Male Genital-Rectal Examination Preparation / Positioning
This is from a Medical School Site on How to do this exam
1. Introduce self.
2. Wash hands and glove.
3. Explain procedures and purposes.
Caption : " I will be examining your penis, scrotum, and testes As I
examine, I will also instruct you on how to perform a Genital Self Exam (GSE).
This should not cause discomfort; however if you feel discomfort, please let
me know."
4. Patient should have gown opened to front with clothing on upper torso.
5. Positioning for the patient: Standing comfortably at end of exam table with
feet about shoulders width apart.
6. Positioning for the examiner: Seated on a low rolling stool. Positioned in
front of the patient.
7. Ask the patient to separate his gown for the exam.
Caption: "Please open your gown."
Inspection and Palpation
1. Assess sexual maturity by visual inspection.
a. Note hair pattern.
b. Note -size and shape of penis and testes.
c. Note color and texture of scrotal sac.
d. Use Tanner's stages as criteria guide.
2. Examiner may use one or two hands for inspection and palpation.
3. Gentle palpation should diagnose common problems such as a urethral
discharge, hydrocele, varicocele, testicular lesions, inguinal hernias, etc.
4. If erection occurs at any time during exam, assure patient this is a natural
reaction, and continue exam.
Genital Self Exam (GSE)
1. Demonstrate and organize the techniques utilized during GSE for the
patient.
a. Instruct the patient in a step-by-step process how to perform the exam
techniques as you are actually conducting the examination.
1) As your visually inspecting the penis, review what he should be
looking for during his visual inspection.
(a) A mirror may be utilized as an aid to visualize all areas of the
genitalia
2) As you are palpating the scrotum, give him instructions on how to
correctly palpate the scrotum.
b. Giving instructions as you are applying technique reinforces how to
organize and conducts the GSE for the patient.
2. Inform patient it is recommend to perform a GSE every month.
Caption: "As I am examining the penis and scrotum, I will instruct you
on how to conduct a Genital Self Exam (GSE) . It is important to perform a GSE
once a month.
Penis
Caption: " I am going to examine the penis and the scrotum now."
1. Place. hand on patient's thigh as first contact and alerts patient exam is
proceeding.
a. Examiner should forewarn patient of contact.
2. Gently grasp shaft of penis and inspect all side of the glens.
a. Inspect for discoloration, inflammation, lesions, rashes; masses,
nodularities.
b. Be sure to examine the inferior side of the penis.
3. Examine the base of the penis and surrounding pubic hair for lice; nits,
and any irregularities.
a. Be thorough with any obese patients.
4. Retract the any foreskin present or ask patient to retract whether
uncircumcised or circumcised.
a. Foreskin should be easily retractable from glens and easy to replace
foreskin to original position.
b. Phimosis : Exists when foreskin cannot be retracted. If the foreskin is
c. Paraphimosis : left retracted for too long, or inflammation is present,
swelling can occur and foreskin may not return to the original position.
Inspect the glands for ulcers, nodules, inflammation,
a. Smegma, whitish material, may be present.
b. Hygiene care: Patient should wash area with mild soap and warm water.
6. Patient or examiner should replace the foreskin.
7. Examine urethra meatus.
a. Note position and size of opening.
b. Gently compress the glands between the index finger and thumb or use both
thumbs.
1) Opens the distal end of the urethra for inspection.
Inspect inside the opening for discoloration, inflammation, discharge, or
lesions.
To check for possible discharge
1) Place the thumb on the superior side and the index finger on the
inferior side of the penis.
2) Gently compress the penis as continuously milking from the base of the
penis to the urethral opening.
3) Slightly more pressure from index finger will aid in producing any
discharge from the meatus.
If discharge is present
1) Check the consistency of fluid.
2) Gently insert a calcium alginate swab 1-3 cm into the urethral canal.
3) Allow swab to remain inserted for 15 seconds for any discharge to be
absorbed.
4) Remove cautiously.
5) A separate swab must be used for each culture medium.
6) Apply discharge from three separate swabs to:
a) Thayer: Martin plate for gonorrhea
b) Glass slide for Gram's stain.
c) Testing source for Chlamydia.
