INGUINAL LYMPH NODES
Literature supports the examination of the male patient in both the supine (Epstein et al., 2000; Swartz, 2002) and the standing position (Walsh et al., 1999; Fuller & Schaller-Ayers, 2000). The exceptional case for not laying the patient down is when checking for scrotal hernias and varicoceles. In a standing position the groin or inguinal area should be examined for lymphadenopathy
(enlargement of lymph nodes and also noting any tenderness). Even in the absence of any sexually transmitted infections, it may be possible to feel lymph nodes that may be non-tender and feel smooth like marbles. Normal lymph nodes can be up to 25 mm or 1 inch in length, so that the mere presence of palpable lymph nodes does not mean that they are abnormal. The lymph nodes are part of the lymphatic system (immune system), and their main function is to filter lymph fluid containing foreign particles, infective agents and malignant cells, as well as facilitating lymphocytes (white blood cells) in producing antibodies (killer cells) against invading organisms.
Lymph nodes may suddenly become swollen and tender as a result of infection or injury (Barkauskas et al., 2002; Swartz, 2002), whereas gradual enlargement without tenderness may result from malignant changes. Patients with painless enlarged lymph nodes should be advised to see their general practitioner for a health check to investigate any systemic diseases. Most sexually transmitted infections (commonly HIV, syphilis, LGV and HSV) can cause acute enlargement and tenderness of lymph nodes. Infection of the genital tract would generally cause enlargement of the local inguinal lymph nodes, and once the infection has been treated the lymph nodes should return to normal in several weeks.
In order to undertake a thorough examination of skin in the genital area it is essential to use a good light with magnification (Fuller & Schaller-Ayers, 2000). The pubic area needs to be checked for infestations, molluscum contagiosum, genital warts, ulceration, dermatosis etc. It is possible to see Phthirus pubis (pubic lice) on pubic hairs or attached to the skin. These can be easily removed and placed on a microscopy slide for microscopic observation. The eggs of the pubic lice can also be seen adhering to the pubic hairs. Infestation with Sarcoptes scabiei (scabies) mites can commonly be seen in the pubic region, where papular skin eruptions emerge over burrows made by the egg-laying female mites. Both pubic lice and scabies infestation can cause intense pruritus, and evidence of scratching may be visible on the skin. Molluscum contagiosum and genital warts are commonly diagnosed by visual examination of the genital and pubic skin. Small white or skin-coloured dome-shaped papules, which are characteristic of molluscum contagiosum, and benign epidermal proliferations, ranging from flat keratinised to pedunculated fleshy warts, can be seen on the skin.
Multiple fluid-filled vesicles or painful ulcers may indicate infection with the Herpes simplex virus or chancroid, whereas a solitary painless ulcer with indurated margins may help the nurse to investigate primary syphilis infection or lymphogranuloma venereum.
Large areas of demarcated macular erythema may indicate a fungal infection such as Tinea cruris (jock itch). This can be easily treated with topical anti-fungal creams but the nurse should instruct the patient on appropriate hygiene requirements to ensure eradication. Erythema of the pubic skin may also result from other dermatological conditions such as eczema, psoriasis, etc., and patients should be advised to see a general practitioner/dermatologist for the management of any non-sexual skin condition.
Ideally the penis should be examined prior to the client voiding urine, as this will reveal any apparent discharge. At this point the nurse can observe the penis for any abnormal curvature, such as those seen in Peyronie's Disease (Swartz, 2002). This is where internal scarring of the corpora cavernosa causes the penis to bend sharply up, down or to the side. Men with Peyronie's may experience pain during sexual intercourse, and, if the condition persists, they may eventually notice shortening of the penis, both of which can be distressing for the patients (Gholami and Lue, 2001). The exact cause of Peyronie's disease is uncertain, but it is probably caused by minor trauma to the penis, which leads to hardening of the tissue (fibrosis) of the tunica albuginea layer that surrounds the corpora cavernosa. The penis will bend in the direction of the fibrous scar tissue, so that if there is hardening on the right side of the penis then the penis will bend sharply right. Usually if the penis is palpated the hardened tissue can be felt. If Peyronie's Disease is suspected the nurse should then advise the patient to see his General Practitioner for a review and surgical referral.
