian Cancer

S:   Usually asymptomatic. May have abdominal enlargement

from fluid accumulation. O: Solid tumor palpated on ovary. Heavy, solid, fixed, poorly denned mass suggests malignancy; benign mass may feel mobile and solid.

Biopsy necessary to distinguish the two types of masses. The Pap smear does not detect ovarian cancer. Women over age 40 should have a thorough pelvic examination every year.

TABLE 26-9: Abnormalities in Pediatric Genitalia

Ambiguous Genitalia

Female pseudohermaphroditism is a congenital anomaly resulting from hyperplasia of the adrenal glands, which exposes the female fetus to excess amounts of androgens. This causes masculinized external genitalia, here shown as enlargement of the clitoris and fusion of the labia. Ambiguous means the enlarged clitoris here may look like a small penis with hy-pospadias, and the fused labia look like an incompletely formed scrotum with absent testes. Other forms of intersex-ual conditions occur, and the family must be referred for diagnostic evaluation

Vulvovaginitis in Child

This infection is caused by Candida albicans in a diabetic child. Symptoms include pruritus and burning when urine touches excoriated area. Examination shows red, shiny, edematous vulva, vaginal discharge, excoriated area from scratching.

Other, more common causes of vulvovaginitis in the pre-pubertal child include infection from a respiratory or bowel pathogen, sexually transmitted disease, or presence of a foreign body.

BREASTS AND REGIONAL LYMPHATICS

Structure and Function Surface Anatomy Internal Anatomy Lymphatics Developmental Considerations The Adolescent The Pregnant Female The Aging Female The Male Breast Transcultural Considerations Subjective Data Health History Questions Breast Axilla Additional History for the Preadolescent Additional History for the Pregnant Female Additional History for the Menopausal Woman Risk Factor Profile for Breast Cancer Objective Data, Preparation The Breasts General Appearance Skin Lymphatic Drainage Areas Nipple Maneuvers to Screen for Retraction

The Axillae Breast Palpation Teach the Breast Self-Examination The Male Breast Developmental Considerations Infants and Children The Adolescent The Pregnant Female The Lactating Female  The Aging Female Summary Checklist: Breasts and Regional Lymphatics Application and Critical Thinking Sample Charting Focused Assessment: Clinical Case Study 1 Focused Assessment: Clinical Case Study 2 Nursing Diagnoses Assessment Video Critical Thinking Questions Abnormal Findings Signs of Retraction and Inflammation in the Breast Breast Lump Differentiating Breast Lumps Abnormal Nipple Discharge Disorders Occurring During Lactation Abnormalities in the Male Breast

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