8. Palpate the shaft of the penis for any masses or irregularities.
a. If a masses etc. is located, determine if the masses is attached to the
shaft or to the foreskin.9. If patient is symptomatic, palpate the shaft for
indurations by using thumb and index finger.
Scrotum
1. Note any swelling within the scrotum i.e. hydrocele or varicocele.
Any swelling should be transilluminated for further evaluation.
2. Examine all sides of the scrotum.
a. Have patient flex leg on side being examined to increase access to area.
b. Lift the scrotum to visually inspect the posterior side.
3. Examine the scrotal sac by rolling the skin between the fingers of one or
both hands.
a. Take special care not to entrap the testes during this portion of the
exam.
b. Check for nodularities, masses, tenderness, or any irregularities.
Testis, Epididymis, Spermatic Cord and Vas Deferens
1. Gently palpate the testis between the fingers of one hand.
a. Avoid excessive pressure during palpation.
1) Excess pressure causes deep aching sensation.
2) Stimulation could cause scrotal muscles to contract and testes to retract
upwards.
b. The testes should feel smooth and glassy in texture.
c. Note size (4 cm), shape (kidney), symmetry (left teste may hang slightly
lower).
d. Check for masses, tenderness, and nodules.
e. A grainy texture indicates an irregularity i.e. testicular cancer.
2. Gently palpate the epididymis between the thumb and index finger.
a The epididymis lies slightly behind the top side of the testes.
b. The epididymis move with the testes, yet can also move independently.
c. The texture feels like a "duster of soft noodles".
d. Note any nodules, masses; tenderness.
3. Palpates the spermatic cord and vas deferens between the thumb and index
finger.
a. To aid in locating the spermatic cord and vas deferens:
1) Gently grasp the scrotal sac between the thumb the thumb and index
finger close to the base, of the penis.
2) Move thumb / finger outward laterally until contact with the cued is
made.
3) Spermatic cord feels like a soft, pliable tubing.
4) The vas deferens usually can be felt as a separate, movable cord within
the tubing.
b. Palpate and follow the spermatic cord and vas deferens upward to the
base of the penis. Ask patient to flex other leg and repeat procedures on
remaining side.
Lower Abdomen
1. Ask the patient to bear down.
Caption: " I am going to examine lymph nodes in the
lower abdominal area and for hernias. Please bear down.”
2. Visually inspect and palpate the femoral and inguinal areas.
a. Palpate with the pads of the fingers of one hand.
b. Palpate for any bulges or protrusions.
c. Palpate lymph nodes in both areas.
Inguinal Canal Evaluation
Caption: "I am going to examine the canal which runs along your
groin area for any hernias I will be inserting my finger into the canal. You
should feel some pressure. If you feel an other discomfort ease let me know."
Positioning for patient and examiner.
1. Ask patient to flex the leg on the side examiner will be evaluating.
2. Use the right hand for the patient's right side and left hand for the
patient's left side.
a. Adjust approach, if patient's anatomy requires.
Insertion Technique
1. Gather up the loose scrotal skin from the base of the scrotal sac.
a. This allows ample skin to be gathered for comfortable insertion of the
finger.
b. Be sure to gather loose scrotal skin outside of the teste to prevent
entrapping teste or spermatic cord as you gather the skin.
2. The spermatic cord moves upward through the slit opening of the inguinal
ring and into the inguinal canal.
a. Follow the spermatic cord up towards the inguinal canal.
b. The inguinal canal follows parallel to and about 1 cm above the inguinal
ligament
c. Examiner should follow the cord in an oblique angle
1) Examiner will be invaginating loose scrotal skin into the canal.
d. Direct the finger into the inginual canal approximately 1-2 cm below the
surface.
e. Avoid directing the finger into the body.
2. Evaluate for Hernias
1. If a mass or resistance is felt as inserting, do not attempt to continue
insertion.If no mass is felt
a. Ask patient to bear down or turn his head and cough.