The penile skin often contains visible Fordyce glands, which are sebaceous (fat-producing) glands (Swartz, 2002) to keep the penile skin lubricated. They can be easily mistaken for genital warts or molluscum contagiosum, despite being little fatty lumps under the skin. The sebaceous glands can become blocked or form into sebaceous cysts, and rarely may become infected. The patient needs to be reassured about their presence.
The prepuce (foreskin) if present, needs to be retracted, noting any phimosis (inability to retract the foreskin) (Swartz, 2002; Fuller & Schaller-Ayers, 2000). The examiner may want to retract the foreskin to determine its mobility (Swartz, 2002). Once the foreskin is retracted the glans penis and sub-prepuce skin can also be examined. It is important to note the presence of smegma (Swartz, 2002; Bellack & Edlund, 1992) or odour (Epstein et al., 2000). It is common to find mild erythema of the prepuce, especially after sex or if proper hygiene care is not taken.
Inflammation of the glans penis (balanitis) and involving the prepuce (balano-posthitis) can be seen once the foreskin is retracted. Balanitis often results from poor hygiene, chemical irritants, bacterial or fungal infection, and drug allergies (sulfphonamides and tetracyclines), and is usually more commonly seen in uncircumcised men (Edwards, 1996). Often the inflamed skin has patches of erosion and linear fissuring can be seen especially on the fore skin. Fungal and bacterial causes should be investigated and balanitis should be treated, as the damaged skin poses a risk for acquiring infections.
Around the rim of the glans penis (corona) it is possible to see penile pearly papules. These are tiny filiform (thread-like) projections, which may range from being skin-coloured to white in colour, and are more common in uncir-cumcised men. Also located symmetrically either side of the frenulum are Tyson's glands. These are secretory glands that produce an oily substance to lubricate the prepuce. The nurse must reassure the patient that these are normal and not contagious and do not require treatment.
Using a thumb and forefinger, expose the external meatus (Fuller & Schaller-Ayers, 2000; Epstein et al., 2000). The meatus is then located and the position noted, as sometimes the meatus may open on the underside or ventral side (hypospadias) (Epstein et al., 2000) or on the upper surface or dorsum of the glans penis (epispadias). Some men may also present with multiple meatal openings; but usually only one is connected to the urethra. Spontaneous discharge can be detected from outside the meatus; but it is essential to part the meatus opening gently and check for meatal stenosis, ulceration, inflammation or warts. After being retracted, the foreskin should always be put back in its correct position to prevent paraphimosis (Swartz, 2002).
The scrotal skin should be examined all the way down to the perineum. If the patient complains about symptoms on the scrotum/perineum it may be better to lay the patient's down for the examination. It is important to observe the patient's face during the examination to check for signs of discomfort (Epstein et al., 2000).
Sebaceous cysts and angiokeratomas are often seen on the scrotal skin. Angiokeratomas appear as black, blue or dark red papules on the skin and they result from dilated capillaries in the dermis, which is covered by epidermal hyperplasia. Angiokeratomas may bleed as a result of friction during sexual intercourse, and may cause anxiety for the patient. Patients need to be reassured that they are not harmful, and that they can see a dermatologist for removal if so desired, although this procedure is not routinely performed.
The testes should be examined, noting any cryptorchidism (undescended testicle), differences in size of testicles, discomfort on exam, fluid collection or nodular growths. It is common for one testicle (usually the left) to hang slightly lower than the other testicle (Epstein et al., 2000; Swartz, 2002), and if only one testicle is present it is important to get an accurate account of what happened to the other testicle. Using both hands the surface of each testicle needs to be palpated under the skin. Any lumps or gritty areas on a testicle (Fuller & Schaller-Ayers, 2000) or any unilateral enlargement should be further investigated with an ultrasound scan. Testicular cancer is a concern for men under the age of 40 and usually more common amongst men with a history of undescended testicles (Forman et al., 1994). Patients with undescended testicles should be advised to see their general practitioner for surgical referral, owing to the increased risk of testicular cancer. Information should be given to the patient regarding regular testicular self-examination at home (Walsh et al., 1999).
The epididymis and vas deferens (spermatic cord) also need to be gently palpated (Swartz, 2002). Pain/tenderness with swelling of the epididymis or spermatic cord may indicate the presence of a descended infection. Epi-didymitis is most commonly caused by infections, and acute epididymitis may result in severe scrotal pain and swelling, so that it may be too painful to examine the scrotal contents at that point. Antibiotic treatment, analgesia (with an oral anti-inflammatory such as Ibuprofen) and scrotal support would usually resolve acute epididymitis.