1) These techniques will cause most hernias to present.
b. Examiner may want to place fingers of free hand over inguinal canal
during maneuvers to aid in evaluation of area
c. Avoid excess movement of finger during invagination and removal.
3. Types of hernias
a. Direct inguinal hernia: Felt pressing on the side of the examiner's
finger.
b. Indirect inguinal hernia: Felt pressing on the tip of the examiner's
finger.
4. Slowly remove finger in the same oblique angle.
5. Ask patient to flex other leg and repeat procedure on remaining side.
Rectal Examination Caption: "I am going to examine the anus, rectum,
and the prostate. I will be inserting my finger into the rectum You should feel
some pressure. If you feel any other discomfort; please let me know. "
Positioning for patient and examiner.
1. Standing position
a. Most commonly used for ambulatory patients.
b. Patient should be facing the end of the exam table and bending over with
arms resting on table.
c. Patient's feet should be slightly separated.
d. One leg should be slightly flexed or resting on a stool.
e. Examiner may want to demonstrate position for patient.
2. Left-lateral (Sims') position
a. Frequently used for non-ambulatory patients.
b. Patient lying on exam table or bed on left side with superior knee flexed
into chest.
3. Examiner should be sitting on rolling stool.
Inspection and Digital Insertion
1. Glove both hands for the examination.
2. Generously lubricate the index finger of the gloved dominant hand with
lubricant.
3. Give the patient instructions on bearing down to reduce discomfort of
insertion.
Caption: "To make the insertion of my finger into the rectum more
comfortable, please bear down as though you were going to have a bowel movement
but you won’t. You will only feel pressure."
4. Ask patient to lift his gown above the waist.
5. Separate the buttocks with two hands and visually inspect the area for
lesions, rashes, and masses.
6. Visually inspect the anus for fissures, hemorrhoids, skin tags.
7. Use thumb and index finger of non-dominant hand to separate buttocks for
digital insertion.
8. Place index finger of gloved dominant hand at the anal opening.
9. Ask the patient to bear down.
Caption : "Please bear down. You should feel some pressure. As I am
palpating the prostate you may feel the urge to urinate. That is a normal
reaction. If you feel any other discomfort; please let me know."
8. Apply gentle posterior pressure and slowly insert finger palmer surface
down.
a. Insert fingers in downward angle towards umbilicus.
b. Allow a few seconds for the external and internal sphincter to relax.
Rectal and Prostate Exam.
1. Evaluate the tone of the sphincter muscles as inserting finger.
a. Rotate finger 360 degrees to evaluate anal sphincter muscle ring.
2. Evaluate all four walls of the rectum: posterior, left lateral, anterior,
and right lateral.
a. Rotate finger 360 degrees during exam to ensure proper palpation.
b. Examine for any masses, nodules, inflammation, genital warts, or
irregularities.
1) Stool is usually present, but is soft and mobile.
2) Tumors or polyps are firmer and fixed.
c. Gently palpate levator ani muscles attached at the posterior and lateral
walls of the rectum for muscle tone, if possible.
3 .Examine the prostate.
a. Position finger palmer surface down.
b. Palpate posteriorly to locate prostate.
c. Prostate should be 2-4 cm long and triangular in shape.
1) The two lateral lobes are separated by a deeper central grove.
2) Palpate in a circular motion to increase ability to identify the lobes
and groove.
d. Palpate and note the following
1) Width and length of gland, and presence of groove.
2) Consistency: Should be firm and rubbery.
a) Softness can occur with infection.
b) Hardness can occur with tumors and diseases.
3) Mobility
4) Tenderness
5) Enlargement
6) Nodules
e. The seminal vesicles are soft, elongated structures extending above the
prostate.
1) These are normally not palpable.
4. Examiner should forewarn patient before removing finger.
5. Slowly remove. finger to avoid any sphincter muscle spasms.
6. Any feces on finger of gloved hand should be tested for occult blood.
Exam Completion
7. Remove glove away from and out of sight of patient.
8. Offer patient box of tissues to remove lubricant from anus and buttocks.
9. Give patient reassuring statement.
10. Allow patient privacy to dress.
11. Discuss findings of examination with patient in office.
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