The testicles can also twist on the spermatic cord (testicular torsion) resulting in obstructed venous flow, pain, and swelling. This is a surgical emergency, as ischaemia can result in a loss of the testicle. If torsion is suspected the patient must be referred to the surgeons for immediate assessment.
Cysts often form in the comma-shaped epididymis, which is attached to the posterior of the testicle (Epstein et al., 2000). Epididymal cysts contain fluids and may be multiple and/or bilateral and cause discomfort. On examination it is possible to palpate above the cysts, and they can be palpated separately from the testicles; they are also fluctuant (a wave-like motion is felt when they are palpated, owing to their containing fluid) and transilluminate (light up brightly when a light is pointed at the cyst in a darkened room). Men with asymptomatic epididymal cysts only require reassurance; but if they are uncomfortable, fluid from the epididymal cysts can be aspirated or they can be removed surgically. These treatment options are only performed after a man has no desire for further children, as scarring is possible after surgery/aspiration and this may cause blockage to the flow of sperm, resulting in infertility.
Infections and injury can lead to the formation of a hydrocele - a collection of serous fluid in the tunica vaginalis. Hydroceles are usually asymptomatic, transilluminate and can resolve without surgical intervention. The patient can visit his GP for further ultrasound scanning if still concerned.
Varicoceles can also be felt in the scrotal sac, and are often desribed as a sack of worms or spaghetti (Fuller & Schaller-Ayers, 2000). They are an enlarged mass of veins that develop in the spermatic cord when valves that regulate the flow of blood become defective, causing impaired circulation of blood away from the testicle and dilation of the veins. Varicoceles are more common on the left spermatic cord and are associated with infertility (Evers and Collins, 2003).
In clinical areas nurses can do a simple transillumination examination by placing the patient in a dark room and applying a strong light to the posterior testicle. The light will transmit through fluid-filled structures (hydroceles,
ADVANCED CLINICAL SKILLS FOR GU NURSES Table 2
Lymph nodes Normal: No lymphadenopathy or palpable shotty lymph nodes.
Abnormal: Enlarged (put approximate size, e.g. 3 cm x 4 cm), state site (bilateral, left or right), pain or tenderness, hard or fluctuant.
Pubic/Genital skin Normal: No abnormalities detected (NAD)
Abnormal: Record findings such as warts, infestations, molluscum, ulceration, rashes, etc. and give a description: Warts: Number visible, location, flat keratinised/fleshy pedunculated
Rashes: size and location of area, macular. Papular, diffused, circumscribed, appearance (inflammation, silvery surface, intact skin, exudation, dry, etc.). Ulceration: number, size, location, tenderness and appearance (superficial, skin erosion, indurated).
Penis Normal: No abnormalities detected (NAD), circumcised or uncircumcised Abnormal: Record findings such as warts, infestations, molluscum, ulceration, rashes etc and give a description. Meatus: record any visible finding for meatal opening, such as discharge, inflammation, ulceration.
Scrotal contents Normal: No abnormalities detected (NAD) Abnormal:
Testes: Number present, abnormal sizes between the two, palpable lesion and location (posterior, anterior, superior, etc.), tenderness. Epididymis: swelling (cysts) or enlargement, lesions, tenderness, unilateral or bilateral. Spermatic cord: same as for epididymis epididymal cysts, spermatoceles) and the structure will glow. However, light will not transmit though solid mass lesions, and these should be further investigated with ultrasound scanning if testicular malignancy is suspected (Krieger and Graney, 1999).
Essentially the lymph nodes, pubic skin, penis and scrotal contents need to be examined, and any findings must be clearly documented (see Table 2). It is always useful for abnormal findings to be drawn on a diagram of the male genital area. Most GUM clinics would have standard drawings for this purpose on either a proforma or a rubber stamp that can be used in the notes.
Examination of the male genitals may cause anxiety for the nurse starting to perform such examinations, but confidence comes with more experience. Essentially the lymph nodes, pubic skin, penis and scrotal contents need to be examined, and any findings to be clearly documented. This should be done as quickly as possible whilst maintaining the dignity of the patient. Providing adequate explanations for the procedure will secure the consent and cooperation of the patient and allow the nurse to conduct the examination in a very short time.
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